Western Australian Consolidated Regulations

NOTIFICATION OF STILLBIRTH AND NEO-NATAL DEATH REGULATIONS - SCHEDULE

Form No. 1

Western Australia

Health Act 1911

STILLBIRTH AND NEO-NATAL DEATH NOTIFICATION

To Executive Director, Public Health and Scientific Support Services

Name of Mother ........................... Home Address .......................... Age .............

Place of Birth .........................................................................................................

Gestation Period ...................... Birth Weight ...................... Sex of Foetus ..........

Single/Plural Birth ................................................ Time of Birth .........................

Date of Birth ............................... Date of Death (if Neo‑Natal) ...........................

NOTE: Neo‑Natal death for the purpose of this report includes death within 28 days of birth.

Please indicate with a tick whichever is applicable.

1. — General Health of Mother

Tuberculosis ........................................         Diseases of the blood ..........................
Rheumatic Fever and sequelae ............         Diabetes ...............................................
Other Cardiac Disease .........................         Tumours of uterus and adnexa ............
Essential hypertension .........................         Mental disorders ..................................
Chronic Nephritis ................................

2. — Acute Infectious Disease of Mother

Rubella ................................................         Other virus disease ..............................
Measles ................................................         Other acute infective disease ..............
Mumps .................................................         (State week of pregnancy in which
Influenza ..............................................                 onset occurred) ..............................

3. — Maternal Disease of Pregnancy

Hyperemesis ........................................         Placenta Praevia ..................................
Pre‑eclampsia ......................................         Other Antepartum Haemorrhage
Eclampsia ............................................                 Pyelonephritis ................................
Hydramnios .........................................

4. — Abnormal Duration of Labour

Duration over 48 hours .......................

5. — Abnormality of Presentation

Persistent occipito‑posterior ...............         Face and brow .....................................
Uncomplicated breech ........................         Transverse and oblique .......................
Complicated breech ............................

6. — Abnormality of Pelvis

Contracted pelvis .................................

7. — Accidents of Labour

Rupture of uterus..................................         Failed forceps .....................................

8. — Labour

(a)         Normal .........................................             (c)         Instrumental .................................
(b)         Manipulative —                  Forceps delivery ..........................
        External version before labour ....                 Embryoctomy and craniotomy ....
        Surgical induction .......................
        Caesarean section ........................
        Version in labour .........................

9. — Abnormality of Foetus

Congenital malformation ....................         Foetal disease due to maternal
Erythroblastosis foetalis......................                 disease ............................................
Macerated foetus.................................         (State disease, see Sect. 1, 2 and 3
        above.)

10. — Abnormalities of Placenta and Cord

Manual removal ...................................         Other ...................................................
Prolapse and presentation ....................        

11. — Neo‑Natal Complications

Intracranial and spinal injury at birth ....         Other birth injury ................................
        Post‑natal asphyxia and atelectasis .....

12. — Other Disease Peculiar to Early Pregnancy

Erythroblastosis ...................................         Other ...................................................
Haemorrhagic disease of new born .....

13. — Principal Pre‑Medication

Morphine .............................................         Pethidine .............................................

14. — Principal Anaesthetics

Chloroform ..........................................         Cyclopropane ......................................
Ether ....................................................         Ethylene ..............................................
Trilene .................................................         Intravenous agents — 
Ethyl chloride ......................................                 Pentothal, Evipan ...........................
Nitrous oxide .......................................                 Relaxing Agents ............................

Other Remarks

.....................................................................................................................................

Date ..............................................

................................................................
Signature of Medical Practitioner.

[Appendix amended in Gazette 30 Jun 2003 p. 2620.]