The front cover of In Utero depicts a transparent, anatomically correct mannequin with wings on a sepia background. The organs of the mannequin are visible and it is posed with its palms up and is looking down and to the left.
The back cover of In Utero is a photograph of a collage created by Kurt Cobain on his living room floor. The collage consists of flowers and plastic body parts and fetuses. Cobain described the piece as "Sex and woman and In Utero and vaginas and birth and death".
Cobain originally wanted to name the album 'I Hate Myself and I Want to Die' as a joke in an attempt to take the band's work less seriously. He decided on In Utero in reference to a poem written by Courtney Love.
The choice of imagery for In Utero relates to the title in its reference to the female anatomy. The representations are said to abstractly express Cobain's feelings toward the sudden fame of his persona and his music.
The collage on the back cover contains symbols from The Woman's Dictionary of Symbols and Sacred Objects, which are arranged on the edge of the image. These vaguely follow the female anatomy theme of the album's packaging.