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Perinatal Mortality Example
Perinatal Mortality Example
REVIEW
IDENTIFICATION DATA
NAME
:
AGE
: 19 YEAR
OCC
: HOUSEWIFE
ADDRESS:
ANC
:
D.O.B
: 27/04/2015 @ 0000 hours
D.O.D
: 27/04/2015 @ 1045 hours
Birth Weight : 1.50 kg
Cause of Death : Undetermined
Place of Death : HOME
G 2 P1
LNMP
: USOD
BOOKING
: 4/2/2015 (18W POG)
REDD
: 04/07/2015
TOTAL CLINIC VISITS : 5X
TOTAL HOME VISITS : 4X
Antenatal history
h/o perinatal death previous baby
Anemia in pregnancy latest HB 8.0 on T. Iberet
1/1 OD
Low maternal weight and height
ANTENATAL HISTORY
Booking done on 4/2/15 ( 18 w pog )
RME 1 done on 25/2/15 redd given ( 22w pog )
H/o admission to hdkl for severe lower abdominal
pain treated as vaginitis and discharged after 2
days. (3/4/2015-5/4/2015)
Noted VDRL +ve during routine blood
investigation treated with IM Benzathine
Penicillin 2 doses, pending 3rd dosage.
Road to death
26th April (30w POG)
9.00 pm mother had alleged fall around 9 pm while trying to
run away from a snake. Post trauma mother had contraction pain
and leaking liquor
27th April (30w + 1 day POG)
12.00 am she delivered baby boy. Conducted by bidan
kampung and cord cut with buloh. Child crying after delivery.
Due to line problem, they unable to contact health team.
1.00 9.00 am child unable to breastfeed, very poor sucking,
lethargy looking, not active.
9.00 am child not moving and breathing
9.50 am JM received call from Tok Batin and informed clinic.
10.45 am Doctor, SN, JM and driver arrived. Noted baby not
breathing, no pulse detected. Pronounced death at 10.45 am
Deceased examination
Baby boy
Weight 1.5kg
Length 41cm
COH 23cm
Chest Circumference 23cm
No spontaneous chest rise, no pulse, pupils fixed
dilated
Thank you