SU5MR CR- 1/2020

STILLBIRTH & UNDER 5 MORTALITY CONSOLIDATION REPORT

STATE: Kedah DISTRICT: Kulim

Name: b/o Moe Sandar Sex: Male DOB: 26.08.2020

Female Age:
MyKid:- Race: Myanmar
Others (state):
MIC: MD694391

Date & Time of Death: Home Address: no.145, Lorong Paya Serdang 1,
26.08.2020 at 0650 Taman Paya Serdang ,09600 Lunas Kedah
Antenatal History (list antenatal issues, medical problem, social concern)

1) Primigravida
2) Wrong date- Date verified at 12/52 3/7 POG

Mrs. SS , a 30-year-old G1P0 had her antenatal booking at Klinik Desa at 9/52 POG. Her general
condition was well. Vital signs were stable. Subsequently Routine Medical Examination (RME) 1 was
done at Klinik Kesihatan at 10/52 + 1/7 POG. Otherwise, vital signs were stable. Transabdominal Scan(
TAS ) was done during RME 1 and noted discrepancy in EDD to rule out wrong date. Her menses was
regular and she was sure of her date. EDD based on LMP: 17/5/2020 and EDD based on scan was
8/5/2020 (using CRL for first trimester) with discrepancy of 9 days .Repeat scan for confirmation was
scheduled and patient to bring first scan done at private. At 12/52 +3/7 POG patient came for scan for
REDD and noted 1st scan at private GP (7/10/19) : CRL 21.3 mm at 9/52 + 1/7 POG REDD: 10/5/2020
and 2nd scan at KK Lunas ( 14/10/19) : CRL 3.53mm at 10/52 +3/7 POG REDD: 8/5/2020. Plan to follow
first REDD 10/5/2020 .

Patient attended all her follow-ups and subsequent scan parameters correspond to date and
were unremarkable. Fetal kick chart was started at 28/52 and she had done daily charting. Her blood
investigations were all normal.She also visited O& G clinic at private follow up for her antenatal care.
She was allowed for post date +7/7 in view her antenatal was uneventful.

Perinatal History (place of delivery, perinatal events, gestation, mode of delivery, BW, resuscitation, Apgar score,
NICU/SCN admission)

7/05/2020

at 10.20p.m : Patient presented to labour room Pantai Hospital at 39/52 + 4/7 with the complaint of contraction
pain and show since 8.30pm. Otherwise no leaking liquor and fetal movement was good.FKC noted
fetus completed 10 kicks as per usual time around 8.30pm
10.46p.m : CTG done showed suspicious CTG
VE done and Os 2cm, cervix fully effaced and membrane intact.
10.50p.m : O&G Consultant was informed regarding the case .
11.00p.m : Repeated CTG was done showed Type 2 Deceleration and patient was planned for immediate
emergency caesarean section.
11.15p.m : Anaesthetist team and Paediatric team was called and informed.
11.25p.m : Patient and patient’s husband was explained regarding the situation and the plan for caesarean
section. They understood and agreed with the operation.
11.58p.m : Patient sent to OT - CTG was repeated prior sending patient to OT was reactive with baseline
tachycardia.

8/5/2020

12.20mn : Baby girl with birth weight 3.09 kg delivered via emergency lower segment caesarean with thick
meconium stained liquor(TMSL), attended by Staff Nurse and Anaesthetist. Oral suction showed
TMSL.
Baby APGAR score was 5 at 1 min and 3 at 5 min.
12.30mn : Baby deteriorating and Code Blue activated. Resuscitation and CPR done by Anaesthetist and Obstetric
team.
12.45mn : Baby attended by paediatrician on call. Resuscitation continued for 35 minutes.
1.20am : Baby showed no sign of living and pronounced dead.

Neonatal History (comorbidity, postnatal visits, hospital admission, feeding issue, social concern)
N/A

Childhood History (main carer, immunization, comorbidity, hospital admission, growth, development, social
concern)
N/A

Events leading to death (timeline terminal events, investigation (laboratory/radiological, post mortem)

1. Severe Birth Asyphxia Secondary to Severe Meconium Aspiration Syndrome.

Investigations:

Cord Blood Gas:

8/5/2020
pH : 6.55
pCO2: 80.6mmHg
pO2: 22mmHg
Bicarbonate: 7mmol/L
Base Excess: -30mmol/L
O2 Saturation : 8%

CXR on 8/5/2020 at 2.41am :

Both lung field are opaque without any aerated lung parenchyma. There is a central tubular lucency noted in
keeping with air within the trachea. Pulmonary vascular pattern and heart size not visualized. The visualize bone
appears normal.

Cause of death
1a:Severe Birth Aspyhxia
1b:Severe Meconium Aspiration Syndrome
1c:
1d:
2:
ICD10 classification:P21.0

Death category: Please tick ( / ) one column either A/B/C and choose (a) or (b) or both as appropriate:
A. Preventable B. Not preventable C. Undetermined
a) Medically treatable a) Palliative case a) Post-mortem done
b) Public health issue b) Non palliative case b) Pending special Ix

Shortfalls: (as determined during district U5M meeting)

Resuscitation by Paediatric team only being conducted 25 minutes after baby being born

Remedial Actions: (as determined during district U5M meeting)

Paediatric team to standby early for fetal distress cases.

Medical Officer: (Name, designation) Verified By: (Name, designation)

Neutral Assessor: (Name, designation)

Comment:
Recommendation.