SU5MR CR- 1/2020

STILLBIRTH & UNDER 5 MORTALITY CONSOLIDATION REPORT

STATE: KELANTAN DISTRICT: Kota Bharu / Tanah Merah

Name: B/O Norainda Suraya binti Osman Sex : Boy DOB: 09 / 07 / 2022 @ 1540 H
RPZII

Age: Day 1 of life

MyKid: - Race: MALAY

MIC: Others (state):

Date & Time of Death: 09 / 07 / 2022 @ 2110 H Home Address: Kg Bechah Pelting, Kota Bharu,
Kelantan
Place of death: NICU HRPZ II

Antenatal History (list antenatal issues, medical problem, social concern)

Mother, 26 years old, G2 P0+1 at 40 weeks 1 day POA

1. GDM on diet control complicated with LGA

- BSP optimised
- HbA1c : 5%
- EFW : 3.3 kg

2. Maternal overweight
- BMI : 25.4

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

Referred case from HTM for fetal distress with failed instrumentation. OT had 1 case on going ortho
case. Initially, pt induced for GDM on diet control with prostin. Today, favourable BISHOP Score

@ 0730 Hours, ARM done, clear liquor. @ 1145 Hours, Os fully. Baby was born via SVD and uneventful
with good APGAR score.

Subsequently noted fetal bradycardia à proceed with vacuum à failed vacuum X 1 due to kiwi cup
dislodge. Then, proceed with forceps à traction x 1 but no fetal head descend. Procedure abandoned.

CTG at HTM : Fetal bradycardia down to 80 bpm, poor tracing and directly send to HRPZII LR

At HRPZ II, membrane absent clear. CTG at HRPZII : poor variability with baseline FHR 130 bpm.
Referred Paeds Team for standby for fetal distress and failed instrumentation . During delivery, noted
difficult manipulation about 8 mins, difficult to delivery baby’s head in view of head deeply engaged in
OP position and impacted. Paeds Team was called for help. O&G team tried to push method from
below however failed. Bilateral hand outside abdomen, proceed with “Path Wardan technique”.
Noted tight cord round neck X 2.

@ 1540 Hours, baby born, not vigorous. Initial steps done and assessment done; No breathing effort,
HR more than 80 bpm, PPV given X 2. Still no breathing effort, 1 episode of gasping, no muscle tone,
HR > 100 bpm. Initial visualisation noted copious secretion – clear liquor. Suction done. Intubated with
ETT size 3.5, anchored at 9 cm. Confirmed with vapour present, symmetrical chest rise, equal air
entry. Manual bagging done. Saturation ranging around 80 – 88%, by auscultation > 100 bpm.
Connect to Neopuff 18/6, then optimised to 22/6. Noted poor perfusion CRT 4 secs, pallor, pulse not
palpable

1st bolus 10 cc/kg (40 cc) & update specialist oncall. 2nd bolus 10 cc/kg (40 cc) fast. Able to maintained
HR 100 – 110 bpm. Breath sound equal and, good chest rise.

Just before transfer, at around 30 mins of life, noted HR manually 55 bpm, SpO2 90% under Neopuff
22/6. CPR commenced immediately with manual bagging. Called extra help immediately. CPR
commenced for 5 mins with IV Adrenaline X 1. Reverted with HR 80 bpm. Upon arrival of NICU oncall,
CPR just stopped. Assessment, baby pale, perfusion 2 secs, HR 90bpm, spoO difficult to detect, good
chest rise, good air entry. Suction ETT : pulmonary haemorrhage. Inserted UVC in OT and blood send.
Call for packed cell transfusion (safe o), FFP stat in OT.

Prior to transferred, spO2 range 60-80% and HR 110 bpm with neopuff. Baby transfered to NICU with
neopuff Pr 22/6.

•cord VBG: ph 7.167/ pco2 53.5/ hco3 15.5/ lac 5.9/ BE -9.2

•cord ABG: ph 7.156/ pco2 54.4/ hco3 15.3/ lact 6.0/ BE -9.6

•first VBG taken from UVC : acidotic

•Patient tranferred from OTZ to NICU and transferred via portable incubator and neopuff bagging
22/6 flow 10L/min. During transportation: SPO2 fluctuating 60-80%, HR 80-100bpm. Prior to
transportation: SPO2 around 80%, HR 120bpm.

•Once arriveed in NICU, connected to ventilator setting 22/6 rate 50, fio2 0.98%. Unable to detect HR
and SPO2 around 50-60%. CPR was commenced immediately; given IV adrenaline x3, IV NaHCO3
10:10 x1; transfused packed cell 15ml/kg (safe O); FFP 35cc, cryoprecipitate 50cc. Patient ROSC after
15 minutes, HR 118, SPO2 84%, Temperature 35', BP 72/42 (48)

•In view of desaturation, needling done negative bilaterally; no pneumothorax, presence of

pulmonary hemorrhage. Change ventilation strategy with HFOV mean 18, freq 9, ampl 50, fio2 0.98.
Highest SPO2 65-70%, hr 118. Hemodynamically supported on

1. IV Adrenaline up to 2mcg/kg/min
2. IV Noradrenaline up to 0.5mcg/kg/min

•Develop multiple episode of desaturation, At 6.12pm, HR dropped again down to 60 bpm and CPR
commenced immediately 10 mins with total IV Adrenaline given x3. Pt had persistent pulmonary
hemorrhage. Another IV Cryoprecipitate 15ml/kg given x1. ROSC after 10 minutes around 6.22pm, HR
ranging 80-90bpm, SPO2 60-70% despite high settings HFOV.

•At 8pm, HR dropped again < 60 bpm. CPR commenced immediately and IV Adrenaline given x3.
Transfused packed cells SAFE O 15ml/kg given STAT. Was started on 3rd inotrope : IV Dobutamine
10mcg/kg/min.

•Noted bleeding from umbilical stump and ETT profusely then was requested for another cycle of DIVC
regime and informed to father.
Neonatal History (comorbidity, postnatal visits, hospital admission, feeding issue, social concern)

Nil

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

Nil

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

After 4th cycle of CPR, father was given time and hold the baby accompanied by sister. Picture of baby
holding by father taken. Father understood and agreed that picture was taken are only for personal
memory and not distributed to others.

Father agreed that he will only shows to his wife and not distributed to others. Once father put baby
back to warmer, noted HR and SPO2 not detected. Upon assestment, no HR and SPO2 detected.
Pronounced death : 9/7/2022 at 2110H.

Cause of death : Severe hypoxic ischaemic encephalopathy with severe pulmonary haemorrhage.

Cause of death

1a: Severe hypoxic ischaemic encephalopathy •with severe pulmonary haemorrhage

Death category: Please tick ( / ) one column either A/B/C and choose (a) or (b) or both as
appropriate:

• Preventable • Not preventable • Undetermined

• Medically treatable • Palliative case • Post-mortem done
• Public health issue • Non palliative case / • Pending special Ix
Shortfalls: (as determined during district U5M meeting)

Remedial Actions: (as determined during district U5M meeting)

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

Dr Muhammad Aiman bin Shuib

Medical Officer

Neutral Assessor: (Name, designation)

Comment:

Recommendation.