mortality review

1. PERINATAL MORTALITY REVIEW
OF MAGH 2079
PRESENTED BY: DR. PRAKASH MAN SHAH
MODERATORS: DR. SHYAM PRASAD KAFLE
DR. LOKRAJ SAH
DR. DEEPAK MISHRA
DR. ARABINDRA YADAV

2. CENSUS
NICU NURSERY NEONATAL
WARD
Total patient 28 55 58
Transfer out 19 30 11
Discharge 1 15 32
DOPR 0 1 5
LAMA 3 1 4
Refer 0 0 0
Absconded 0 0 0
Remaining 4 8 6
Mortality 1 0 0

3. NICU NURSERY NEONATAL
MALE
FEMALE
14 (50%)
14 (50%)
36 (65%)
19 (35%)
39 (67%)
19 (33%)
TERM
PRETERM
16 (57%)
12 (43%)
37 (67%)
18 (33%)
52 (90%)
6 (10%)
NORMAL
WEIGHT
LBW
VLBW
ELBW
16 (57%)
8 (29%)
4 (14%)
0
31 (56%)
21 (38%)
3 (6%)
0
47 (81%)
10 (17%)
1 (2%)
0
TOTAL 28 65 58

4. TRANSFER IN
NICU NURSERY
NURSERY 5 NICU 24
PEDIA ER 12 PEDIA ER 9
GYNAE EMG OT 4 GYNAE EMG OT 8
LABOUR ROOM 3 LABOUR ROOM 7
ANW 1 POSTNATAL WARD 2
POST NATAL
WARD
NNW
1
2
NEONATAL WARD 3
MCH 2
TOTAL 28 55

5. PERINATAL MORTALITY : 1

6. BABY OF SUJATA LAMA
BIRTH HISTORY ID:79163561
• Time of Delivery- 01:26 PM
• Date of delivery- 2079/10/18
• Birth weight- 1420 grams
• POG = 28+4 weeks
• Mode of delivery- SVD
• APGAR at birth was 7,8,9 at 1,5 and 10 min of life.

7. MATERNAL HISTORY
• 25 years, Primi, gestational age 28+4 weeks.
• Blood Group : A Positive
• Serology( HIV, HBsAg, VDRL) : Non-reactive
• Unbooked/immunized
• No significant h/o in mother
• LSCS done for LSOL with Preterm labour

8. • Baby was admitted to NICU on 2079/10/18
• Issue of
– Prematurity (28+4 )
– VLBW ( 1420 grams)
– Respiratory distress, developed after few minutes
of birth (SAS score 2-3/10)

9. • On examination: baby was active
• HR : 154 bpm
• SPo2: 93% under BCPAP
• CP/PP: ++/+
• CRT : < 3 sec
• S/E: Chest: B/L Equal air entry
• CVS: S1S2M0
• P/A: soft , non distended
• CNS: Tone, activity, cry : Normal

10. • Inj Caffeine was started
• Base line investigations were sent.
• Antibiotics was started in view of sepsis.
• At 24 HOL , Baby developed 2 episodes of
apnea
• Baby then developed shock for which
Dopamine was started and titrated
• Later Adrenaline and Dobutamine was added
for correction of shock

11. • Baby again developed apnea at 27 HOL for
which baby was intubated for nonresponsive
on tactile stimulation and bag and mask
ventilation.
• At 29 HOL Baby developed bradycardia for
which baby received 1 cycle of CPR with 1
dose of adrenaline.
• At 31 HOL, baby again went into sudden
desaturation with bradycardia.

12. • Baby received resuscitation for 40 mins with 5
cycles of CPR and 4 doses of adrenaline
• Baby had no signs of life , so declared dead at
11:20 PM on 2079/10/19

13. PRINCIPAL CAUSE OF DEATH
EXTREME PREMATURITY
SECONDARY CONDITIONS:
• APNEA OF PREMATURITY
• SEPTIC SHOCK

14. COMMON PROBLEMS
1) HIGH ADMISSION RATE OF NEONATE BORN
THROUGH VACCUM ASSISTED VAGINAL
DELIVERY
2) SWAB STICK UNAVAIBILITY FOR HIGH
VAGINAL SWAB

15. THANK YOU