Maternal Death Investigation Procedures

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Maternal Death Investigation Procedures: 

Maternal Death Investigation Procedures

Definition: 

Definition The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental cause

Maternal Mortality Ratio (MMR): 

Maternal Mortality Ratio (MMR) Maternal Mortality Ratio represents the obstetric risk associated with each pregnancy. It is calculated as the number of maternal deaths during a given year per 100,000 live births during the same period

Maternal Mortality Ratio (MMR): 

Maternal Mortality Ratio (MMR) Number of maternal deaths during the year x 100,000 Total live births

Reporting : 

Reporting Telegram should be sent to the DPH and the Mission Director within 24 hours of the event Resident as well as visitor deaths to be informed Visitor deaths to be informed to the concerned DDHS also

Line listing: 

Line listing Death of all women during pregnancy irrespective of the cause, to be line listed After investigation if the cause of death is not due to maternal cause the name should be deleted. Example: Suicide, accident, murder Visitor deaths to be informed to the concerned DDHS

Investigation: 

Investigation All maternal deaths including visitors occurring within the district should be investigated by using verbal autopsy format Resident maternal deaths occurring outside the district should also be investigated

Investigation: 

Investigation Verbal autopsy reports for the visitor deaths to be sent to the concerned DDHS

Case Study : 

Case Study Based on the verbal autopsy findings case study has to be developed for every case It will be useful for brief presentation during the District Maternal Death Audit Meeting, sharing the experience in the PHC / GH MO meetings and staff meetings

Maternal Death Audit: 

Maternal Death Audit All maternal deaths occurring within the district to be investigated Resident Maternal Deaths occurring outside the district should also be audited

Conduct of Maternal Death Meeting: 

Conduct of Maternal Death Meeting District Maternal Death audit meeting to be conducted by the District Collector every month All deaths occurred during the previous month to be included for the audit

Stake holders: 

Stake holders Concerned Service Providers at all levels – HSC or Health Post, GH, Private All District Committee members Relatives and friends of the diseased

Minutes of the meeting: 

Minutes of the meeting DMCHO should maintain attendance and minutes of the meeting Every month minutes should be sent regularly within one week of conduct of delivery

Follow up action: 

Follow up action Maternal Death Audit findings will help to identify the problems in the system and the community Try to develop solutions to the problems identified and convert them to action points

Follow up action: 

Follow up action Deaths caused by quack doctors / nurses should be complained to police for criminal action

Case Illustrations - 1: 

Case Illustrations - 1 Severely anaemic 11 th gravida mother was admitted a week back in a GH by the PHC team. The mother delivered in the GH and developed PPH as expected. On the way to CEmONC centre which is 40 km away from the GH the woman died due to shock Incident

Case Illustrations - 1: 

Case Illustrations - 1 Severely anaemic women should be admitted a week before EDD in CEmONC centre for delivery Adequate quantity of the woman’s blood group should be available Packed cell transfusion may be given before delivery Lesson and action

Case Illustrations - 2: 

Case Illustrations - 2 A private nursing home doctor came to a CEmONC centre by travelling about an hour and collected two units of blood for emergency transfusion for a PPH case. By the time he returned to his hospital he found the mother dead Incident

Case Illustrations - 2: 

Case Illustrations - 2 Instead of wasting time for mobilizing blood, quickly transport to the CEmONC center and give blood transfusion Before mobilizing inform the CEmONC centre and give first aid by following the active management of third stage of labour protocols Lesson and action

Case Illustrations - 3: 

Case Illustrations - 3 A mother put on DIL absconded from the hospital fearing the difficulties involved in the transport of dead body. On receiving the message from the CEmONC centre the PHC team traced the mother and brought her back to the Hospital and she survived Incident

Case Illustrations - 3: 

Case Illustrations - 3 Always maintain good communication with the CEmONC centre Tracking – a technique to save mothers Lesson and action

Case Illustrations - 4: 

Case Illustrations - 4 A PN mother who came to a CEmONC centre was treated with Cotrimoxazole She developed Puerperal Sepsis and died Incident

Case Illustrations - 4: 

Case Illustrations - 4 All PN mother who has fever should be treated as Puerperal sepsis unless proved otherwise Admit and give parenteral antibiotics If unwilling for admission treat at home by giving the medicines through the VHN Give Cap. Ampicillin and Tab.Metronidazole for 7days for all home deliveries Lesson and action

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