ANNEXURE-I Women Death First Information ... - Nrhmharyana.org

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ANNEXURE IIIName of the BlockPHC/District:MDR FORM TO BE FILLED BY THE MO INCHARGE OF PHC/CHC/SDH/DH(To be filled after the report of the CBMDR)(To be submitted along with the report of CBMDR to the Civil Surgeon)To be filled by the block medical officer for each maternal death in the block after investigationParticulars of the deceased Name: Age:Name of the husbandGravida/ParaVisitor/Resident/AddressTiming of Death Pregnancy During MTP Delivery Within 42 daysafter delivery orMTPReligion/Caste/CommunityPlace & Date of deathDate of investigation bycommunitybasedcommittee

1.Delay in Seeking CareNot aware of danger signsProblem not identified/ identified and neglectedDelay in decision makingNo birth prepararednessBeliefs and customsAny other/specifyFill in appropriate cause of Delay 12.Delay in reaching first level health facilityDelay in getting transportDelay in mobilizing fundsNot reaching appropriate facility in timeDifficult terrainAny other/specifyFill in appropriate cause of Delay 2

ADMISSION AT INSTITUTION WHERE DEATH OCCURREDType of facility where died:PHC24x7PHCSDH/RURALHOSPITAL/CHCDISTRICTHOSPITALMEDICALCOLLEGE/TERTIARYHOSPITALPRIVATEHOSPITALPVTCLINICOTHERDiagnosis at admission:AbortionEctopicpregnancyNot in labour In labour PostpartumDiagnosis when died:AbortionEctopicpregnancyNot in labour In labour PostpartumDuration from onset of complication to admission: □□ Hrs □□ minsCondition on Admission: □Stable □ Unconscious □ Serious □Brought deadReferral from another centre? □ Yes □ No□Don’t knowIf yes, how many centres? □□ Specify type4. Antenatal CareDid she receive ANC? Yes□ No □ Don’t know □

If no, reason: Lack of awareness □ Lack of accessibility □ Lack of funds□Lack of attendee□ family problems □If Yes, Type of Care Provider (mark all):College/Tertiary Hosp□S/C ANM □ M/O PHC□ M/O CHC □ Specialist SDH □ Specialist D/H □ SpecialistPrivate Hosp □ (Please Specify Type of Doctor/Nurse)If yes, was she told she has risk factors? Yes□ No □ Don’t know □Type ofComplicationPrevious C/SectionAbnormalPresentation/lieAnaemiaGlycosuriaHypertension withProteinuriaHypertensionTwins etcAPHEctopic/pain inabdomenOther ( Pleasespecify)Yes No Don’t know Other

Comments on antenatal care - List any medication5. DELIVERY, PUERPERIUM AND NEONATAL INFORMATIONDid she have labor pains? Yes□ No □ Don’t know □If Yes, was a partograph used? Yes□ No □ Don’t know □In which phase of labor did she die?LatentphaseActivephaseSecondstageThirdstage> 24 hrsafterbirthDuration of labour: □□hrs □□mins

DeliveryUndelivered Vaginal Vaginal(assisted) Caesarean(unassisted) Vacuum/forceps sectionComments on labour ,delivery and puerperiumDetails of Baby:Baby Birth weight(g)5 min ApgarscoreOutcome StillbornNeonataldeathAliveAlive at 7 daysNeeded resuscitation Y/ NIf yes, who gave ENBC? If died, probable causeComments on baby outcomes( in box below)

Other Contributory (or antecedent) cause/s: Specify9. CASE SUMMARY (please supply a short summary of the events surrounding the death)Form filled by:NameDesignationInstitution and location / Block / DistrictDate:Signature and Stamp

Annexure IVMaternal Death Review Register(To be compiled for every maternal death by officer in-charge of the facility)Name of District:______________________________________Name of PHC/CHC/SDH:/Other___________________________

Sr.NoName ofdeceasedAgeDateofdeathAddressHusband’s nameCause of death(tick √)MaternalNon-MaternalPrimaryinformationprovidedbyDate of fieldinvestigationIf died due tomaternal causes,pl. specifyreasonsAction takenSignature & Date of MO I/C of the PHC/CHC/SDH/Other:Note: Maternal death is defined as the death of a woman who dies from any cause related to or aggravated by pregnancy or its management(excluding accidental or incidental causes) during pregnancy or child birth or within 42 days of termination of pregnancy, irrespective ofduration and site of pregnancy.

Annexure VMaternal Death Review Form{To be filled by the District Level Committee after receiving the report of CBMDR (Annexure-II) and of MO Incharge(Annexure-III)Name of the Deceased:Husband’s Name:Age:Address:Block & District from where death reportedDate of Death:Place of Death:Whether first information report received within 24hours of deathWhether CBMDR conducted (Yes/No):If yes, date of reportWhether CBMDR report received by the districtcommittee (Yes/No)?Whether MO’s report (Annexure-III) received(Yes/No) ?Date of receipt of report

Whether any necessity felt by the committee to seekthe testimony of the family members of the deceased(Yes/No)?If yes, whether testimony sought?If yes, the details of the persons interrogated:What additional information about the death of thewoman emerged during such interrogation?Comment how far the committee is satisfied with the report of CBMDRComment how far the committee is satisfied with the report of the MO InchargeCAUSE OF DEATH :(In the opinion of the committee)Probable direct obstetric (underlying) cause of death: Specify:Indirect Obstetric cause of death: Specify::

Other Contributory (or antecedent) cause/s: SpecifyIN YOUR OPINION WERE ANY OF THESE FACTORS PRESENT?System Example Y N ? SpecifyPersonal/FamilyLogistical ProblemsFacilitiesDelay in woman seeking helpRefusal of treatment or admissionRefusal of admission in facilityLack of transport from home to health carefacilityLack of transport between health carefacilitiesHealth service - Health servicecommunication breakdownLack of facilities, equipment orconsumablesLack of bloodLack of OT availabilityHealth personnelproblemsLack of human resourcesLack of AnesthetistLack of SurgeonsLack of expertise, training or education

Comments on potential avoidable factors, missed opportunities and substandard careCorrective Action suggested with time listingAUTOPSY: Performed/Not PerformedIf performed please report the gross findings and send the detailed report laterCASE SUMMARY (please supply a short summary of the events surrounding the death)

Form filled by:NameDesignationDistrictDate:Signature and Stamp

ANNEXURE-VISr.No.(To be filled by the District MDR Committee and submitted to the State HQ, NRHM)1 2 3 4 5 6 7 8 9 10Name of the Husband’s CompleteDateWhether deceased Relevant cause ofDeceased with Nameaddressofbelonged to JSYdeathage & CasteDeathcategoryPeriod ofdeath (ANC,duringdelivery,post MTP,Post natalperiod)Place of death(Home, SC, PHC,CHC, SDH, DH,Medical College,Pvt. Inst., Anyother)Remark, Corrective actiontaken by MDR Committeewith time listing