Making Every Baby Count

3.6 Fetal heart sounds on admission no yes unknown
3.7 Partograph used no yes unknown
3.8 Mode of delivery CVD assisted vaginal caesarean other, specify unknown
3.9 Time between decision for action and birth n/a < 30 mins 30–60 min > 60 mins unknown
3.10 Apgar score 1 min = 4 or more 3 or less unknown
5 min = 4 or more 3 or less unknown
3.11 Resuscitation not needed bag + mask not done other, specify unknown
3.12 Sex of baby male female unknown
3.13 Birth weight g ≥ 2500 g 1500–2499 g 1000–1499 g < 1000 g unknown
Section 4: Details of the death
4.1 Date of death DD MM YYYY
4.1.1 Time of death : h
4.2 Type of death (circle one)
4.3 Main maternal condition none identified
LBW VLBW ELBW
neonatal
death
intrapartum
stillbirth
antepartum
stillbirth
_______________________________________________
Main maternal condition followed by the corresponding number.
Use the reference page below to write in corresponding number.
Include more than one if applicable
4.4 Cause of death (circle one) M1 M2 M3 M4 M5 other unknown
a. congenital
b. antepartum complications
c. intrapartum complications
d. complications of prematurity
e. infection Tetanus Sepsis Pneumonia Meningitis
f. other, specify
g. unknown/unspecified
Syphilis Diarrhoea Other, specify if known:
Section 5: Critical delays and modifiable factors
5.1 Critical delays delay 1. not identified 1. delay recognizing need for care:
delay 2. not identified 2. delay seeking care:
delay 3. not identified 3. delay receiving care:
5.2 Modifiable factors
Family-related none identified specify:
e.g. late/no antenatal care; cultural inhibition to
seeking care; no knowledge of danger signs; financial
constraints; partner restricts care-seeking; use of
traditional/ herbal medicine; smoking / drug / alcohol
abuse; attempted termination; etc.
Administration-related none identified specify:
e.g. neonatal facilities; theatre facilities; resuscitation
equipment; blood products; lack of training; insufficient
staff numbers; anaesthetic delay; no antenatal
documentation; etc.
Provider-related none identified specify:
e.g. partogram not used; action not taken; inappropriate
action taken; iatrogenic delivery; delay in referral;
inadequate monitoring; delay in calling for assistance;
inappropriate discharge; etc
other none identified specify:
stillbirth,
unknown timing
unknown
Actions to address the critical delays and modifiable factors
Form completed by: ______________________________________________
Date: ____________________________________
c/s: caesarean section; CVD: cephalic vaginal delivery; ELBW: extremely low birth weight; EmOC: emergency obstetric care; HAART: highly active
antiretroviral therapy; HIV: human immunodeficiency virus; IPT: intermittent preventive treatment; LBW: low birth weight; LMP: last menstrual period;
NVP: nevirapine prophylaxis; TT: tetanus toxoid; VLBW: very low birth weight
Reference page: Maternal conditions
72 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
ICD-PM maternal condition group
Main maternal conditions included in group
M1: Maternal complications of pregnancy 1. incompetent cervix