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    Republic of The Philippines City Government of Tacloban Tacloban City - o

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    Lita Mea
    The document summarizes a neonatal death investigation report. It provides maternal information about the 37-year-old mother, including her medical and obstetric history. It describes the labor and birth at a private birthing clinic and subsequent transfer to the hospital where the baby was delivered but did not cry and died the next day from hypoxic ischemic encephalopathy. The analysis finds issues with the birthing clinic's referral practices and recommends ensuring clinics follow rules and providing practitioner education.

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    Republic of The Philippines City Government of Tacloban Tacloban City - o

    Uploaded by

    Lita Mea
    31 views4 pages
    The document summarizes a neonatal death investigation report. It provides maternal information about the 37-year-old mother, including her medical and obstetric history. It describes the labor and birth at a private birthing clinic and subsequent transfer to the hospital where the baby was delivered but did not cry and died the next day from hypoxic ischemic encephalopathy. The analysis finds issues with the birthing clinic's referral practices and recommends ensuring clinics follow rules and providing practitioner education.

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    The document summarizes a neonatal death investigation report. It provides maternal information about the 37-year-old mother, including her medical and obstetric history. It describes the labor and birth at a private birthing clinic and subsequent transfer to the hospital where the baby was delivered but did not cry and died the next day from hypoxic ischemic encephalopathy. The analysis finds issues with the birthing clinic's referral practices and recommends ensuring clinics follow rules and providing practitioner education.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    31 views4 pages

    Republic of The Philippines City Government of Tacloban Tacloban City - o

    Uploaded by

    Lita Mea
    The document summarizes a neonatal death investigation report. It provides maternal information about the 37-year-old mother, including her medical and obstetric history. It describes the labor and birth at a private birthing clinic and subsequent transfer to the hospital where the baby was delivered but did not cry and died the next day from hypoxic ischemic encephalopathy. The analysis finds issues with the birthing clinic's referral practices and recommends ensuring clinics follow rules and providing practitioner education.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 4

    Republic of the Philippines

    City Government of Tacloban


    Tacloban City
    -o-
    CITY HEALTH OFFICE

    Neonatal Death Investigation Report

    INTRODUCTION:

    Hypoxic-ischemic encephalopathy (HIE) is a type of brain damage caused by insufficient


    oxygenated blood flow during or near the time of birth. Terms that are sometimes used as
    synonyms for HIE include birth asphyxia and neonatal encephalopathy.
    There are many potential causes of HIE, including high-risk pregnancy conditions, labor
    and delivery issues, and medical mistakes. Usually, HIE can be prevented through careful fetal
    monitoring and timely intervention in response to complications. However, medical
    professionals may miss opportunities to prevent HIE, or perform negligent actions that cause
    HIE.
    It is estimated to occur in about 1.5 per 1,000 live births, although this estimate may be
    imprecise. It accounts for 23% of neonatal death worldwide, and babies that survive may
    develop cerebral palsy (CP), intellectual and developmental disabilities (I/DDs), epilepsy, and
    many other associated conditions.

    MATERNAL INFORMATION:

    General Information

    Name: MJP
    Age: 37 years old
    Civil Status: Single
    Educational Level: Highschool Level
    Occupation: Housewife
    Insurance Coverage: Philhealth
    Socioeconomic Status: Middle Class

    Medical History:

    History of chronic illness, allergies, asthma & hypertension: with history of asthma and
    gestational hypertension on the 5th and last pregnancy
    History of operations and hospitalizations: None
    Smoker: None smoker and never smoked
    Alcohol Intake: Drinks alcohol occasionally
    Assess Nutritional Status: Obesity due to eating unhealthy food; daily consumption of pork and
    chicken every meal and canned goods.

    Obstetric History:

    OB Score: G6 P6 T6 A0 L5

    Year of Type of Place of Attendant Complications Outcome Alive Remarks


    Delivery Delivery Delivery at Birth of (yes/no) (if baby
    (start Pregnancy died put
    with first age at
    child) death
    and
    cause of
    death)
    08-26-04 NSVD Tagbilara Doctor None Female Yes
    n City
    Hosital
    07-05-05 NSVD Mangagoy Doctor None Male Yes
    Surigao
    Hospital
    06-23-08 NSVD Mangagoy Doctor None Male Yes
    Surigao
    Hospital
    06-03-11 NSVD Tagbilara Doctor None Female Yes
    n City
    Hospital
    09-20-16 NSVD EVRMC Doctor Asthma attack Male Yes
    and
    Gestational
    Hypertension
    03-11- NSVD EVRMC Doctor Asthma attack Female No
    2019 and
    Gestational
    Hypertension,
    Obesity

    Prenatal History:

    # of prenatal visits: 6 Prenatal visits at San. Pio Birthing Clinic Brgy. 105 Purok 5
    Laboratories: CBC, U/A, 3 times UTZ during course of pregnancy
    Medications/vitamins taken during the pregnancy: Prenatal vitamins ( FeSO4+FA)
    # of postpartum visits: no followup checkup
    Labor and Birth History (based on mother’s recollection):

    As per mothers recollection, prior to the day of delivery, she experienced 2 days labor at
    home. In the morning of the following day she decided to go to a private birthing clinic where
    she had her prenatal checkups for admission and delivery because she was experiencing labor
    pains. During assessment of the primary health care on duty her blood pressure was elevated.
    As a first aid to her current situation the healthcare provider gave a medication sublingually to
    lower her blood pressure twice as medical management. However, despite of the intervention
    given her blood pressure was still elevated. Hence, she decided to seek further medical
    management and evaluation on the afternoon of the same day at Eastern Visayas Regional
    Medical Center (EVRMC). When she arrived at the said facility she was admitted at the
    Reproductive Health and Neonatal Care of EVRMC. She delivered a baby girl via NSVD at 6Am
    of March 11,2019.

    Chronology of events: (Bigen with initial complaint and record until death)

    During admission at the Emergency room the resident on duty assessed and advised her
    to be admitted at the hospital because she was having true labor and will delivered her baby
    soon. When she was at the hospital doctor performed an internal examination (IE) many times
    that she cannot remember how often it was just to check the progress of her labor. On the night
    of March 10,2019 at 8pm the doctor performed again an internal examination where the doctor
    told her as verbalized by the mother “kayano mo ako ginihian?” and she relied saying “waray
    man ako umihi doc”. After that, she noticed that her diaper gets soaked immediately even
    though she was not urinating. However, she was afraid to inform the doctor about her concern
    because as she verbalized “nagiinisog an doctor ky damo an mga pasyente”. Because of the
    thinking she might be yelled too by the doctor she kept silent until 6 am of March 11, 2019 she
    called the attention of the doctor and other medical staff that her baby was coming out. On that
    event while she was delivering her baby, a medical staff performed a fundal push to help the
    baby comes out. And when the baby was out, she noticed the baby did not cry. As the
    immediate response of the medical staff, the newborn was brought immediately at the ICU. But
    prior to that she was able to had “Unang Yakap” with her newborn child. The next day, her SO
    was called by a doctor and she thought that the baby will be brought to her for breastfeeding.
    Unfortunately it did not happen, because when the SO returned she announces the death of her
    newly born child.

    Baby and mothers condition


    When the newborn was delivered, she did not cry and was brought at the ICU. On the
    next day, the doctor announces that the newborn child was dead. However, the mother’s
    condition was stable. After 3 days at the hospital, she was discharged without any
    complications.

    Actions Taken (Treatment, medicines)


    The day that the mother was discharge, there were medicines that was given to her that
    was written at her “Tagubilin”.
     Co-Amoxiclav 625mg/tab 3 x a day for 3 days
     Methyldopa 250mg/tab 2 x a day for 2 weeks
     Tramadol 500mg/tab 3 x a day for pain
     Ferrous sulphate once a day for 3 months
    A followup checkup on March 19, 2019 @ 8 AM

    Place of death : Eastern Visayas Regional Medical Center


    Date of death : March 12, 2019
    Cause of death : Hypoxic Ischemic Encephalopathy

    Analysis and Findings

    Proper referral system plays a vital role in every health facility. It ensures that the patient
    will receive the best possible care or treatment she/he can get. Some facility may overlook this
    because of personal interest that they don’t even think the welfare of their patients as long as
    they can get something to them. Like for instance to this patient, that she gave her trust to the
    personnel she knew at the birthing clinic. She had her prenatal check-ups there even if she had
    her prenatal checkups at the barangay health center on her previous pregnancy, thinking that
    her friend will ensure the safety of her unbornchild. But unfortunate things happen.
    As to my recommendation, the city government should ensure that every birthing clinic is
    following rules in properly operating there businesses. And that there should be seminars or
    orientation to private health practitioner on how to manage and refer their patient.

    Prepared by:
    Japhet A. Gonzales - NDP

    Noted by:
    Mel Tirso G. Maravilles

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