Mortality Audit-Understanding Auditing .pptx

how to present mortality audit

1. MATERNAL MORTALITY AUDIT DR. DOUGLAS ADJEI ANNAN MBChB, Ghana

2. OUTLINE DEMOGRAPHICS OBSTETRIC HISTORY ISSUES SURROUNDING DEATH COMMENTS ON INTERVENTIONS LESSONS LEARNT AND FOLLOW-UP ACTIONS RECOMMENDATIONS 12/5/2023 2

3. demographics Age: 31 years At 39 + 5 Seamstress P2AA 12/5/2023 3 O bstetric history P1: Term SVD Female, Uneventful P2: Term SVD Male, Uneventful

4. Index pregnancy Booking was at 12 weeks Had 3 anc visits, last visit was in October 10,2023 . Booking labs – A + ve , HBsAg – ve , Sickling neg , retro 1 st screening – 280. V drl and retro second screen not done. Last hb 26/9/2023 – 11.1 g/dl Took one obs scan during the ANC period. 12/5/2023 4

5. HISTORY Patient presented with waist pains, lower abdominal pains and loss of liquor (3 days duration) on 30/11/2023 at 4;15 am. ON EXAMINATION Looked well, not pale, no jaundiced, afebrile, well hydrated. 12/5/2023 5

6. Examination Vitals BP . 146/76 P. 53 BPM T. 36.7 RR. 16 CPM. 12/5/2023 6

7. Examination ABD;CONTARCTING, GRAVID, SFH - 38 CM, FHR - 134 BPM V/E; OS WAS 4 CM DILATED, RUPTURED MEMBRANES WITH MECONEUM STAINED LIQUOR GRADE 3 . AN IMPRESSION OF ACTIVE PHASE OF LABOUR WITH MECONEUM STAINED LIQUOR GRADE 3 WAS MADE. 12/5/2023 7

8. DURING LABOUR 30 MINUTES LATER, THE FHR HAD DROPPED TO 90 TO 100 BPM. MO ON DUTY WAS CALLED AND REVIEWED PATIENT. A DIAGNOSIS OF FETAL DISTRESS AT 4 CM WAS MADE AT 5:40 AM AND WAS PREPARED FOR A CAT 1 EM CS. 12/5/2023 8

9. DURING LABOUR PATIENT WAS PLACED ON THE CTG FEW MINUTES AFTER AND WAS FOUND TO HAVE FHR - 80 TO 110 BPM . INTRAUTERINE RESUSCITATION WAS STARTED WITH IVF 1 L NS AND MADE TO LIE ON THE LEFT LATERAL SIDE, WITH INTRANASAL OXYGEN STARTED . FHR IMPROVED TO 120 TO 130 BPM AFTER RESUSCITATION . 12/5/2023 9

10. DURING LABOUR FEW MINUTES AFTER, At 6:05 AM PATIENT COMPLAINED OF CHEST PAIN AND DIFFICULTY BREATHING . ON IMMEDIATE ASSESSMENT , PATIENT WAS FOUND TO HAVE TONIC CLINIC SEIZURES INVOLVING THE UPPER LIMBS WHICH LASTED FOR 10s AND SELF ABORTED.  SHE WAS ALSO NOTED TO HAVE GRUNTING SOUNDS. 12/5/2023 10

11. IN LABOUR WARD ON ASSESSMENT, AIRWAY WAS PATENT BUT HAD SOME SECRETIONS IN THE MOUTH WHICH WAS SUCTIONED BP . 77/43 MMHG P. 40 BPM RR. 24 CPM SPO2. 88% IRA. PROTEINS 2+ 12/5/2023 11

12. IN LABOUR WARD RESUSCITATION STARTED IMMEDIATELY AIRWAY WAS PROTECTED WITH AN OROPHARYNGEAL TUBE AND WAS PUT ON OXYGEN VIA NON REBREATHER FACE MASK AT 10 L/MIN LOADING DOSE OF MGSO4 GIVEN. IVF 1 L R/L WAS MADE TO RUN FAST. START DOSE OF IV ATROPINE 0.5 MG WAS GIVEN O/A LOW PULSE. 12/5/2023 12

13. IN LABOUR WARD RESUSCIATION CONTINUED ANAESTHETIST CAME AROUND AND INFORMED AND STARTED PREPPING FOR INTUBATION AND IMMEDIATE DELIVERY. SPECIALIST WAS CALLED AND INFORMED ABOUT THE CASE PATIENT WAS ABOUT TO BE SENT TO THEATRE WHEN PERIPHERAL PULSES BECAME UNRECORBABLE, HEART SOUNDS NOT HEARD AT 6;10 AM. CHEST COMPRESSIONS WAS STARTED IN THE LABOUR WARD AND SUSTAINED TO THEATRE FOR INTUBATION. 12/5/2023 13

14. IN THEATRE PATIENT WAS IMMEDIATED INTUBATED AND VENTILATED WHILES CHEST COMPRESSIONS CON TINUED. IV ADRENALINE WAS GIVEN IN 3 REPEATED DOSES. IV DOBUTAMINE WAS ALSO GIVEN WHILE CHEST COMPRESSIONS CONTINUED. CPR CONTINUED FOR CLOSE TO 45 MINS . PERIMORTEM CAESAREAN SECTION WAS DONE WHILES CHEST COMPRESSIONS AND VENTILATION CONTINUED. 12/5/2023 14

15. PERIMORTEM CS FINDINGS  FSB, AGARS 0/0, CEPHALIC, PLACENTA WAS POSTERIOR HIGH, NO RETROPLACENTAL CLOTS, NTO, UTERUS LOOKED GROSSLY LOOKED NORMAL. EBL -500 MLS OF DARK BLOOD . 12/5/2023 15

16. IN THEATRE CPR CONTINUED FOR 45 MINS + PATIENT DID NOT RESUME SPONTANEOUS CARDIOPULMONARY ACTIVITY. CENTRAL AND PERIPHERAL PULSES ABSENT, NO CARDIAC ACTIVITY ON AUSCULTATION. PUPILS WERE FIXED AND DILATED . WAS DECLARED CLINICALLY DEAD BY SPECIALIST AT 6:57 AM. CAUSE OF DEATH: SUSPECTED PULMONAY EMBOLISM. 12/5/2023 16

17. LABS FBC DONE (30/11/2023) HB 12.1 PLT 201 WBC 6.31 NEU 3.31 12/5/2023 17

18. POST MORTEM AUTOPSY HAS BEEN CONDUCTED, YET TO RECEIVE THE FINDINGS. 12/5/2023 18

19. Comments on interventions 12/5/2023 19

20. Lessons Learnt and Follow up actions 12/5/2023 20

21. 12/5/2023 21 Recommendations