maternal near miss review

MATERNAL NEAR MISS REVIEW

December 2014

Operational Guidelines

Ministry of Health & Family Welfare Government of India

Maternal Health Division

lfpo

India aims to achieve the Millennium Development Goal 5 of reducing maternal mortality. During the last two decades, India has witnessed a significant reduction in the quantum of maternal deaths. Furthermore, to reach the goal we need to have a true representation of the causes of maternal deaths, so as to identify gaps and take corrective measures. Traditionally, the analysis of maternal deaths has been the criteria of choice for evaluating medical and systemic causes.

As you are aware, Maternal Death Review system has been institutionalised in India. However, much more needs to be known. The pregnant women who suffer severe complications and come close to maternal death but do not die are the “near-misses” which need to be investigated for finding programme gaps. Due to the success of modern medicine, maternal deaths are fewer in number but there are innumerable “near miss” events which have the potential to teach us lessons.

Near miss cases often precede the loss but are largely ignored because nothing (death) happened. Once we unfold the reasons for the near miss cases, we can take effective measures to avoid these eventualities. I hope that these guidelines will be an empowering tool for the medical colleges, where majority of near miss cases are likely to happen. Knowing the cause of near misses can lead to taking measures for further improvement of health outcomes.

I believe that the MNM Guideline will be useful to the States in identifying the required action needed for improving both maternal and neonatal health.

Lov VermaSecretary (HFW)

FOREWORD

The successful implementation of NRHM since its launch is 2005 is clearly evident by the many fold increase in OPD, IPD and other relevant services being delivered in the Public health institutions, however, the quality of services being delivered still remains an issue. The offered services should not only be judged by its technical quality but also from the perspective of service seekers. An ambient and bright environment where the patients are received with dignity and respect along with prompt care are some of the important

factors of judging quality from the clients’ perspective.

Till now most of the States’ approach toward the quality is based on accreditation of Public Health Facilities by external organizations which at times is hard to sustain over a period of time after that support is withdrawn. Quality can only be sustained, if there is an inbuilt system within the institution along with ownership by the providers working in the facility As Aristotle said “Quality is not as act but a habit”

Quality Assurance (QA) is cyclical process which needs to be continuously monitored against defined standards and measurable elements. Regular assessment of health facilities by their own staff and state and ‘action-planning’ for traversing the observed gaps is the only way in having a viable quality assurance prgramme in Public Health. Therefore, the Ministry of Health and Family welfare (MOHFW) has prepared a comprehensive system of the quality assurance which can be operationalzed through the institutional mechanism and platforms of NRHM.

I deeply appreciate the initiative taken by Maternal Health division and NHSRC of this Ministry in preparing these guidelines after a wide range of consultations. It is hoped that States’ Mission Directors and Programme Officers will take advantage of these guidelines and initiate quick and time bound actions as per the road map placed in the guidelines.

(Anuradha Gupta)

Anuradha Gupta, IASAdditional Secretary & Mission Director, NRHM Telefax : 23062157E-mail : anuradha–[email protected]

Hkkjr ljdkjLokLF; ,oa ifjokj dY;k.k ea=kky;fuekZ.k Hkou] ubZ fnYyh & 110011

Government of IndiaDepartment of Health and Family Welfare

Ministry of Health and Family Welfare Nirman Bhawan, New Delhi - 110011

PREFACE

LOV VERMASecretary

yo oekZ Hkkjr ljdkjLokLF; ,oa ifjokj dY;k.k foHkkxLokLF; ,oa ifjokj dY;k.k ea=ky;


Ministry of Health and Family Welfare

Maternal mortality is a critical indicator to assess the quality of services provided by a health care system. Globally, there has been decline in MMR, and India is leading this global trend. One of the key contributors to our success is the stepped up resources and additional efforts being made under NHM for improving health care.

India aims not only to achieve the Millennium Development Goal 5 of reducing maternal mortality but keep the decline accelerating beyond 2015. To achieve this, we need to have a true representation of the causes of maternal deaths, so as to identify gaps and take corrective actions.

Government of India initiated Maternal Death Review to identify and assess the gap in programme implementation and take corrective action. However, the current MDR format is not equipped to gather information on those pregnant women who delivered through complications and just about averted mortality. Investigating such cases of life threatening obstetric morbidity or maternal near miss helps in taking measures for further improvement of service delivery and programme.

The present guidelines on MNM will be an empowering tool for the medical colleges, where majority of near miss cases are likely to happen. Knowing the cause of near misses can lead to taking measures for further improvement of health outcomes.

I would like to see all Centres of Excellences and Medical Colleges initiating this important intervention on priority which can be subsequently scaled up in phases.

(C. K. Mishra)

FOREWORD






(Anuradha Gupta)




Ministry of Health and Family Welfare Nirman Bhawan, New Delhi - 110011C. K. Mishra, IAS

Additional Secretary & Mission Director, NHMTelefax : 23061066, 23063809E-mail : [email protected]

FOREWORD

Dated : 17th November, 2014

Maternal mortality is a critical event to assess the quality of a health care system. The standard indicator for measuring this is the Maternal Mortality Ratio (MMR), defined as the ratio of the number of maternal deaths per 100,000 live births. Due to improved health care, there has been decline in MMR globally and in India as well MMR has declined steadily. There is a need to further accelerate this decline for achieving our national and international targets and goals.

Women who have survived complications during pregnancy and childbirth have been studied as surrogates of maternal deaths and been termed Maternal Near Miss. Reviews of such cases are considered a less threatening approach to improve maternal health care by the service providers.

With this tool, we will be able to identify the delays during the near miss and thereafter and take corrective action. Moreover, service providers are happy to report MNM since ultimately the life of the mother is saved; this has been proved during the pilot conducted on MNM.

This will enable us to utilise the opportunities to prevent the deaths of mother who might face a similar fate. As Near Miss occurs much more frequently than maternal deaths, a more reliable quantitative analysis can provide a comprehensive profile of the health system functioning.

Near misses are relatively simpler to analyse and easier to resolve. This knowledge will help in identifying the contributory factors of maternal deaths so that actions can be taken at community and health systems level. I am sure that these guidelines will definitely bring a sharper focus on decreasing number of maternal deaths and morbidities in India.

(Dr. Rakesh kumar)

FOREWORD






(Anuradha Gupta)




Ministry of Health and Family Welfare Nirman Bhawan, New Delhi - 110011Dr. Rakesh Kumar, IAS

JOINT SECRETARY Telefax : 23061723E-mail : [email protected] : [email protected]

FOREWORD

This is well known that complications during pregnancy and child birth can take place at any point of time, so it is important that the basic and emergency obstetric care health facilities remain in readiness in terms of infrastructure, HR, equipments etc. for timely management of complications. If such complications are not managed on time sometimes they become fatal. Government of India initiated Maternal Death Review to know the gap in the implementation of the programme and take corrective action.

The review however is not able to capture those pregnant women who suffered complications and delivered but just missed the fatality. As you know, there are several advantages of investigating near miss cases e.g. they are more common than maternal deaths, provide useful information on the same pathways that leads to morbidity and death, less threatening for service providers as women has survived, women can be interviewed and as a result more realistic analysis of gaps can be done. Thus investigating severe maternal morbidity (near-miss) helps to identify women at highest risk of maternal death and helps allocate resources especially in the area where it is needed most.

I would like to express that these guidelines would not have been possible without the constant encouragement from Mr. C.K Mishra, AS&MD & Ms Anuradha Gupta, Ex AS& MD. Dr. Rakesh Kumar, Joint Secretary (RMNCH+A) headed the expert group meeting and gave valuable inputs in framing this guideline.

I would like to acknowledge the contribution of all members of the Expert Group in developing the content of these technical and operational guidelines. I would also like to acknowledge my colleagues in MH Division especially Dr. Dinesh Baswal, DC(MH) and development partner’s for their valuable efforts and inputs in developing this document.

The present guidelines are an empowering tool for the OBGYN Department of Medical Colleges where majority of near miss are likely to happen. Systematic review of such cases can help to bring forth various contributory factors whether it is medical, social, economical and other factors for necessary corrective actions which could be taken at State, District or at Community level for reduction in maternal mortality and morbidity.

(Dr. Himanshu Bhushan)

FOREWORD






(Anuradha Gupta)




Ministry of Health and Family Welfare Nirman Bhawan, New Delhi - 110011Dr. H. BHUSHAN

Deputy Commissioner (MH) Telefax : 23062930E-mail : [email protected]

PROGRAM OFFICER’S MESSAGE

Maternal Near Miss Review Operational Guidelines - December - 2014 11

I. Introduction 15

II. Process of MNM-R 16

III. Implementation plan of MNM-R 19

IV. Committees under MNM-R 19

V. Roles and Responsibilities of Nodal officers 20

VI. Training Plan 21

VII. Monitoring and Evaluation 22

VIII. Budget 24

IX. Annexures

1. Facility-based MNM-R form 25

2. Criteria for identification of MNM cases 35

3. MNM-R register 43

LIST OF CONTENTS

Maternal Near Miss Review Operational Guidelines - December - 201412

AIDS Acquired Immuno Deficiency SyndromeALT Alanine TransaminaseANC Ante-natal CareARDS Acute Respiratory Distress SyndromeAST Aspartate TransaminaseBP Blood PressureBPL Below Poverty LineBS Blood SugarCAB Circulation Airway BreathingCCF Congestive Cardiac FailureCMO Chief Medical Officer CS Civil SurgeonCT Computed Tomography DLC Differential Leukocyte CountDHO District Health OfficerECG ElectrocardiogramELISA Enzyme Linked Immuno-Sorbent AssayEmOC Emergency Obstetric CareFBS Fasting Blood SugarFBMNM-R Facility Based Maternal Near Miss ReviewFFP Fresh Frozen PlasmaFIGO International Federation of Gynaecology and Obstetrics FiO2 Fraction of inspired oxygenFOGSI Federation of Obstetrics and Gynaecological Societies of IndiaGoI Government of IndiaHb HaemoglobinHBsAG Hepatitis B Surface AntigenHELLP Haemolysis Elevated Liver Enzymes Low PlateletHIV Human Immunodeficiency VirusICU Intensive Care UnitIV IntravenousJVP Jugular Venous PressureK PotassiumKFT Kidney Function TestLFT Liver Function TestLSAS Life Saving Anaesthesia SkillsLVF Left Ventricular FailureMCTS Mother and Child Tracking SystemMOs Medical Officers MDR Maternal Death ReviewMNM Maternal Near MissMNM-R Maternal Near Miss ReviewMoHFW Ministry of Health and Family WelfareMRI Magnetic Resonance ImagingNa SodiumNICU Neonatal Intensive Care UnitPaCO2 Partial pressure of carbon dioxide in the bloodPaO2 Partial pressure of oxygen in the bloodPIP Project Implementation PlanPPBS Post Prandial Blood SugarPPH Postpartum HaemorrhageRBS Random Blood SugarTLC Total Leukocyte CountTSH Thyroid Stimulating HormoneUK United KingdomUSG UltrasonographyVDRL Venereal Disease Research LaboratoryWHO World Health Organization

ABBREVIATIONS AND UNITS


LIST OF CONTRIBUTORS

1. Shri C. K. Mishra, AS & MD (NHM), MoHFW

2. Dr Rakesh Kumar, JS (RMNCH+A), MoHFW

3. Dr Himanshu Bhushan, DC (I/c MH), MOHFW

4. Dr Manisha Malhotra, DC (MH), MOHFW

5. Dr Dinesh Baswal, DC (MH), MoHFW

6. Dr Pratima Mittal, Prof.& Head, Dept of OBGY, VMMC & Safdarjung Hospital, New Delhi

7. Dr M.K. Mittal, Sr. Specialist / Consultant Radiologist, Safdarjung hospital, New Delhi

8. Dr Bhartendu Kumar, Assoc. Prof. Of Surgery, SKMCH, Muzaffarpur

9. Dr Ratna Kumar, Chennai, Ex HOD, Institute of OBGYN, Chennai, Tamil Nadu

10. Dr K. Kolanda Swamy, Director Public Health , Govt. of TN, Chennai

11. Dr Ragini Mehrotra, HOD, OBG, AIIMS, Bhopal

12. Dr Sudhir Gupta, Prof & Head, Depart of Gastroenterology, GMC & Superspeciality Hospital,Nagpur

13. Dr Somesh Gupta, Assoc. Prof., Department of Dermatology & Venereology, AIIMS, New Delhi

14. Dr Suneeta Mittal, Sr. Cons. OBGY, Fortis Hospoital, Gurgaon

15. Dr Archana Mishra, DD (MH), GoMP

16. Dr Suchitra Pandit, President, FOGSI

17. Dr Achala Batra, Dept. of OBGY, Safdarjung Hospital, New Delhi

18. Dr Aman Kumar Singh, Technical Expert STI, NACO

19. Dr P.R.Deo, UNFPA State Program Coordinator, Madhya Pradesh, Bhopal

20. Dr Anchita Patil, NPO, UNFPA, New Delhi

21. Dr Thelma Sequeira, Avni Health Foundation

22. Mr Ajey Bharadwaj, Avni Health Foundation

23. Dr Pushkar Kumar, Lead Consultant, MH, MoHFW

24. Dr Rajeev Agarwal, Senior Mgt. Consultant, MH, MoHFW

25. Dr Ravinder Kaur, Senior Consultant, MH, MoHFW

26. Dr Gulfam Ahmed Hashmi, Regional Coordinator, NRU, MoHFW

27. Dr Ashish Chakraborty, Regional Coordinator, NRU, MoHFW

28. Mr. Prasanth K. S., Senior Consultant, PHA Division, NHSRC, New Delhi

29 Dr Neelima Singh, Faculty, Indian Institute Of Health and Family Welfare, Hyderabad

30 Dr Nomita Chandiok, ICMR, New Delhi

31 Dr Raja Mahendra, Radiologist, Daga Hospital, Nagpur

32 Dr Charu Lata Mahorkar, OBGY, Nagpur

33 Dr Arunabh Ray, BTAST, Patna

34 Mr Shridhar Pandit, PO, NHM, Govt. of Maharashtra

35 Dr Gorakh Gopalkrishna Mandrupkar, Joint Secretary, FOGSI

36 Dr Archana Kharyal, Research Officer, SAHAYOG

37 Sharmila G. Neogi, Maternal Health Specialist, USAID, India


MGIMS Wardha

38 Dr B.S. Garg, Secretary, KHS, MGIMS, Sevagram

39 Dr S. Chhabra, Director Prof. OBGY, MGIMS, Sevagram Wardha

40 Dr. Poonam Varma Shiv Kumar, Prof. & HOD, OBGY, MGIMS, Sevagram

41 Dr Surekha Tayade, Prof. OBGY, MGIMS, Sevagram Wardha

42 Dr Manjiri Ramteke Podder, Assist. Prof., Dept of OBGY, MGIMS, Sevagram

● Representatives & Experts from FOGSI & FIGO


Maternal mortality is a critical indicator to assess the quality of services provided by a health care system. The standard indicator for measuring it is the Maternal Mortality Ratio (MMR), defined as the ratio of the number of maternal deaths per 100,000 live births. Globally there has been decline in MMR, in India too this is declining steadily due to the additional efforts and resources put under NHM for improving health care. There is a need to further accelerate this decline for achieving our national and international goals and targets under them.

It is well known that complications during pregnancy and child birth can occur at any point of time, and it is important to ensure that readiness in terms of infrastructure, HR, equipment etc. for timely management of complications are available at all the basic and emergency obstetric care health facilities. If such complications are not managed on time they can become fatal. The Maternal Death Review guidelines launched by Government of India is a tool available with health managers and policy makers at various levels to critically look at health system performance, identify gaps and initiate corrective steps through convergent action. A major limitation of the MDR process is that the health professionals and other stakeholders involved in the service delivery fear that the great misfortune that has befallen on the pregnant mother puts the blame squarely on their shoulders, and they look at the MDR process with great suspicion as if it is a mechanism to expose them to public scrutiny and outrage. Moreover, the mother who interacted with the system was not available to share her experience. The review that captures the experiences of those pregnant women who suffered complications during pregnancy but survived a major fatality due to timely intervention provides a lot of learning opportunities, which is available more easily due to the availability of the mother as well as the willingness of health professionals who are eager to share their ‘success’ stories. There are various advantages of doing Maternal Near Miss-Review (MNM-R) (See Box 1). Investigating such cases of life threatening obstetric morbidity or Maternal Near Miss would help bringing further improvements to the programme.

Box. 1 Advantages of investigating near miss events

● Near miss cases are more common than maternal deaths

● The major reasons and causes are the same for both MNM and MDR, so review of MNM cases is likely to yield valuable information regarding severe morbidity, which could lead to death of the mother, if not intervened properly and in time.

● Investigating the instances of severe morbidity may be less threatening to providers because the woman survived

● One can learn from the women themselves since they survived and are available for interview about the care they received

● All near misses should be interpreted as free lessons and opportunities to improve the quality of service provision

Purpose of the document

The operational guidelines is designed for use by program managers at different levels of public health system to assist them in undertaking systematic MNM-R and use this information to bring health system improvements aimed at reduction of maternal morbidity and mortality.

● To identify the technical and non-technical causes of MNM

● To identify the health system response to maternal emergencies

● To identify the gaps and contextualise corrective measures to be taken in the health care system

● To provide regular feedback and response needed to achieve the goals

● Identify best practices

INTRODUCTION


What is Maternal Near Miss (MNM)?

A Woman Who Survives Life Threatening Conditions during Pregnancy, Abortion, and Childbirth or within 42 Days of Pregnancy Termination, irrespective of Receiving Emergency Medical/Surgical Interventions, is called Maternal Near Miss.

PROCESS of MNM-R

The process of MNM-R involes ;

a) Notification (MO/HOD-if case meets inclusion criteria)

b) Data Transmission (Institution to district to state )

c) Review (Institutional & district level)

d) Analysis & Feedback for initiating necessary action.

Once the MNM is confirmed using the tool given in the guideline for diagnosing MNM, the MO/HOD of OBG-

GYN notifies it to the FNO within 24 hours. There upon FBMNM-R form is filled by MO/HOD with support

from FNO and submitted to district within a week. A copy of the same is kept with the institution for records,

The Medical Superintendent with support from FNO and taking inputs from HOD/MO of the department

will review the case. In the monthly review meeting the MNM-R committee members will be invited. The

review reports will be sent to the district for further action. A snap shot of the process is given in the flow

chart below;

Case identification as per the criteria

Filling the tools

Facility based review of cases & undertaking local corrective action

Data feeding

District level review of cases

Corrective measures undertaken at different levels (Institution/District/State)

{Analysis & Feedback

Chart 1. Maternal Near Miss Review Process.


DIaGNOSING MNM

Inclusion Criteria:

Critically ill pregnant, labouring, post-partum and post-abortal women admitted to notified health institutions.

Criteria for identifying and notifying the MNM case:

Whenever any pregnant woman comes to the health facility in a critical condition, she needs to be given

urgent medical treatment. However prior to the discharge of such cases, there is a need to identify whether

the case falls under the category of Maternal Near Miss. For identification of an MNM case the following

criteria (minimum three from each category) must be met with:

1) Clinical findings (either symptoms or signs),

2) Investigations

3) Interventions

Or

Any single criteria which signifies cardio respiratory collapse (indicated by a heart symbol)

The clinical findings, investigations and interventions have been put under three broad categories

(annexure 2)

1) Pregnancy specific obstetric and medical disorders,

2) Pre-existing disorders aggravated during pregnancy,

3) Accidental / Incidental disorders in pregnancy.

These broader categories have further been segregated under different clinical situations like haemorrhage,

sepsis, hypertension etc. So it is important for the MO in-charge of the case to carefully see criteria for

identification of MNM Case (annexure-2) and scrutinise the suspected MNM case. A snap shot of the

process involved in diagnosing and notifying MNM - R is given in the flow chart below;


Chart 2. Diagnosing and Notifying MNM-R

Case satisfies MNM-R Inclusion Criteria

Criteria for identifying and classifying MNM-R

Clinical findings / Investigations / Interventions OR any single criteria that indicates cardio respiratory

collapse

Categorize based on;

1) Pregnancy specific obstetric and medical disorders,

2) Pre-existing disorders aggravated during pregnancy,

3) Accidental / Incidental disorders in pregnancy.

Identify adverse events in each category

For each adverse event elaborate possible disorders/ conditions or Complications

The results of investigations which make women fall under MNM category are identified

The interventions that saved the mother is recorded

MNM-R TOOLS

There are two formats in which the data need to be entered –

1. Facility based Maternal Near Miss Review (FBMNM-R ) form – annexure 1

2. MNM-R case register – details of columns to be made in the register – annexure 3

# annexure 2 illustrates the criteria for diagnosing the MNM

Investigating severe maternal morbidity (near-miss) would aim to document the frequency and nature of

maternal near-miss at hospital level and to evaluate the level of care at maternal life-saving emergency

services. This will also provide the gaps for corrective actions to be taken at various levels.


Implementation plan of MNM-R

In the initial phase the MNM-R will be implemented in selected well performing medical colleges or tertiary

centres. Once the implementation of Maternal Near Miss at Medical Colleges is successfully established, then

States can decide to extend it to District hospitals/other FRUs.

MNM-R is complementary to MDR and purpose of MNM-R is to identify the gaps in service delivery at the

earliest which will ultimately help in preventing maternal morbidity and mortality.

In order to initiate MNM-R in a State the following steps have to be undertaken;

● A G.O. /policy decision on Implementation of the program by the State

● Notification of institutions to conduct MNM-R

● Provision of adequate budget and timely release to the notified institute

● Sensitization of State Program Officers

● Training of Medical College faculty and staff

● Printing of different formats

The committees under MNM-R

The MDR committee constituted at district and institutional level for review of maternal deaths will also

conduct the review of MNM cases.

The committees;

● Review MNM cases and share the findings for corrective action with all the concerned departments

● Make recommendations - to initiate actions related to infrastructural strengthening, to augment

human resource availability, to strengthen protocols and competence of staff, to ensure adequate

Supplies and Equipment

● Analysis & Feedback - A statement of detected gaps, identified best practices, corrective measures to

be taken should be sent to state nodal officer for state review meeting

The committees are ;

1. Facility Based Maternal Death/ Near Miss Review Committee (FBMNM-R Committee)

2. District level CS/CMO Maternal death/ Near Miss Review Committee (DBMNM-R Committee)

The review will focus on

a) Circumstances under which the woman received care

b) Cause of maternal near miss

c) Steps that are required to prevent such morbidities in future

The State Task Force for MDR committee will also support implementation of MNM-R at the state level.

Maternal Health division of MoHFW with support from NHSRC will provide monitoring support to all the

states.


Roles and Responsibilities of Nodal Officers

Implementation of MNM-R requires coordinated effort of various nodal officers designated at various levels

to support and monitor the processes to ensure the quality of data collected, analysed and feedback shared

for concerted action at the various levels.

State Nodal Officer (SNO)

● Identifying the level and names of the health facility (Initially Medical Colleges) where program will

be implemented

● Collect relevant data on MNM cases district-wise/institution-wise and carry out detailed analysis

● Ensuring availability of different formats and other requisite tools before initiation of program

● Priority action and timeline for the gaps identified under MNM and periodic review of progress

● Nominate the district nodal officers

● Provision of adequate budget and timely release to the implementing institute.

● Ensure the trainings at various levels

● Facilitate the preparation of an annual MNM-R report for the state and organize a dissemination

meeting to sensitize the various service providers and managers. The annual report may contain

typical maternal death case studies which may be used during the training of medical and paramedical

functionaries.

● To make sure that the budgetary requirement of MNM-R reflects either in the state/ NHM PIP

District Nodal Officer (DNO)

District RCH Officer can be designated as the District Nodal Officer.

1. Maintain the line list of facility based MNM cases in the district; facilitate the data entry and ensure

FBMNM-R at the district level

2. Organize monthly District level MNM-R meetings under the directions of the CMO; maintain the

minutes of meetings; follow up on actions to be taken and prepare the Action Taken Report

3. Participate in meetings of the State Level Task-force and follow up on specific recommendations

pertaining to the district

4. Undertake planning and budget estimates for MNM-R in the district where the programme is

implemented

5. To make available the necessary equipment/ supplies (especially laboratory diagnostic facilities) in

advance to all such health facilities conducting MNM-R in the district

Medical Superintendent/ In-charge of Health Facility

● Nominate FNO for the MNM-R program

● Form MNM-R Committee(may include Staff of OBGYN, Anaesthesia, Nursing, Blood Bank, Other

relevant individuals)

● Forwarding the MNM-R tool with case sheet to district CMO/CIVIL SURGEON within a week

● Taking local corrective actions as per MNM-R findings


Facility Nodal Officer (FNO)

● Ensuring all cases of MNM are reported

● Preparing meeting calendar and calling the committee on a designated day and date

● Review of MNM cases in MDR committee

● Send the report and its findings to district CMHO/ Civil Surgeon

● Attend MDR/ MNM review meetings at district

HOD Obstetrics / Duty Medical Officer

● Identify MNM as per the indicated criteria and record in the relevant register

● Complete FBMNM-R form and send to the MNM-R Nodal officer of the facility within 48 hours of

patients discharge

● ENSURING NO CHANGES ARE MADE ON THE CASE SHEET

● To ensure MNM-R formats are filled in before discharge of the case

Training Plan

The basic premise of the training plan is that all personnel directly involved with the MNM-R process get

trained and all other officers whose cooperation is required in the smooth conduct of review (as well as

follow up actions based on recommendations of the MNM-R Committees) get oriented in the concept and

process of MNM-R.

A one day sensitization cum training of trainers for the states will be conducted at the national level by the

National Health System Resource Centre (NHSRC) under the guidance of MH division of Ministry of Health

and Family Welfare.

At the state level a half day sensitization meeting involving all convergent departments and state nodal

officers from the directorate, SIHFW, SHS will be held. A one day training at the state level will invite the

faculty (FNO, HOD, MS etc.) of the notified institutions along with District officers.

District orientation could be undertaken involving convergent departments.

At the institution level MOs of all departments in the facility will sensitized in a half-day session, followed by

one day training of the faculty directly involved in the MNM-R.

The training schedule depicting the cascade of trainings undertaken at State, District and Institutional level

is given below;


Table 1. Training schedule

Level Type Participants Duration Training materials

National Training State nodal officers for MNM-R

1 dayMNM-R guidelines and formats, case studies, role plays on MNM-R

State

Sensitization All state programme officers and convergent departments

½ day MNM-R guidelines

Training All nodal officers (district, facility)

1 day

MNM-R guidelines and formats, case studies, role plays on MNM-R, develop systems for review and remedial follow up actions

District Sensitization All district programme officers and convergent departments

½ day MNM-R guidelines

Institutions

Sensitization All division heads ½ day MNM-R guidelines

Training

All faculty and staff of Obstetrics & Gynaecology department

1 dayMNM-R guidelines and formats, case studies, role plays on MNM-R, registers, analysis of data

Monitoring and Evaluation

While a biological complication is assigned as a cause of MNM, in fact most MNM cases result from a chain of

events that includes many social, cultural and medical factors. The tools for MNM-R have been developed with

the objective of identifying gaps and reasons for severe maternal morbidities which could also lead to maternal

deaths so that corrective actions to fill such gaps can be taken for improving service delivery. Private sector

providers may also find this useful in instituting maternal near miss reviews. The guideline will help program

managers, Medical Superintendents, officer in charges and district program managers who are routinely engaged

in delivery of maternal health interventions in the implementation of this program.

Individual facilities should ensure availability of all the relevant data both in hard and softcopy. Since a large

set of data is captured, analysis of data for surveillance, interventions, corrective actions etc. will be a challenge.

Centralised online software to feed the data, carry out analysis and generate reports for action will be developed

in due course by GOI. The data of individual facilities can be transferred to this portal once this portal is developed.

The Nodal officers will evaluate the important variables and identify the gaps for initiating corrective measure

so as to prevent such morbidities in future. The major outcomes which need to be focussed in are number of

women in a centre reporting with MNM or become MNM, the causes of MNM, referral places and the quality of

care given, antenatal care and its quality, identified complications in pregnancy, labour care and complications in

delivery, iatrogenic injuries, requirement of blood & its availability, interventions needed to save the women, good

practices & reasons in terms of delay 1, 2 or 3


Indicators for Monitoring

1. Total Number of MNM cases in the reporting month

2. MNM cases reviewed by CMHO

3. Out of total MNM cases indicate the number against following complication:

a. PPH

b. Eclampsia

c. Anemia

d. Septic Abortion

e. others

4. Type of gaps identified after review

5. Status of corrective action taken for the gaps identified

Key points to remember

● The findings from MNM-R should not be utilized for taking punitive action against service providers.

● Any single criteria which signifies cardio respiratory collapse, makes a case of MNM

● The committee on MDR will perform functions of MNM-R committee

● Training budget should be proposed in the State PIP


Budget

Establishment cost

S. No Non-Recurring Items aMOUNT

1 Computer, printer and MNM-R software downloading ( for each facility) 1,00,000/-

2

Training Cost – 1 day orientation

State Level, per (1 Batch of 40)

Facility Level, (1 Batch of 20)

183000

26500

Training cost

1 day training of MNM-R at state, batch of 40

S. No Head Unit Cost Number of Participants

Days Total

1 TA for Participants ( to and fro by Train) 3000 40 1 120000

2 DA to trainees 700 40 1 28000

3 Lunch & tea 200 40 1 8000

4 Per Diem/ Honorarium for Trainers** 1000 2 1 2000

5 Logistic expenses like study material, course material, photocopying, job aids, flip cart, LCD etc. ( Rate x Days of Training x number of participants)

200 40 1 8000

Sub Total 166000

Incidental overhead ( 10% of sub-total) 16600

Total for one batch of 40 candidates for 1day

183000

1 day training of MNM-R at facility, batch of 20

S. No Head Unit Cost

Number of Participants

Days Total

1 DA to trainees 700 20 1 14000

2 Lunch & tea 200 20 1 4000

3 Per Diem/ Honorarium for Trainers** 1000 2 1 2000

4 Logistic expenses like study material, course material, photocopying, job aids, flip cart, LCD etc. ( Rate x Days of Training x number of participants)

200 20 1 4000

Sub Total 24000

Incidental overhead ( 10% of sub-total) 2500

Total for one batch of 20 candidates for 1day 26500

Note: *** TA to be given as per state norms.

* The state need to adjust the training norms as per the training load of the district and state.

# Support is provided to conduct of CDR meetings at various levels (district committee, facility committee etc.). The same funds can be utilized for conduct of MNM-R meetings.

## for sensitization meetings, cost of tea/snacks plus incidental expenses(photocopying, printing, telephone, Fax etc.) @3000/- may be booked. Since only local people are involved, no TA/DA is required except cost of outstation resource persons, which needs to be separately budgeted in PIP.


ANNExUREFaCILITY BaSED MaTERNaL NEaR MISS REVIEW FORM

(MNM-R FORM)

Name & Address of Medical College/FRU_______________________________________________________

________________________________________________________________________________________

Name of Nodal PersoN ____________________________________Contact No__________________________

FOR OFFICE USE ONLY

MCTS No (mandatory)

FBMNM-R NO. (Of the facility) (with Date / Month / Year)

NOTE :

� This form must be filled for all cases of Maternal Near Miss as per Definition and criteria

( as per Annexure 1)

� FB MNM-R number must be put serially e.g 001-dt-mth-yr.

� Mark with √ wherever applicable

� For Date use Day/Month/Year format. For time use 24hours clock format.

� Complete form at the time of discharge of woman with Maternal Near Miss, keep photocopy & send

original to Nodal Officer MNM - R Committee

� New series starts with new year

� Attach copy of discharge summary with this form

1. GENERaL INFORMaTION

a. Full Name______________________________________ b. Age _________ (in years)

c. Inpatient No___________________ d. Contact No __________________

e. Complete address______________________________________________________________

f. Education: Illiterate literate Upto 5th class 6th to 12th class Beyond 12th class

g. Below Poverty Line status: BPL Certificate / Self certified Not BPL

h. Date of admission: Day Month Yr. Time: Hours Min

i. Date of discharge: Day Month Yr. Time: Hours Min

j. Date and time when became near miss : Day Month Yr Hours.

Mins

01


k. Type of Discharge: By Hospital On Request Left Against Medical advice

Referred to Other Centre Absconded

l. Provisional Diagnosis At Admission

m. Final Diagnosis At Discharge : ________________________________________________________

_____________________________________________________________________________

n. Duration of Hospital stay: Days Hours

o. Duration of ICU stay: Days Hours

2. CONDITION aT TIME OF aDMISSION

a. Patient admitted in Hospital with severe illness

b. Admitted with no disorder, became Near Miss

c. Admitted with disorder, became Near Miss

3. TYPE OF aDMISSION

a. Self b. Referred

4. REFFERaL

a. If referred from outside, no. of places visited prior Specify Type, - Public, How many

Private, How many

b. Attended by: Doctor Nurse Other staff None

c. From last visited place before referral, referral slip completed: Yes No

d. Transportation provided from the referring facility: Yes No

5. ILLNESS DURaTION

a. Duration from illness to 1st health facility : Days Hours

b. Duration from 1st facility to this facility : Days Hours

c. Duration from admission to Near Miss Morbidity : Days Hours

6. STaTUS aT aDMISSION

a. Gravida Parity Abortion Living Children

b. Antenatal < 22 weeks > 22 & < 34 weeks > 34 & < 37 weeks

> 37 & < 42 weeks > 42 weeks

c. Intra-natal Postnatal Abortion Post abortion Other

d. Days since delivery/abortion: Within 24 hrs. >24 hrs.- 1week >1 week - 6 weeks.

Not applicable


7. UNDERLYING DISORDERS aT aDMISSION

Haemorrhage

abortion Ectopic Pregnancy Gestational Trophoblastic Disease

antepartum Bleeding

Placental causes Late pregnancy Bleeding other than placental causes

Placenta Previa Placental abruption Scar dehiscence Rupture uterus Others

Intrapartum Bleeding

Postpartum bleeding Atonic Traumatic Mixed

Infection

Viral such as Hepatitis/HIV AIDS/Others, Malaria, Dengue, Scrub Typhus, Other infections occurring in

Antepartum Intrapartum Post partum Post abortal

Hypertensive disorders of pregnancy

Gestational Hypertension - Mild Severe

Pre-eclampsia - Mild Severe

Eclampsia Others

Labour related Disorders

Prolonged / Obstructed / Rupture uterus Inversion of Uterus Retained placenta Any other

Medical Disorders

Anaemia Heart disease Lower Respiratory Tract Infection

Diabetes Others

Incidental/ accidental Disorders E.g. Surgical including Iatrogenic, Trauma, Violence, anaesthetic complications, etc.

8. aNTENaTaL PERIOD

Did she receive ANC? Yes, Number of Visits: No Not Applicable

a. If Yes,

i. Type of Care Provider : *Nurse *Medical Officer *Specialist (* Public Sector)

Others including private sector

ii. Quality of care provided : a. Eye checked for pallor b. BP taken c. Abdominal examination d. Urine checked e. Hb checked

iii. Was she informed about problems in present pregnancy? Yes No

iv. Was referral made to appropriate facility? Yes No

v. Referral slip with details: Yes No


B. If No Antenatal care –

Reasons: a. Lack of awareness b. Lack of accessibility c. Lack of funds d. Lack of attendee

e. Family problems f. Others

9. SIGNIFICaNT PaST HISTORY- Personal Medical Surgical Obstetrical

a. Gynaecological b. Family

Details

10. COMPLaINTS WITH DURaTION (Please tick all the presenting complaints)

Hours Days Hours Days

Vaginal bleeding Convulsion

Vaginal discharge Unconscious state

High grade fever Syncope

Abdominal pain Breathlessness

Severe headache Palpitations

Swelling of feet / body Chest pain

Blurring of vision Orthopnea

Right upper quadrant pain Yellowness of Urine/ Skin

Passing of scanty amount of urine Others


11. EXaMINaTION FINDINGS Sy

stem

s

Examination at admissionat the time

of Near Miss

Syst

ems

Examination at admissionat the time

of Near Miss

Date & Timeof examination

Ab

do

min

al F

ind

ing

s

Distension

Gen

eral

Temp (oC) Scars

Pulse/min Soft / Guarding

Respiration/min Tenderness

Blood pressure Organomegaly

Pallor Lump

Icterus

Cyanosis

Per S

pec

ulu

m

Bowel Sounds

ClubbingCervix

Lymph Nodes EnlargementVagina

Oedema (Feet/Face)Others

Jugular Venous Pressure

Per V

agin

um

Cervical dilatation

Cervical effacement

Cervical position

CN

S

Conscious Cervical consistency

Orientation Station of Head

Pupils (Size, Light Reaction) Membrane’s Status

Deep Tendon Reflex – Pres-ent/Absent

Liquor

Plantar -Extensor/FlexorOthers

Any neurodeficit

CV

S Any abnormality detected Uterus Size

Uterus Position

Uterus Consistency

RS Any abnormality detectedUterine tenderness

Fornices

Ab

do

min

al F

ind

ing

s

Fundal height

OthersUterine contraction pres-ent/absent

Presentation/Position

An

y O

ther

s

Estimated Baby size

Liquor

Fetal Heart Rate (regular/irregular)


12. INVESTIGaTIONS

Type Samples Collected at admissionat the time

of Near MissType Samples Collected at admission

at the time of Near Miss

Blo

od

Hb

KFT

Creatinine

TLC/ DLC Urea

Platelet Na+

Peripheral Smear K+

Bleeding Time,

Clotting Time

Clot observation time

Infe

ctio

us

Dis

ease

s Sc

reen

ing

HIV – I & II

Blood group, Rh type HBsAg

Hb - Electrophoresis VDRL

Uri

ne

Urine albumin Rapid Dengue

Urine sugar Rapid Malaria

Urine ketone Widal

Urine microscopy Blood C/S

Urine C/S

BSL

BS (F) Cervical Swab

BS (PP) Vaginal Swab

BS (RBS) Lochial Swab

LFT

Alk phos

Fun

du

s Ex

am.SGPT Ophthalmoscopy

SGOT

Bilirubin (Total)

Bilirubin (Direct)

Imag

ing

USG

DopplerProteins (Total)

Albumin xray chest/ abdomen CT / MRIGlobulin

13. DELIVERY DETaILS:

a. Known Unknown Not Applicable

b. Place of Delivery : Public Hospital Private Hospital Home Other

c. Did she have labor pains? Yes Spontaneous Induced No

If Yes, was a partograph used? Yes No Don’t know

d. Indication for Induction : ______________________________________________________

e. Duration of labour : Hours Minutes


f. Mode of Delivery U

nd

eliv

ered

Vaginal Caesarean Section LaparotomyIndication

(CS/Instrumental)

No

rmal

Assisted

Bre

ech

Mu

ltip

lePr

egn

ancy Elective

Emer-gency

Rupture uterus

* Ectopic Pregnancy

Episiotomy Forceps Vacuum

* In Ectopic pregnancy woman does not deliver, but fetus may be removed during Laparotomy

g. Anaesthesia (any adverse reaction) :

General anaesthesia Reg- Epidural / Spinal Local

h. In which phase of labor did she develop complications ?

First stage

Second stage

Third stage Post Birth

Within < 6 hrs. of birth > 6 - < 24 hrs of birth > 24 hrs after birth

i. Specify the complication

atonic PPH

Traumatic Vaginal /Cervical tear

Broad Ligament

Haematoma

Rupture Uterus

Intrapartum Eclampsia

Retained placenta/Inversion

Others

Cervical /Vaginal / Perineal tear

j. Who conducted the delivery?

Traditional Birth Attendant/Family member Nurse Resident Doctor Specialist

Others

14. PUERPERIUM / POST aBORTaL / POST LaPaROTOMY

a. Uneventful Eventful Not Applicable

b. If Eventful - PPH Sepsis Post Partum Eclampsia Others

15. BLOOD TRaNSFUSION

a. Received: Yes No

b. In which period: Antenatal Intranatal Postnatal Post abortal Other


Details of Blood / Components transfusion

Sr. No. Components Quantity Total

1 Whole Blood

2 Packed cells

3 FFP

4 Platelets

16. DETaILS OF BaBY

Outcome

Stillborn

Live birth Neonatal Death Admitted in NICU

Discharged Discharged Died

17. SYSTEM INVOLVEMENT : Single Multiple

Cardiovascular system Respiratory System

Hepatobiliary System Urinary System

Genital System Hematological System

Central Nervous System Gastrointestinal System

Immune System Musculoskeletal System

18. CONDITION aT DISCHaRGE

Completely recovered Yes No

If No, Details of Residual morbidity


19. INTERVENTIONS DETaILS – aT PLaCES FROM WHERE REFERRED aND aT INSTITUTION

Intervention

Previous Facility Present Facility

Yes No Specify Yes No Specify

ICU admission requiring resuscitative (CAB) or cardio respiratory support

Resuscitative Procedures/Intubation

Mechanical Ventilation

Use of cardiotonics/ Vaso pressors

Digitalization

Evacuation

Laparotomy with procedures - B lynch,Stepwise Devascularization etc.

Hysterectomy

Internal Iliac Ligation

Manual Removal of Placenta

Reposition of Inverted uterus

Repair of Genital injuries

Repair of bladder, bowel

Dialysis

Management of Ketocidosis

Drugs to reduce cerebral odema (Mannitol)

Anticoagulant therapy

Others


20. IN YOUR OPINION WERE aNY OF THESE FaCTORS PRESENT?

System Example Y N

Specify

aNC INC PNC

Personal/Family

Delay in woman seeking helpIf yes, why –

Lack of Awareness Lack of Resources Past Adverse Experience

Refusal of treatment

or admission

Refusal of admission in facility

Logistics

Lack of transport from home to health care facility

Lack of transport between health facilities

Lack of communication network

Referral Facility/facilities

Infrastructural issues

Lack of medications, instruments, equipments or consumables

Non utilization of available medications, instruments, equipments or consumables

Lack of blood /blood products

Present Facility/facilities

Infrastructural issues

Lack of medications, instruments, equipments or consumables

Non utilization of available medications, instruments, equipments or consumables

Lack of blood /blood products

21. Form filled by:

22. Name of the Unit Consultant / Incharge Signature and Stamp

Designation Date:

Institution

23. Name of the Nodal Officer Signature and Stamp

Designation Date:

Institution


AN

NEx

URE

02C

rite

ria

for

iden

tifi

cati

on

of M

NM

Cas

es

•Fo

r d

iag

no

sis

of

Nea

r M

iss,

th

e p

atie

nt

sho

uld

mee

t M

inim

um

3 c

rite

ria:

on

e ea

ch fr

om

1) c

linic

al fi

nd

ing

s(ei

ther

sym

pto

ms

or

sig

ns)

, 2) i

nve

stig

atio

ns

& 3

) in

terv

enti

on

s d

on

e O

r

an

y si

ng

le c

rite

ria

wh

ich

sig

nifi

es c

ard

io r

esp

irat

ory

co

llap

se a

s in

dic

ated

wit

h h

eart

( )s

ymb

ol

1.1

PR

EGN

aN

CY

SP

ECIF

IC O

BST

ETR

IC a

ND

MED

ICa

L D

ISO

RD

ERS

ad

vers

e Ev

ent

Dis

ord

ers/

Co

nd

itio

ns

or

Co

mp

licat

ion

s C

linic

al fi

nd

ing

s R

esu

lts

of I

nve

stig

atio

ns

Inte

rven

tio

ns

Sym

pto

ms

Sig

ns

Ha

EMO

RR

Ha

GE

Sp

on

tan

eou

s

•A

bo

rtio

n

T

erm

inat

ion

o

f Pre

gn

ancy

(S

afe/

Un

safe

)

•Ec

top

ic P

reg

nan

cy

•G

esta

tio

nal

Tro

ph

ob

last

ic

Dis

ease

•A

nte

par

tum

hem

orr

hag

e

-Pla

cen

ta p

revi

a

-Pla

cen

tal a

bru

pti

on

•Sc

ar d

ehis

cen

ce

•Ru

ptu

re u

teru

s

•Su

rgic

al in

jury

du

rin

g la

bo

ur,

Cae

sare

an S

ecti

on

/ Fo

rcep

s o

r Va

cuu

m d

eliv

ery

•Th

ird

Sta

ge

com

plic

atio

ns,

e.g.

In

vers

ion

of u

teru

s, re

tain

ed

pla

cen

ta, C

ervi

cal t

ear,

oth

ers

•Po

st p

artu

m h

aem

orr

hag

e

-Ato

nic

-Tra

um

atic

•A

mn

ioti

c Fl

uid

Em

bo

lism

An

y B

leed

ing

fro

m o

r in

to

the

gen

ital

tra

ct le

adin

g to

•A

ir H

un

ger

•Sy

nco

pal

att

acks

•A

lter

ed c

on

scio

us

stat

e

•Ta

chyc

ard

ia >

120/

min

Lo

w

volu

me

pu

lse

•B

rad

ycar

dia

<40

/min

•Ta

chyp

nea

>40

/min

•B

rad

ypn

oea

< 6

/m

in

•B

loo

d p

ress

ure

- Sy

sto

lic <

90

mm

Hg

- D

iast

olic

< 6

0 m

mH

g

•A

bse

nt

per

iph

eral

refle

xes

•O

ligu

ria

wit

h o

utp

ut <

30m

l/h

ou

r

•A

cute

fall

Hb

< 5

gm

%

or 3

0 %

fall

in

hae

mat

ocr

it (f

all i

n h

emo

glo

bin

so

as

to a

ffec

t ox

ygen

sat

ura

tio

n)

• F

all i

n o

xyg

en s

atu

rati

on

bel

ow

90

%

• P

aO2 :

FiO

2<20

0

• P

aCO

2>50

mm

Hg

• P

late

let

< 2

0,00

0 (A

cute

Dec

line

in

pla

tele

t co

un

t m

ore

sig

nifi

can

t)

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or

any

oth

er te

st d

on

e w

hic

h p

rove

s d

eran

ged

co

agu

lati

on

pro

file

• S

eru

m c

reat

inin

e >

3.5m

g/d

L

•EC

G –

Isch

emic

chan

ges

, ST

inve

rsio

n,

elev

atio

n

• IC

U a

dm

issi

on

req

uir

ing

re

susc

itat

ive

(CA

B) o

r car

dio

re

spir

ato

ry s

up

po

rt

• B

loo

d &

blo

od

pro

du

cts

tr

ansf

usi

on

(mo

re t

han

90

ml/

kg

bo

dy

wei

gh

t/ >

5 u

nit

s o

f blo

od

)

• U

se o

f car

dio

ton

ics/

vaso

pre

sso

rs

(

Mep

hen

tin

e/D

ob

uta

min

e/

D

op

amin

e et

c)

• C

ircu

lato

ry c

olla

pse

req

uir

ing

Em

erg

ency

Su

rger

y fo

r co

ntr

olli

ng

blo

od

loss

su

ch a

s u

rgen

t Ev

acu

atio

n, L

apar

oto

my

wit

h o

r wit

ho

ut

Hys

tere

cto

my,

In

tern

al Il

iac

Lig

atio

n o

r an

y Su

turi

ng

of t

ears

wit

h a

b

ackg

rou

nd

of h

emo

rrh

age

• D

ialy

sis-

per

ito

nea

l/

hem

od

ialy

sis

(ren

al re

pla

cem

ent

ther

apy)

PaO

2 : P

arti

al p

ress

ure

of o

xyg

en in

th

e b

loo

d, F

iO2

: Fra

ctio

n o

f in

spir

ed o

xyg

en, P

aCO

2 : P

arti

al p

ress

ure

of c

arb

on

dio

xid

e in

th

e b

loo

d.


SESI

S

Ter

min

atio

n o

f

p

reg

nan

cy

•Se

pti

c

Ab

ort

ion

s

Sp

on

tan

eou

s

•Pr

elab

ou

r ru

ptu

re o

f m

emb

ran

es T

erm

/Pre

term

•Pu

erp

eral

sep

sis

•Po

st s

urg

ical

pro

ced

ure

s ( E

.g.

Ces

area

n s

ecti

on

, lap

aro

tom

y,

evac

uat

ion

, man

ual

rem

oval

of

pla

cen

ta ,

oth

ers

)

•H

igh

gra

de

feve

r

•A

bd

om

inal

pai

n

•D

iste

nti

on

of a

bd

om

en

•Va

gin

al fo

ul s

mel

ling

d

isch

arg

e

•D

ecre

ased

uri

nar

y o

utp

ut

•A

lter

ed c

on

scio

usn

ess

•D

ifficu

lty

in b

reat

hin

g

•D

elir

ium

/alt

ered

co

nsc

iou

s st

ate

•Pe

rsis

ten

t ri

se in

Tem

p >

39.2

ºC,

no

t re

spo

nd

ing

to ro

uti

ne

trea

tmen

t

•H

ypo

ther

mia

tem

p <

37

0 C

•Pu

lse

rate

> 1

20/m

in

•Th

read

y, lo

w v

olu

me

pu

lse

•Ta

chyp

no

ea>

20/

min

•R

ebo

un

d te

nd

ern

ess

of

abd

om

en, g

uar

din

g, r

igid

ity

•C

linic

al e

vid

ence

of s

epti

c fo

cus

in b

od

y,

P

us

dis

char

ge

fro

m

w

ou

nd,

cer

vix

or v

agin

a

•Le

uco

cyto

sis

( >15

,000

/cu

mm

)

•M

icro

bia

l cu

ltu

re p

osi

tive

fo

r org

anis

ms

•U

ltra

sou

nd

sho

ws

intr

a u

teri

ne/

pel

vic/

ab

do

min

al

colle

ctio

n

•Im

agin

g m

od

alit

y

sho

win

g b

lad

der

/bo

wel

/u

teri

ne

inju

ries

e

.g..

air

un

der

dia

ph

rag

m

• IC

U a

dm

issi

on

for r

esu

scit

ativ

e p

roce

du

re

like

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

•Sh

iftin

g to

intr

aven

ou

s fo

urt

h g

ener

al

An

tib

ioti

cs li

ke(S

ulb

actu

m+

Cef

op

eraz

on

e co

mb

inat

ion

s, Im

epen

um

etc

)

• B

loo

d c

om

po

nen

t t

ran

sfu

sio

n (

up

to 9

0 m

l /k

g b

od

y w

eig

ht/

>5

un

its

of b

loo

d)

• U

se o

f car

dio

ton

ics/

vas

o p

ress

ors

(Mep

hen

tin

e/D

ob

uta

min

e/

Do

pam

ine

etc)

•

Su

rgic

al p

roce

du

re d

on

e (E

vacu

atio

n,

Lap

aro

tom

y fo

r Dra

inag

e o

f pu

s,R

epai

r of

Bla

dd

er, B

ow

el a

nd

/o

r Hys

tere

cto

my)

• D

ialy

sis

– p

erit

on

eal /

hem

od

ialy

sis

( ren

al

rep

lace

men

t th

erap

y)

HY

PER

TEN

SIO

N•

Hyp

erte

nsi

ve d

iso

rder

s o

f p

reg

nan

cy (P

reg

nan

cy in

du

ced

h

yper

ten

sio

n, P

reec

lam

psi

a,

Ecla

mp

sia,

HEL

LP S

ynd

rom

e)

•C

onv

uls

ion

s

•D

imin

uti

on

/Blu

rrin

g

of v

isio

n

•Se

vere

ep

igas

tric

pai

n

•Se

vere

hea

dac

he

no

n

resp

on

sive

to p

ain

ki

llers

•D

ifficu

lty

in b

reat

hin

g

•Pa

lpit

atio

ns

•A

lter

ed c

on

scio

us

stat

e

•B

P >

160/

110m

m H

g

•D

eep

Jau

nd

ice

•O

ligu

ria

/ an

uri

a /

hae

mat

uri

a

• c

om

a

•C

oag

ula

tio

n fa

ilure

• P

ulm

on

ary

edem

a

• E

vid

ence

of c

ircu

lato

ry

colla

pse

•Pr

ote

inu

ria

> 1

gm

/dl

• S

. Cre

atin

ine

>3.

5 m

g /

dL

• E

leva

ted

S B

iliru

bin

(> 6

m

g/d

L)

• A

LT, A

ST( >

100

IU/L

)

•Th

rom

bo

cyto

pen

ia

<20

,000

•H

aem

oly

sis

on

p

erip

her

al s

mea

r

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or a

ny

oth

er

test

do

ne

wh

ich

sh

ow

s d

eran

ged

co

agu

lati

on

p

rofil

e

•H

yper

ten

sive

reti

no

pat

hy

> G

RA

DE

II

•A

bn

orm

al E

CG

( ST

in

vers

ion

, ele

vati

on

/ ar

rhyt

hm

ias)

• C

ereb

ral h

emo

rrh

age

on

CT

scan

• IC

U a

dm

issi

on

for r

esu

scit

ativ

e p

roce

du

re

like

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• N

on

resp

on

der

to M

agn

esiu

m s

ulp

hat

e

• M

ech

anic

al V

enti

lati

on

• B

loo

d &

blo

od

pro

du

cts

tra

nsf

usi

on

(mo

re

than

90

ml/

kg b

od

y w

eig

ht/

>5

un

its

of

blo

od

)

• U

se o

f car

dio

ton

ics/

vas

o p

ress

ors

(Mep

hen

tin

e/D

ob

uta

min

e/

Do

pam

ine

etc)

• S

tatu

s ec

lam

pti

cus


PO

STPa

RTU

M

CO

LLa

PSE

•A

mn

ioti

c Fl

uid

Em

bo

lism

•U

teri

ne

Inve

rsio

n

•A

cute

co

llap

se o

f p

atie

nt

afte

r del

iver

y•

Pusl

e n

ot

reco

rdab

le

•B

P n

ot

reco

rdab

le

•C

ard

iore

spir

ato

ry a

rres

t

•A

cute

fall

Hb

< 5

gm

%

(f

all i

n h

emo

glo

bin

so

as

to a

ffec

t ox

ygen

sa

tura

tio

n)

• F

all i

n o

xyg

en

satu

rati

on

bel

ow

90 %

• P

aO2 :

FiO

2<20

0

• P

aCO

2>50

mm

Hg

• P

late

let

< 2

0,00

0 (A

cute

Dec

line

in p

late

let

cou

nt

mo

re s

ign

ifica

nt)

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or a

ny

oth

er

test

do

ne

wh

ich

pro

ves

der

ang

ed c

oag

ula

tio

n

pro

file

•EC

G –

Isch

emic

chan

ges

, ST

inve

rsio

n,

• e

leva

tio

nw

• IC

U a

dm

issi

on

req

uir

ing

resu

scit

ativ

e (C

AB

) o

r car

dio

resp

irat

ory

su

pp

ort

• B

loo

d &

blo

od

pro

du

cts

tra

nsf

usi

on

(mo

re

than

90

ml/

kg b

od

y w

eig

ht/

>5

un

its

of

blo

od

)

• U

se o

f car

dio

ton

ics/

vaso

pre

sso

rs

(

Mep

hen

tin

e/D

ob

uta

min

e/

D

op

amin

e et

c)

• C

ircu

lato

ry c

olla

pse

req

uir

ing

Em

erg

ency

Su

rger

y fo

r co

ntr

olli

ng

blo

od

loss

su

ch

as u

rgen

t Ev

acu

atio

n, L

apar

oto

my

wit

h o

r w

ith

ou

t H

yste

rect

om

y , I

nte

rnal

Ilia

c Li

gat

ion

o

r an

y Su

turi

ng

of t

ears

wit

h a

bac

kgro

un

d o

f h

emo

rrh

age

•

Dia

lysi

s- p

erit

on

el/

hem

od

ialy

sis

LIV

ER

DY

SFU

NC

TIO

N /

FaIL

UR

E

•A

cute

fatt

y liv

er o

f pre

gn

ancy

•A

cute

Fu

lmin

ant

hep

atic

failu

re

•C

onv

uls

ion

s

• A

lter

ed b

ehav

ior

•B

leed

ing

fro

m v

ario

us

site

s

(no

se, g

um

s, IV

acc

ess

po

rts,

vari

ces)

•U

nco

nsc

iou

snes

s

•D

eep

jau

nd

ice

•H

epat

ic fl

aps,

trem

ors

•A

bn

orm

al b

leed

ing

sit

es

- h

aem

atu

ria,

hae

met

emes

is,

hae

mo

pte

sis,

ble

edin

g g

um

s et

c.

•El

evat

ed S

eru

m

Bili

rub

in (>

6m

g/d

L)

•A

bn

orm

al li

ver e

nzy

mes

A

LT,A

ST

(> 1

00 IU

/ L)

•A

bn

orm

al E

CG

•

Co

agu

lati

on

pro

file

der

ang

ed

•

USG

sh

ow

ing

sh

ow

ing

ch

ang

es o

f

Acu

te fa

tty

liver

Fib

rosc

an s

ho

win

g c

han

ges

o

f acu

te fa

tty

liver

• IC

U a

dm

issi

on

for

r

esu

scit

atio

n a

nd

c

ard

iore

spir

ato

ry s

up

po

rt

• R

esu

scit

atio

n

• M

ech

anic

al v

enti

lati

on

• B

loo

d a

nd

com

po

nen

t tr

ansf

usi

on

(mo

re t

han

90

ml/

kg b

od

y w

eig

ht/

>5

un

its

of b

loo

d)


Ca

RD

IaC

D

YSF

UN

CTI

ON

/ Fa

ILU

RE

•C

ard

iom

yop

ath

y

( an

tep

artu

m, p

ost

par

tum

)

•B

reat

hle

ssn

ess

spec

ially

at

nig

ht

•Pa

lpit

atio

ns

•C

hes

t p

ain

•O

rth

op

no

ea

•Ta

chyc

ard

ia p

uls

e >

120

bp

m

•D

ysp

no

ea

•O

rgan

ic M

urm

urs

•C

ard

iom

egal

y

•Si

gn

s o

f CC

F/LV

F

•A

bn

orm

al E

CG

•

Ab

no

rmal

ec

ho

card

iog

rap

hy

•

x ra

y ch

est

(wit

h s

hie

ldin

g o

f ab

do

men

) sh

ow

ing

Gro

ss

Car

dio

meg

aly

• A

cid

Bas

e va

lues

PH <

7.35

or >

7.45

PCO

2 >50

or <

30 m

mH

g

PO2 a

rter

ial <

80

mm

Hg

• IC

U a

dm

issi

on

for r

esu

scit

ativ

e p

roce

du

re

like

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• V

enti

lato

ry s

up

po

rt

• D

igit

alis

atio

n

• U

se o

f car

dio

ton

ics

1.2

PR

EEX

ISTI

NG

DIS

OR

DER

S a

GG

Ra

Va

TED

DU

RIN

G P

REG

Na

NC

Y

an

aem

ia•

Iro

n /

Folic

Aci

d D

efici

ency

•Si

ckle

cel

l Dis

ease

•Th

alla

sem

ia

•A

pla

stic

An

aem

ia

•D

ysp

nea

•Pa

lpit

atio

ns

•Sy

nco

pal

Att

ack

• A

lter

ed c

on

scio

us

stat

e

•Fe

atu

res

of S

ickl

e ce

ll cr

isis

su

ch a

s b

on

e p

ain

s, jo

int

pai

ns,

acu

te

abd

om

inal

pai

n e

tc

•Sw

ellin

g o

ver b

od

y

•Se

vere

Pal

lor

•Ja

un

dic

e

•Ta

chyc

ard

ia- p

uls

e ra

te >

120/

min

•Ta

chyp

nea

>20

/min

•Te

nd

er, i

nfla

med

join

ts

•St

ern

al t

end

ern

ess

•Sp

leen

om

egal

y

•A

nas

arca

•A

scit

es

• S

ign

s o

f co

ng

esti

ve c

ard

iac

failu

re

•B

leed

ing

Ten

den

cies

•H

emo

glo

bin

bel

ow

5 g

m/d

l

•H

emo

glo

bin

sta

tus

no

t ab

le to

m

ain

tain

O2

satu

rati

on

of 9

0%

•Pl

atel

et <

20,

000

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or

any

oth

er te

st d

on

e w

hic

h p

rove

s d

eran

ged

co

agu

lati

on

pro

file

•El

evat

ed S

Bili

rub

in

( > 6

mg

/d

L)

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• B

loo

d /

com

po

nen

t tr

ansf

usi

on

( U

pto

90

ml /

kg/

>5

un

its

of b

loo

d)

• U

se o

f car

dio

ton

ics/

vaso

pre

sso

rs

(

Mep

hen

tin

e/D

ob

uta

min

e/

Do

pam

ine

etc)

Res

pir

ato

ry

Dys

fun

ctio

ns

•A

sth

ma

•Tu

ber

culo

sis

•Pn

eum

on

ia

•B

reat

hle

ssn

ess

/Air

h

un

ger

•H

igh

/Lo

w g

rad

e fe

ver

•C

hro

nic

wei

gh

t lo

ss

•Ta

chyc

ard

ia- p

uls

e ra

te >

120/

min

•Ta

chyp

nea

- >

20/m

in

•O

rth

op

nea

•A

bn

orm

al C

hes

t si

gn

s

( Ro

nch

i, C

rep

ts, A

bse

nt

bre

ath

so

un

ds)

•Si

gn

s o

f Car

dio

resp

irat

ory

failu

re

•C

yno

sis,

flap

s

•Va

rio

us

lesi

on

s o

n c

hes

t x

ray

(wit

h s

hie

ldin

g o

f ab

do

men

) sp

ecifi

c to

d

isea

se

• A

bn

orm

al A

cid

Bas

e

valu

es

PH <

7.35

or >

7.45

PCO

2 >50

or <

30 m

mH

g

PO2 ar

teri

al <

80

mm

Hg

PO2 ve

no

us

<40

mm

Hg

• IC

U a

dm

issi

on

for

resu

scit

atio

n a

nd

Car

dio

resp

irat

ory

Sup

po

rt, a

nd

or

End

otr

ach

eal

Intu

bat

ion


Car

dia

c

Dys

fun

ctio

ns

•R

heu

mat

ic H

eart

Dis

ease

•C

on

gen

ital

Hea

rt D

isea

se

•C

ard

iom

yop

ath

ies

•A

ort

ic A

neu

rysm

•C

olla

gen

Dis

ord

ers

•B

reat

hle

ssn

ess/

Air

h

un

ger

•O

rth

op

nea

•Pa

lpit

atio

ns

•Pa

roxy

smal

no

ctu

rnal

d

ysp

nea

•C

hes

t p

ain

•Ta

chyc

ard

ia -

pu

lse

rate

>12

0/m

in

•B

rad

ycar

dia

> 4

0/m

in

•Ir

reg

ula

r pu

lse

•Ta

chyp

nea

> 4

0/m

in

•B

rad

ypn

oea

< 6

/min

•O

rgan

ic m

urm

urs

•C

ard

iom

egal

y

•Te

nd

er h

epat

om

egal

y

•Si

gn

s o

f CC

F/LV

F

Pitt

ing

ed

ema,

rais

ed J

VP,

bas

al

crep

ts e

tc.

•A

bn

orm

al E

CG

• A

bn

orm

al E

cho

card

iog

rap

hy

• A

bn

orm

al A

cid

Bas

e va

lues

PH <

7.35

or >

7.45

mm

Hg

PCO

2 >50

or <

30 m

mH

g

PO2 a

rter

ial <

80

mm

Hg

PO2 v

eno

us

<40

mm

Hg

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• V

enti

lato

ry s

up

po

rt,

• D

igit

alis

atio

n

• U

se o

f car

dio

ton

ics

Hep

atic

D

ysfu

nct

ion

•

Cir

rho

sis

of l

iver

•Po

rtal

hyp

erte

nsi

on

•A

cute

live

r fai

lure

•Ye

llow

nes

s o

f uri

ne

/ey

es/o

ther

bo

dy

par

ts

•C

onv

uls

ion

s

•A

lter

ed b

ehav

ior

•B

leed

ing

fro

m v

ario

us

site

s

( no

se,g

um

s, IV

acc

ess

po

rts,

vari

ces)

•D

eep

Jau

nd

ice

• H

epat

ic fl

aps/

tre

mo

rs

•A

bn

orm

al b

leed

ing

sit

es

- h

aem

atu

ria,

hae

mat

emes

is,

hae

mo

pty

sis,

ble

edin

g g

um

s et

c.

•A

bn

orm

al b

leed

ing

fro

m n

ose

, g

um

s, I/

V s

ites

, var

ices

•H

epat

om

egal

yAsc

ites

•El

evat

ed S

eru

m B

iliru

bin

(>6

mg

/d

L)

•A

bn

orm

al li

ver e

nzy

mes

ALT

,AST

(>

100

IU /

L)

•A

bn

orm

al E

CG

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or

any

oth

er te

st d

on

e w

hic

h p

rove

s d

eran

ged

co

agu

lati

on

pro

file

•Im

agin

g m

od

alit

ies

sho

win

g

hep

ato

meg

aly

,sp

len

om

egal

y an

d a

ny

oth

er a

bn

orm

alit

ies

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• M

ech

anic

al

Ven

tila

tio

n

• B

loo

d a

nd

c

om

po

nen

t

t

ran

sfu

sio

n

END

OC

RIN

aL

DIS

OR

DER

S

Dia

bet

ic

Ket

oac

ido

sis

Thyr

oid

Cri

sis

•G

esta

tio

nal

dia

bet

es m

ellit

us

•D

iab

etes

mel

litu

s

•A

lter

ed

con

scio

us

stat

e

•B

reat

hle

ssn

ess

/ A

ir

Hu

ng

er

•Pa

lpit

atio

ns

•C

onv

uls

ion

s

•B

lad

der

/Bo

wel

d

ysfu

nct

ion

• F

eatu

res

of c

ircu

lato

ry c

olla

pse

•N

euro

log

ical

defi

cit

like

mu

scu

lar w

eakn

ess,

par

esis

, p

leg

ia

•

Alt

ered

co

nsc

iou

snes

s

• C

om

a

•K

eto

acid

osi

s p

H <

7.3

5

RBS

> 2

00 g

/dL

•A

bn

orm

al E

CG

•El

ectr

oly

te

imb

alan

ce (

Sr N

a <

129

K <

3.2

- >5.

5

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• M

ech

anic

al

Ven

tila

tio

n

•R

esu

scit

ativ

e

Pro

ced

ure

s

•M

anag

emen

t o

f

Ket

oci

do

sis

(Insu

lin

or g

luca

go

n)

•Th

yro

toxi

cosi

s

•Th

yro

id s

torm

•Ph

eoch

rom

ocy

tom

a

•Pa

lpit

atio

ns

•C

onv

uls

ion

s

•B

lad

der

/Bo

wel

d

ysfu

nct

ion

•A

lter

ed c

on

scio

usn

ess

• C

om

a

•Ta

chyc

ard

ia p

uls

e >

120

bp

m

•Sr

T4

.elev

ated

( >

200

IU)

•Lo

w T

SH (<

0.2

IU)

•Is

chae

mic

ch

ang

es o

n E

CG

•El

evat

ed V

inyl

man

dili

c ac

id

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• M

ech

anic

al

Ven

tila

tio

n

•R

esu

scit

ativ

e

Pro

ced

ure

s


Neu

rolo

gic

al

Dys

fun

ctio

n

•Ep

ilep

sy

•C

ort

ical

vei

n t

hro

mb

osi

s

•Sy

nco

pal

att

acks

•C

onv

uls

ion

s

•U

nco

nsc

iou

s st

ate

•A

lter

ed c

on

scio

us

stat

e an

d

com

a

•A

bn

orm

al re

flexe

s ( h

yper

or

abse

nt)

•Pa

resi

s/p

leg

ia

• C

ard

iore

spir

atoy

failu

re

•A

bn

orm

al E

EG

•A

bn

orm

al a

cid

–b

ase

stat

us

• C

T/M

RI h

ead

sh

ow

ing

ab

no

rmal

itie

s

• IC

U a

dm

issi

on

for r

esu

scit

ativ

e p

roce

du

re li

ke (C

AB

) or

card

iore

spir

ato

ry s

up

po

rt

•Sh

iftin

g to

intr

aven

ou

s A

nti

bio

tics

fou

rth

gen

erat

ion

• M

ech

anic

al v

enti

lati

on

•H

epar

anis

atio

n

Ren

al

Dys

fun

ctio

n /

Failu

re

•M

edic

o re

nal

dis

ease

e.g

ch

ron

ic/a

cute

ren

al fa

ilure

•R

enal

art

ery

sten

osi

s

•Tr

ansp

lan

t co

mp

licat

ion

s

•C

olla

gen

Dis

ord

ers

•R

edu

ced

/ a

bse

nt u

rin

e

•Ed

ema

all o

ver b

od

y

•B

reat

hle

ssn

ess

(du

e to

vo

lum

e ov

erlo

ad)

•U

nco

nsc

iou

s st

ate

• O

ligu

ria

- < 4

00 m

l uri

ne

ou

tpu

t in

24

ho

urs

no

t re

spo

nd

ing

to fl

uid

th

erap

y an

d

diu

reti

cs

•A

nu

ria

• C

om

a

• U

SG s

ho

win

g re

nal

ab

no

rmal

itie

s

• D

op

ple

r USG

sho

win

g s

ten

oti

c re

nal

arte

ry

•D

eran

ged

KFT

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

•N

eed

for d

ialy

sis

per

ito

nel

/ h

emo

dia

lysi

s

1.3

INC

IDEN

TaL

aN

D a

CC

IDEN

TaL

Ca

USE

S IN

PR

EGN

aN

CY

acc

iden

t/as

sau

lt/

surg

ical

pro

ble

ms

•Tr

ip o

r fal

l

•Ve

hic

ula

r acc

iden

t

•V

iole

nce

•B

lun

t tr

aum

a ab

do

men

•A

ssau

lt

•B

urn

s

•Po

iso

nin

g

•C

ance

rs

•A

cute

su

rgic

al c

on

dit

ion

•Su

icid

e at

tem

pt

•Sn

ake

bit

e

•o

ther

•H

isto

ry o

f tra

um

a o

r acc

iden

t, su

icid

e at

tem

pt

•Sy

nco

pe

•Pa

in (a

bd

om

inal

or

per

tain

ing

to s

pec

ific

site

)

•B

lurr

ed v

isio

n

•B

leed

ing

• C

onv

uls

ion

s

• A

lter

ed b

ehav

ior

• A

lter

ed c

on

scio

us

stat

e

•Ta

chyc

ard

ia >

120

/min

,

l

ow

vo

lum

e p

uls

e

•B

rad

ycar

dia

<60

/min

•Ta

chyp

nea

>20

/min

•B

loo

d p

ress

ure

Syst

olic

< 9

0 m

mH

g

Dia

sto

lic <

60

mm

Hg

•Te

nd

ern

ess,

rig

idit

y an

d g

uar

din

g

of

ante

rio

r ab

do

min

al w

all

wit

h/

wit

ho

ut

dis

ten

sio

n

• C

ard

iore

spir

ato

ry fa

ilure

•Ev

iden

ce o

f tra

um

a /b

urn

s

•A

cute

fall

Hb

< 5

gm

( fa

ll in

h

emo

glo

bin

so

as

to a

ffec

t ox

ygen

sa

tura

tio

n)

•Fa

ll in

oxy

gen

sa

tura

tio

n b

elo

w 9

0 %

• P

aO2 :

FiO

2<20

0

• P

aCO

2>50

mm

Hg

•Pl

atel

et <

20,

000

acu

te d

eclin

e in

p

late

let

cou

nt

mo

re s

ign

ifica

nt

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or

any

oth

er te

st d

on

e w

hic

h p

rove

s d

eran

ged

co

agu

lati

on

pro

file

•U

SG s

ho

win

g t

rau

ma

to v

ital

org

ans

•Im

agin

g m

od

alit

y sh

ow

ing

Inju

ry to

b

lad

der

, bo

wel

, liv

er, s

ple

en

•C

T/M

RI s

ho

win

g i

nju

ry

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• B

loo

d &

blo

od

pro

du

cts

tr

ansf

usi

on

( m

ore

90

ml/

kg

bo

dy

wei

gh

t/ >

5 u

nit

s o

f blo

od

)

• U

se o

f car

dio

ton

ics/

vaso

pre

sso

rs

(Mep

hen

tin

e/D

ob

uta

min

e/

Do

pam

ine

etc)

• S

urg

ical

pro

ced

ure

s d

on

e

(

lap

aro

tom

y fo

r

in

trap

erit

on

eal h

aem

orr

hag

e,

re

pai

r of b

lad

der

,

b

ow

el, s

ple

en, l

iver

, kid

ney

,

b

urr

ho

le fo

r hea

d in

jury

)


an

aph

ylax

is•

An

aest

het

ic d

rug

s

•A

nti

bio

tics

•A

nti

mal

aria

ls

•Ir

on

pre

par

atio

ns

•A

nti

conv

uls

ants

•B

loo

d t

ran

sfu

sio

ns

•O

ther

reac

tio

ns

•H

isto

ry o

f tak

ing

th

e d

rug

•B

reat

hle

ssn

ess

•A

ir H

un

ger

•Sy

nco

pe

•N

ot

pas

sin

g u

rin

e

• A

lter

ed c

on

scio

us

stat

e

• T

ach

ycar

dia

> 1

20/m

in

thre

ady,

low

vo

lum

e p

uls

e

• B

rad

ycar

dia

<60

/min

• T

ach

ypn

ea >

20/m

in

• B

loo

d p

ress

ure

- Sy

sto

lic <

90

mm

Hg

-

D

iast

olic

< 6

0 m

mH

g

•O

ligu

ria/

An

uri

a

•Fa

ll in

oxy

gen

sa

tura

tio

n b

elo

w 9

0 %

o

n ro

om

air

• P

aO2 :

FiO

2<20

0

P

aCO

2>50

mm

Hg

• P

rote

inu

ria

> 1

gm

/dl

•S.

Cre

atin

ine

>3.

5 m

g /

dL

•El

evat

ed S

Bili

rub

in (6

mg

/dL)

ALT

, AST

( >10

0 IU

/L)

•Th

rom

bo

cyto

pen

ia

<20

,000

•H

aem

oly

sis

on

per

iph

eral

sm

ear

• C

lot

ob

serv

atio

n t

ime

> 7

min

. or

any

oth

er te

st d

on

e w

hic

h p

rove

s d

eran

ged

co

agu

lati

on

pro

file

• E

CG

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• B

loo

d &

blo

od

pro

du

cts

tra

nsf

usi

on

(mo

re 9

0

ml/

kg b

od

y w

eig

ht/

>5

un

its

of b

loo

d)

•

Use

of c

ard

ioto

nic

s/ v

aso

p

ress

ors

(Mep

hen

tin

e/D

ob

uta

min

e/ D

op

amin

e et

c

• U

se o

f Ad

ren

alin

e R

enal

dia

lysi

s- p

erit

on

eal/

h

emo

dia

lysi

s (R

enal

R

epla

cem

ent T

her

apy)

Infe

ctio

ns

•M

alar

ia

•D

eng

ue

•H

1N1

vira

l Dis

ease

•Lo

wer

resp

irat

ory

tra

ct

infe

ctio

ns

•A

RDS

•M

enin

git

is

•En

chep

hal

itis

•In

fect

ive

hep

atit

is

( A,B

,C,E

)

•H

IV/A

IDS

•Sc

rub

typ

hu

s

•N

eph

riti

s

•O

ther

•H

igh

gra

de

feve

r (w

ith

/w

ith

ou

t ch

ills

and

ri

go

r)

•Ye

llow

nes

s o

f uri

ne

•A

lter

ed b

ehav

ior

•B

reat

hle

ssn

ess

•A

bd

om

inal

pai

n

•A

bd

om

inal

Dis

ten

sio

n

•U

nco

nsc

iou

s st

ate

•C

onv

uls

ion

s

•A

lter

ed c

on

scio

us

stat

e

•Pe

rsis

ten

t ri

se in

Tem

p >

39.2

˚C

, no

t re

spo

nd

ing

to ro

uti

ne

trea

tmen

t

•H

ypo

ther

mia

tem

p ,

37 O

C

•Pu

lse

rate

> 1

20/m

in

•Ta

chyp

nea

> 2

0/m

in

•C

hes

t si

gn

s (C

rep

ts, c

rack

les,

ron

chi,

dec

reas

ed o

r ab

sen

t ai

r en

try)

•N

eck

rig

idit

y

•C

om

a

•B

leed

ing

fro

m v

ario

us

site

s

•Le

uco

cyto

sis

( >15

,000

/cu

mm

)

•To

xic

gra

nu

les

on

per

iph

eral

sm

ear

•Lo

w p

late

lets

(<50

,000

)

•M

icro

bia

l cu

ltu

re p

osi

tive

for

org

anis

ms

•D

eng

ue

, par

ach

eck,

mal

aria

l par

asit

e p

osi

tive

on

ELI

SA/

per

iph

eral

sm

ear

•H

1N1

ELIS

A p

osi

tive

•Sp

inal

flu

id p

osi

tive

for i

nfe

ctio

n

•El

evat

ed s

eru

m b

iliru

bin

(>6

mg

)

•A

bn

orm

al li

ver e

nzy

mes

(> 1

00 IU

)

•A

bn

orm

al E

CG

•A

bn

orm

al E

EG

•C

lot

ob

serv

atio

n t

ime

> 7

min

. or

any

oth

er te

st d

on

e w

hic

h p

rove

s d

eran

ged

co

agu

lati

on

pro

file

•Po

siti

ve H

epat

itis

mar

kers

•H

IV E

LISA

po

siti

ve

•IC

U a

dm

issi

on

for r

esu

scit

ativ

e p

roce

du

re li

ke (C

AB

) or

card

iore

spir

ato

ry s

up

po

rt

•Sh

iftin

g to

intr

aven

ou

s A

nti

bio

tics

of f

ou

rth

gen

erat

ion

(Su

lbac

tum

+ C

efo

per

azo

ne

com

bin

atio

ns,

Imep

enu

m)

• B

loo

d c

om

po

nen

t

tran

sfu

sio

n (

up

to 9

0 m

l /

kg b

od

y w

eig

ht/

>5

un

its

of b

loo

d)

• U

se o

f car

dio

ton

ics/

vas

o p

ress

ors

(Mep

hen

tin

e/D

ob

uta

min

e/

Do

pam

ine

etc)

•In

ject

able

an

tim

alar

ials

•U

se o

f dru

gs

to re

lieve

cer

ebra

l o

dem

a (M

ann

ito

l)

•A

nti

retr

ovir

al t

her

apy


Emb

olis

m a

nd

In

farc

tio

n•

Pulm

on

ary

emb

olis

m

•C

ereb

ral e

mb

olis

m (s

tro

ke)

•C

ard

iac

emb

olis

m

(myo

card

ial i

nfa

rcti

on

)

•B

reat

hle

ssn

ess

•A

ir h

un

ger

•C

olla

pse

•A

cute

ch

est

pai

n

•Sy

nco

pe

•Ta

chyp

nea

- >

20/m

in

•B

P : 1

) Sys

tolic

s <

90 m

hg.

2) D

isys

tolic

s <

60 m

hg.

•W

eak

pu

lse

•A

bn

orm

al c

hes

t si

gn

s (R

on

chi,

Cre

pts

, eff

usi

on

)

• C

ard

iore

spir

atoy

failu

re

•Sw

eati

ng,

co

ld a

nd

cla

mm

y sk

in

•Va

rio

us

lesi

on

s o

n c

hes

t x

ray

per

tain

ing

to d

isea

se

•A

bn

orm

al E

CG

• C

T/M

RI s

ho

win

g L

esio

n

• IC

U a

dm

issi

on

for

resu

scit

ativ

e p

roce

du

re li

ke

(CA

B) o

r car

dio

resp

irat

ory

su

pp

ort

• B

loo

d c

om

po

nen

t

tran

sfu

sio

n (

up

to 9

0 m

l /kg

b

od

y w

eig

ht/

>5

un

its

of b

loo

d)

• U

se o

f car

dio

ton

ics

/

vaso

pre

sso

rs

(

Mep

hen

tin

e/D

ob

uta

min

e/

D

op

amin

e et

c

•A

nti

coag

ula

nt

ther

apy

•D

rug

s to

red

uce

cer

ebra

l o

dem

a (M

ann

ito

l)


Ma

TER

Na

L N

EaR

MIS

S R

EVIE

W R

EGIS

TER

TO B

E FI

LLED

AT

NO

TIFI

ED IN

STIT

UTI

ON

S/D

ISTR

ICT

Na

ME

OF

THE

FaC

ILIT

Y: _

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

DIS

TRIC

T: _

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

Yea

r:__

____

____

____

____

Mo

nth

:___

____

____

____

____

Sr No

Nam

e H

us-

ban

d’s

/ P

artn

er’s

n

ame

ag

ea

dd

ress

w

ith

m

ob

ile

no.

MC

TS

No.

Dat

e &

Ti

me

of

ad

mis

sio

n

ad

mit

ted

w

ith

no

D

iso

rder

ad

mit

ted

wit

h

Dis

ord

er*

1/2

/3

ad

mit

ted

as

Nea

r M

iss

Inte

rven

tio

ns

do

ne

#D

ate

of

Dis

char

ge

Rem

arks

Sig

nat

ure

of t

he

Do

cto

r In

char

ge

wit

h d

esig

nat

ion

an

d d

ate

12

3N

ame

and

D

esig

nat

ion

Sig

nat

ure

wit

h d

ate

*1 -

Pre

gn

ancy

sp

ecifi

c o

bst

etri

c an

d m

edic

al d

iso

rder

/s

2 -

Pre

exis

tin

g d

iso

rder

s ag

gra

vate

d in

pre

gn

ancy

3- a

ccid

enta

l/ in

cid

enta

l dis

ord

er/s

AN

NEx

URE

03

# In

terv

enti

on

s sh

ou

ld b

e w

ritt

en b

road

ly u

nd

er fo

llow

ing

det

ails

–

-

ICU

adm

issi

on

-

Car

diop

ulm

onar

y re

susc

itat

ion

-

Mec

hani

cal

vent

ilati

on

-

Use

of c

ardi

oton

ics

as v

asop

ress

ins,

dopa

min

e or

dub

otam

ine

-

Dig

ital

izat

ion

in c

ardi

apul

mon

ary

colla

pse

-

Mas

sive

blo

od /b

lood

pro

duct

tran

sfus

ions

-

Intr

aven

ous

high

er a

ntib

ioti

cs

-

Rena

l or p

erito

nial

dia

lysi

s

- Bl

ood

coag

ulat

ion

diso

rder

lead

ing

to h

epar

aniz

atio

n an

d an

tico

agul

ants

-

Man

agem

ent o

f ket

oaci

dosi

s

-

Man

agem

ent o

f sta

tus

epile

ptic

us

- Su

rgic

al p

roce

dure

s as

lapa

roto

my

, hys

tere

ctom

y, b

lync

h su

ture

, ste

pwis

e

vasc

ular

liga

tion

incl

udin

g in

tern

al il

iac

ligat

ion,

rep

air o

f bow

el, b

ladd

er,

Repa

ir o

f vau

lt, c

ervi

cal t

ears

and

dra

inag

e of

hae

mat

oma

etc

-

Any

oth

er in

terv

enti

on w

hich

is li

fe s

avin

g

## T

his

reg

iste

r to

be

pri

nte

d a

t a

3 s

ize

for

actu

al u

se


NOTES

Ministry of Health & Family Welfare Government of India

Nirman Bhawan, New Delhi - 110011Website: www.mohfw.gov.in & www.nhm.gov.in

Maternal Health Division

maternal near miss review

Documents