Professional Documents
Culture Documents
Annexure-1
CONFIDENTIAL
NOTE:
1. This FBMDR Form must be completed in duplicate for all maternal deaths, including
abortions and ectopic gestation related deaths, in pregnant women or within 42 days after
termination of pregnancy irrespective of duration or site of pregnancy.
2. Mark with an ( ) where applicable (mark with ?` when uncertain).
3. Attach a copy of the case sheet/records of the deceased with this form.
4. Complete the form in duplicate within 24 hours of a maternal death. The original remains at
the institution where the death occurred and the copy is sent to the District MDR
Committee for district level monthly review.
(Ref. Chapter 3, para 3.7 & 3.10 of MDR guidelines)
Block: .. District: .
Live Births
Still Births
Abortions
Day
Month
Date of admission:
Day
Date of Delivery:
Month
Day
Date of death:
Year
min
Hrs
min
Hrs
min
Time of admission
Year
Month
Hrs
Time of Delivery:
Year
Time of death:
24x7
PHC
SDH/RURAL
HOSPITAL/CHC
DISTRICT
HOSPITAL
MEDICAL
COLLEGE/TERTIARY
HOSPITAL
PRIVATE
HOSPITAL
PVT
CLINIC
OTHER
Ectopic
pregnancy
Not in labour
In labour
ABORTION
Postpartum days--
Previous C Abortion
section
(Specify
type)
Ectopic
pregnan
cy
Vesicular
Mole
Anaemia
Multiple
pregnancy
APH
CPD
Abnormal
presentati
on
PPH
Hydramnios
Diabetes
PET/
Eclampsia
Medical
conditions
Others
Ectopic
pregnancy
Not in labour
In labour
ABORTION
Postpartum days--
PPH
Abortion
(specify)
Ectopic
pregnancy
Vesicular
Mole
Anaemia
(failure)
Diabetes
Eclampsia
APH
Inversion
of uterus
Post
operative
complicati
on
Pulmonary
embolism
CVA
Medical
condition
Others
Hrs
Hrs
mins
mins
24x7 PHC
SDH/Rural
Hospital/
CHC
District
Hospital
Private
Hospital
Private clinic
Others
Induced
Incomplete
MVA D&C
Illegal
MVA D&C
Hysterotomy Others
3. Post Abortal Period Uneventful Sepsis Haemorrhage others
Extra Amniotic Installation
No
Yes No
Yes No
Yes No
Yes No
Yes
Days Hrs
4. Time taken to initiate treatment since onset of the problem
5. Was the termination procedure done in more than one centre Yes
No
V. ANTENATAL CARE
Pregnancy registration Status: Y/N
Lack of awareness
Lack of accessibility
Lack of attendee
Family problems
Yes
No
Dont know
Lack of funds
If Yes, Number of ANC CHECKUPS& Type of Care Provider (mark one or more):
M/O PHC
Short
stature
APH
Abortion
hydramnios
Ectopic
pregnancy
Big baby
Vesicular
Mole
Abnormal
presentation
Anaemia
Diabetes/GDM
PET
Grand
multi
Medical
conditions
Others
Specify
Preterm
labour
Surgical
conditions
Ectopic
pregnancy
Eclampsia
Preterm
labor
Leaking
membranes
Anaemia
(with/without
failure)
Vesicular
Mole
Anaemia
(with/without
failure)
Heart Disease (with/without
failure)
Other
Medical
conditions
Others
Specify
Hrs Mins
Hrs Mins
At the present Institution Hrs Mins
At the first point of contact
Comments on antenatal care, complications and list medication, if any (give details of
Tablet Iron, Folic acid also):
Yes
No
Yes
Yes
Duration of labour:
Mode of Delivery
Undelivered
Eclampsia
Dont know
No
Dont know
No
Obstructed
labour/
Rupture Uterus
Inversion
of Uterus
Others
Specify
hrs mins
SpontaneousVaginal
(with/without episitomy)
Vacuum/forceps
Caesarean section
Time taken to initiate treatment since the onset of the Problem: Hrs
Mins
Second stage
Third stage
Fourth stage
If eventful, specify
PPH
Sepsis
CVA/PE
Anaemia
Eclampsia
Post
partum
Psychosis
Post op
Medical
complica condition
tion
s
Others
No
No , If yes, specify
Early pregnancy
Antenatal
Intrapartum
Postpartum
Anaesthesia/ ICU
Evacuation
Transfusion
Transfusion
Version
Removal of
retained POC
Laprotomy
Anaesthesia GA
Spinal
Laprotomy
Other
surgeries
Instrumental
del.
Caesarean
section
Hysterectomy
Transfusion
Local
Transfusion
Hysterectomy
Epidural
Hysterectomy
Hysterotomy
Manual
removal of
placenta
ICU monitoring
Details of Baby:
Baby Birth
Weight(gms)
(gms) (gms)
Needed resuscitation:
Apgar
Score
Outcome
Still
born
Alive
at
birth
Died
immediately
after birth
Alive at:
7 days 28 days
Yes / No
MBBS
doctor/ other
specialist
Staff Nurse
Others
(specify)
hrs
Aspiration
including
MAS
Congenital Preterm
Anomalies
Respirator
y distress
Others
VIII.
System
Example
Personal/Family
Y N
Specify
Refusal of treatment
or admission
Refusal of admission in facility
Logistical Problems
Facilities
Health personnel
problems
Lack of OT availability
Lack of human resources
Lack of Anesthetist
Lack of Surgeons
Lack of expertise, training or
education
IX. AUTOPSY:
Performed
Not Performed
If performed please report the gross findings (and send the detailed report later):
X. CASE SUMMARY: (please supply a short summary of the events surrounding the death)
Designation:
Name & address of the Facility:
Block/Tehsil:
District: