MATERNAL NEAR MISS REVIEW
Transcript of MATERNAL NEAR MISS REVIEW
MATERNAL NEAR MISS REVIEW
December 2014
Operational Guidelines
Ministry of Health & Family Welfare Government of India
Maternal Health Division
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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]
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Government of IndiaDepartment of Health and Family Welfare
Ministry of Health and Family Welfare Nirman Bhawan, New Delhi - 110011
PREFACE
LOV VERMASecretary
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Government of IndiaDepartment of Health and Family Welfare
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
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]
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Government of IndiaDepartment of Health and Family Welfare
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
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 - 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
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]
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Government of IndiaDepartment of Health and Family Welfare
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
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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
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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
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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
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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
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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
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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.
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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;
Maternal Near Miss Review Operational Guidelines - December - 201418
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.
Maternal Near Miss Review Operational Guidelines - December - 2014 19
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.
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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
Maternal Near Miss Review Operational Guidelines - December - 2014 21
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;
Maternal Near Miss Review Operational Guidelines - December - 201422
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
Maternal Near Miss Review Operational Guidelines - December - 2014 23
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
Maternal Near Miss Review Operational Guidelines - December - 201424
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.
Maternal Near Miss Review Operational Guidelines - December - 2014 25
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
Maternal Near Miss Review Operational Guidelines - December - 201426
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
Maternal Near Miss Review Operational Guidelines - December - 2014 27
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
Maternal Near Miss Review Operational Guidelines - December - 201428
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
Maternal Near Miss Review Operational Guidelines - December - 2014 29
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)
Maternal Near Miss Review Operational Guidelines - December - 201430
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
Maternal Near Miss Review Operational Guidelines - December - 2014 31
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
Maternal Near Miss Review Operational Guidelines - December - 201432
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
Maternal Near Miss Review Operational Guidelines - December - 2014 33
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
Maternal Near Miss Review Operational Guidelines - December - 201434
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
Maternal Near Miss Review Operational Guidelines - December - 2014 35
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.
Maternal Near Miss Review Operational Guidelines - December - 201436
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
Maternal Near Miss Review Operational Guidelines - December - 2014 37
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)
Maternal Near Miss Review Operational Guidelines - December - 201438
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
Maternal Near Miss Review Operational Guidelines - December - 2014 39
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
Maternal Near Miss Review Operational Guidelines - December - 201440
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
)
Maternal Near Miss Review Operational Guidelines - December - 2014 41
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
Maternal Near Miss Review Operational Guidelines - December - 201442
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)
Maternal Near Miss Review Operational Guidelines - December - 2014 43
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
Maternal Near Miss Review Operational Guidelines - December - 201444
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