Mortality review process
Page content: Perinatal definitions and mortality rate (for statistical purposes) | Perinatal death review | Perinatal autopsy service | Post neonatal infant and child death definitions | Post neonatal infant and child death review | Maternal death review
The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) reviews all perinatal, paediatric (from 28 days of age up to but not including the 18th birthday) and maternal deaths in Victoria to consider clinical features of each case and to assess preventability.Perinatal definitions and mortality rate
Stillbirth
The birth of an infant weighing at least 400g or of at least 20 weeks gestation, which shows no signs of life after birth.
Neonatal death
The death of a live born infant, within 28 days of birth, whose birth weight was at least 400g or of at least 20 weeks gestation.
| Stillbirth rate = (per 1,000 total births) |
number of stillbirths x 1,000 |
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total live births + stillbirths
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| Neonatal mortality rate = (per 1,000 live births) |
number of neonatal deaths x 1,000 |
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total live births
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| Perinatal mortality rate (per 1,000 total births) |
(number of total neonatal deaths + stillbirths) x 1,000 |
| total live births + stillbirths |
Note: The term "live-birth" is used in the of Births, Deaths and Marriages Registration Act 1996 and means the birth of an infant regardless of gestational age or birth weight, who breathes or shows signs of life after being born. Such infants require registration as births and if death occurs the Perinatal Death Certificate and Confidential Medical Report on Perinatal Death are to be completed.
Note: The term "live-birth" is used in the of Births, Deaths and Marriages Registration Act 1996 and means the birth of an infant regardless of gestational age or birth weight, who breathes or shows signs of life after being born. Such infants require registration as births and if death occurs the Perinatal Death Certificate and Confidential Medical Report on Perinatal Death are to be completed.
Perinatal death review
The CCOPMM compiles a case file on every perinatal death and submits selected cases to the specialist committees so that any potentially contributing factors in management can be identified. This allows all practitioners to share the benefits of their colleagues' experience. Clinical lessons that might not emerge from an individual practice may readily be apparent from the cumulative experience of around 62,000 births annually.
CCOPMM relies on the co-operation of obstetricians, neonatologists, paediatricians, midwives, general practitioners and medical records personnel to assist with gaining the maximum amount of relevant information on each case.
The Perinatal Death Certificate and the Confidential Medical Report on Perinatal Death are completed for stillbirths and neonatal deaths.
In cases where circumstances are suspicious or where there are suspected serious deficiencies in care, the Coroner should be consulted.
In order to adequately consider and classify perinatal deaths, CCOPMM also requires copies of relevant pathology reports. In particular, in every case of perinatal death, the placenta should be sent for histological examination and a copy should be provided for the CCOPMM. Clinicians are reminded that if the cause of perinatal death is not apparent, an autopsy may well provide important information for the parents in planning for future pregnancy, and this information needs to be transmitted to the parents in a sensitive manner.
The Stillbirth and Neonatal Committees of the CCOPMM consider cases after all available information is collated. On the basis of this information, a judgment is made about suspected contributing factors.
In deciding that a suspected contributing factor was present, the determination is not that death was certainly preventable, but that if a preferable course of action had been followed, the risk of death would be likely to have been reduced. A suspected contributing factor is considered to be present when the management of the mother or infant was considered sub-optimal.
Perinatal autopsy service
In circumstances where there is uncertainty about the precise cause of death, a perinatal autopsy and pathological examination of the placenta will often provide helpful information for the parents as well as for clinicians.
In seeking consent for a perinatal or infant postmortem examination, the understandable reluctance of parents to subject their infant to such a procedure must be respected and dealt with sensitively. Many parents in retrospect regret not having the answers that a post mortem examination may provide, whether they be positive or negative. Furthermore, the results of a postmortem examination may be helpful in the management of a subsequent pregnancy. In approximately one third of "unexplained" stillbirths, an expert postmortem examination reveals an explanation for the death.
In view of the recent adverse publicity surrounding infant autopsies, the Department of Human Services has issued guidelines for hospitals with respect to gaining consent and other aspects of the retention, use and disposal of tissue obtained at autopsy.
It is vital to the accuracy of the CCOPMM's surveys that full advantage be taken of the autopsy service available for perinatal deaths occurring in Victoria, which is subsidised by the CCOPMM. To use the service, the attending doctor, following the obtaining of consent, should contact the pathology department of the nearest teaching hospital with specialist expertise in perinatal pathology and arrange with a funeral director to transport the infant and the placenta. The CCOPMM meets costs associated with the autopsy service, and the service involves no expense for parents. Pathologists and funeral directors should send their accounts, showing all relevant details, to:
The Executive Support Officer
Consultative Council on Obstetric and Paediatric Mortality and Morbidity
GPO Box 4923
Melbourne 3001
Placental pathology
The placenta should be sent to pathological examination in all cases of fetal death, and where possible for all early neonatal deaths. Cultures should be taken from the foetal surface of the placenta in cases of actual or suspected infection. The placenta should be sent for pathological examination in the following additional circumstances:
- Neonatal hypoxic ischaemic encephalopathy
- Small for gestational age
- Pre term delivery < 34 weeks
- Antepartum haemorrhage
- Suspected chorioamnionitis
- Diabetes
- Preeclampsia
- Macroscopic placental abnormalities
Post neonatal infant and child death definitions
- Infant death
- A death, occurring within one year of birth in a live born infant whose birth weight was at least 400g or at least 20 weeks gestation if the birth weight was not known. This category includes neonatal deaths.
- Post neonatal infant death
- A death of an infant aged greater than 28 days and less than one year of age.
- Child death
- A death of a child occurring after and including their first birthday and up to, but not including, their 18th birthday.
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Infant Mortality Rate = |
(number of neonatal deaths + post neonatal deaths) x 1,000 |
| total live births |
Post neonatal infant and child death review
Death certificates are received from the Registry of Births, Deaths and Marriages, and case files are created. Information is then sought from many sources including the following: hospital case records, individual doctors, pathology departments, Coronial Services, and the Newborn Emergency Transport Service. The Infant and Child Mortality Committee reviews interesting, complex or contentious cases. The Committee makes recommendations and discusses potential preventable factors.
Infant and child deaths are classified under the following sections:
- Determined at birth: birth hypoxia, birth defects, pre maturity and other birth determined conditions
- Sudden Unexpected Death in Infancy (SUDI): sudden and unexpected deaths in infants and very young children where an autopsy fails to reveal an adequate cause of death.
- Unintentional Injury: motor vehicle accidents, drowning, fire, asphyxiation and other unintentional injuries.
- Acquired Disease: infection, malignancy and other acquired conditions.
- Intentional Injury: intentional injury and suicide.
Maternal death review
Maternal deaths are reviewed by the Maternal Mortality Committee of the Consultative Council on Obstetrical and Paediatric Mortality and Morbidity (CCOPMM).
Definition
CCOPMM uses the definition of maternal death recommended by the most recent revision of the International Classification of Diseases (ICD-10), which defines maternal death as:
"the death of a woman while pregnant or within 42 days of the termination of the pregnancy irrespective of the cause of death."
CCOPMM reviews and reports separately those deaths which fall into the category of 'late maternal death', i.e. when death occurs within a year of the birth or termination of the pregnancy when the death is from direct or indirect causes, although these occurrences are very rare.
Classification
Maternal deaths are classified into three groups:
- Direct maternal deaths where the death is considered to be due to a complication of the pregnancy itself (for example, haemorrhage from placenta praevia).
- Indirect maternal deaths where the death is considered to be due to a pre-existing condition aggravated by the physiological changes of pregnancy (for example, heart disease, diabetes).
- Incidental deaths, where death is considered unrelated to pregnancy (for example, motor vehicle accident).
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Maternal Mortality Ratio = |
number of maternal deaths (all categories) x 100,000 |
| (total stillbirths and live births) |