Professional Documents
Culture Documents
Year
State : ..........................................................
PNM1/97
(Pindaan 2000)
Hospital / District : ..
Please complete a form for all of birth weight equal to or more than 500 g (or 22 completed weeks of pregnancy if birth weight is not known)
to 27 completed days of age. Please tick (3) in relevant box.
1.
MOTHER
2.
(c) Early neonatal death (age : 0-6 days and BW > 500 g)
(d) Late neonatal death (age : 7-27 days and BW > 500 g)
13.
Mother's name :
Delivered by:
other doctor
Obstetrician
Staff Nurse
6.
unknown
Murut
Iban
Bidayuh
singleton
non-citizen
specify : .
5.
triplets
twin
unknown
4 and above
unknown
(applies only for multiple births - specify 1st, 2nd, 3rd etc)
15.
no
Chinese
Indian
Bajau
Melanau
vaginal bleeding
other
Indigenous
group in Sabah
& Sarawak
Orang Asli
(S. Malaysia)
diabetes mellitus
THIS PREGNANCY
7.
Gravida
8.
Abortion
unknown
FOETUS/NEONATE
unknown
16.
Sex :
male
female
unknown
indeterminate
9.
10.
ultrasound
unknown
17.
day
month
year
unknown
18.
24 hour clock
(g) others
specify : ..
(h) unknown
District :
(e) others:
specify ....
19.
State : .
day
please indicate the District and State with most number of antenatal
visits
12.
11.
unknown
Para
TBA
unknown
others
JD/Midwife
Place of delivery:
(a) home
(g) others
specify : ..
(h) unknown
20.
month
year
24 hour clock
DEATH
Is it stillbirth or livebirth?
STILLBIRTH
LIVEBIRTH
Is it macerated or fresh?
Macerated
Stillbirth
Is there any LCM?
(a) LCM
present
Fresh
Stillbirth
Is there any LCM?
LCM
(a) LCM
LCM
absent
present
absent
LCM absent
Is gestation <37 weeks?
(a) LCM
present
(b) Normally
formed MSB
(c) Asphyxial
condition
Asphyxial condition
absent
did the baby die from infection?
(e) Infection
present
infection absent
are there any other specific
causes of death?
Note:
LCM = Lethal Congenital Malformation
MSB = Macerated Stillbirth
FSB = Fresh Stillbirth
21.
(c) Asphyxial
condition Present
(g) unknown
cause
Death Classification
a) Lethal Congenital malformation/defect (SB & ND)
Specify:
neural tube defects (eg. anencephaly, large
spina bifida)
complex/cyanotic heart disease
recognisable syndrome (eg. Edward, Patau)
Others (specify)
not recognisable syndrome eg.multiple gross
congenital abnormalities.
hydrop foetalis
others (please specify)
(b) Normally formed MSB (SB)
Reporting Officer :
Name
Designation
Contact address
:
:
:
APPENDIX 2.1
Fill in the year in which the death occurred in the boxes provided. The case number will be
computer generated.
Case No.
Year
Write down the name of the state and district where the death occurred.
Item 1
MOTHER
Item 2
Item 3 (a)
I/C No. :
fill in the new IC number
if not available, enter the number (No.) from other documents (eg. Passport number, old
I/C number)
(b)
citizen
non-citizen (include permanent resident) and specify citizenship status if not
Malaysian citizen eg.
unknown
Indonesia
Philippines
Thailand
Bangladesh
Myanmar
Singapore
India
Brunei
Vietnam
Pakistan
others
Item 4
write down the mothers permanent residential address at time of antenatal care
Item 5
mothers age in years (to nearest completed year) obtained from the I.C/any
identification document.
Item 6
THIS PREGNANCY
Item 7
state the gravida, para and abortion status of the pregnancy before the delivery occurs.
Item 8
Item 9
ii
Item 10
fill in time of delivery if known, according to 24 hours clock. If time is not known, then
tick unknown
Item 11
Item 12
Place of delivery:
fill in the place of delivery. If the baby is delivered while the mother is being transported
to intended place of delivery, tick box during transport. If others specify eg. In the
bush, public toilet etc.
Item 13
Delivered by :
refers to the person who conducted the delivery. If unknown, tick in the box provided.
Tick under others for husband, mother, in-laws, friend, etc.
Item 14(a)
Item 14(b)
In multiple pregnancies, specify the birth order of foetus/baby who died eg. 1, 2, 3, etc.
(this item applies only for multiple births and not previous pregnancies).
Item 15
hypertensive disorders of
pregnancy
diabetes mellitus
vaginal bleeding
anaemia
prolonged rupture of
membranes
preterm labour
iii
FOETUS / NEONATE
Item 16
Sex of foetus.
Item 17
Item 18
Place of death:
specify for FSB/livebirth only.
if dead on arrival to classify as 'during transport'.
Item 19
Item 20
Item 21
Cause of death:
a)
b)
c)
d)
iv
e)
o
o
o
f)
g)
Unknown
where cause of death is not known, tick unknown
Death
Is it stillbirth or livebirth?
Stillbirth
Is it macerated or fresh?
Macerated
Stillbirth
Is there any LCM?
LCM
present
LCM
absent
Livebirth
Is there any LCM?
Fresh
Stillbirth
Is there any LCM?
LCM present
LCM
present
LCM
absent
LCM absent
Is gestation < 37 weeks?
Conditions associated
With immaturity
Normally
formed MSB
Asphyxial
Condition
Infection present
Asphyxial condition
present
Infection absent
Are there any other specific causes
of death?
Other specific
condition
Unknown
cause
(b)
a high congenital malformation rate may raise questions about facilities for
perinatal screening or procedures for early neonatal diagnosis of potentially
treatable lesions eg. congenital heart disease.
(c)
vi
References:
1.
Wigglesworth JS. Monitoring perinatal mortality. A pathophysiological approach. Lancet 1980; ii : 684-6
2.
Keeling JW, MacGillivray I, et al. Classification of perinatal death. Arch Ds Child 1989; 64 : 131-51
3.
Hey EN, Llyod DJ. Wigglesworth JS. Classifying perinatal death : fetal and neonatal factors. Br J Obstet
Gynaecol 1986; 93 : 1213-23
4.
Barson AJ, Tasker M, Lieberman BA, Hillier VF. Impact of improved perinatal care on the causes of death.
5.
Wong SL, Teng SC, Mohan AJ, Cheng HH, Ariffin, K. A. study of perinatal mortality in selected districts in
Negeri Sembilan and Perak. Health System Research Report, Public Health Institute, Malaysia 1988.
6.
Amar HSS, Maimunah AH, Wong SL. Utilisation of Wigglesworth Pathophysiological Classification for
Perinatal Mortality in Malaysia. Arch Ds Child 1996; 4 : F56-59.
vii