And Paediatric Mortality and Morbidity

Consultative Council on Obstetric

and Paediatric Mortality and Morbidity

APPENDIX C–Neonatal Death Report Checklist– The death of a liveborn infant, any gestation and weight, less than 28 days

NEONATE DETAILS
Given names: / Surname:
Date of birth: / Date of death:
Agreed Gestation:
Neonatal discharge summary attached:
Including:

• CTGs when the baby died from hypoxic-ischaemic encephalopathy (HIE), or where the CTG was non re-assuring
• Medical condition/disease causing death and its circumstances

/ Yes / No
MATERNAL DETAILS
Given names: / Surname:
Date of birth: / UR number:
Gravidity: / Parity:
Height: / Weight:
Maternal discharge summary attached:
Including:

• Antenatal and intrapartum care

• Underlying conditions including diagnosis and complications

• Co-morbidities

• Post mortem offered

/ Yes / No
Core investigations for all neonatal deaths / Attached
Maternal / Yes / Not yet available / Test not indicated /not performed
Kleihauer-Betke test or flow cytometry / / /
Maternal full blood examination / / /
Maternal group & antibody screen / / /
Maternal renal function tests including uric acid / / /
Maternal liver function tests / / /
Maternal CMV IgM and IgG / / /
Maternal toxoplasma IgM and IgG / / /
Maternal parvovirus B19 IgM and IgG / / /
Syphilis / / /
Rubella / / /
Maternal low vaginal/peri-anal culture (GBS status) / / /
Maternal high vaginal microscopy/culture / / /

APPENDIX C – Neonatal Death Report Checklist(continued)– The death of a liveborn infant, any gestation and weight, less than 28 days

Core investigations for all neonatal deaths / Attached
Infant and placenta / Yes / Not yet available / Test not indicated / not performed
Arterial cord pH or cord lactate / / /
Venous cord pH / / /
Newborn screening test / / /
Cord blood samples (chromosomal analysis, investigation of infection, FBC with smear) / / /
Infant blood group, DCT and antibody screen / / /
Surface swabs (ear and throat) for microbiological cultures / / /
Post-mortem examination performed / / /
If no post-mortem performed, alternative investigations such as
babygram (An x-ray film that visualizes the entire skeletal
system, including the chest and abdomen of a newborn infant), or
relevant biopsies (eg skin, liver and muscle). / / /
Placental microbiological cultures / / /
Macroscopic examination of the placenta, cord and membranes by the clinician / / /
Placenta, cord and membrane histopathology (please DO NOT place in FORMALIN) / / /
Placenta and amnion biopsy for chromosomal analysis
Infant blood samples for haematological assessment (FBC, blood group, DCT, C reactive protein and microbiological culture) / / /
Infant transferrin isoforms if hydropic / / /
Radiological (including CT and MRI) and ultrasound reports / / /
Further maternal investigations based on specific conditions / Attached
Yes / Not yet available / Test not indicated / not performed
Maternal bile acids - fasting / / /
Maternal HbA1c / / /
Thrombophilia screen; including anti-cardiolipin antibodies, lupus anticoagulant, activated protein C resistance (and/or factor V Leiden), fasting homocysteine, protein C, protein S, prothrombin gene mutation, antithrombin III / / /

CCOPMM strongly recommends familiarity with the Clinical Practice Guideline for Perinatal Mortality (2009, Perinatal Society of Australia and New Zealand), available at:. For further information on investigations for high risk newborns, see p.106.

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POST to: CCOPMM, GPO Box 4923, Melbourne, Victoria, Australia 3001