FIMR Project Area: AL7
Case Summary # 1
FIMR Project Area: AL7
FIMR ID: AL700
FIMR Case #: AL700
Case Type
Type Death : Infant
Gender: male
Age unit: days
Days baby lived: 19
Primary Cause of Death: SIDS
Cause of death: SIDS
Info Sources
General Completeness of Records: Adequate
Sources of Information
CMS
EMS
Hospital records
Prenatal Care provider
Vital Stats
Issues
EMS
Hospital records
Maternal Interview
Maternal Interview Declined
Type Contact: Letter
Type Contact: Phone
Type Contact: Phone
Notes
Information obtained from prenatal care provider, care coordination record, hospital record, pediatrician’s office record, EMS record and ER records. Program card sent and returned. Follow-up phone call X 2. Spoke with patient by phone and patient declined maternal interview. No documentation of sleep position noted in EMS or hospital death record.
Parental Demographics
Mother’s
Race: black or African American
Hispanic/haitian: Not applicable
Marital Status: Single
Age at delivery: 21
Education: College no degree
Father’s
Race: Black of African American
Hispanic/Haitian: Not Applicable
Marital Status: Single
Age at delivery: 22
Education: College no degree
Psychosocial Overview
Life Course Perspective
Mother was in foster care from age 10-12.
Income Employment
Household Info- No Info
Mom’s Employment – Student
Dad’s Employment – Student
Housing
House
Transportation
Owns car
Financial Assistance Prior to Pregnancy
Family members
WIC
Received Referrals/ Assistance with
WIC
Social Support
Church members
Family members
Father of baby
Friends
Home Visitor
Violence/Abuse
No issues
Payment of care
Prenatal: Medicaid HMO
Labor and delivery: Medicaid HMO
Pediatric: Traditional Medicaid
Reimbursement Issues
No Issues
Notes
Mother lives at home with her mother and siblings. Has been in relationship with father of baby for several years. Both are third year college students. Record indicate strong family support and clergy support. Home visit completed by care coordinator.
Mom’s Medical History
Dental/gum infection: wisdom teeth extraction
Gastrointestinal condition: cholecystectomy
Other: repair of broken nose
Mom’s OB History
Pregnancy History
# children – 0
# live births – 0
# SABS/IUFDs/TOPS – 0
FAMILY Planning
Gravida – 1
Intention of pregnancy – unplanned
Pregnancy
Prenatal Care
Provider – OB
Week entered prenatal care : 9
# Visits – 15
Initial PN labs
9 weeks 3 days
AB0 – AB + negative AB screen
Hemoglobin and hematocrit: Hgb 10.2 Hct 32.8
Hepatitis B – negative
HIV – negative
PAP – WNL
Rubella – Immune
Syphilis – RPR nonreactive
Vaginal Culture – GC negative, Chlamydia negative
Routine second Trimester Labs
Declined AFP/triple/Quad screen
Labs 2nd and third trimester
28 weeks and three days
3 hour GTT 86, 139, 153, 124
31 weeks
24 hour urine details: 332 gm protein
Fetal Assessment
10 weeks 0 days
Office ultrasound
+ cardiac activity estimate dates
19 weeks 2 days
Office ultrasound
+ cardiac activity Fetal anatomy WNL
Mom’s Weight & BMI
Pregravid weight (lbs); 205
Height – 5 feet 5 inches Total inches 65
BMI – 34.1
BMI ranking – obese
Weight at delivery: 213
Weight change: 8
Weight gain result: inadequate
Substance Abuse
Smokes < 1 ppd
Conditions During pregnancy
Hypertension (pregnancy induced)
Obesity
Education during pregnancy
Common discomforts/relief measures
Complications/danger signs
Signs/symptoms of genitourinary infection
Signs/symptoms preterm labor
Signs/ Symptoms ruptured membranes
Signs and symptoms that should be reported immediately
Who to call after hours and weekends
Bedrest and PIH symptoms
Prenatal Care notes
Patient entered prenatal at 9 weeks gestation. Initial labs values were WNL. Pt developed increased in blood pressure and was placed on bedrest at 30 weeks gestation. Patient was admitted at 35.1 weeks gestation for bedrest observation due to increase in BP with headache and visual spotting.
Admission
Admission Information
Gestation 35 weeks 1 day
Level of hospital: B
Temp – 98.5 Pulse 81 Resp 18 BP 150/100
Presenting Symptoms and Previous Treatments: Increased BP with headache and spots in vision.
Admission Reason: Hypertension
Admission Findings
Membranes Intact
Vaginal Exam 1/50/-2
Contractions – none
Fetal heart rate – 140’s
Labs ordered on admission
ABO – AB+ negative antibody screen
SGOT – 28
WBC 8.1 Hgb 10.4 Hct 30.7
Platelets 256
Group B strep negative
24 hour urine – protein 360 creatinine cl 138
Urine C & S lactobacillus
Notes
Patient admitted from MD office for increase blood pressure. Daily NST and monitoring of BP continued for 6 days. Pt to be induced at 36 weeks. Cervidil placed at 1700 on 4/3/11. Magnesium started at 1720 at 2 gm/hour. In the am on 4/4 Ve 3/80/0. Amniotomy performed with clear fluid. Pitocin augmentation started and labor lasted 6 hours.
Delivery
Gestation 36 weeks
Delivery method – spontaneous vaginal
Person delivering baby – OB
Support person with mother in L & D – father of baby
Notes: patient pushed for about 20 minutes. Infant delivered OP over 2 degree MLE. Placenta expressed intact. Epidural anesthesia. 3 vessel cord. Patient remained on magnesium sulfate
Placenta Pathology
No info
Postpartum Care
Patient remained on Mgso4 and was discontinued 4 hours after delivery. BP remained elevated and patient was placed on Procardia XL 60 mg daily and was discharged on medication.
Duration of PP stay – 3 days
Family Planning – Depo Provera
Postpartum teaching
Family planning/birth spacing
Fluid intake
Medications
PP self care
Return to work
Vaginal rest warning signs of when to call doctor
Ambulatory Postpartum care
Postpartum Appointment 6 weeks kept
Weight 188 Blood pressure 122/72
Depo provera injection given
UA negative Hct 30
Newborn Assessment
Birth Weight 6 pounds 10 ounces 3005 grams
APGAR 8 at 1 min 9 at 5 minutes
Description of Baby at delivery:
Alert, pink spontaneous respirations
Crown-Heel Length: 47 cm
Head circumference : 33 cm
Stimulation at birth no issues blue bulb suction
Temp 97.2 Heart rate 148 Respiratory rate 48 BP 65/42
Notes:
Infant discharged at 48 hours. Infant breastfeeding well. Discharge weight 6-12. NBS normal. Hearing Screen passed.
Discharge teaching
Back to sleep
Bathing
Breastfeeding education support
Care of circumcision
Care seat safety
Cord care
Infant care
Infant safety
Medical follow-up
Recognizing illness/complication
Safe sleeping
Signs/symptoms requiring immediate attention
Voiding/stooling
Weight gain
Well-baby care
Ambulatory Pediatric Care
Provider Type – Pediatrician
Number of well baby visits – 1
Infant seen in pediatrician office at 2 weeks. Weight 7 -10 temp 97.6 HR 124 Resp 32 Head circ 34.5 Length 48 cm. Mild hip click felt U/S obtained normal
ER hospitalizations
Reason for Visit
Full arrest unresponsive. Father found baby unresponsive. Father had laid down to rest two hours prior. No evidence of trauma. No spontaneous respirations. No pulse. Abdomen distended. Pupils fixed and dilated.
Death in hospital
Father laid down to rest approximately 2 hours later woke up and found the baby unresponsive. Father called 911. Infant was in full arrest and unresponsive. No evidence of trauma. No spontaneous respirations and no pulse. Pupils fixed and dilated. Abdomen distend. Entubated with 2.5 ETT. IV started in R arm. NG tube placed with significant aspirate noted. CXR confirmed NG tube placement. X ray report shows increase opacity in right upper lung field. Epinephrine given at 1715, 1730 and 1745. NS boluses given. Infant was then pronounced. No documentation of sleep position noted in ER record on EMS record.
No scene investigation or autopsy performed.