1. Certifying perinatal deaths
MEDICAL CERTIFICATION OF Cause of death,
TONGA
November, 2018

2. Perinatal deaths Scope of perinatal deaths: - neonatal deaths
- stillbirths
Neonatal Definition: A child who is born of any age who shows signs of life who dies between 0-27 completed days
- 0-7 days: early neonatal death
days: late neonatal death
Stillbirth (or fetal death): A child who is born who does not show any signs of life
- WHO definition states between 22 weeks completed gestation
and 500grams birth weight
- check with your legislative requirements in-country on definition
A perinatal death can be either a live birth or a stillbirth according to
the World Health Organization definition and formally covers the period
from 28 completed weeks of gestation up to (but not including) 7 days
after birth. The decision regarding the lower limit of the perinatal period
depends on the facilities in the country for a preterm neonate to survive.
In some countries, the perinatal period may start at 22 completed weeks.
Definition needs to be updated – be aware of your own country’s definition – places to look BDM legislation, hospital policy
The death certificate does not ask for an underlying cause of death.
Instead, it asks for the main cause in the fetus (stillbirth) or infant (live
birth), and the main cause in the mother. It asks for other causes and for
other relevant circumstances.

3. Perinatal deaths
Neonatal deaths generally form the majority of infant deaths
High quality data helps us address maternal and infant health
Related to SDG 3:

4. Perinatal deaths 2 types of death certificates possible:
General death certificate
Perinatal death certificate
WHO recommends general death certificate
Demographic information is extremely important for perinatal deaths
2 types of death certificates – normal or perinatal WHO recommends using general now
Remember – neonatals need a birth certificate and a death certificate
Stillbirths should have MCCD as well, but registered only as a birth

5. Certificate of cause of perinatal death
Demographics are really important for infant deaths – birthweight and gestation is important

6. Certificate of cause of perinatal death

7. Enforce, Implement & Evaluate

8. Perinatal deaths Activity:
Look at your own country’s death certificate and document what recommended variables are missing. Record what type of death certificate you are using (i.e. general death certificate or perinatal)

9. Perinatal deaths Conditions in mother versus baby
Very important interaction
Be aware of causes which can occur in both mother and baby
E.g. hypertension, haemorrhage
Need to give more exact terms e.g. pre-eclampsia, abruption of placenta, maternal hypertension
Are conditions pre-existing?
E.g. diabetes (state whether gestational or existing, hypertension, other circulatory conditions)

10. Perinatal deaths
Communicate conditions in mother that may have caused condition in baby
E.g. prematurity
Tell the coder why – early onset of labour from incompetent cervix? Placental abruption? (this helps interventions)
External versus natural
Asphyxia (cord accident, bedclothes over baby)
Congenital versus acquired
E.g. pulmonary hypoplasia, hydrocephalus

11. SPECIFIC CONDITIONS Pre-term labour Growth restriction Prematurity
Use if no clear pathology (e.g. chorioamnionitis) of labour before 37 weeks
Growth restriction
Use best diagnostic tools available
Difficult in many settings
Prematurity
Avoid using without pathology known
Obstructed labour
Enter as main condition if reason is related to mother (transverse pelvis) but enter as secondary condition if reason is for transverse fetus
HIV
Always enter if existent in mother

12. RESOURCES Perinatal review committee at hospital ICD-10 PM
Take to review meetings if you don’t have an official committee
ICD-10 PM

13. FILLING OUT DEATH CERTIFICATE
Need to consider certificate used in your country
Sequence needs to take into account mother and baby
If different from WHO standard consider how to communicate relevant information
Maternal care, existing conditions in mother and maternal conditions all need to be taken into account
Don’t forget to fill out a birth notification and medical cause of death certificate for perinatal deaths

14. ACTIVITY
Do exercises provided – fill out once on WHO recommended certificate. Fill out again on own country certificate and consider how to communicate all relevant information if variables are not included on the death certificate.

15. Activity 1
A pregnant mother with poorly controlled Diabetes Mellitus delivered a infant weighing 3.5 kg at 37 weeks of gestation.
The baby developed hypoglycaemia and had a loud murmur and a large heart on chest x ray.
The echocardiogram showed multiple anomalies in the heart. The baby died on the second day of life.

16. ACTIVITY 2
A 1,480-gram male infant was born at 32-weeks gestation to a 20-year-old primiparous woman. The infant developed respiratory distress syndrome and required mechanical ventilation for 7 days. Despite receiving adequate calories for growth, the infant gained weight poorly and had persistent diarrhea. Steatorrhea was confirmed upon microscopic examination. Results from a sweat chloride test given on the 21st day after birth were negative, but the patient had an elevated sweat chloride concentration of 85 millimoles per liter when the test was repeated at 35 days of age. On the 37th day after birth, the infant became lethargic and was noted to be oedematous. Escherichia coli was cultured from the infant’s cerebral spinal fluid, total serum proteins were reported to be low, and clotting studies were prolonged. The infant died at 45 days of age despite appropriate life-saving efforts. Gross autopsy confirmed the clinical impression of cystic fibrosis.

17. ACTIVITY 3
The patient was a 30 year old woman with a healthy four year old boy. She had a normal second pregnancy apart from hydramnios. Ultrasound examination of the fetus at 36 weeks noted the presence of anencephaly. Labour was induced. A stillborn anencephalic fetus weighing 1500g was delivered.