King Fahad Medical City

Neonatal Intensive Care

Unit

CHECK LIST
Optimizing Medical Care of Extreme Prematurity 23 to 26+6 weeks
Resuscitation, Transport & Admission Process
Date of Delivery: 14/1/2023 Gestational Age:

Time of Delivery: 17:20 Birth Weight: 530 grams

Mode of Delivery: SVD Consultant: Elwasila Hussein Elwasila Eltayeb

Stage (1): Anticipation & Preparation for Delivery

No. Information Done Not Done Comment

/Yes /No
1- Received Dexamethasone or Done Completed dexamethasone
betamethazone
2- Received Magnesium Sulfate Done Completed Mgso4 for neuro protection
3- Received antibiotics Done Completed Intravenously Antibiotics.
4- Notify the Neonatologist on call ?? Time of Attendance: /min
Infant born at: 17:20 ????
5- Bed and ventilator/ CAPAP prepared ???
before going to attend delivery

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6- Notify consultant ( attend) No, was emmergency

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 Stage (2): in labor room
A) Initial Steps & CPAP

No Step Responsibility Done Not Done Comment

1- Pre-warm room temp 23-25 C before delivery NRP Nurse ????
2- Notify the obst. to delay cord clamping NRP Nurse ?????
3- Cover the baby with plastic bag & Hat NRP Nurse ?????
4- Apply CAPAP immediately Physician Ppv then intubation (no time)
5- PPV applied / duration Physician Done

B) Intubation Procedure
No Step Responsibility Done Not Done Comment
1- Pre-Intubation
1-1 Prepare two ETT , Stylet. RT ????
1-2 Prepare the CO2 detector. RT ???
2- Intubation
2-1 Time of Intubation Documentation Nurse Time ( Apgar Time): min
2-2 Number of Intubation Attempts Documentation Nurse Number of Intubation: once
3- Post-Intubation
3-1 If Co2 detector Does NOT Change in color, RT Not done
And physician remove the ETT:
- Provide IPV with facial mask.
- Immediately prepare the 2nd. ETT.
Note: Be sure you prepare the same size of ETT
unless the doctor requests other size.
3-2 Fix ETT and Secure it. RT done
3-3 Surfactant Administration, 10-30 minutes Physician/RT 31 min
postnatal age

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 Stage (3): Transport to NICU

No Step Responsibility Done Not Comment

Done
1- Before Moving
1-1 Check the oxygen saturation & H.R. Physician Done SPO2 : HR: /min
1-2 Check for ENOUGH oxygen supply BEFORE RT Done
moving to NICU.
1-3 Make sure the baby is well warped. NRP Nurse Done
1-4 Inform the admission Nurse about the baby's Documentation Done ?
condition & type of respiratory support. Nurse
2- During Transportation
2-1 Monitor oxygen saturation. Physician Done
2-2 Keep an eye on pressure manometer RT Done ?
Of oxygen cylinder.
2-3 Alarm and notify the physician if there is any RT/NRP Done ?
concern during the transportation. Nurse

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 Stage (4): Admission to NICU
Date of Admission: Time of Admission:

Neonatology Consultant: Assistant/Fellow: (DR)

Charge Nurse (CN): Admission Nurse(AN): Documentation Nurse(DN): Respiratory Therapist(RT):

1- To Achieve Body temperature 36,5 To 37.5 C 2- To Achieve Pre ductal Oxygen saturation 90 %
No Monument Responsibility Done Not Done COMMENTS

1 Position the head 30 degree AN Done

2- Check Axillary Temp at admission AN Done Temp: c

3- Control Noise and Light limits CN Done ?

4- Do baby measurements when baby is settled AN

Wt; on admission , D3
length & HC:D3 ,weekly

5- Do initially peripheral line unless difficult. AN+CN+DR Done

Stabilize the baby then insert UVC and UAC

6- Document start and end time of UVC and UAC fixation. Documentation Nurse Done Start Time : End Time:
Note: Allowed Time 20 minutes
7- Delay insertion OGT until baby settled. AN Done

8- Subsequent doses of Surfactant: DR + RT Not done

2nd dose;______ Fio2:_____
3rd dose:______ Fio2:______

9- Give Loading dose of Caffeine within 12 hours. DR+ AN Done

10- Start TPN Starter. DR+ AN Done

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11- Give first dose of IV antibiotics DR+AN Done

Add Cefotaxime if there is cerclage or baby is sick.

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