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235 Appendices NMH Annual Rep t | 2020 This checklist, adapted from the 'STABLE Program', 6th edition, 2013, has been produced by the National Neonatal Transport Programme (NNTP) and endorsed by the Faculty of Paediatrics, Royal College of Physicians, Ireland, in March 2014. – 1 – Clinical Information Criteria (place a tick in the box that Instructions corresponds to the patient information) 1 ≥ 36 weeks gestation Go to ˛ 2 Weight Gestation = 35 weeks gestation May not be eligible Contact cooling centre < 35wks gestation Not Eligible Weight 2 ≥ 1800 grams Go to ˛ 3 Blood Gas < 1800 grams Not Eligible Blood Gas 3 pH < 7.0 Criteria met thus far. or Go to EXAM* pH = ______ Base Excess = ________ Base excess ≥ -16 Source: Cord No gas obtained Go to ˛ 4 History of acute Or or perinatal event 1st infant blood gas at <1hour of life pH 7.0 to 7.15 or Base excess -10 to -15.9 Arterial Capillary Venous May not be eligible; pH >7.15 or Base Excess < 10 Go to ˛ 4 History of acute Time Obtained: ______ : _______ perinatal event 4 Variable / late foetal HR decelerations Any ticked, Prolapsed / ruptured / tight nuchal cord Go to ˛ 5 Apgar score Uterine Rupture Acute Perinatal Event Maternal haemorrhage / placental abruption (tick all that apply) Maternal trauma (eg. vehicle accident) Mother received CPR No perinatal event May not be eligible; or Go to ˛ 5 Apgar score Indeterminate what the event was because of home birth or missing information Apgar Score at 5 Apgar ≤ 5 at 10 minutes (yes) Criteria met thus far. Go to EXAM* Apgar ≤ 5 at 10 minutes (no) Go to ˛ 6 Resuscitation (no, was 6 or greater at 10 minutes) after delivery Resuscitation after Delivery 6 Continued need for PPV or Criteria met thus far. (tick all that apply) Intubated at 10 minutes?(yes) Go to EXAM* _____ PPV/intubated at 10 minutes _____ CPR PPV/Intubated at 10 minutes?(no) May not be eligible _____ Adrenaline administered Go to EXAM* 1 minute ___________ 5 minute ___________ 10 minute ___________ CANDIDACY CHECKLIST FOR NEONATAL THERAPEUTIC HYPOTHERMIA (COOLING) PATIENT'S NAME: ______________________________________________ HOSP. NO: ___________________ TIME of BIRTH: ______:______ hrs. CURRENT AGE in hours /minutes: ______ hrs.______ mins. If current age is greater than 6 hours, call tertiary cooling centre before proceeding. Directions for the use of this checklist: Start at the top and work through each numbered component. When directed to proceed to the exam, refer to the exam found on page 2. If there is missing data,(such as a known perinatal event and / or Apgar scores) and you are in doubt as to whether or not the patient qualifies for cooling, consult with the tertiary cooling centre promptly to discuss the patient. *Note: If patient is < 6 hours old and meets the gestation, weight and blood gas criteria and has a witnessed seizure, patient is eligible for 'COOLING' regardless of additional exam findings. Consult the tertiary cooling centre to discuss any questions or concerns.