|
Maternal
|
| Previous preterm birth |
|
Antenatal
|
| Maternal antibiotics in labour |
| Antenatal corticosteroids |
|
Baby and birth
|
| Date and time of birth |
| 1st SCN admission (date, time and admitted from) |
| Intubated at resuscitation |
| Temperature at admission |
| Base excess after birth |
| Cord lactate and first lactate |
| Hypoxic-ischaemic encephalopathy |
| Seizures |
|
Respiratory
|
| Main indication for respiratory support |
| Surfactant |
| Method of administration of first dose of surfactant |
| Date and time of surfactant first given |
| Numbers of doses of surfactant |
| Air leak requiring drainage |
| Date and time of first drainage of pulmonary air leak |
|
Respiratory support
|
| IPPV (intermittent positive pressure ventilation) |
| Date and time intubated for ongoing ventilation |
| Date and time of final extubation from mechanical ventilation |
| Remain ventilated/ongoing ventilation at final discharge |
| Nasal CPAP (continuous positive airway pressure) |
| Date and time of initiation of nasal CPAP |
| Date and time of final cessation of nasal CPAP |
| Remain nasal CPAP at final discharge |
| Nasal high flow |
| Date and time of initiation of nasal high flow |
| Date and time of final cessation of nasal high flow |
| Remain nasal high flow at final discharge |
|
Cardiac
|
| Patent ductus arteriosus |
| Pharmacological treatment for patent ductus arteriosus |
|
Infection
|
| Probiotics |
| Infection (type and date of specimen) |
| Antibiotics/antiviral (name, date and time) |
|
Nutrition
|
| Parenteral nutrition |
| Date and time of initiation |
| Date and time of cessation |
| Remain parenteral nutrition at final discharge |
|
Feeding
|
| Breast milk feeding at onset of enteral feeds |
| Donor breast milk in any quantity |
| Breast milk (any) at discharge to home |
|
IVH and cranial ultrasound
|
| Left and right IVH |
| Cerebellar haemorrhage |
| 6-week head ultrasound |
|
Other suggested items
|
| Hypoglycaemia |
| Lowest blood glucose + date and time |
| Treatment |
| Signs |
| Neonatal abstinence syndrome |
| Maternal medication/substance use |
| Treatment |
| Jaundice |
| Highest total bilirubin (level + test date and time) |
| Treatment |
| Vitamin K given |
| Final destination from this hospital |
| Transferred to another hospital |
| Death |
| Discharge to home |
| How many admissions altogether to this special care nursery (SCN)? |
| Date of 2nd SCN admission and discharge |
| Date of 3rd SCN admission and discharge |
