Should the baby be intubated before transfer? A lower threshold for intubation should be used than on the neonatal intensive care unit, to minimise the need to intervene in transit. In an infant > 30 weeks gestation, if the vital signs (pulse, blood pressure, respiratory rate, temperature) have been consistently stable in oxygen < 50% and if the Paco₂ is normal, it may be acceptable to move the baby without intubation. If the infant is: unstable

• has a rising oxygen requirement > 50%

• has a rising PaCO₂

• has recurrent apnoea

• is < 30 weeks gestation

If already intubated, the endotracheal tube (ETT) must be correctly positioned and secure. ETTs must be secured to a high standard, to avoid accidental extubation in transit.

Adequate respiratory support must be given.

Surfactant must be administered if indicated.

Arterial access, if not already established, should be considered in infants who require repeated blood gas analysis or accurate blood pressure measurement. If siting a line will not influence practice before or during the journey, then it may be acceptable to delay this until after the transfer.

Correct positioning and security of the catheter must be checked.

Circulation with fluids and/or inotropes should be supported early, as indicated.

Assess temperature and consider the support required for transfer.

Use temperature maintenance adjuncts, such as chemical gel mattresses.^20,21

Measure and stabilise blood glucose.

Secure intravenous access.

Screen for infection as indicated.

Start treatment.

Discuss plans with parents. Ascertain their plans about travelling to referral unit. Liaise with midwifery staff about maternal transfer.

Ensure the team at the referral unit will have all the necessary information to advance the care of the baby.