Oregon AWHONN

Promoting the Health of Women and Newborns

December 2017 Vol. 4 No. 11

In This Issue

Hear Ye, Hear Ye: Time, Blood, Pain and Money Saved by Simple Procedure!

Pat Scheans DNP, NNP-BC


When was the last time a new practice change actually made things easier for all involved? Get ready---here it is…


Before tossing out that length of umbilical cord and placenta, first put it to good use. There is evidence to support sparing the neonate pain and blood loss by using the blood that would have been thrown away with the umbilical cord and/or placenta for the initial sepsis evaluation. Often, a limited evaluation is recommended for suspicion of sepsis or chorioamnionitis at birth. This work up consists of a blood culture and a complete blood count (CBC).


Drawing the blood culture from the umbilical cord or placenta is a practice that is quick and easy. The initial blood count can be delayed, and the CDC GBS guidelines reflect this: “Limited evaluation includes blood culture (at birth) and CBC count with differential and platelets (at birth and/or at 6 –12 hours of life)” https://www.cdc.gov/groupbstrep/guidelines/downloads/secondary-prevention.pdf


For those using the Kaiser Sepsis Risk calculator, you may have noted that CBC results are not part of the calculation for initial treatment: https://neonatalsepsiscalculator.kaiserpermanente.org/


This means that, unless baby needs antibiotic therapy, they can stay skin to skin instead of being disrupted/disturbed by a blood draw.


Umbilical cord blood is the fetus’, now newborn’s, blood. (Some NICUs also send CBC and blood spot screens using cord blood.) In terms of bacterial contamination, the germs on the cord or placenta came from the same place that the newborn did. Meticulous disinfection is the key to any blood culture, no matter the site from which it is drawn.


The cord easily provides a generous sample. Larger volumes of blood inoculating the culture bottle improves sensitivity, accuracy and identification of low concentrations of circulating organisms. Experience has shown that adequate samples are still obtainable after delayed/timed/physiologic cord clamping, so keep up the good work on that front.

There is evidence to support sparing the neonate
pain and blood loss by using the blood that
would have been thrown away with
the umbilical cord and/or placenta for
the initial sepsis evaluation

Win-win situation!

  • Less pain for newborns
  • Less crying
  • More babies remain skin to skin
  • Less need for blood transfusions for preterm infants
  • Less family stress
  • Less RN time
  • Less RN stress
  • More accurate results

Initial Steps:
  1. Share literature
  2. Get buy in from all stakeholders
  3. Get approval from laboratory/microbiologist to initiate this procedure (logistics)
    1. Plan for labeling of culture bottle
    2. Plan for documentation: drop down for umbilical cord or placenta as the sample source
    3. Plan for iffy situation: will lab allow drawing and holding the culture for a couple hours until a decision about whether culture is needed (ie baby develops symptoms)

Sample umbilical cord blood culture procedure:
  1. Prebrief with the team about cord clamping plan and whether a blood culture is needed
  2. Clamp umbilical cord segment in the middle so that blood gases and blood culture can be drawn from separate halves of the cord. This keeps the punctures from the blood gases from dripping while the blood culture specimen is drawn. (see illustration)
  3. Blood gases are the first priority if cord draw is difficult/limited.
  4. Draw umbilical cord gases from one-half of cord, since they can only be obtained from the cord. The baby can be drawn for the culture if need be.
  5. Scrub umbilical cord for 30 seconds with chlorhexidine gluconate and allow to air dry.
  6. Draw blood culture specimen from prepped and dried half of the cord while wearing mask and sterile gloves.
  7. Draw blood specimen volume appropriate for type of culture bottle.
  8. Attach sterile transfer needle/device.
  9. Remove the cap from the blood culture bottle and transfer specimen per facility procedure.
  10. Label and transport per facility procedure.
  11. Documentation per facility procedure.

Triple clamp cord segment like so:

Here are a couple of videos that show placental blood draw:

https://www.youtube.com/watch?v=5niR8Y9XB_M

https://www.youtube.com/watch?v=_N7OuhgmxPI

References

Carroll, P. D. (2015). Umbilical cord blood- an untapped resource. Clinics in perinatology42(3), 541-556. DOI: 10.1016/j.clp.2015.04.017


Centers for Disease Control and Prevention. (2016). Group b strep (GBS). Retrieved from

https://www.cdc.gov/groupbstrep/guidelines/algorithms-tables.html


Moore, S. P., Newberry, D. M., & Jnah, A. J. (2017). Use of placental/umbilical blood sampling for neonatal admission blood cultures: Benefits, challenges, and strategies for implementation. Neonatal Network36(3), 152-159. DOI: 0.1891/0730-0832.36.3.152

Upcoming Events

Mid-Willamette Valley Chapter Meeting

I care much more about saving the lives of mothers and babies than I do about a fancy museum somewhere.

Melinda Gates