Launceston General Hospital SDMS ID:0 fP2010/0481-001 Clinical Guidelines 2.

6-07WACS Title: DRAFT Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: Umbilical cord blood analysis is an objective measure of fetal response to labour. Paired arterial venous sample of umbilical cord are recommended as arterial-venous differences of blood gas parameters may indicate (i) the etiology of fetal acidosis and (ii) the duration of the hypoxic insult. Definitions: Pathological fetal acidaemia is defined as an umbilical artery blood pH of less than 7.00. A base deficit of >12mmol/L suggests metabolic acidosis and is associated with an increased risk of neonatal morbidity. Umbilical artery acid-base status should be performed as a minimum after: Abnormal fetal heart rate in labour When a fetal blood sample has been taken in labour Instrumental vaginal delivery Emergency caesarean section Birth, if the babys condition is poor Apgar less than 7 at five minutes. Procedure: Immediately after birth and while the placenta is still insitu double clamp a 20 cm segment of cord. Sampling of the cord gases can now be delayed until after the delivery of the placenta. Using heparinised syringes take blood from the umbilical artery first and then the umbilical vein. Remove all air bubbles from the samples and gently roll the syringes for 20 seconds. Analyse the samples as soon as possible after collection. If there is likely to be a delay place the syringes in a slurry of crushed ice and water. Record the results. Normal Cord Blood Gases and pH in Term Infants pH Base Excess mmol/L Umbilical Artery 7.10 to 7.38 -9.0 to 1.8 Umbilical Vein 7.20 to 7.44 -7.7 to 1.9
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Umbilical Cord Blood Collection and Analysis Cord pH Sampling 2.6 Collection and analysis of umbilical cord blood for assessing fetal hypoxia. Midwifery and medical staff, QVMU Umbilical cord blood, cord pH

pO2 mmHg 4.1 to -31.7 30.4 to 57.2

pCO2 mmHg 39.1 to 73.5 14.1 to 43.3

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Competency All staff performing blood gas analysis using the blood gas analyser should: Attend a training session with accredited trainer. Be allocated their own user ID when competency demonstrated. Attend an annual refresher and/ or assessment with pathology staff or accredited trainer.

Attachments Attachment 1 Attachment 2 Attachment 3

Background Information Essential Steps for Blood Gas Syringe Samples (GEM 3000) References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 BACKGROUND INFORMATION Umbilical artery pH and BE values are directly related to fetal production of carbon dioxide and of lactate as the principal fixed acid contributing to metabolic acidosis in the fetus, and inversely related to umbilical flow as the conduit for clearance of these metabolic by products from the fetus. Umbilical vein pH and BE values in turn are related to the delivery of carbon dioxide and lactate to the placenta by the umbilical artery relative to their clearance by the placenta. A difference in partial pressure of carbon dioxide of more than 25mm Hg between arterial and venous umbilical cord gases suggests an acute rather than chronic acidosis.

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ATTACHMENT 2

Collection of Blood Gas Samples

Point of care testing equipment provides reliable results PROVIDED the sample is of the highest quality.

Essential Steps in collection of Blood Gas Syringe Samples (GEM 3000)

1 Expel Air Any air present in the sample will greatly affect the results. Expel any air. (Sample 0.2 mL) Mix Mix Mix Immediately after collection mix the sample thoroughly. This will prevent the sample from clotting. (20 times, 20 seconds) Store on Ice If there is any delay in analysis (> 5 minutes) store the sample on ice. Mix Mix Mix Remix the sample before analysis. Red cells settle out very quickly. (20 times, 20 seconds) Check for Clots Expel a small drop of blood onto a tissue, look for any signs of clotting. DO NOT analyse the sample if clots are present. You risk taking the analyser off-line and affecting more patients. Collect another specimen. Analyse Sample You have followed all the steps to collect a good sample so everything should be fine. Problem? Insufficient Sample? Clot Detected? DO NOT keep trying with that sample. You risk losing the analyser and affecting every patient on the unit. (PS: the message insufficient sample means that the sample cannot be aspirated. This often means the sample is clotted, not necessarily that there isnt enough blood.)

Essential Steps in collection of Capillary Gas Samples (GEM 3000)

1 Ensure a Good Blood-flow A good and rapid blood-flow is the most critical step. Wipe away the first drop, it contains tissue fluids which will distort the results. Fill Capillary Quickly The rapid filling of the capillary helps to ensure adequate mixing of the sample. Incline the capillary slightly so the blood runs uphill. This avoids air-bubbles. Twirl the capillary to mix. (Sample 0.15 mL, the third mark on capillary). Analyse Without Delay Samples must be analysed without delay. Continue to Twirl samples until analysis.
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ATTACHMENT 3 REFERENCES Harris M, Beckley S, Garibaldi J, Keith R & Greene K 1996 Umbilical cord blood gas analysis at the time of delivery Midwifery 12, 146-150. Maclennan A 1999 A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. BMJ 319, 1054-9. Ramin S 2005 Umbilical cord blood acid-base analysis. Online: http://uptodateonline.com/utd/contnent/topioc.do?topicKey=labordel/1115&view=print Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2006, Intrapartum Fetal Surveillance. Clinical Guidelines Second Edition Royal College of Obstetricians and Gynaecologist 2001 The use of electronic fetal monitoring: The use and interpretation of cardiotocograhy in intrapartum fetal surveillance . Evidence-based Clinical Guideline Number 8. Shallow H 2003 Should cord pH be performed routinely after normal birth? Midwives vol. 6 no. 1, 28-31. Victory R, Penava D, da Silva O, Natale R & Richardson B 2004 Umbilical cord pH and base excess values in relation to adverse outcome events for infants delivering at term. American Journal of Obstetrics and Gynaecology 191, 2021-8.

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