Contraindications

This is usually an emergency procedure with no contra-indications in this setting.

It is argued that intraosseous access is quicker and it may be more appropriate if readily available.

Equipment

• Personal protective equipment
• Sterile gloves
• Sterile drapes
• Skin prep eg. chlorhexidine
• Umbilical catheter 3.5F or 5F
• Iris forceps/small curved haemostat
• Scalpel
• Scissors
• Umbilical tape
• Suture and needle driver
• Adhesive tape
• Intravenous tubing and 3-way stopcock
• 3ml or 5ml syringe containing N. Saline

Procedure

• Prepare
  
  • Prime the umbilical catheter by attaching a 3-way tap to it and connecting a syringe containing saline to one of the ports. Push the salline so that a small amount flows from the other end of the catheter.
  • Have all the instruments and equipment ready
• Keep warm
  • Ensure the infant is kept warm - ideally under a well lit radiant heater.
• Keep it clean
  
  • Given the nature of neonatal resuscitation this procedure is usual somewhat time pressured. Do your utmost to ensure sterility.
  • Prep the skin with chlorhexidine or the agent that your facility uses.
  • Place sterile drapes to create a sterile field.
• Place the umbilical tape
  • around the base of the cord. Tie a loose, single knot, so that it can be tightened later.
• If you have an assistant
  • you may ask them to lift and thus support the cord, with small haemostats or similar, whilst you are working. This is not essential.
• Cut the cord
  • Lift up the end of the cord and cut it cleanly across, with the scalpel, about 2cm from the base. If there is a lot of bleeding (unlikely), tie the umbilical tape, somewhat firmly to achieve haemostasis.
• Examine the cord
  • identify the vein (thin walled, larger, often oozing some blood or with a clot within it, most often at the 12 o'clock position) and the 2 (sometimes just one) arteries (thick walled, smaller, firmer).
• Dilate the end of the umbilical vein
  • use the iris forceps/small curved haemostat
• Insert the catheter
  
  • grasp near the tip and gently insert it into the vein. Do not force the catheter at any point. Direct it slightly cephalad, which is the vein's natural route.
  • the depth should not be more than 2-4 centimetres from the abdominal wall. Ideally, it should be just 1-2 cm beyond when blood can be aspirated using the attached syringe.
  • If blood cannot be aspirated then flush gently with saline via the syringe and try aspirating gently again. If blood still cannot be aspirated then try advancing the catheter just a little bit further or withdrawing it slightly.
• Secure the catheter
  
  • tie the umbilical tape firmly but not tightly at the base of the cord.
  • pass a suture through the base of the cord (distal to the umbilical tape and away from the vein/catheter). Tie the suture around the catheter firmly, but with out occluding it.
  • make a tape bridge (or make a support out of a cut upside down medicine cup) to support the catheter and increase its' attachment to the infant.
• Administer medications/fluids via the 3-way tap.
Umbilical vein catheter insertion

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