Use of a New Doppler Umbilical Cord Clamp to Measure

Heart Rate in Newborn Infants in the Delivery Room

Robert P. Lemke MD1, Michael Farrah BMET2, and Paul J. Byrne MBChB1
1
2

Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada

Department of Clinical Engineering, University of Alberta, Edmonton, Alberta, Canada

Address correspondence:
Robert Lemke, MD
Stollery Childrens Hospital
3A3 Walter C Mackenzie HSC
8440 112 St NW
Edmonton, Alberta
T6G 2B7
Email: rplemke@shaw.ca

Author Disclosure: All three authors have applied for a patent on the device described in
this paper in multiple jurisdictions.
ABSTRACT
Objective: As an initial proof of concept, to determine whether a prototype umbilical cord clamp containing a
Doppler ultrasound probe could quickly detect and accurately measure the heart rate of term newborns 5 min after
birth.
Methods: Clinically stable, spontaneously breathing newborns in room air, 37 weeks gestation, had the prototype
clamp applied to the base of their umbilical cord. We noted the time needed to detect a signal and then monitored
the audible Doppler pulsations for approximately 1 minute while we simultaneously palpated the femoral pulse to
confirm a 1:1 correlation.
Results: A total of 16 term infants (9 female, GA 392 weeks, BW 3265425 grams, one minute Apgar 82, five
minute Apgar 91) had the cord clamp applied. In all cases a Doppler signal was detected immediately after contact
with the skin, and remained strong and correlated 1:1 with the palpated pulse for at least one minute. Movement and
crying resulted in some noise but the Doppler heart rate signal was unaffected.
Conclusion: Under controlled conditions, a prototype umbilical cord clamp containing a Doppler ultrasound probe
was able to detect and monitor the heart rate of 16 healthy newborns after birth. The technique has potential
applications in guiding newborn resuscitation and requires further study.
Key words: newborn, Doppler, resuscitation, newborn heart rate monitor, delivery room

INTRODUCTION
The transition from fetus to an air-breathing
infant is a complex physiological process.1
Although most babies are successful in this
regard, a significant number require some
emergent assistance during this transition,24
and resuscitation interventions are not
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themselves without risk.5-7 Fundamental to

the decision making protocol described in
the Neonatal Resuscitation Program
developed by the American Heart
Association, is accurate real time knowledge
of a newborn infants rapidly changing heart

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rate.1,3,7 Continuous electronic monitoring of

fetuses in utero, and of older infants
in nurseries commonly occurs, and yet in the
newborn during the critical first few minutes
of life, heart rate measurement routinely
relies on simple palpation and auscultation.1
This critical information, used to initiate and
guide
resuscitation
is typically only
intermittently obtained, difficult to verify in
retrospect, and when done under stressful
circumstances is subject to error.1,6,810
Although more recently, electronic
monitoring has been used in the delivery
suite for neonates immediately after delivery
a number of problems remain.1,11 First, the
blood, mucus, amniotic fluid and vernix
caseosa, which covers newborns must first
be cleaned from the skin to ensure that
adhesive probes stick and good contact
between the skin and probe is achieved.10
Even in experienced hands, application takes
time and may paradoxically divert attention
away from the actual resuscitation.12
Second, the most investigated monitoring
modality, pulse oximetry, depends on good
tissue perfusion to ensure an error free
signal.12,13 Unfortunately
perfusion
is
poorest in those babies who are the most
compromised. Finally, in all cases there is a
time delay between the time the umbilical
cord is cut and the baby is transferred to the
overhead warmer before auscultation
and/or palpation can occur.3,7
We noted that Doppler ultrasound is an
effective method to quickly detect pulsation
that is unaffected by contamination of the
skin with bodily fluids. Moreover we
recognized that clamping a device to the
umbilical cord can provide a robust
mechanical method of fixation that is
unaffected by the presence of bodily fluids.
In fact the umbilical cord is an ideal site for
such a monitoring device because it is
centrally located on the body, universally

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present, contains no pain receptors and is

infrequently needed after birth. We therefore
envisioned a new umbilical clamp, housing
an integral wireless Doppler ultrasound
probe, which is quick and simple to firmly
attach to the babys cord immediately after
birth. The heart rate data generated by the
device could be transmitted wirelessly in
real time to a monitor for audible and
numeric display and data trending and
storage.
METHODS
This pilot study was reviewed and approved
by the Human Ethics and Research Board of
the University of Alberta. Informed consent
was obtained from the mother prior to birth
for each patient enrolled.
In order to prove our concept, we developed
a simple prototype cord clamp (Figure 1)
which consisted of a milled polyethylene
plastic housing through which the umbilical
cord passed and positioned a pencil Doppler
ultrasound probe with its tip covered in gel
(Koven Technologies, St Louis, Missouri)
against the infants abdominal wall at the
base of the cord. We hypothesized that
this umbilical clamp, would detect a
pulsation in the intra-abdominal arteries
within 5 seconds of application to the skin
and do so for at least 1 minute within the
first 5 minutes after birth. Moreover, this
pulsation would correlate 1:1 with the
heartbeat as determined by concurrent
palpation of the femoral pulse. The intended
pilot study population were clinically stable,
spontaneously breathing newborns in room
air, 37 weeks gestation, who did not
require resuscitation
beyond
simple
stimulation. Any infant with a suspected
congenital anomaly, or who was requiring
oxygen or ventilatory support, or a
gestational age < 37 weeks was excluded.

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pulsations for at least 1 minute while we

simultaneously palpated the femoral pulse to
confirm a 1:1 correlation. Once the
monitoring period was completed, the
Doppler cord clamp assembly was removed
by unclipping the housing from the cord. We
then applied a second Hollister cord clamp
at the base of the cord, and trimmed the
excess cord before returning the baby to the
parents.

The application of the Doppler cord clamp

in the delivery suite was straightforward. At
birth, the obstetrician was asked to clamp a
hemostat to the cord in such a way as to
provide at least 10 cm of cord for us to apply
our device. After delivery, the infant was
first handed to the resuscitation team for
assessment and appropriate care. At 4
minutes, if the baby was deemed stable, we
attached the device to the base of the cord,
applying mild traction to the cord through
the housing using a Hollister disposable cord
clamp (Hollister Incorporated, Libertyville,
Illinois) to minimize movement. We noted
the time needed to detect an audible signal
and then monitored the audible Doppler

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We planned to use the prototype clamp on a

total of 10 to 20 newborns to assess i). the
process of clamp application, ii). the clamps
ability to detect pulsation and iii). its ability
to measure heart rate. This sample size was
arbitrary but based on our belief that it
constituted a reasonable sample to reveal
any needed modifications of the device
and/or process
of
application
for
further development.
We
completed
successful
clamp
application,
pulse
detection and heart rate measurements in 16
newborns. In 8 infants, a 10 MHz probe,
applied 15 degrees from midline, and
directed 45o cephalad from vertical, was
used to target an umbilical artery as it passed
caudad in the abdominal wall. In
the remaining 8 babies, a 5 MHz probe was
applied midline, directed 45o cephalad from
vertical, to target deeper arteries in the
pelvis. Data collection consisted of standard
demographic data (i.e. gender, birth weight
and Apgar scores) and observations
regarding the application of the device,
signal
acquisition
and strength,
and
correlation with palpated pulse.
RESULTS
A total of 16 term infants (9 female, GA
392 weeks, BW 3265425 grams,
one minute Apgar 82, five minute Apgar
91 [mean standard deviation]) had
the cord clamp applied by one of the authors
within 5 minutes of birth at the Caseroom of

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the Grey Nuns Community Hospital in

Edmonton, Alberta, Canada. In 8 infants the
umbilical artery was the target and in the
remaining 8 deeper pelvic arteries were
insonated. In all cases an audible Doppler
signal was detected immediately after
contact with the skin and remained clear and
strong and correlated 1:1 with the palpated
femoral pulse for at least 1 minute. The
average heart rate measured immediately
after application of the clamp was 14527
bpm (mean standard deviation) for an
umbilical artery target and 15020 bpm for
the deeper signal target. There was no
subjective difference noted in signal strength
or ease of acquisition between the two
targets. Eleven infants were crying during
the use of the Doppler cord clamp and the
remaining five were quiet. Movement
and crying resulted in some noise but the
Doppler heart rate signal was unaffected.
As anticipated, the presence of bodily fluids
on the cord and infant skin did not interfere
with signal detection. Overall the clamp was
well tolerated by all the infants.
DISCUSSION
In this proof of concept study, we
successfully used a prototype Doppler cord
clamp to detect and monitor the heart rate of
16 healthy term infants in the delivery room
of a community hospital. Under these very
controlled circumstances, the clamp provided rapid and accurate heart rate data
using two different potential Doppler signal
sources.
The use of Doppler ultrasound to measure
heart rate immediately after birth has not
been previously described. Because of
concerns regarding the inaccuracy of
clinically assessed heart rate measurements,
a number of studies have explored the use of
ECG and/or pulse oximetry in newborn
resuscitation.10,11 However, concerns remain

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for a number of reasons. Data are not

available for up to 90 seconds because of
delays associated with skin cleaning, probe
application
and signal
acquisition.12,13
Moreover, in low skin perfusion states, pulse
oximetry can be inaccurate.11,13 Despite
these limitations, the use of pulse oximetry
is encouraged to provide some form of
objective heart rate data.1,3,7 There are a
number of theoretical factors which could
result in attenuation and/or interference with
the Doppler signal and thereby limit the
usefulness
of
the cord
clamp
in
resuscitation. First, in the case of the
umbilical arteries, vasospasm and clotting
are physiologic processes which ultimately
obliterate these vessels as a source for heart
rate data. While there are no published
data available to document the speed with
which
the
umbilical
arteries
become nonpulsatile after the cord is clamped
and cut, in our pilot study we had no
difficulty detecting a pulse signal up to 5
minutes of age suggesting that it may take
some time to lose the umbilical arterial
signal completely. Second, the presence
of bowel gas is well known to attenuate
ultrasound signal strength. However, at
birth the bowel is fluid filled and it takes
time for swallowed gas to travel distally.
We were able to easily detect a deeper
pelvic Doppler signal in our study
patients, many of who were crying and
presumably swallowing air, suggesting that
this would not be an important concern in
newborns
soon
after
birth.
Finally, movement can introduce noise in
the Doppler signal, which if of sufficient
intensity, could interfere with or obliterate
the pulse waveform and result in signal
loss. Again, this was not an issue in the
patients we studied. Moreover, we suggest
that this is of minimal practical importance
in the Doppler cord clamps application because it is in the quiet or

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unresponsive infant that resuscitation

concerns arise, not the vigorous, crying
neonate.
In this study we targeted pulsations from
deep and superficial arteries using commercially available pencil Doppler probes of
5 and 10 MHz respectively. Although it is
clear that the superficial vessel signal source
should be the umbilical artery, the identity
of the specific arteries, which provided the
deeper pulse signal, is not clear from this
study. Likely target arteries include the
aorta, iliac or the abdominal umbilical
artery. All of these vessels are large and
would be expected to provide an accurate
signal
even
in
the
severely
hemodynamically
compromised
newborn. One potential practical problem with
the attachment of a monitoring system to the
umbilical cord is its possible interference
with the insertion of umbilical lines should
the need arise. To overcome this issue we

designed the prototype clamp to engage the

cord 3 cm above the infants abdomen, and
to be easily removed thereby ensuring an
adequate length of cord if subsequent
umbilical line insertion was needed.
The application of a prototype umbilical
Doppler clamp in this pilot study detected
accurate heart rate in newborns after birth.
Our ultimate goal is to have the clamp
applied to the infants cord while at the
mothers perineum. This would document
heart rate immediately after birth,
information which is currently not readily
available. Such objective heart rate data
could then be used to both signal the need
for and guide neonatal resuscitation. The
potential clinical application of this device
in both sick and well infants is apparent.
However, the device is in a very early
prototype development and there is still
considerable work to be done before it could
see clinical use.

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