Is palpating the umbilical cord an accurate method for assessing a newborn's heart rate?

Why Palpating the Umbilical Cord is NOT Correct for Newborn Heart Rate Assessment

Palpating the umbilical cord significantly underestimates the newborn's heart rate by an average of 21 beats per minute compared to electrocardiography, making it an inaccurate and potentially dangerous method that could lead to unnecessary or delayed resuscitation interventions. 1

The Evidence Against Umbilical Cord Palpation

Magnitude of Inaccuracy

• Palpation underestimates heart rate by approximately 21 bpm on average (147±19 bpm by palpation vs 168±22 bpm by ECG), according to the 2023 International Consensus on Cardiopulmonary Resuscitation 1
• In some studies, the underestimation was even more severe, with mean differences ranging from -20 to -31 bpm at different time points (60 seconds through 5 minutes of life) 2
• The 2023 ILCOR guidelines explicitly state that "palpation is inaccurate and imprecise compared with electrocardiography for heart rate assessment at birth" 1

Clinical Implications of This Error

The underestimation of heart rate by palpation creates serious clinical risks:

• A baby with an actual heart rate of 120 bpm might be assessed as having only 100 bpm, potentially triggering unnecessary positive pressure ventilation 1
• Conversely, a truly bradycardic infant with a heart rate of 80 bpm might be assessed as 60 bpm or lower, leading to premature escalation to chest compressions 2
• The 2010 ILCOR consensus specifically warns that "there is a high likelihood of underestimating heart rate with palpation of the umbilical pulse" 1

What Should Be Used Instead

First-Line Recommendations

According to the 2023 International Consensus guidelines:

• Electrocardiography (ECG) is the preferred method when accurate heart rate estimation is needed and resources permit (conditional recommendation, low-certainty evidence) 1
• Auscultation of the precordium with a stethoscope should remain the primary clinical method when ECG is unavailable 1
• Pulse oximetry combined with auscultation may be reasonable alternatives, though they have limitations including delayed signal acquisition (typically 52-57 seconds from birth) 1

Why Auscultation is Superior to Palpation

• Auscultation underestimates heart rate by only -4 to -13 bpm compared to ECG, significantly more accurate than palpation's -20 to -31 bpm error 2
• In one randomized trial, auscultation correctly identified the heart rate range in 87% of measurements when heart rate was <100 bpm 2
• The 2010 guidelines state that "auscultation of the heart is the most accurate [clinical assessment], with palpation of the umbilical cord less so" 1

Common Pitfalls and Misconceptions

Why Providers Still Use Umbilical Cord Palpation

• Perceived convenience: The umbilical cord is immediately accessible and doesn't require equipment 3
• Tradition: Older guidelines mentioned umbilical pulse as an option, though with caveats 1
• Misunderstanding of "preferable to other palpation locations": The 2010 guidelines stated umbilical palpation was preferable to brachial or femoral pulse palpation, but this was not an endorsement of its accuracy - merely that it was the "least bad" palpation site 1

The Reality of Other Palpation Sites

To put umbilical cord palpation in perspective:

• Femoral pulse: Identified correct heart rate in only 20% of cases, undetectable in 45% 3
• Brachial pulse: Identified correct heart rate in only 25% of cases, undetectable in 60% 3
• Umbilical cord: While "better" at 55% correct identification, still had 20% undetectable and 25% incorrectly categorized 3

Practical Algorithm for Heart Rate Assessment

When resources are available:

1. Apply ECG leads immediately for continuous, accurate monitoring 1
2. Use auscultation to confirm ECG readings or if pulseless electrical activity is suspected 1

When ECG is unavailable:

1. Use auscultation with a stethoscope as the primary method 1
2. Apply pulse oximetry probe to the right hand/wrist (before connecting to instrument) for supplementary information 1
3. Never rely solely on umbilical cord palpation for clinical decision-making 3

Critical caveat: Heart rate assessment must be rapid - every second counts in neonatal resuscitation. The goal is to obtain an accurate heart rate within the first 60 seconds of life to guide interventions appropriately 1, 2

Bottom Line for Your Provider

Explain that umbilical cord palpation systematically underestimates heart rate by 20+ beats per minute, which could lead to either unnecessary aggressive interventions or dangerous delays in needed resuscitation. 1, 2 The provider should use a stethoscope for auscultation of the precordium as the primary clinical method, or ideally use ECG monitoring when available. 1