Management of Blood-Stained Umbilical Cord at Birth
A blood-stained umbilical cord at birth requires immediate visual inspection before clamping to identify potential cord avulsion, vascular abnormalities, or structural defects that may necessitate emergency intervention. 1, 2
Immediate Assessment Protocol
First Step: Rapid Visual Inspection
- Examine the cord immediately upon delivery before clamping to identify the source of blood staining. 2
- Look specifically for:
- Cord avulsion (separation from placenta) - a life-threatening emergency requiring immediate action 1
- Vascular rupture or bleeding from cord vessels 2
- Structural abnormalities including true knots, non-coiled vessels, or vascular malformations 3, 4
- Blood originating from maternal sources versus fetal hemorrhage 2
Critical Decision Point: Does the Infant Require Immediate Resuscitation?
If cord avulsion is suspected or the infant shows signs of acute blood loss:
- Proceed immediately with cord clamping and neonatal resuscitation - do not delay for deferred cord clamping 1, 5
- Prepare for volume resuscitation and possible blood transfusion 1
- Anticipate severe anemia and shock 1
If the infant appears vigorous and blood staining is minimal:
- Defer cord clamping for at least 60 seconds while maintaining close observation 6, 5
- This recommendation applies to both term and preterm infants who do not require immediate resuscitation 6
Gestational Age-Specific Management
For Preterm Infants (<37 weeks)
- Defer cord clamping for at least 60 seconds if the infant does not require immediate resuscitation (strong recommendation, moderate-certainty evidence showing reduced mortality with NNT of 18) 6, 5
- For infants 28+0 to 36+6 weeks who cannot receive delayed cord clamping, consider umbilical cord milking as an alternative to improve hematologic outcomes 6, 7
- Avoid intact cord milking in infants <28 weeks' gestation due to increased risk of severe intraventricular hemorrhage 6, 7
For Term Infants (≥37 weeks)
- Delay cord clamping for at least 60 seconds (or until cord stops pulsating) to reduce anemia and improve neurodevelopmental outcomes 6, 5
- This provides higher hemoglobin levels and improved iron stores at 2 months of age 8
Post-Delivery Evaluation
Immediate Neonatal Assessment
- Perform Apgar scoring at 1,5, and 10 minutes 1
- Assess for signs of hypovolemia or anemia: pallor, tachycardia, poor perfusion, hypotension 1
- Monitor for hyperbilirubinemia more closely as it may be more common after significant blood loss 1
Cord and Placental Examination
- Document cord structure: number of vessels, presence of true knots, coiling pattern 3, 2, 4
- Non-coiled (straight) umbilical vessels are associated with increased perinatal morbidity including intrauterine death, preterm delivery, and fetal distress 4
- Examine the placenta for completeness and signs of abruption or avulsion 1
Common Pitfalls to Avoid
- Never assume blood staining is benign without visual inspection - cord avulsion is rare but immediately life-threatening 1, 2
- Do not delay assessment - make the decision about immediate resuscitation need within seconds of delivery 5
- Do not confuse false knots (benign kinks) with true knots which increase risk of asphyxia and fetal demise 3
- Do not defer cord clamping if there is any suspicion of ongoing hemorrhage or hemodynamic compromise 1, 5