CLINICAL PRACTICE PROTOCOL

Cord Blood Specimen Labelling
SCOPE (Area): Maternity Unit, Theatre
SCOPE (Staff): Medical, Nursing, Midwifery
Printed versions of this document SHOULD NOT be considered up to date / current


Rationale

Indications for cord blood specimens :

  • RhD negative women

  • women with known antibodies

  • women whose blood group and antibody status is unknown

  • or for the purpose of cord blood gas analysis


Expected Objectives / Outcome

 

Using three patient identifiers

  • The cord blood specimen is labelled with the correct patient details.
  • The request form is completed correctly, with both baby and mother's details.
  • The cord blood specimen and specimen declaration on the Blood Product Request Form are signed by the collector.


Indications

The cord blood specimen is collected from the umbilical cord at the time of birth to test for blood group and direct antiglobulin test (DAT, Coombs) in order to:

  • identify babies who are at risk of haemolytic disease of the newborn (HDN)

  • issue RhD Immunoglobulin to RhD negative mothers

The cord blood specimen is collected from the umbilical cord at the time of birth to test for blood gas analysis in order to:

  • assess fetal wellbeing

  • determine management strategy in the unwell newborn


Issues To Consider

  • DO NOT label the cord blood specimen with the mothers patient label. Modifications to the mothers patient label are NOT acceptable.

  • A separate Blood Product Request Form must be used for cord and maternal blood specimens.

  • Take care with patients who have the same or similar name.

  • Take care with multiple births.


Detailed Steps, Procedures and Actions

 

PROCESS STANDARDS:

 

KEY POINTS:

1. Check that the requesting person has signed the Blood Product Request Form and has completed all relevant sections.

  • Cord blood specimens must be ordered on the Blood Product Request Form

2. Check that the babys details are on the Blood Product Request Form.

Baby with a UR number

  • The babys patient label may be used or babys details may be handwritten on Blood Product Request Form.

Baby without a UR number

  • Babys details must be handwritten on Blood Product Request Form.

  • The mothers patient label with modifications is NOT acceptable.

 

 

 

  •  (See Box 4 for details)

3. The mothers patient label must be placed in the Clinical Notes section of the Blood Product Request Form.

  • Baby of is written on the mothers label

4. Check that the following baby details match exactly on the Blood Product Request Form and on the babys identification band.

  • Surname

  • Baby of, Twin1 of mothers first name

  • UR number (if issued)

  • Date of birth

  • Gender

 

DO NOT PRE-LABEL TUBES

 

  •  The infant's name is not registered on the system until discharge so always write Baby of etc

  • For multiple births write Twin1, Twin2, Quad1 etc.  Note: No space between Twin and the number

5. Place cord blood specimen into tube

 

6.  The specimen must be labelled Cord Blood with the following detail:

  • Surname

  • Baby of, twin1 of mothers first name

  • UR number (if issued)

  • Date of birth

  • Gender

  • Only specimens that have been handwritten will be accepted in the laboratory.

  • Specimens with patient labels attached will be discarded

Note: If sample taken in theatre it is the responsibility of the midwife to ensure they witness the blood draw (particularly in case of multiple births) and complete the documentation on the form and tube

7.   Sign and write date and time of collection on sample tube

 

8.  Sign the specimen declaration on the Blood Product Request Form and write date and time of collection

 

The signature or initials on both the request form declaration and sample tube must match i.e. if an initial is on the tube, then the form must also have the same initials; if the tube is signed, the form must be signed.

9. Place the labelled specimen and Blood Product Request Form in a laboratory specimen bag and send to the laboratory.

  •  If an adverse event (actual or near miss) is associated with the collection of a cord blood specimen, document details in the health record and complete a Riskman Incident Report.


Related Documents

BHS re;ated docs


References

List of appropriate references used to develop the protocol.


Related Documents

POL0012 - Blood Components - Crossmatching For Transfusion
NCP0034 - Patient Registration
POL0036 - Patient Identification And Procedure Matching
CID0001 - Tell Us What You Think
SOP0001 - Principles Of Clinical Care


References

Australian and New Zealand Society of Blood Transfusion, Australian College of Nursing. (2019). Guidelines for the administration of blood products (3rd ed.). Retrieved from


Appendix

Appendix 1 Cord Blood Request Form



Reg Authority: Clinical Online Ratification Group Date Effective: 15/09/2021
Review Responsibility: Transfusion Liaison Consultant Date for Review: 30/09/2024
Cord Blood Specimen Labelling - CPP0174 - Version: 6 - (Generated On: 06-05-2025 05:45)