Journal of Perinatology (2015) 35, 476–480

© 2015 Nature America, Inc. All rights reserved 0743-8346/15

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ORIGINAL ARTICLE
Simple measurements to place umbilical catheters using surface
anatomy
AO Gupta1, MR Peesay2 and J Ramasethu2

OBJECTIVE: To use external anatomical landmarks to determine a new method for the estimation of appropriate insertion length of
umbilical catheters, suitable for newborn infants of varying birth weight (BW) and gestational age.
STUDY DESIGN: Neonates who had umbilical venous (UVC) or arterial (UAC) catheters placed soon after birth were included in the
study. Catheters were placed using formulas derived by Shukla (1986) and/or Wright (2007), and adjusted to appropriate positions
confirmed radiologically: UAC tip between T6–T10 vertebral bodies and UVC at the level of the diaphragm ± 0.5 cms. Final catheter
length was compared with the length estimated by Shukla/Wright formulas and to four additional morphometric measurements:
umbilicus to nipple (UN), umbilicus to midpoint of inter-mammary distance, umbilicus to xiphoid process and umbilicus to
symphysis pubis (USp).
RESULT: Of 216 infants, 32 were excluded; UVC was placed in 170 infants and UAC in 125 infants. Among the morphometric
measurements, UN − 1 cm ( UN distance minus 1 cm) provided the best estimate of accurate insertion length of UVC, (r = 0.984,
P o 0.001) and estimated correct insertion length of 94% of UVCs compared with 57% accuracy with Shukla formula for all BW
categories (P o 0.001). Morphometric measurement UN − 1+2 USp (UN distance minus 1 cm plus twice the distance from umbilicus
to symphysis pubis) showed significantly better correlation with appropriate insertion length of UAC (r = 0.985, P o0.001) and
estimated correct insertion length of 92% of UACs in all infants as compared with 57% accuracy with Shukla formula (P o 0.001),
and the correct insertion length in 94% of very low BW infants as compared with 68% accuracy with Wright formula (P o0.001).
CONCLUSION: Simple and intuitive morphometric measurements UN and USp provide more accurate estimates of appropriate
insertion lengths for umbilical catheters in infants with all BWs than commonly used BW-based formulas.
Journal of Perinatology (2015) 35, 476–480; doi:10.1038/jp.2014.239; published online 22 January 2015

INTRODUCTION Our objective was to determine which morphometric measure-

Catheterization of the umbilical artery and vein is a common
procedure in neonatal intensive care units, providing immediate
vascular access to premature and critically ill infants soon after
birth. Umbilical arterial catheters (UAC) are placed for continuous
blood pressure monitoring, and for blood sampling for arterial
blood gases, biochemical and hematological testing. Umbilical
venous catheters (UVC) provide stable intravenous access for
infusion of parenteral nutrition, medications and for exchange
transfusions.1 Numerous measurements and formulas have been
proposed to estimate the final appropriate insertion length
of the umbilical catheters.2–6 However, these measurements are
not exact, and often result in over- or under-insertion of the
catheters. Moreover, none of the birth weight (BW)-based
formulas has been found to be universally applicable to infants
of varying BWs or gestational ages.7–9 It is important to predict
the appropriate insertion length of umbilical catheters to avoid
the need for frequent adjustments and repeat X-rays to confirm
final placement. Mal-positioned catheters can cause serious
complications, such as cardiac arrhythmias, myocardial perfora-
tion, pleural or pericardial effusions, liver injury, intestinal necrosis
and thrombosis.1,10–11
We hypothesized that external morphometric measurements
correlate with internal anatomy for accurate placement of
umbilical catheters.
ments, using external anatomical landmarks, provide the best
correlation with appropriate insertion length of umbilical catheters,
applicable to newborn infants of all BWs and gestational ages.
We performed a study comparing the accuracy of insertion
length of umbilical catheters estimated by Shukla3 (UAC = 3 × BW
(kg)+9 cm, UVC = UAC/2+1 cm) or Wright4 (UAC = 4 × BW (kg)+7)
formulas against the external morphometric measurements.
METHODS
Newborn infants who had umbilical catheters placed at MedStar George-
town University Hospital Neonatal Intensive Care Unit between March
2012 and February 2014 were included in the study. Infants with major
congenital anomalies with dysmorphology, hydrops and unsuccessful
placement of umbilical catheters (for example, UVC in the liver, UAC
doubling back in the aorta, misplaced into iliac artery and low position
UAC) were excluded.
UACs were placed using the Shukla3 formula for infants with BW
41500 g and using the Wright4 formula for infants with BW o1500 g.
UVCs were placed using the Shukla3 formula in all infants. Catheters were
placed by neonatal fellows, neonatal nurse practitioners or pediatric resi-
dents under supervision. Catheters were considered to be in appropriate
position if the UAC tip was between the 6th and 10th thoracic vertebra
(T6–T10) and UVC tip was at the level of diaphragm ± 0.5 cm.10,12 UAC was
considered over-inserted if the catheter tip was above T6 and under-
inserted if it was below T10. If the catheter was too deep, it was withdrawn

1
Nemours/Alfred I DuPont Hospital for Children, Wilmington, DE, USA and 2MedStar Georgetown University Hospital, Washington, DC, USA. Correspondence: Dr J Ramasethu,
Division of Neonatal-Perinatal Medicine, MedStar Georgetown University Hospital, 3800 Reservoir road, NW, Suite M-3400, Washington 20007, DC, USA.
E-mail: jr65@gunet.georgetown.edu
Received 8 October 2014; revised 4 December 2014; accepted 5 December 2014; published online 22 January 2015
 Umbilical catheter placement using surface anatomy
AO Gupta et al
477
to the appropriate position (confirmed by repeat X-ray) and re-sutured into
place. If the catheter was mal-positioned or not in far enough, it was
removed and replaced with a new catheter. The final appropriate position
of the catheters on the chest X-ray (CXR) was recorded. For radiographic
measurements Amalga (Microsoft Amalga Unified Intelligence System)
software was used.
Four additional morphometric measurements were collected by a single
observer in all the infants with umbilical catheters, independent of
placement and adjustments. This did not affect the adjustment of the
catheters or require additional X-rays (Figure 1).

1. Umbilicus to nipple (UN)

2. Umbilicus to xiphoid process (UXp)
3. Umbilicus to midpoint of inter-mammary distance (UIMD)
4. Umbilicus to symphysis pubis (USp)

UN, UXp and UIMD were collected to estimate the insertion length of
UVC. Considering the normal course of the umbilical arteries, downwards
into the pelvis, curving at the level of symphysis pubis before joining
the internal iliac artery, we anticipated that measuring USp would be vital
to estimate the insertion length of UAC (Figure 2). Measurements were
obtained from the base of the umbilicus, and umbilical stump length was
not included in the measurements.
Data collection included BW, gestational age, final insertion length of Figure 1. Morphometric measurements. IMD, inter-mammary dis-
UAC and UVC confirmed by CXR, final position of catheters on CXR and tance; UIMD, umbilicus to midpoint of IMD; UN, umbilicus to nipple;
morphometric measurements. Infants were divided in two subgroups USp, umbilicus to symphysis pubis; UXp, umbilicus to xiphoid
based on the BW: 41500 and ⩽ 1500 g. process.
The final appropriate insertion length of the umbilical catheters was
compared with the morphometric measurements and with the estimated
length obtained by the Shukla and Wright formulas. Statistical analysis was
performed using the Pearson’s correlation coefficient and Fisher’s exact
test for categorical variables using SAS 9.3 (Cary, NC, USA) software. P-value
of o0.05 was considered statistically significant. The study was approved
by the Georgetown University Institutional Review Board.

RESULTS
Umbilical catheters were placed in 216 infants during the study
period. Thirty-two infants were excluded: 3 infants had congenital
anomalies and 29 were excluded for unsuccessful placement of
the catheters. Among the 184 eligible infants, UVC was placed
in 170 infants and UAC in 125 infants. Table 1 shows the BW and
gestational age distribution of eligible infants.
Table 2 shows the proportion of UVCs that would have been
overestimated or underestimated using the different morphometric
measurements or Shukla formula, compared with the final
appropriate insertion length of UVC. UIMD measurement over-
estimated the measurement length in 21% of UVCs and under-
estimated the length in 2%. UXp measurement underestimated the
insertion length of all UVCs. Using the UN measurement would have
led to over-insertion of 94% of UVCs without any under-insertions.
Data analysis revealed that the UN distance invariably over-
estimated the UVC length by 1 cm. Subtraction of 1 cm from UN
distance (UN − 1 cm) would have decreased the over-insertion rate Figure 2. Normal path of umbilical arterial catheter (UAC) and
from 94% to 4%, but increased the rate of under-inserted catheters umbilical venous catheter (UVC).
to 2%. Morphometric measurement of UN − 1 cm estimated the
correct insertion length of UVCs in 94% of infants of all BWs as
compared with 57% with the Shukla formula (Po0.001). insertion length of UACs compared with the final appropriate
Table 3 shows the correlation between the final insertion length insertion length. The measurement of UIMD+2 USp would have
of UVC and different morphometric measurements (UIMD, UXp led to final UAC tip placement above T6 in 14% of patients with
and UN), UN − 1 cm and the Shukla formula. Morphometric none below T10. The UXp+2 USp measurement would have
measurement of UN − 1 cm showed better correlation with final underestimated the UAC tip placement in 66% of the patients. The
insertion length of UVC as compared with the Shukla formula for measurement of UN+2 USp would have led to the overestimation
all BW categories (P o 0.001). of UAC insertion length in 54% of patients but subtraction of 1 cm
Considering the normal course of the umbilical arteries, we (UN − 1 cm+2 USp) would have decreased over-insertion rate to
projected that adding twice the distance from umbilicus to the 6% with a 2% rate of under-insertion of UACs. Morphometric
top of the symphysis pubis (2 USp) to UIMD, UXp, UN or UN − 1 cm measurement of UN − 1+2 USp would have estimated the correct
should provide an estimate for appropriate insertion length of insertion length of UACs in 91% of infants with BW 41500 g, as
UAC. Table 4 shows the accuracy of the different morphometric compared with 53% using the Shukla formula (P o 0.001). In very
measurement and Shukla and Wright formulas for estimation of low birth weight (VLBW) infants, the UN − 1+2 USp measurement

© 2015 Nature America, Inc. Journal of Perinatology (2015), 476 – 480

 Umbilical catheter placement using surface anatomy
AO Gupta et al
478
would have estimated the correct insertion length of UACs in 94%
of infants compared with an accuracy rate of 64% using the Shukla
formula and 68% using the Wright formula (P o 0.001).
Morphometric measurement UN − 1+2 USp provided better
correlation with final insertion length of UAC as compared with
Shukla and Wright formulas for all BW categories (P o 0.001;
Table 5). Even though the correlation coefficient of UIMD+2 USp,
UXp+2 USp and UN+2 USp were not significantly different from
UN − 1+2 USp, these measurements showed less accurate estima-
tions of correct insertion length of UACs (Table 4).
DISCUSSION
Accurate placement of umbilical catheters is important in order to
avoid frequent handling of critically ill infants, radiation exposure,
risk of infections and catheter related complications.1,10–11 Many
formulas and measurements have been derived to predict the
accurate placement of umbilical catheters, and multiple studies
have compared the different formulas and measurements.2–9
There is no universal formula, measurement or nomo-
gram available for placement of umbilical catheters, which is
satisfactory for infants of all BWs and gestational ages.6–9 In our
study, we derived two simple surface anatomy-based morpho-
metric measurements (UN and USp), which can be used univer-
sally in all the neonates irrespective of BW or gestational age. We
compared these measurements against the two most commonly
used BW-based formulas derived by Shukla and Wright.3–4
The Shukla and Wright formulas were derived by regression
equations on small number of patients and have been found to
have significant limitations. Shukla and Ferrera derived a modified
Table 1. Gestational age and birth weight distribution of infants with
umbilical catheters
UVC Total BW41500 g BW ⩽ 1500 g
N = 170 n = 109 n = 61
regression equation utilizing BWs of 43 neonates (mean BW of
2037 g, s.d. 1077 g) with UACs and 10 UVCs, and prospectively
used this formula to insert 25 UACs and 16 UVCs.3 They found all
catheter tips to be in ‘acceptable positions’. Wright et al. observed
that the Shukla formula consistently led to the over-insertion of
UACs in VLBW infants.4 They derived a new regression equation,
and in a prospective study comparing the new formula in 35
VLBW patients vs the Shukla formula in 39 VLBW patients, found
that their formula was significantly less likely to result in over-
insertion of UACs in VLBW infants (3% vs 49% using Shukla
formula) but resulted in an increase in the number of low-sited
catheters (11%). Wright et al. did not include infants with
BW41500 g, and made no recommendation about the measure-
ment of UVCs. ‘In quest of a universal formula’, Kumar et al.
prospectively compared the Shukla and Wright formulas for
placement of UACs in 99 infants of different BW categories and
found that the Wright formula resulted in the under-insertion of
UACs in 2 of 24 ( 8%) VLBW infants, with no over-insertions,
whereas the Shukla formula resulted in the over-insertion of UACs
in 14 of 49 (29%) VLBW infants with no under-insertions.9 Kumar
et al. also showed that both the Wright and the Shukla formulas
resulted in correct insertions in term neonates, but there were
only 13 term infants in each group. Kumar et al. concluded that
there is no formula that can be applied universally across all
gestational ages.
The widely used Dunn nomogram using total body length and
shoulder to umbilicus distance to estimate appropriate catheter
length for placement of UACs and UVCs was derived from post
mortem measurements on 50 infants, ranging in weight from 600
to 4027 g.2 In a prospective study, Verheij et al.,8 showed that the
Dunn method resulted in correct positions in only 63% of UACs
(24/38) and in 40% of UVCs (28/67) in infants with a mean BW of
1997 g (s.d. 1223 g). Moreover, it has been shown that the
measurement from shoulder to umbilicus is highly inconsistent.
Lopriore et al. surveyed 101 practitioners in the Netherlands and
reported that only 14% of practitioners knew the correct

Gestational 33 (24–41) 37 (30–41) 28 (24–34)

age (weeks)
Birth 2000 (490–4800) 2930 (1502–4800) 1080 (490–1500) Table 3. Correlation coefficient comparing final appropriate insertion
weight (g) length of UVC with different morphometric measurements and Shukla
formula
UAC Total BW41500 g BW ⩽ 1500 g
N = 125 n = 78 n = 47 Birth weight UIMD UXp UN UN − 1 cm Shukla

Gestational 34 (24–41) 37 (30–41) 27 (24–31) Total (N = 170) 0.9053 0.2981 0.9841 a

0.9841a
0.8883
age (weeks) 41500 g (n = 109) 0.9469 − 0.0024 0.9597a 0.9597a 0.7876
Birth 2160 (490–4800) 3180 (1502–4800) 765 (490–1500) ⩽ 1500 g (n = 61) 0.9548 0.8313 0.9637a 0.9637a 0.8231
weight (g)
Abbreviations: IMD, Umbilicus to midpoint of inter-mammary distance; UN,
Abbreviations: BW, Birth weight; UAC, umbilical arterial catheter; UVC, Umbilicus to nipple distance; UXp, Umbilicus to xiphoid process distance.
a
umbilical venous catheter. Data shown as median (range). Denotes Po0.001 as compared with the Shukla formula.

Table 2. Expected position of umbilical venous catheter with different morphometric measurements and Shukla formula

Over-insertion Under-insertion

Neonates UIMD UXP UN UN − 1 cm Shukla UIMD UXP UN UN − 1 cm Shukla

Total 35 (21%) 0 160 (94%) 7 (4%) 61 (36%) 3 (2%) 170 (100%) 0 4 (2%) 12 (7%)
N = 170
41500 g 24 (22%) 0 105 (96%) 5 (5%) 31 (28%) 1 (1%) 109 (100%) 0 2 (2%) 9 (8%)
n = 109
⩽ 1500 g 11 (18%) 0 55 (91%) 2 (3%) 30 (49%) 2 (3%) 61 (100%) 0 2 (3%) 3 (5%)
n = 61
Abbreviations: UIMD, umbilicus to midpoint of inter-mammary distance; UN, umbilicus to nipple distance; UXp, umbilicus to xiphoid process distance.

Journal of Perinatology (2015), 476 – 480 © 2015 Nature America, Inc.

 Umbilical catheter placement using surface anatomy
AO Gupta et al
479
Table 4. Expected position of umbilical arterial catheter with different morphometric measurements, Shukla and Wright formulas

Over-insertion (above T6) Under-insertion (below T10)

Neonates UIMD UXP UN UN − 1 Shukla Wright UIMD UXP UN UN − 1 Shukla Wright

+2 USP +2 USp +2 USp +2 USP +2 USP +2 USp +2 USp +2 USP

Total 17 (14%) 0 67 (54%) 8 (6%) 43 (34%) N/A 0 83 (66%) 0 2 (2%) 11 (9%) N/A
N = 125
Birth weight 41500 g 10 (13%) 0 49 (63%) 5 (6%) 30 (38%) N/A 0 60 (77%) 0 2 (3%) 7 (9%) N/A
n = 78
Birth weight ⩽ 1500 g 7 (15%) 0 18 (38%) 3 (6%) 13 (27%) 3 (6%) 0 23 (49%) 0 0 4 (9%) 12 (26%)
n = 47
Abbreviations: UIMD, umbilicus to midpoint of inter-mammary distance; UN, umbilicus to nipple distance; USp, umbilicus to symphysis pubis distance; UXp,
umbilicus to xiphoid process distance.

Table 5.Correlation coefficient comparing final appropriate insertion length of umbilical arterial catheter with different morphometric
measurements, Shukla and Wright formulas

Neonates UIMD UXp UN UN − 1 Shukla Wright

+2 USp +2 USp +2 USp +2 USp formula formula

Total 0.9841 0.9701 0.9851 0.9851a 0.9195 N/A

N = 125
Birth weight 41500 g (n = 78) 0.9373 0.9139 0.9447 0.9447a 0.8292 N/A
Birth weight ⩽1500 g (n = 47) 0.9573 0.9224 0.9675 0.9675a,b 0.8878 0.8929
Abbreviations: UIMD, umbilicus to midpoint of inter-mammary distance; UN, umbilicus to nipple distance; USp, umbilicus to symphysis pubis distance; UXp,
umbilicus to xiphoid process distance. aDenotes Po0.001 as compared with the Shukla formula. bDenotes Po0.001 as compared with the Wright formula.

technique of measuring this distance, which is the perpendicular
distance between two parallel lines at the shoulder and at the
umbilicus and not the direct measurement between the shoulder
and umbilicus.13
Vali et al. derived anatomic path-based calculations based on
radiographic measurements to predict the accurate insertion
lengths of umbilical catheters in a retrospective study of 82 UVCs
and 55 UACs and found a better correlation as compared with
Shukla and Wright formulas.7 However, the measurements
recommended would not be easy to perform on squirming or
sick neonates (UVC length = umbilicus to the mid-xiphoid to bed
distance, measured on the lateral aspect of the abdomen; UAC
length = 1.1 × (xiphoid to ASIS+umbilicus to ASIS)+1.6, where ASIS
is the anterior superior iliac spine).
In summary, measurements derived by Dunn2 and Vali7 are
difficult to obtain and impractical, and BW-based formulas derived
by Shukla3 and Wright4 remain inexact and cannot be applied in
neonates with all BWs.
We propose two simple, intuitive and easily obtainable
measurements (UN and USP), which correlate well to the accurate
insertion length of the umbilical catheters as compared with the
Shukla or Wright formulas. The morphometric measurements
correlated well with the final insertion length of umbilical
catheters: UN − 1 cm with UVC and UN − 1+2 USp with UAC. The
large number of patients including 61 VLBW infants is a major
strength of our study. On subgroup analysis, the morphometric
measurements were found to have a good correlation with the
final insertion length of the umbilical catheters in all the neonates
regardless of their BW. Our estimated under-insertion rate for UAC
was only 2–3% as compared with 9% with Shukla formula and
26% with Wright formula. Under-insertion of UACs is a concern,
given the association with gut ischemia and thrombosis of renal
and mesenteric arteries.10–11 Over-inserted catheters can be
adjusted easily, by retracting them under sterile precautions.
Although there is no definitive evidence, under-inserted catheters
are usually replaced and not advanced once the sterile field has
been disturbed, because of the potential risk of infection. Our
results were consistent with the previous studies, which showed
more over-insertion of catheters with the Shukla formula and
under-insertion of UACs with the Wright formula.
One of the limitations of our study is that it is an observational
study. Although we derived the measurements to provide the
best estimates for placement of umbilical catheters, we did not
use these measurements prospectively to place the umbilical
catheters.
The confirmation of accurate position of the catheters by CXR
rather than ultra-sonogram would be considered to be a limitation
by some. Bedside ultrasonography has been found to be superior
to radiographs for determining accurate placement of umbilical
catheters,14,15 but it is not always available in many neonatal units.
We used the level of the diaphragm for determination of accurate
insertion length of UVCs, as the appropriate location of the UVC
tip should be at the cavo-atrial junction, which is close to the level
of the diaphragm. It has been shown that on CXRs, extrapolating
the curve of the right atrial border medially to its intersection with
the inferior vena cava is more accurate than using the level of
vertebral bodies for appropriate location of the UVC tip.15
CONCLUSION
In conclusion, simple, intuitive and easily obtainable morpho-
metric measurements: UN and USp, provide more accurate
estimates of appropriate insertion lengths for UVC and UAC in
infants with all BWs than commonly used BW-based formulas.
Insertion length of UVC can be best estimated by UN − 1 cm and
UAC by UN − 1+2 USp. Validity of these morphometric measure-
ments will be studied prospectively.

© 2015 Nature America, Inc. Journal of Perinatology (2015), 476 – 480

 Umbilical catheter placement using surface anatomy
AO Gupta et al
480
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
No external funding was secured for this study.
AUTHOR CONTRIBUTIONS
AOG contributed to the study design, collected and analyzed the data, and
drafted the initial manuscript. MRP conceived the idea that external
morphometric measurements should correlate with the internal anatomy for
umbilical catheter placement, obtained pilot data, contributed to the study
design and writing the manuscript. JR designed the study, coordinated
and supervised data collection and analysis, reviewed and revised the
manuscript. All authors have reviewed and approved the final manuscript as
submitted.
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