A prospective study of factors influencing the time of separation of umbilical cord.
A study done by Noar, and his collogues, (6) showed that the umbilical cord is a "subject very close to the parents hearts" and can be a source of immense anxiety for parents, with any delay in separation, discharge, odor, or granuloma causing a concern for parents.
The Oxford Midwives Research Group, (7) addressed the issue of maternal anxiety about care of the umbilical cord by altering the cord separation times. The group proposed that maternal anxiety may be alleviated by decreasing the length of time the cord is attached, this study was undertaken to evaluate effect of mode of delivery and gestational age on time of separation of umbilical cord, however, they found no significant difference in separation times between early and late clamping. Delayed separation of the cord, after more than 1 month, has been associated with neutrophil chemotactic defects and overwhelming bacterial infection. (3)
A study by Mugford, (8) indicated that in countries where mothers are visited by midwives during the postnatal period, problems with the cord often determine the number of visits.
Data on the pattern of umbilical cord stump care, separation time and the effect of different cord care regimens are useful for many reasons. They will guide health care provider's in differentiating between normal and abnormal cord separation time in order to avoid necessary interventions, which may lead to neonatal morbidity and mortality especially in developing countries where the level of hygiene is low. It is also important in designing neonatal care programs for mothers and other caregivers. This study is undertaken to determine mean separation time and effect of maternal, infant and medical interventions on separation time.
A study by Oudesluys-Murphy, et al, (4) included 911 neonates. The mean time of separation was 7.4 days. Cord separation was delayed when antibiotics needed to be administered. The cord separated slightly earlier in female than in male infants.
A study done Narindersingh, et al, (5) in Punjab, on 250 newborns concluded that age of cord separation in an average newborn was 7.74 days. They did not document any difference in time of fall of umbilical cord in babies born preterm and at term in both vaginal and Caesarean deliveries. The study demonstrated that the babies delivered by Caesarean section had separation of cord at a later time (mean 8.98 days) as compared to babies delivered by vaginal route.
A study conducted by Sarwono E, et al, (6) at Indonesia, included 98 healthy Indonesian newborn's to determine the normal time of separation and evaluated factors which may influence it. The authors looked for a relationship between cord separation and sex, birth weight, gestational age, parity of the mother and nutrition of the new born. Mean separation time was 10.9 days (S.D. 3: range 5-23 days). None of the factors analysed had a statistically significant influence. Cord care consisted of triple dye; no umbilical infections were found.
RHL The WHO Reproductive Health, (7) Library says, Topical umbilical cord care at birth showed no differences in umbilical cord infection rates when use of a topical antiseptic was compared with dry cord care or placebo and Topical triple dye and antibiotics seemed to be associated with longer cord separation times.
MATERIALS AND METHODS: The study was conducted at a tertiary hospital, the study was conducted over a period of three months (February -April) in 2014. Newborns of 28 weeks and above admitted during this period were eligible. Newborns < 28 weeks, with severe congenital malformations, exchange transfusion, umbilical sepsis, abdominal wall defects, umbilical vein catheterization were excluded. Sampling was done using purposive sampling technique. At the time of enrolment, an informed written consent was obtained from the parents.
Information was obtained on the age and sex of the infant, gestational age at delivery, mother's parity, and mode of delivery, birth weight, and resuscitation method, use of antibiotics, phototherapy, cord blood TSH values obtained from laboratory and cord separation time was noted. Newborn whose umbilical cord shrivels off during the stay in the hospital, data was collected directly and noted, and a self-addressed postcard will be given to parents of newborns whose umbilical cord was intact at time of discharge. Parents were advised to note and write the date of fall of umbilical cord on post card and mail it.
DATA ANALYSIS: The data was cleaned validated and analyzed using SPSS version 13. Quantitative variables were summarized using range, mean and standard deviation. Categorical variables were tabulated using frequencies. The level of significance calculated using Fisher's Exact Test, Chi square tests, for all tests was set at P< 0.05 considered statistically significant.
RESULTS: Out of the 128 neonates requested to participate in the study, 120 (94%) accepted. Ten neonates excluded, were because of umbilical vein catheterization (8), exomphalus major (1), and exchange transfusion (1), among 110, males were 54 (49.0%) and 56(51.0%) females. The time interval between birth and separation of the umbilical cord ranged from 3 to (11) days with a mean of 5.62 [+ or -] 2.37 days, the umbilical cord separated within the early neonatal period (1 week of life) in 95.8% of all infants, and in the rest the cords separated after one week but within two weeks.
Table 1 reveals that there was no statistically significant difference in separation time between males and female newborns. Males- 5.72 [+ or -] 2.39 days, Females- 5.53 [+ or -] 2.35 days, P=0.435.
Table 2 reveals that there was no statistically significant difference in separation time between preterm. Mean time of separation in term - 5.56 [+ or -] 2.1 days, mean separation time pre term 5.72 [+ or -] 2.0 days, P value -0.673.
Table 3 reveals that there was no statistically significant difference in separation time between weight groups, P value- 0.495
Table 4 reveals that there was statistically significant delay in separation time between neonates who received antibiotics (6 [+ or -] 2.4 days), as compared to neonates who not received, (5.53 [+ or -] 2.33 days). P value 0.017
Table 5 reveals that there was no statistically significant difference in separation time between child with high TSH and normal TSH values. P value -1
DISCUSSION: The interval between birth and umbilical cord separation among newborns in our study ranged from 3 to 11 days with a mean 5.62 [+ or -] 2.37 days. This is shorter than the mean separation time found in different studies, study done at Indones revealed mean separation time 7.4 days, (4) study done at Punjab revealed mean separation time of 7.74 days, (5) study done in Nigeria revealed mean separation time of 8.73 days, (9) In keeping with most previous studies, we did not observe significant differences in the mean cord Separation time by gender, (2,4) however, this finding contrasts with the report from Ibadan, (9) male infants had shorter duration of separation.
In our study there was no difference in mode of delivery on separation time but previous studies did noted delay in Separation time in those babies born by caesarian section delivery compared to those who had spontaneous vaginal or assisted delivery, which suggested that it could be a reflection of decreased bacterial contamination of the umbilical cord in those delivered by caesarean section with consequent decreased leukocyte migration to the cord, (2) in our study there was a significant delay in separation in babies who received antibiotics, mostly intravenously, few topical application of Neosporin powder, this was also observed in previous studies, (5) This was also reported by earlier studies, (2,4) This tends to be supported by reports indicating that umbilical cord separation is mediated through leukocyte infiltration and digestion, in our study we looked into the effect of phototherapy and hypothyroidism effects on separation of the cord, there was no statistically significant difference.
There seems to be no consensus on the best cord care practice. The Cochrane data base of systematic reviews concluded that "we are unable to be sure what is the best practice for cord care in institutions in developed countries, (5) but there is no evidence that doing anything better than keeping the cord clean is helpful, (10) However, the following have been recommended: hand Washing before and after contact with the umbilical area, use of sterile instruments to cut the cord, keeping the cord clean and dry, exposing cord to air, folding the diaper below the level of the umbilicus and encouraging breast feeding and skin--skin contact with the mother to promote colonization with nonpathogenic bacteria from the mother's skin flora.
Limitations of study; this is hospital based study, small sample size; cord care practices at home vary. Hence, our findings may not reflect all varieties of cord care practices in the community.
CONCLUSION: Early discharge has increased the need for women to receive accurate, relevant information on how to care for themselves and their newborns when discharged from the hospital. These findings help health care provider's doctors and nurses to provide consistent, accurate information to women that would enable them to confidently assess and treat their newborns, and also when to expect cord separation.
(1.) Ford LA, Ritchie JA. Maternal perceptions of newborn umbilical cord treatments and healing. J Obstet Gynecol Neonatal Nurs. 1999 Sep-Oct; 28 (5): 501-6.
(2.) Novack AH, Mueller B, Ochs H. Umbilical cord separation in the normal new born. Am J Dis Child. 1988 Feb; 142 (2): 220-3.
(3.) WHO. Care of the umbilical cord. A review of the evidence. WHO/RHT/MSM/9 8.4 ed. Geneva: Am J Dis Child 1988; 142:220-3.
(4.) Sarwono E, Disse WS, Ousdesluys-Murphy HM, Oosting H, De Groot CJ. Umbilical cord: factors which influence the separation time. Paediatr Indones. 1991 Jul-Aug; 31(7-8): 179-84.
(5.) Zupan J, Garner P. Topical umbilical cord care at birth. Cochrane Database Syst Rev. 2000; (2): CD001057. Review. Update in: Cochrane Database Syst Rev. 2004; (3): CD001057.
(6.) Naor N, Merlob P, Litwin A, Wielunksy E. Time of separation of the umbilical cord: a comparative study of treatment with alcohol and Rikospray. Eur J Obstet Gynecol Reprod Biol. 1989 Aug; 32 (2): 89-93.
(7.) Oxford Midwives Research Group. (1991). A study of the relationship between the delivery to cord clamping interval and the time of cord separation. Midwives, 7, 167-176.
(8.) Mugford M, Somchiwong M, Waterhouse IL. Treatment of umbilical cords: a randomised trial to assess the effect of treatment methods on the work of midwives. Midwifery. 1986 Dec; 2 (4): 177-86.
(9.) AE, Olowu JA. Umbilical cord separation time in healthy Nigerian newborns. Paediatr 2006; 118 (5): 1864-1871. Midwifery 1986; 2: 2: 177-86. Nig J Paediatr 2005; 32:19-25.
(10.) Arad I, Eyal F, Fainmesser P. Umbilical care and cord separation. Arch Dis Child 1981; 56: 887-8.
Lokesha R , Anil Shetty 
[1.] Lokesha R.
[2.] Anil Shetty
PARTICULARS OF CONTRIBUTORS:
[1.] Junior Resident, Department of Pediatrics, Father Muller Medical College and Hospital, Mangalore.
[2.] Associate Professor, Department of Pediatrics, Father Muller Medical College and Hospital, Mangalore.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Lokesha R, Junior Resident, Department of Pediatrics, Kankanady, Mangalore.
Date of Submission: 17/11/2014.
Date of Peer Review: 18/11/2014.
Date of Acceptance: 28/11/2014.
Date of Publishing: 02/12/2014.
Table 1: time of cord separation and neonate's gender Separation time (Days) Male Female Total 2-4 10 12 22 5-7 36 43 79 >8 6 3 9 Total 54 56 110 Table 2: Umbilical cord separation and gestational age Separation time Gestational age 2-4 days 5-7 days 8 days Total Term 18 56 7 81 Preterm 4 23 2 29 Total 22 79 9 110 Table 3: Name umbilical cord separation and birth weight Birth Weight Separation time 2-4 days 5-7 days 8 days Total < 1.5 kg 3 18 3 24 1.5-2.5 kg 9 40 3 52 2.5-4 kg 10 20 3 33 >4kg 0 1 0 1 Total 22 79 9 110 Table 4: Cord separation and antibiotics Antibiotics Separation time 2-4 days 5-7 days 8 days Total Not received 22 60 8 90 Received 0 19 1 20 Total 22 79 9 110 Table 5: Cord separation and TSH value TSH ([micro]IU/ml) Separation time 2-4 days 5-7 days 8 days Total <20 21 73 9 103 >20 1 6 0 7 Total 22 79 9 110
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Lokesha, R.; Shetty, Anil|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Clinical report|
|Date:||Dec 4, 2014|
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