Sharon Trotter RM BSc

Management of the umbilical cord: a guide to best care

The full reference for this draft article is: Trotter S (2003) Management of the umbilical cord - a guide to best care. RCM Midwives Journal 6 (7): 308-11

Introduction

Current information and practice on umbilical cord care is, at best, confusing. This paper attempts to clarify the situation.

By explaining the physiology of cord separation, how different treatments affect this process and reviewing the most up to date recommendations, I hope to take cord care back to basics.
The resulting guidelines for professionals and parents alike are evidence-based, with the primary objective of reducing the risk of infection. This streamlining is paramount, so as to avoid confusion, which is all too evident today.

WHO Recommendations
Evolution of Cord care
The Physiology of Cord Care
Present Practices in the Developed World
Proposed New Guidelines for Cord Care
Discussion
Further Research
Summary
Key Points of Cord Care
References

WHO Recommendations

The last in-depth review of all the available research was published by the World Health Organisation (WHO 1999). This is a wide-ranging report, covering both developed and developing countries, home and hospital deliveries. Throughout, the basic principles remain the same. In order to prevent loss of life or illness, resulting from infection, it is vital to follow 3 main rules:

1. Strict asepsis at delivery
2. Cutting the cord with a sterile instrument
3. Keeping the cord and surrounding area clean and dry until separation.
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Evolution of Cord care

The basis of cord care, as we know it today, has evolved through many years of traditional and cultural customs.
The cutting of the cord is achieved in various ways throughout the world. Examples include; the Gadsup midwives of New Guinea, who cut the umbilical cord with a bamboo knife heated over an open fire and a similar practice in Guatamala, where scissors are heated over a candle made from grease (Perry D S 1982). These may seem strange, but there is an obvious attempt to avoid infection throughout.
Care of the cord following delivery is even more varied but once again the underlying aim is to avoid infections to the cord and the surrounding area. Treatments range from the application of ashes and fresh colostrum in Kenya, coconut oil and flowers by the American Samoans to cow dung as an umbilical dressing! ( Perry D S 1982).
Needless to say the risk of tetanus neonatorum is still very real in many parts of the world and it is with this in mind that we need to be careful about the advice we give as midwives. Respect for cultural beliefs and traditions is vital in gaining the confidence of mothers, so that we can work together to bring about a standardised set of guidelines that will work in any situation worldwide.

Throughout the western world, the increase in use of various baby products, alcohol wipes, dyes, creams and powders have only served to complicate matters. [back to top]

The Physiology of Cord Care

The umbilical cord is a unique tissue consisting of two arteries and one vein covered by a mucoid connective tissue known as Whartons Jelly, which is covered by a thin layer of mucous membrane (a continuation of the amnion). During pregnancy the placenta provides all the nutrients for foetal growth and removes waste products simultaneously through the umbilical cord.

Following delivery, the cord quickly starts to dry out, harden and turn black (a process called dry gangrene). This is helped by exposure to the air. The umbilical vessels remain patent for several days, so the risk of infection remains high until separation.

Colonisation of the area begins within hours of birth as a result of non-pathogenic organisms passing from mother to baby via skin to skin contact. Harmful bacteria can be spread by bad hygiene; poor hand washing techniques and especially by cross infection by health care workers.

Separation of the umbilical cord continues at the junction of the cord and the skin of the abdomen, with leucocyte infiltration and subsequent digestion of the cord. During this normal process, small amounts of cloudy mucoid material may collect at the junction. This may unwittingly be interpreted as pus. A moist and/or sticky cord may present, but this too is part of the normal physiological process. Separation should be complete within 5-15 days, although it can take longer. The main reasons behind prolonged separation include the use of antiseptics and infection.

Antiseptics appear to reduce the number of normal non-pathogenic flora around the umbilicus. This reduction in leucocytes prolongs the healing process and hinders cord separation.

After the cord has separated, a small amount of mucoid material is still present until complete healing takes place a few days later. This means that there is still a risk of infection, although not as great as in the first few days. [back to top]

Present Practices in the Developed World

In the developed world present applications include:

• Alcohol
• Hexachloraphane powder (Sterzac)
• Chlorhexadine or Betadine solution
• Triple Dyes
• Tincture of Iodine
• Silver Sulphadiazine
• Topical antibiotics (WHO 1999)

The use of umbilical binders was discontinued in most hospitals in the 1950s and 1960s. It was found that their use, only served to increase the likelihood of infection by not allowing the cord to dry ( Perry D S 1982). [back to top]

Previous Studies and their implications

Many studies have been carried out to compare differing treatments and their effect on infection rates, colonization and length of cord separation. ( Barr J 1984, Mugford et al 1986, Salariya E M 1988, Verber I G 1992, Medves J 1997). The overall results conclude that the more the cord is treated, the longer it will take to separate. Prolonged cord separation rates are also associated with reduced colonization levels.

This would suggest that a certain level of colonization, is actually a healthy sign and not necessarily a pre-curser to infection. This is why 24hr rooming-in is such an important factor in the care of the newborn. It not only avoids cross infection by healthcare workers but also encourages early colonization of non-pathogenic organisms, which in turn promotes faster healing (Rush J P 1987).

Maybe J Barr (1984) was right when she postulated that; 'Whartons Jelly may possess an, as yet, unknown factor, that is essential to the natural healing process'. It certainly seems to be true that the use of treatments on the umbilical cord, appears to interrupt and prolong the natural process of cord separation.
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Proposed New Guidelines for Cord Care

Aseptic Technique at Delivery:

• Scrupulous attention to hand washing before and after vaginal examinations and prior to cutting of the cord.
• Lay the baby on a clean surface to cut the cord.
• If gloves have been contaminated during delivery, they should be changed prior to cutting the cord.
  Always use a sterile instrument to cut the cord.
• The cord should be cut no closer than 3cms from the cord stump as this avoids excessive bleeding,(Billinbton W R et al 1963) whilst in some cultures it is left much longer.

Skin to Skin contact and 24hr Rooming-In:

• Immediate skin to skin contact following delivery is important because it will encourage non-pathogenic colonization from mother to baby. It is also known to encourage bonding, attachment and successful breastfeeding.*
• 24hr rooming-in is now common practice in hospitals worldwide. This is important because it cuts down the risks from cross infection and nosocomial infection.*
• As the mother is the sole carer, there is less chance of healthcare workers spreading infections from one baby to another.
  

Breastfeeding:

• Early and frequent breastfeeding should be encouraged as this provides added protection against infection.
• Breast milk contains antibodies that will help the baby to fight infections.
• Colostrum and breast milk are known to contain many anti-infective properties. They are commonly used to treat eye infections in developing countries (Singh N et al 1982). [back to top]

Open Cord Care:

• Hand washing before and after all baby cares
• Leave the cord open to the air. This will allow the cord to dry out naturally.
• Minimal handling of the cord and surrounding area will cut down the risk of cross infection.
• Clothes should be clean and loose fitting to allow air to circulate.
• Fold down the napkin so that the cord is left exposed.
• In some Maternity units the cord clamp is routinely left in situ. This is thought to augment cord separation due to the added weight.
  

Keeping the Cord and surrounding area clean:

• It is important to use only plain water for cleaning, as the use of other products may interrupt the natural healing process ( Medves J 1997, Trotter S 2002).
• It is not necessary to bath babies every day. A top'n'tail wash is quite adequate and will allow the cord to stay dry.
• If contaminated with urine or faeces use cottonwool soaked with water to wash the cord and surrounding area. Pat dry carefully with a clean towel.
• Never use dry cottonwool as it may leave filaments behind on the cord.
• There is no need to use antiseptic lotions or powders.

Tetanus Immunisation:

• It remains important for women of childbearing age to be protected against Tetanus, so that passive immunity can be conferred to their baby in the weeks prior to infant immunisation.
  

Sick or Premature Infants:

• Where infants cannot benefit from 24hr rooming-in, it may be necessary to use a topical antiseptic for the first few days.
• This can be followed by 'open cord care' when the cord has become dry and hard.
• The reasons behind these extra precautions include; the higher risks of nosocomial infection, the increased number of carers and the infants compromised immune system. [back to top]

Observe for signs of infection (Omphalitis):

• These include redness, erythema, oedema and tenderness.
• Infection is known to prolong the patency of the umbilical vessels, leading to bleeding from the cord.
  Purulent discharge may also be present.
• Pyrexia, lethargy and poor feeding alongside the signs of infection point to systemic involvement.
  Complications of the above include septicaemia and peritonitis.
• Broad-spectrum antibiotic cover is the treatment of choice. If a microbiology swab result is available, specific antibiotics can be targeted.
• The prevalence of a moist and/or sticky cord base, which may or may not be smelly, is not necessarily a positive sign of infection. If the baby is alert, feeding well and afebrile, then the chances of infection remains low. Observation is the only treatment required in this instance.
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Discussion

It is always difficult to introduce new guidelines, when there doesn't seem to be a problem with the existing treatments. However, in the case of cord care, there is overwhelming evidence to suggest we do need updating.

For the majority of healthy newborns, who are being cared for by their mothers, a system of 'open cord care' is now appropriate. Minimal handling of the cord should ensure quick and trouble free separation.
By excluding the use of antiseptics treatments and baby products, the natural process of dry gangrene can continue unhindered.

The only exception to these guidelines is for sick and premature infants as explained earlier.
It must be stressed that the complications of infection, although alarming, are very rare. In the developed world, the overall figure is 0.5% (McKenna H, Johnson D 1977). Even in the urban slums of India, a rate of only 3% was found (Singhal P K et al 1990).

This is why an evidence-based approach to cord care is so important. By introducing easy to follow guidelines we, as midwives, can hopefully reduce infection rates even further. [back to top]

Further Research:

Although 'open cord care' is in common use throughout the world, more research studies may be beneficial to persuade those still using unnecessary treatments.
Does leaving the cord clamp in situ have an effect on infection or separation rates?
Studies into the care of sick and premature infants using the updated guidelines would also beneficial.
It would also be interesting to see how effective natural plant/herb treatments may be, as an alternative to conventional antiseptics. This would include breast milk and colostrum, which is known to possess antimicrobial properties. (Stanway 1996).
Midwifery time saved as a result of increased time to separation of the cord. [back to top]

Summary

At the very heart of this, is the cost, both emotional and financial, of neonatal mortality and morbidity.
Cost effectiveness should not be underestimated. Savings can be made, as a result of the reduced need to use antiseptic products. Added to this is the potential savings to be made in midwives time, which is the most expensive commodity in the care of mother and baby (At present extra visits are usually as a direct result of cord separation problems).

Updating cord care, using evidence-based research is the best way forward for midwives everywhere. Only then, can we teach women to care for their infants in the safest possible way. This will not only avoid confusion but will lead to continuity of care and reduced infection rates. [back to top]

Key Points of Cord Care:

1. Hand washing before and after all baby cares.
2. Leave cord open to air or cover with clean, loose clothing.
3. Fold napkin down below the cord until separation.
4. Leave alone unless contaminated by faeces or urine.
5. Clean, if necessary with plain water.
6. Observe for signs of infection.
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References:

Barr J. (1984) The umbilical cord: to treat or not to treat? Midwives Chronicle and Nursing Notes, 97(1159): 224-6.

Billinbton WR, Welbourn HF, Wandera KCN, Sengendo AW. (1963) Custom and Child Health in Uganda, III Pregnancy and childbirth. Trop Geo Med, 15: 134-7.

McKenna H & Johnson D. (1977) Bacteria in neonatal omphalitis. Pathology, 9:111-3.

Medves J. (1997) Cleaning solutions and bacterial colonization in promoting healing and early separation of the umbilical cord in healthy newborns. Canadian Journal of Public Health, 88 (6): 380-2.

Mugford M, Somchwong M, Waterhouse IL. (1986) Treatment of umbilical cords: a randomised trial to assess the effect of treatment methods on the work of midwives. Midwifery, 2:177-86.

Perry D S. (1982) The umbilical cord: Transcultural care and customs. Journal of Nurse-Midwifery, 27(4): 25-30.

Rush J P at al. (1987) Rooming-in and visiting on the ward: effects on newborn colonization rates. Infection Control, 2(supp3):10-5.

Salariya E M & Kowbus N M. (1988) Variable umbilical cord care. Midwifery, 4:70-6.

Shrivastava SP, Kumar A, Ojha AK. (1990) Neonatal morbidity and mortality in ICDS urban slums. Indian Pediatrics, 27:485-8.

Singh N, Sugathan PS, Bhujwala RA. (1982) Human colostrum for the prophylaxis against sticky eye and conjunctivitis in the newborn. Journal of Tropical Pediatrics, 28(feb : 35-7.

Stanway A, Stanway P. (1996) Breast is Best; a common sense approach to breastfeeding. Pan Books: London: 44- 50.

Trotter S. (2002) Skincare for the newborn: exploring the potential harm of manufactured products. Midwives Journal, 5(11): 376-8.

Verber I G & Pagan F S. (1992) What cord care-if any? Archives of Disease in Childhood, 68: 594-6.

World Health Organization. (1999) Care of the Umbilical Cord:A Review of the Evidence (44 pages). Reproductive Health (technical support) Maternal and newborn Health/safe motherhood. Geneva
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