Sharon Trotter RM BSc
Midwife, Breastfeeding Consultant and Neonatal Skincare Advisor
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
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 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:
The basis of cord care, as we know it today, has evolved through many years of traditional and cultural customs.
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 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]
In the developed world present applications include:
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]
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.
Aseptic Technique at Delivery:
Skin to Skin contact and 24hr Rooming-In:
Open Cord Care:
Keeping the Cord and surrounding area clean:
Sick or Premature Infants:
Observe for signs of infection (Omphalitis):
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.
The only exception to these guidelines is for sick and premature infants as explained earlier.
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]
Although 'open cord care' is in common use throughout the world, more research studies may be beneficial to persuade those still using unnecessary treatments.
At the very heart of this, is the cost, both emotional and financial, of neonatal mortality and morbidity.
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]
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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.
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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.
|© Sharon Trotter 2013|