Nigerian Journal of
Paediatrics 2011;38 (4):175 -181
ORIGINAL
Mukhtar-Yola M
Survey of Umbilical Cord care and
Iliyasu Z
Wudil
B J
Separation time in Healthy Newborns in
Kano
Received:5th February
2011
A b
s t r a c t
B a
c k g ro u n d : The
hundred and forty nine
(60.9.
Accepted:13th October
2011
interval between delivery
and
p e r c e n t )
m o t h e r s
a p p l i e d
umbilical cord separation
varies
methylated spirit, 145
(25.3
Mukhtar-Yola M (
)
worldwide. Some
maternal, foetal
percent) used hot
compress, while
Wudil B J
and perinatal factors
including
50 (8.7 percent)
applied toothpaste
Department of
Paediatrics Aminu cord care practices are known to
on the cord. Twenty
(3.5 percent)
Kano Teaching
Hospital.
affect this
interval.
others applied herbs,
while nine
Email :
mariyamukhtar@yahoo.com
Objectives: To
establish the
mean
(1.6 percent) applied
dusting
umbilical cord
separation time and
powder to the umbilical
stump.
the effect of maternal
and infant
Cord
separation
time
was
Iliyasu Z
characteristics,
perinatal factors
significantly shorter
among babies
Department of
Community
and cord care practices
on this time
whose mothers were of
high parity,
Medicine
.
among healthy babies in
northern
unbooked, and of low
educational
Murtala Mohammed
Specialist
Nigeria.
status. In addition,
the use of razor
Hospital, Kano
Nigeria
M e
t h o d s :
A n
i n t e r v i e w e
r
blade, thread, hot
compress or
questionnaire was
administered on
application of herbal
preparations
mothers of healthy
babies at Child
or
toothpaste
significantly
Welfare Clinics of a
tertiary and
shortened the
separation time
secondary level
hospital in Kano.
(P<0.05).
In each case,
information was
Conclusions: Cord
separation time
obtained about mother's
parity,
and cord care practices
varied.
place of antenatal care
and
Nigerian mothers often
use
delivery, gestational
age, birth
unorthodox
interventions to shorten
weight, time of
umbilical cord
cord separation time;
however, the
separation after birth
and cord
risk of omphalitis that
may result
treatment
practices.
from this is real. We
recommend
Results: Five
hundred and
seventy
that each centre should
adopt and
seven (96.2 percent) of
600
teach mothers a
standard hygienic
mothers interviewed,
took part in
c o r d
c a r e
p r a c t i c e
w h i l e
the study, four of
these mothers had
discouraging the use of
herbs and
twin gestation.
Responses showed
untested
materials.
that cord separation
time ranged
from 2 -14 days (4.20
1.70)Three
Keywords:
Umbilical
cord,
Separation time, Cord
care, Kano
Introduction
stiff (dry gangrene).
The devitalized tissue of the cord
stump can be an
excellent medium for bacterial
EACH year,
approximately one million newborns
growth, especially if
the stump is kept moist and
unclean substances
areapplied to it.
2,3
worldwide die of
infection caused by bacteria that
Adequate care
enter the body via the
umbilical cord. When the cord
1
of the umbilical cord
stump of the newborn infant
is cut, the stump is
suddenly deprived of its blood
may prevent infections.
At present, various topical
supply. The stump soon
dries and turns black and
methods are used for
cord care, including washing
176
with soap and water,
cleaning of the stump with
newborns in Kano,
northern Nigeria. The aim is to
alcohol, application of
dry heat, use of dusting
establish the mean
separation time and the effect of
powder or antimicrobial
creams. Powders currently
maternal and infant
characteristics, perinatal factors
used contain varying
amounts of zinc oxide, talc,
and cord care practices
on the cord separation time.
starch or alum, and
other ingredients. Some powders
We also sought to find
out the mothers' sources of
also contain
hexachlorophane or chlorhexidine.
4
information about cord
care and their perceived best
Common antimicrobial
agents applied, include triple
cord care
practices.
dye, tincture of
iodine, iodophors, antibiotic
ointments, silver
sulfadiazine, povidone-iodine and
chlorhexidine.
4
Materials and Methods
Setting
The normal process of
cord separation is by
inflammation of its
junction with the abdominal
skin, resulting in
collection of small amounts of
The study was conducted
at the Infant Welfare Clinics
cloudy mucoid material
at the junction. This is often
ofAminu Kano Teaching
Hospital, Kano and Murtala
misinterpreted as
pus.
2,3
Variable times for
cord
Mohammed Specialist
Hospital, Kano. These are the
separation have been
reported, with the commonly
two largest hospitals
in metropolitan Kano. The study
reported periods being
between five and fifteen days
was conducted over a
period of three months
after birth.
4,5
Factors that may alter
this process of
(October-December) in
2006. Mothers of all healthy
cord separation include
delivery by caesarean
newborns delivered
during this period were eligible.
section, antibiotic
use, application of antiseptics to
Mothers whose babies
had omphalocoele or other
the cord, defective
neutrophil mobility, and infection
related congenital
abnormalities and those who
in the neonate.
3,6
required hospital
admission for illnesses at birth,
were excluded from the
study. Informed consent was
Antiseptics have also
been associated with delayed
obtained from mothers
before recruitment to the
cord separation,
besides making neonatal care more
7
study. Permission was
obtained from both hospital
expensive. A study by
Mugford et
al
8
indicated that
authorities and the
institutional ethical committee of
in countries where
mothers are visited by midwives
Aminu Kano Teaching
Hospital. A standardized
during the postnatal
period, problems with the cord
interviewer
administered questionnaire was pretested
often determine the
number of visits.
and modified for
clarity before being used to
interview 600 mothers.
Only mothers who had their
Data on the pattern of
umbilical cord stump care,
babies
within
the
preceding
six
weeks
separation time and the
effect of different cord care
wereinterviewed to
enhance recall. A pair of trained
regimens are useful for
many reasons. They will
research assistants
that were fluent in the local
guide health care
providers in differentiating
(Hausa) language
administered the questionnaires at
between normal and
abnormal cord separation time
the two
hospitals.
in order to avoid
unnecessary interventions, which
may lead to neonatal
morbidity and mortality
Information was
obtained on the age and sex of the
especially in
developing countries where the level of
infant, antenatal care,
gestational age at delivery,
hygiene is low. It is
also important in designing
4
place of delivery,
mother's parity, mode of delivery,
neonatal care
programmes for mothers and other
birth weight, cord care
practices and cord separation
caregivers.
time.
Mothers in Africa often
worry and sometimes get
Data analysis
quite anxious about the
time it takes for the cord to
fall off. As a result
of this, different interventions are
The data was 'cleaned',
validated and analysed using
SPSS version 12.
10
often practised to
shorten the cord separation time.
Quantitative variables
were
Although umbilical cord
separation time and the
summarised using range,
mean and standard
effect of cord care
practices and perinatal factors
deviation. Categorical
variables were tabulated using
have been reported from
Ibadan
9
in southwest
frequencies and
percentages. The student t test and
Nigeria, no such
studies have been published from
Analysis of variance
(ANOVA) were used for
northern Nigeria, where
the culture and climatic
comparing means
depending on the number of
conditions are
different.
groups. Bonferonni's
correction was applied for
multiple comparisons.
The level of significance for
It is against this
background that we report the
all tests was set at
P< 0.05.
umbilical cord care and
separation time in healthy
177
Result
Table
2: Maternal and Infant Characteristics
and Time of Cord
Out of the 600 mothers
requested to participate in the
Separation
(n=577)
study, 577 (96.2%)
accepted. The rest either declined
Cord Separation Time
(days)
Characteristics
No. (%)
Mean±
SD t or F value df P
value
consent or had
exclusion criteria mainly due to
admissions in the
neonatal period. The babies of the
Antenatal care
respondents consisted
of 277 (48.0%) males and 300
Booked
561 (97.2) 4.22±
1.71 2.52
575 0.023
(52.0%) females. The
time interval between birth
Unbooked
16 (2.8)
3.38±
1.31
and separation of the
umbilical cord ranged from 2 to
Gestational age (wks)
14 days with a mean of
4.20 ± 1.70 days. The
umbilical cord
separated within the early neonatal
(range 28 - 44 wks)
period (1 week of life)
in 95.8 percent of all infants,
st
<32
3 (0.5)
3.67±
0.58
4.4
3
0.002
and the rest of the
cords separated by the end of two
32-36
17 (2.9)
4.53±
1.33
weeks of life. Table
1.
37-42
452 (78.3)
4.32±
1.79
Table
1 Time
of Cord
Separation and
Baby's Gender
(n=577)
>42
105 (18.2)
4.04±
1.86
Birth weight (kg)
Cord separation
Males
Females
Total
(range 1.2- 5.9kg)
time
No(%)
No(%)
<1.5
1 (0.2)
4.00±
0.0
0.41
3
0.75
(Days)
1.5-2.499
16 (3.5)
3.81±
1.05
2-4
195(50.9)
188(49.1)
383(66.4)
2.5-4.0
383 (84.2) 4.28±
1.82
5-7
69(40.6)
101(59.4)
170(29.5)
>4.0
55 (12.1)
4.18±
11.61
8-10
12(57.1)
9(42.9)
21(3.6
>10
1(33.3)
2(66.7)
3(0.5)
Though 577 mothers knew
their approximate
Total
277(48.0)
300(52.0)
577(100.0)
gestational ages by
date, only 455 knew the birth
2
weight of their babies,
as 105 babies were delivered at
=0.38 df=1 P=0.54
Range=2-14 days MeanSD
home and 17 mothers
could not recall the birth
[All=4.201.70;
Males=4.10± 1.69;
Females=4.28± 1.71]
[t=-1.29 df=575
P=0.20]
weights of their babies
delivered in hospital. It is not
uncommon in this
environment to attend antenatal
There was no
significant difference in cord
care which is free but
to deliver at home because of
separation time by
gender. Three hundred and forty
cost implications. .
There was no significant
nine (60.9%) mothers
applied methylated spirit, 145
relationship between
the cord separation time and
(25.3%) hot compress,
and 50 (8.7%) used
birth weight. Babies of
primiparous mothers had
toothpaste ( Macleans ). Other applications
included
significantly longer
cord separation time compared to
herbal preparation in
20 (3.5%) and dusting powder
those of higher parity
(F=3.53 df=4 P=0.007).
in nine (1.6%)
others.
Similarly, among
educated mothers, the higher the
level of education the
longer the cord separation time
Five hundred and sixty
one (97.2%) mothers booked
(F=8.41 df=4 P=0.0001).
Furthermore, babies of
for antenatal care.
Babies whose mothers had
lower birth order had
longer cord separation time
antenatal care had
significantly longer cord
compared to those of
higher birth order (F=3.36 df=4
separation time (t=2.52
df=575 P=0.023). Four
P=0.01).
hundred and fifty two
(78.3%) of the babies were
term, 20 (3.5%) were
preterm and 105 (18.2%) post
Babies delivered by
caesarean section had
term. Babies delivered
before 32 weeks of
significantly longer
cord separation time compared to
gestational age had
significantly shorter cord
those delivered
spontaneously through the vagina. In
separation time
compared to more mature babies
contrast, assisted
vaginal delivery (forceps or
(F=4.4 df=3 P=0.002).
Three hundred and eighty
ventouse) was
associated with shorter cord separation
three (84.2%) of the
babies had normal birth weight,
time compared to others
methods of delivery. (F=5.55
16 (3.5%) had low birth
weight while 55 (12.1%)
df=2 P=0.004). Babies
delivered at home had shorter
babies were macrosomic
while one baby was of
cord separation time
compared with those delivered
extreme low birth
weight. Table 2
in the hospital
(F=11.07 df=2 P=0.0001).
178
The effects of certain
perinatal factors on the mean
cutting the umbilical
cord at birth remained
cord separation time
are shown in Table 3. There
Independent predictors
of cord separation time as
were 573 responses as 4
mothers had twins. It can be
shown in table
4.
seen that the use of
razor blade instead of hospital
scissors to cut the
cord, shortened separation time
Regarding sources of
knowledge about cord care, 363
(F=14.02 df=2
P=0.0001). Similarly, the use of
(62.9
% ) of the mothers reported that health workers
thread instead of
plastic cord clamp to ligate the
told them how to care
for the cord during antenatal
umbilical
cord
(F=9.69
df=2
P=0.0001)
visits or before
discharge from hospital following
significantly shortened
the cord separation time.
delivery. Others
sources included their own mothers
Regarding cord
treatment, babies whose cords were
in 146 (25.3 % ) instances, their grandmothers in
40
treated by the
application of methylated spirit
(6.9
% ) and friends in 28 (4.9 % )
others. Respondents
(alcohol) had the
longest mean separation time. In
opined that even though
they might not have used the
contrast, those babies
whose cords were treated with
option at birth, they
thought the best cord care
Macleans
(toothpaste) had the
shortest cord
methods included
methylated spirit (277; 48.0 % ),
hot
separation time. The
separation time for those who
water compress (164;
28.4 % ), methylated spirit plus
used hot compress or
herbal preparations were in
hot compress (67;
11.6 % ),
Macleans toothpaste (29;
between the other two.
After controlling for the
5.0
% ), herbal preparation (19; 3.3
% ), Macleans plus
confounding effects of
other variables, only
hot compress (16;
2.8 % ) and five (0.9
% ) mentioned
maternal education and
the instrument used for
dusting powder.
Table 3: Perinatal factors and cord care by
age of cord separation
Cord Separation Time
(days)
Characteristics
No. (%)
Mean±
SD
t or F value
df
P Value
Instrument used to cut cord
Hospital
scissors
338 (58.6)
4.50±
1.81
New blade
238 (41.2)
3.76±
1.42
14.02
2
0.0001
Old blade
1 (0.2)
3.00±
0.00
Cord
‘clamp’ used
Thread
332 (57.5)
3.94±
1.57
Plastic cord
clamp
239 (41.4)
4.56±
1.79
9.69
2
0.0001
Others
6 (1.0)
3.83±
2.23
Cord
treatment
Methylated
spirit
349 (60.9)
4.54±
1.84
Hot compress
145 (25.3)
3.82±
1.23
Macleans tooth
paste
50 (8.7)
3.12±
1.22
11.77
4
0.0001
Herbal
preparation
20 (3.5)
3.95±
1.70
Dusting powder
9 (1.6)
3.44±
0.88
NB Four mothers has
twins.
179
Table 4: Predictors of
Cord separation Time among Healthy Newborns in Kano
Non-standardized
Standardized
Coefficients
Coefficients
B
Std. Error
Beta
T
P Value
(Constant)
4.500
0.444
10.138
0.001
Parity
-0.090
0.405
-0.128
-0.223
0.824
Mode of delivery
0.033
0.088
0.016
0.377
0.706
Maternal
education
0.180
0.061
0.132
2.941
0.003
Cord cutting
instrument
-0.454
0.168
-0.133
-2.702
0.007
Cord Clamp
-0.175
0.164
-0.053
-1.064
0.007
Separation time
compared to those who had
Discussion
spontaneous vaginal or
assisted delivery. This was
also reported by
earlier workers
3,5,15
who suggested
The interval between
birth and umbilical cord
that it could be a
reflection of decreased bacterial
separation among
newborns in Kano ranged from
contamination of the
umbilical cord in those delivered
two to 14 days with a
mean of 4.201.70 days. This is
by caesarean section
with consequent decreased
leukocyte migration to
the cord. This tends to be
2
shorter than the mean
separation time found in
Ibadan, Nigeria (8.73.7
days),
9
Ankara, Turkey
supported by reports
indicating that umbilical cord
(8.23.2 days) and other
developing countries.
1
4,11
In
separation is mediated
through leukocyte infiltration
addition, the mean
separation time was much shorter
and digestion.
3,11,12
Therefore,
interventions that limit
than the figures
reported from Europe and United
4
cord contamination may
cause significant delays in
States of America (13.9
days). The different cord
3
cord separation
time.
care regimens had
various effects on cord separation
time as observed by
earlier workers.
6,8
In contrast to previous
studies,
4,5
For instance,
we found
significant
we found significantly
shorter separation time among
effects of maternal
booking status, gestational age,
babies whose cords were
treated with hot compress,
parity and types of
instruments and ligatures used on
herbal preparation,
Macleans (toothpaste) and
cord separation time.
Babies of booked mothers had
dusting powder compared
to those whose cords were
longer cord separation
time. This could be related to
treated with methylated
spirit (alcohol). The
the increased likelihood
of booked mothers to be
differences in cord
separation time could be
informed about hygienic
cord care practices. In
attributed to the
effect of unorthodox cord care
addition, booked
mothers are also more likely to
practices coupled with
the generally low level of
deliver in hospital and
have the umbilical cord cut
hygiene, which probably
resulted in higher rates of
with sterile hospital
scissors, and to use methylated
bacterial colonization,
and early falling off of the
spirit (alcohol) as a
means of cord care. Babies
umbilical cord.
11
Hayward et al reported
that
delivered preterm had
shorter cord separation time
umbilical cord
separation is mediated through
that could be related
to differences in immune
leukocyte infiltration
and digestion. Another reason
12
response.
may be because of the
very hot weather and low
humidity in northern
Nigeria.
Recent evidence
Cord care was not
standardized in the centres where
indicates that rubbing
alcohol does not promote
this study was
conducted.
drying, is less
effective against bacteria than other
This is the reason for
the varied cord treatment
antimicrobials, and
delays cord separation time
4,13,14
methods used. However,
the majority of mothers used
thread or plastic cord
clamps. A WHO review
4
however, it may reduce
the incidence of omphalitis
which remains a
clinical issue, especially in
reported that plastic
cord clamps effectively close all
developing
countries.
vessels in the
umbilical cord and are easy to use.
However, they are more
expensive and may not be
In keeping with most
previous studies, we did not
easily available in the
rural areas. Majority of mothers
observe significant
differences in the mean cord
in the present study
applied methylated spirit
separation time by
gender.
3,5
However, this
finding
(alcohol) and this was
associated with the
contrasts with the
report from Ibadan , where a
9
longestmean separation
time. This study found that a
shorter cord separation
time was found among male
quarter of mothers
applied heat treatment by using hot
infants.It was observed
that babies delivered by
compress, which
resulted in a shorter separation time.
The danger here is not
the heat itself, but the use of
180
Rags and heated soil,
which may introduce bacterial
doing anything better
than keeping the cord clean is
helpful ” . Few
interventions for cord care have been
16
spores leading to
sepsis and tetanus.
evaluated by randomized
controlled trials. However,
Another interesting
emerging method of cord care
the following have been
recommended: hand
used by more than eight
percent of mothers is the
Washing before and
after contact with the umbilical
application of
toothpaste to the cord stump. Babies of
area, use of sterile
instruments to cut the cord,
such mothers had the
shortest mean separation time of
keeping the cord clean
and dry, water on cotton swabs
3.12 days. The
ingredients of commonly used
may be used to clean
the base of the cord, exposing
toothpastes in the
study area include sorbitol,
the cord to air or
covering loosely with lose clean
hydrated silica,
fluoride and cellulose gum. The
cloth, folding the
diaper below the level of the
effects of these
constituents on cord tissue need
umbilicus and
encouraging breast feeding and skin-
further evaluation.
Similarly, the use of herbal
skin contact with the
mother to promote colonization
preparations in cord
care by some mothers may
with non pathogenic
bacteria from the mother's skin
introduce toxic
substances or lead to bacterial
flora.
contamination of the
cord. In order to prevent
neonatal morbidity and
mortality due to neonatal
This study has
limitations. The first is that the study
sepsis and tetanus, it
is particularly important to
was hospital based.
Therefore, participants are more
inform mothers,
especially primigravida on good
likely to be educated,
booked and to have delivered in
cord care
practices.
hospital. Hence, our
findings may not reflect all
varieties of cord care
practices in the community,
They should be
instructed to keep the cord clean by
particularly in
relation to herbal substances applied to
washing with warm water
and soap and exposing it to
the umbilical stump.
Similarly, although most
room air. They should
not to apply any substance to
communities in
northwest Nigeria tend to have
the cord, and should
seek medical attention if there
similar socio-cultural
characteristics, other parts of
are signs of swelling
or redness in the peri-umbilical
northern Nigeria are
not as homogenous; therefore,
region or if there are
systemic symptoms. In our study
cord care practices may
be different in those parts.
population, even among
booked mothers, up to 38
percent of mothers said
they were not informed about
In conclusion, centres
should identify safe, cheap and
cord care during
antenatal care. A high proportion
easy to follow
guidelines for cord care. Since
(42.4%) of those who
delivered in hospital said they
controlled trials have
shown that cutting the cord with
were not taught how to
care for the cord before
clean instruments,
washing with clean warm water or
discharge from
hospital. These missed opportunities
cleaning the base with
moist cotton wool and
call for the
development of strategies under the
exposure to room air
are effective ways of caring for
maternal-newborn
continuum of care to reduce
the cord, healthcare
workers should therefore
neonatal mortality in
similar centres in developing
encourage mothers to
practise these in addition to
Countries.
exclusive breast
feeding. The application of
dangerous and untested
substances to the umbilical
There seems to be no
consensus on the best cord care
stump should be
discouraged while further
practice. The Cochrane
data base of systematic
investigations should
be undertaken to determine the
reviews concluded that
“ we are unable to be sure what
effects of these
unorthodox substances on umbilical
is the best practice
for cord care in institutions in
cord tissue.
developed countries ”
but there is no evidence that
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