Indian Pediatrics - Editorial

Brief Report

Indian Pediatrics 1999; 36:588-590

Umbilical Cord Fall in Preterm and Term Newborns in Vaginal and Caesarean Deliveries

Narinder Singh,
Sudesh Sharma,
Ravreet Singh

From the Department of Pediatrics Government Medical College Amritsar, Punjab, India,

Reprint requests: Dr. Narinder Singh, 36, Sant Avenue, Mata Kaulan Marg, Near S.S.P. Residence, Amritsar, Punjab, India.

Manuscript Received: May 22, 1998; Initial review completed: July 27, 1998;
Revision Accepted: December 8, 1998.

Umbilical cord is an important lifeline during intrauterine life but has little significance after birth when it shrivels and falls usually within 6-8 days of life. Occasionally, it may take a longer time to fall off. A delay in separation of cord is often a cause of maternal concern which can be prevented if a proper explanation is given. The present study was conducted to evaluate the effect of mode of delivery and prematurity on the time of fall of umbilical cord.

Subjects and Methods

The study was conducted in the Obstetrics abd Gynecology ward of the Government Medical College, Amritsar. The study group consisted of 250 newborns (150 term + 100 pre term) of which] 32 were delivered vaginally (61 term + 71 preterm) and 118 by Caesarean section (89 term + 29 preterm). Gestational age was calculated from the last menstrual period of the mother. Neonates with morbidity during perinatal period (perinatal asphyxia, pathological hyperbilirubinemia, congenital anomalies, clinically detectable infections including umbilical stump infections) were excluded from the study. Newborns were grouped as; Group I - Pre term vaginal, Group II - Term vaginal, Group III - Pre term Caesarean and Group IV - Term Caesarean. After bathing the babies with soap and water, triple dye (Brilliant Green 2.29, Proflavine hemisulfate - 1.4 g, and Crystal Violet - 2.29 g in distilled water sufficient to make 1000 ml) was applied to stump and surrounding 1inch of skin within 12 hours of birth and once daily thereafter until the cord separated. Parents were told to keep the cord dry. No bandage or dressing was applied to the stump. The babies who developed morbidity during the study like pathological hyper- bilirubinemia, sepsis including umbilical infections, etc. were excluded from the study. Babies were followed up daily in the hospital until the cord separated. Mothers of babies whose cord did not separate. in hospital were instructed to apply dye on cord once daily after the separation. The time of cord separation was noted by questioning the mothers at the time of follow up in the hospital.

Results

Out of the total 250 cases, 178 newborns without any complications were followed up. Out of these, 56 were vaginal preterm, 40 were vaginal term, 20 were Caesarean preterm and 62 were Caesarean term.

In all the groups the time of cord fall ranged between 3-31 days. Five babies had cord fall after 21 days of life as shown in Table I.

In majority of vaginal preterms (48.2%) the cord separated between 6-8 days of life, followed by 3-5 days in 32.1 %, and 9-] ] days in 14.3%. Only in 5.4% of case, the time of cord separation was more than 11 days. The time of cord fall ranged between 3 to 21 days with average time of separation being 6.93:t2.92 days. One baby had cord separation on the 21st day of life.

TABLE I

Days of Fall of Umbilical cord in Different Groups

Total Babies	Fall of umbilical cord (days)				Range	Mean	SD
	3-5	6-8	9-11	>11
Preterm Vaginal
Group I	18	27	8	3	3-21	6.93	2.92
n=(56)
Term Vaginal
(Group II)	16	19	3	2	3-17	6.40	2.75
(n= 40)
Total	34	46	11	5	3-21	6.71	2.85
Vaginal (96)
Preterm Caesarean
(Group III)	4	7	4	5	4-31	10.10	6.88
(20)
Term Caesarean
(Group IV)	9	31	12	10	3-27	8.77	4.11
(62)
Total	13	38	16	15	3-31	8.98	4.82
Caesarean (82)

Similarly, in Group II, the time of cord fall was between 6-8 days in 47.5%, 3-5 days in 40% and 9-11 days in 7.5%. Only in 2 cases (5%) cord separation occurred beyond 11 days. The time of cord separation varied between 3- 17 days with an average time of cord fall being 6.4:t 2.75 days.

In Caesarean preterms (Group III) The range of cord separation was 4-31 days. with the average time of cord separation being 10.10 :t 6.88 days. In majority of the babies (35%) cord separated between 6-8 days. Separation of umbilical cord was delayed beyond 11 days in 25% of cases, whereas an equal number of cases (20%) had their umbilical cord separated between 3-5 days and 9-11 days. Three babies had cord fall after 21 days of life.

In term Caesarean (Goup IV), the maxi- mum number of babies (50%) shed their cord within 6-8 days. Cord separated between 9-11 days, beyond II days, 3-5 days in 19.4%, 16.1 %, and 14.5%, respectively. The range of cord fall was 3-27 days with mean of8.77:t4.ll days. Only 2 babies had cord fall after 21 days.

On evaluation of the results in vaginal and caesarean delivered babies, most of the vaginal (47.9%) as well as Caesarean delivered babies (46.3%) shed their cord within 6-8 days of birth. In 18.3%cases delivered by Caesarean section, the cord fall was delayed beyond 11 days as compared to 5.2% of babies delivered by vaginal route. The mean age of cord fall was 6.7:t2.85 days in vaginally delivered babies (p21 days) in one vaginal and four Caesarean deliveries.

Discussion

In the present study, 47.2% of the newborns had separation of the umbilical cord on or before the 8th day of life, while in 26.4% the cord had fallen off by the 5th day. Cord separation was delayed beyond 11 days in 11.2% of babies.

The present 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 (mean 6.71 days). These findings are consistent with earlier observations (1,2).

A delay in cord separation as a result of Caesarean section probably reflects decreased bacterial contamination of umbilical cord with subsequent decrease in number of leukocyte attracted to the cord(2).

Umbilical cord separation is most likely mediated through leukocyte infiltration and subsequent digestion of umbilical cord. Interventions that impede or inhibit migration and activity of leukocytes are likely to prolong the interval between birth and cord separation. Similarly, naturally occurring defects in leukocyte functions and migration will have the same effect, i.e., studies have documented difference in total leukocyte count, resting oxygen consumption of polymorphonuclear leukocytes and quantitative NBT dye reduction of leukocytes between neonates delivered vaginally and by Caesarean section(3).

In conformity with earlier data (1,2) we 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. In the present study, the mean age of cord separation in an average newborn was 7.74 days. This clearly differs from the time re- ported by Novack et al.,(2) (13.9:t4.7 days) and Wilson et al.,(4) (15.0:t7.2 days), but compares more closely with time of cord separation reported in other studies (1,5,6,7).

It is concluded that mode of delivery such as Caesarean section affects the fall of umbilical cord significantly whereas prematurity does not affect it.

References

1. BhalJa IN, Nafis N, Rohatgi P, Singh J. Some observations on separation of umbilical stump in the newborn. Indian J, Pediatr 1975; 42: 329-334.

2. Novack AH, MulJar B, Ochs H. Umbilical cord separation in normal newborn. Am J Dis Child 1988; 142: 220-223.

3. Frazier JP, Clearly TG, Pickering LK, Kohl S, Ross PJ. Leuckocyte functions in healthy neonates following vaginal and Caesarean section. deliveries. J Pediatr 1982; 101: 269-272.

4. Wilson CB, Ochs HD, Almquist J, Dassel S, Mauseth R, Ochs VH. When is umbilical cord separation delayed? Pediatr 1985; 107: 292- 294.

5. Totterman LE, Autio S. Treatment of umbilical cord of newborn. Acta Obstet Gynecol Scand 1970; 49: 57-59.

6. Oudesleys MAM, Eilers GAM, CJ De Groot. The time of separation of umbilical cord. Eur J Pediatr 1987; 146: 387-389.

7. Arad I, Eyal F, Fainmener P. Umbilical care and cord separation. Arch Dis Child 1981; 56: 887-888.