RESEARCH PAPERS

ALCOHOL VERSUS STERILE WATER CLEANING FOR NEWBORN UMBILICAL CORD CARE
By RANJANI. P * MARIA PAIS **** BABY S. NAYAK ** SONIA R. B D'SOUZA *** MANJULA *****

*-**** Manipal College of Nursing, Manipal University, Manipal, India. ***** Canara College of Nursing, Bailur Educational Trust, Kundapur, India.

ABSTRACT Concern about the umbilical cord care arises when there is delay in the cord separation or cord infection. Greater percentage reduction in the cord separation time by using sterile water than alcohol has been reported. Randomized control trial was carried out at postnatal wards of medical college attached hospitals of Udupi district among 80 newborns. The analysis revealed, no significant difference in the cord separation time, and cord infection rate of newborn umbilical cord treated with alcohol and sterile water. The cost spent for the alcohol group is three times more than that of sterile water group. The birth weight, gender of newborn and parity of mother had no effect on the time of separation of the umbilical cord. Sterile water cleaning is safe and cost effective means of umbilical cord care in term infants. Keywords: Newborn, Umbilical cord care, Alcohol, Sterile Water. INTRODUCTION The umbilical cord is an important life line during intrauterine development of the fetus but has little significance after birth when it shrivels and is shed soon after. Concern about the cord arises when there is delay in its separation or there is need to obtain material for culture studies as in tetanus neonatorum (Bhalla, Nafis, and Rohatgi, 1975). There is no single method of cord care which has been proven to limit colonization and disease (American academy of pediatrics, 1977). Umbilical infections are now rare event in the healthy full term infants. The contributions of hand washing, standard precautions, knowledge of transmission and alcohol cleaning to the reduced rate of umbilical infections have been assumed (Dore, Buchan, Coulas, et al,1998). Cleaning the umbilical cord with sterile water has shortened the time of cord separation (Medves, O'Brien, 1997). Several studies demonstrated as alcohol is inferior with regard to decreasing colonization. Some studies could not even demonstrate a significant difference in alcohol and water or no treatment. Alcohol was also significantly proven to prolong cord separation time. In light of alcohol's limited effect on decreasing colonization, and its deleterious effect of prolonging cord separation time, it is not recommended as a routine treatment for umbilical cord care (McConnell, Lee, Couillard and Sherrill,2008). The findings of the literature review indicate that the current standard of umbilical cord care may be based on historic practices and traditions rather than scientific investigation and justification. There appears to be little support for continued alcohol use. Yet, insufficient evidence is available to support an immediate change in the standard of care from topical antimicrobial treatment of the umbilical cord. Further research is recommended to establish evidence-based recommendations for practice (McConnell, Lee, Couillard and Sherrill, 2008). In the present study an attempt has been made to find out the most effective method of cord care. Natural drying is a safe and effective means of umbilical cord care in preterm infants (Evens, George, Angst and Schweig, 2004). Cord separation was delayed when antibiotics administered to the neonate to treat sepsis, when the infant was born prematurely, delivered by Caesarean section or had a low birth weight. The cord separated slightly earlier in female than in male infants (Murphy, Eilers and DeGroot, 1987). Evidence does not

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support continued use of alcohol for low risk newborn cord care (Shafique MF et al., 2006). There were no significant differences noted when comparing the mode of delivery, sex, race of infant, with respect to time interval for their cord separation (Rais Bahrami K, Schulte EB and Naqvi M, 1993). The babies delivered by Caesarean section had delayed separation of cord (mean 8.98 days) as compared to babies delivered by vaginal route (mean 6.71 days) (Singh N, Sharma S and Singh R, 1999). Dry cord care did not increase the risk of omphalitis in NICU patients (Aygun C, Subasi A and Kucukoduk S, 2005). Clean cord care is sufficient and the application of an antiseptic is not required for home deliveries and after discharge from hospital (WHO, 1998). The Objectives of the Study Compare alcohol cleaning and sterile water cleaning of newborn umbilical cord in terms of cord separation time, cord infection and cost of cord care. out the association between cord separation time Find and birth weight of newborn, gender of the newborn and parity. Hypotheses There will be a significant difference in the cord separation time of newborn between alcohol group and sterile water group. There will be a significant difference in the infection rate of umbilical cords of newborns between alcohol and sterile water group. There will be a significant difference in the cost of cord care of newborn between alcohol group and sterile water group. There will be a significant association between the cord separation time and birth weight, gender and parity of newborns of both groups. Method Design Design selected for this study is Randomized controlled trial. Population All newborns, admitted in the postnatal ward of Kasturba hospital, Manipal and Dr. T. M. A Pai hospital, Udupi from 15
th

Criteria for Sample Selection Newborns who are born at 38 - 40 weeks of gestation were included in the study. The newborns who had congenital anomalies, were on antibiotics and had admitted in Neonatal intensive care unit were excluded from the study. Sample Size and Sample The required sample size calculated for 95% confidence limit with power of 80% was 70.Considering the subject attrition rate a final sample size of 84 was chosen by simple random method (lottery method). Among them 80 who fulfilled the criteria were included in the study (40 alcohol group and 40 sterile water group). Four newborns were excluded from the study as one newborn was shifted to the NICU, two newborns cord separation time was not reported and for one newborn instead of sterile water once alcohol was used. Characteristics of the Sample Table 1 depicts the maternal and newborn characteristics and analysis of sample characteristics (p value) revealed no statistically significant differences between the groups. Ethical Considerations Ethical clearance was obtained from Institutional Ethics Committee (IEC) and informed consent was obtained from the parents. During recruitment, the researcher emphasized that participation was voluntary and that any time mother could choose not to answer questions or withdraw their newborn from the study without their newborn care being affected. It was emphasized that their information would remain confidential and that there would be no way of identifying them. Mothers were informed that there were no known risks in participating and that the results may contribute to best future care of newborns. Procedure of Data Collection Once the eligible newborns got admitted to the postnatal ward informed consent from mother was obtained, newborns were randomized into one of two groups (Alcohol group, sterile water group). The alcohol group received the standard care (cleaning the umbilical cord with alcohol) and the sterile water group received cord care with sterile water. Cord care was given once daily till the cord detachment or till the discharge of the mother

January to 12th March, 2009 were included as study population.

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Alcohol group (n=40) Gender of newborn Male Female Birth weight of newborn(gm)* Maternal age(years)* Parity of the mother Primi gravida Multi gravida Mode of delivery Spontaneous Induced Caesarean Maternal history of antenatal complications Yes No Maternal history of infection during antenatal period Yes No Mother received antibiotics during intra natal period Yes No Initiation of breast feeding(hours)* Sponge bath given Yes No Apgar score 1 mt* Apgar score 5 mt* 21 (52.5%) 19 (472.5%) 2962.3490.5 28.24.5 24 (60%) 16 (40%) 4 (10%) 2 (5%) 34 (85%) 14 (35%) 26 (65%) 2811.9391.8 26.63.0 31 (77.5%) 9 (22.5%) 4 (10%) 0 36 (90%) 0.11 0.13 0.08 0.09 Sterile water group (n=40) P-value

the first draft, development of criteria check list, content validation of the tool, pretesting of the tool, reliability of the tool and preparation of the final draft. Description of the Tools Background Proforma was used to collect the sample characteristic from the record. This tool was designed with 20 items to collect baseline information of the newborn and the mother like date of birth, gender, birth weight, apgar score at 1and 5mts, initiation of breast feeding (in hours), sponge bath given or not, mothers age, parity, history of antenatal complications, mode of delivery, antibiotic therapy during

0.35

10 (25%) 30 (75%)

14 (35%) 26 (65%)

0.32

intra natal period, duration of rupture of membrane in hour prior to delivery, duration of labour in hours, history of maternal infection during antenatal and intra natal period.

2 (5%) 38 (95%)

2 (5%) 38 (95%)

0.69

Umbilical cord infection was measured using the cord rating scale. The scale is based on the definitions of cord infection and descriptions in the literature of cord healing, including that mild bleeding may occur at the time of separation and that a small drop of blood or small amount of discharge with no offensive odor requires no medical intervention. The assessment included rating the newborns cord for redness, discharge, odor, swelling, dryness, examining the newborns skin for pustules and axillary temperature of newborn, and given a possible total score of 0-13. A score 0-8 is considered to indicate no infection. A score greater than 9 is considered to indicate infection. Checklist was used to mark the cord separation time and Proforma was used to assess the total cost. Content validity of the Tools To ensure the content validity, the tools along with the blue print and objectives of the study were given to seven experts from the field of nursing, pediatrics medicine and obstetrics medicine. The experts were requested to give their suggestions and opinions regarding the relevancy, accuracy and appropriateness of the items. Tool I: The items present in the tool were 19. There were 100% agreement for 18 items and 1 item had 71.4% for relevancy. The suggestion was to exclude the item since the skin to skin contact is practiced only for preterm and low birth weight infant in the study setting, and was accepted. There was a suggestion to add an item with reference to bathing practice and also split the item no 19. Thus the

5 (12.5%) 35 (87.5%) 9.95.0 24 (60%) 16 (40%) 8.90.22 9.90.15

6 (15%) 34 (85%) 8.84.4 21 (52.5%) 19 (47.5%) 90.00 100.00

0.74 0.46 0.49 0.15 0.32

*Continuous data are presented as mean SD

Table 1. Characteristics of Alcohol and Sterile water group

(minimum 3 days). Cord is cleaned from the tip to base along the entire cord in a circular motion. Pretested and validated observation checklist on umbilical cord infection was used to rule out the infection. Background information about mother and newborn was collected using pretested and validated proforma. Cord separation time was noted. If umbilical cord separation did not occur during hospital stay, information on cord separation was obtained by telephone communication. Variables /Measurement The main outcome variables were Cord separation time, Cord infection and Cost of cord care. Development of Research Tools and Techniques Tools were developed by the investigator after relevant literature review and suggestions were taken from guides and experts. The steps involved in the development of the tools were: development of the blue print, preparation of

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Background proforma had a total of 20 items. Tool II: Total items present in the tool were 7. There were 100% agreement for 6 items and 1 item had 71.4% agreement for accuracy. Modifications were done as per the suggestions from experts for the items which had 71.4% agreement. Tool III and IV: There was 100% agreement. Reliability of the tool Reliability of the tool was established among 20 healthy full term newborns in postnatal ward of Kasturba hospital, Manipal, after obtaining the administrative permission. The reliability of the cord rating scale was established by using inter rater reliability. The tool was found to be reliable (Intra class reliability coefficient =.9561 and Pearson correlation = .916). Pilot Study Pilot study was conducted in the postnatal ward of Kasturba hospital Manipal, from 4th to 12th January, 2009, after obtaining written permission from the ethics committee, administrators of Kasturba hospital Manipal and mothers of newborn. The pilot study was done on 10 samples. The sample had same characteristics as the main study sample. The study design was found feasible by the investigator. Hence no modifications were made in the study. Results Data was analyzed using statistical package for social sciences (SPSS), version 11.5. Description of cord separation time of newborns The cord separation time in alcohol and sterile water group were calculated in hours. The data presented in the Table2, shows that the mean and median of the alcohol group are slightly higher (136.759 and 126.725 respectively) than that of the sterile water group (121.163 and 118.330 respectively), which shows that the cord separation time was delayed in alcohol group.
Variable Cord separation time Group Alcohol Sterile water N 40 40 Mean 136.759 121.163 Median 126.725 118.330 Standard Deviation 42.697 42.916 (N = 80) Cord separation time and birth weight Alcohol Sterile water 40 40

Comparison of cord separation time of newborns Independent 't' test computed to compare the cord separation time. The data (Table 3) shows that there was no significant difference between the cord separation time of both the group (t =1.69, p= 0.107). It is inferred that there is no significant difference in the cord separation time between the use of alcohol and sterile water. Cord Infection There was no sign of cord infection among the newborns in both alcohol and sterile water group. Description of cost of cord care The cost of alcohol and sterile water varied with length of postpartum hospital stay and cord separation time. Alcohol (2ml) for control group and sterile water (2ml) for treatment group was used daily to clean the cord, and cost was determined based on cost per use. The overall cost of cord care in alcohol group was 60.50 rupees and sterile water group was 20.50 rupees, which shows sterile water is cost effective. Correlation between the cord separation time and birth weight Pearson correlation coefficient computed to show the relation between cord separation time and birth weight of the newborn. The data presented in Table 4 shows no significant relation between cord separation time and birth weight (Control r =0.071, p=0.665, Treatment- r = 0.209, p = 0.196). The birth weight of the newborn had no effect on the time of separation of the umbilical cord. Association between the Cord Separation Time and Gender of the Newborn and Parity of Mother Independent 't' test is computed to show the association
Variable Cord Group Alcohol N 40 Mean 136.759 121.163 (N = 80) T-value Mean difference 15.596 1.629 df 78 P-value 0.107

Separation time Sterile water 40

Table 3. The independent 't' test value of control and treatment group for cord separation time
Variable Group N Correlation coefficient ( r) 0.071 0.209 Significance 0.665 0.916 (N = 80)

Table 2. Mean, Median and Standard deviation for cord separation time in hours

Table 4. Correlation between the Cord Separation time and Birth Weight of the Newborn

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between cord separation time and gender of the newborn and parity of the mother. The result shows that gender of the newborn and parity of mother had no effect on the cord separation time. (Alcohol- t = 1.538, p=0.132, Sterile water- t= 1.731, p= 0.092), (Alcohol- t= 1.837, p= 0.074, Sterile water- t = 1.506, p= 0.140). Discussion The current study revealed that the cord separation time in alcohol group is longer than the sterile water group. The cost of cord care is three times higher in alcohol group than the sterile water group. The findings of the study are supported by the study done in Alberta which reveals that the cord separation time is shorter in sterile water group than that of alcohol group (Medves JM, and O'Brien BA, 1997). Another similar study supports the finding of the current study, conducted with an objective to compare the effects of alcohol and tap water on separation of the umbilical cord in 103 infants. The researcher found that the umbilical cord in the alcohol group had a longer separation time than in the tap water group (6.4 versus 8.4days) (Bourke E, 1990). In the current study no newborn in either group was identified with a cord infection. This finding was supported by the study done in Alberta. The researcher compared the efficacy of alcohol versus sterile water in promoting umbilical cord detachment in 136 samples. The study findings revealed absence of infection in both the group (Medves JM, and O'Brien BA, 1997). Another study conducted in Hamilton supports the finding of the current study. The investigator compared alcohol cleaning versus natural drying in 1811 full term newborns. The result showed absence of cord infection in both the group (Dore S, et al., 1998). The current study revealed that the cost incurred for the alcohol group is three times more than that of sterile water group. The study finding is similar to the study done in Hamilton. The investigator compared the cost of alcohol with that of natural drying group. The cost of alcohol use was approximately $ 0.52 (US) per vaginal birth and $ 1.90(US) per cesarean birth with a 96 hour length of stay (Dore S, et al., 1998). The present study showed no significant relation between birth weight and cord separation time. This finding supports the finding of the study done in Kanpur (Bhalla JN, Nafis N, Rohatgi P 1975). , The present study revealed that the gender of newborn had no effect on the time of separation of the umbilical cord. This is contradicted by the study done in Netherland. The researcher studied the perinatal factors and separation time of the umbilical cord. The time of cord separation affected by the sex of the infant, with cord separation occurring earlier in female than in male infants as documented in a study conducted by Murphy, Eilers and De Groot, 1987. The present study revealed that the parity of mother had no effect on the time of separation of the umbilical cord. This finding supports the finding of the study done in Indonesia. In this study the babies were analyzed according to parity of mother but no significant association could be established between the parity of mother and umbilical cord separation time (Sarwono E, Disse WS, Ousdesluys-Murphy HM, 1991). Further we would like to state that the study is limited to term newborn and hospitals attached to Medical colleges. Sample from peripheral hospitals probably evaluate such results better. Conclusion Mean time for cord separation in the alcohol group was longer than that of sterile water group. No newborn in either group was identified with a cord infection defined as redness, discharge, odor, swelling, pustules, hyperthermia and dryness. Sterile water can be used for cord care in term newborns. Umbilical cord care with sterile water is cost effective. It appears that sterile water is a safe and effective means of umbilical cord care in term newborns. Implications The study findings have greater implications for Nursing in the areas of research, administration, community and practice. Nursing Research The main goal of nursing research should be to improve patient care. Health care system now a day is driven by cost. Research outcomes related to cost is having very important effect. Umbilical cord cleaning with alcohol was

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not superior to sterile water cleaning; the cost of care is more in alcohol group. Appropriate utilization of research helps nurses to make decisions based on evidences for newborn care. Evidence does not support continued use of alcohol for low risk newborn cord care. Nursing Administration The findings of the study could be made use of by health personnel both (nursing and non nursing) holding administrative positions to formulate policies and make necessary changes in the health care delivery system. Ward incharge should replace sterile water instead of alcohol for umbilical cord care by making necessary changes in the policies and procedure. In-service education for nursing personnel regarding newborn care including care of umbilical cord should be arranged by administrators with up to date knowledge of nursing personnel, so that they can implement what they have learned. Cost effective care of umbilical cord by the nursing personnel should be encouraged by the administrators. Community In this advanced modernization and complexity, medical care and health care becomes a commercialized commodity beyond the reach of the common man. In this social context the findings of the study have a great impact on community health care delivery system. As this treatment (sterile water cleaning of umbilical cord care) is safe, cost effective, accessible, feasible and affordable to common people. Nursing Practice This study finding suggest a need for nurses to provide more thorough and consistent information for all mothers during pregnancy and after giving birth about what to expect at the newborns cord site and how to care for it. Specifically, including information in the teaching plan on the potential for odor and bleeding with cord separation as well as the rationale for recommended cord care protocols may promote parents willingness to continue with the recommended treatment. Recommendations Based on present study, recommendations offered for future research are Study can be done in large sample to increase validity and generalization. Study can be done to compare sterile water cleaning and natural drying of umbilical cord. Similar study can be done in preterm and sick newborns (Who are kept in neonatal intensive care units). Influence of gestational age, mode of delivery and phototherapy on umbilical cord separation can be studied. Exploratory, descriptive study on maternal perceptions of umbilical cord treatments and healing can be done. References [1]. Andrich, MP Golden, SM. (1984). Umbilical cord care: a ., study of bacitracin ointment vs trible dye. Clin Pediatr; 11:170-4. [2]. American Academy of Pediatrics, (1997). committee on fetus and newborn standards and Recommendations for hospital care of newborn infants. 6th ed. Evanston IL: American academy of pediatrics; 121-2. [3]. Bhalla, J.N., Nafis, N., Rohatgi, P (1975). Some . observations on separation of the umbilical stump in the newborn. Indian J Pediat; 42:329-334. [4]. Bourke, E. (1990). Cord care. Too much or too little. Aust J Adv Nursing; 7(2):19-22. [5]. Dore, S., Buchan, D., Coulas, S., Hamber, L., Stewart, M., Cowan, D., et al. (1998). Alcohol versus Natural drying for newborn Cord Care. J Obstet Gynecol Neonatal Nurs.; 27: 621-627. [6]. Evens, K., George, J., Angst, D., Schweig, L. (2004). Does umbilical cord care in preterm infants influence cord bacterial colonization or detachment? J Perinatol.; 24:100-4. [7]. Forfar, J., Balf, C., Jones, E., Edmunds, P (1953). . Staphylococcal infection of newborn. Br Med J.;11:170-4. [8]. Ford, LA., Ritchie, JA. (1999). Maternal perceptions of newborn umbilical cord treatments and healing. J Obstet Gynecol Neonatal Nurs.; 28: 501-506. [9]. Medves, J.M., O'Brien, BA. (1997). Cleaning the umbilical cord with water than alcohol shortened the time to separation with no change in colonization. Can J public

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health; 88: 380-2. [10]. McConnell, T.P Lee, C.W., Couillard, et all. Trends in ., umbilical cord care: scientific evidence for practice. Available from:www.gentlebirth.org/archives/cord care.html-36k. [11]. Murphy AMO, Eilers GAM, De Groot C.J. (1987). The time of separation of the umbilical cord. Eur J Pediatr;146:387-389. [12]. Novack, AH., Mueller, B., Ochs, H. (1988). Umbilical cord separation in the normal newborn. Arch Dis Child; 142: 220-223. [13]. Perry D. (1982). The umbilical cord: Transcultural care and customs. J Nurse-Midwifery; 27:25-30. [14]. Rais-Bahrami, K., Schulte. E.B., Naqvi, M. (1993). Postnatal timing of spontaneous umbilical cord separation. Am J Perinatol.; 10: 453-4. [15]. Rathompson, Rennison W. (1987). Time of separation of the umbilical cord and its relation to the infection in infancy. Br Med J; 295:472-473. [16]. Shafique, M.F., Ali, S., Roshan, E., Jamal, S. (2006). Alcohol application Versus Natural drying of Umbilical cord. J Pak Med Assoc; 31. [17]. Singh, N., Sharma, S., Singh, R. (1999). Umbilical cord fall in Preterm and Term newborns in Vaginal and Caesarean Deliveries. Indian Pediatr; 36: 588-590. [18]. Sarwono, E., Disse, W.S., Ousdesluys-Murphy, H.M., Oosting, H., De Groot, C.J. (1991). Umbilical cord: factors which influence the separation time. Paediatr Indones; 31:179-84. [19]. World Health Organization. (1998). Care of the umbilical cord: a review of the evidence. Geneva. [20]. Zupan, J., Garner P (2000). Topical umbilical cord . care at birth. In Cochrane data base syst Rev.

ABOUT THE AUTHORS

Ms. Ranjani P is currently working as lecturer in the Department of Fundamentals of Nursing, Manipal College of Nursing, Mangalore.

Dr. Baby S Nayak is currently working as Professor and Head of Department of Child Health Nursing, Manipal College of Nursing Manipal.

Mrs. Sonia R B D'souza is currently working as Associate Professor and Acting HOD of Department of Obstetrics and Gynaecological Nursing, Manipal College of Nursing, Manipal.

Mrs. Maria Pais currently working as Assistant Professor in the Department of Obstetrics and Gynaecological Nursing, Manipal College of Nursing, Manipal.

Ms. Manjula P currently pursuing her final year MSc Nursing from Canara College of Nursing, Kundapur.

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