Treatment of umbilical cords: a randomised trial to assess the effect of treatment methods on the work of midwives

Midwifery, (1986) 2, I77-186 © Longman Group UK Ltd 1986

T r e a t m e n t o f u m b i l i c a l cords: a r a n d o m i s e d t r i a l t o assess t h e e f f e c t o f t r e a t m e n t m e t h o d s on t h e w o r k o f m i d w i v e s Miranda Mugford, Malinee Somchiwong and Isobel L. Waterhouse

T h e national code of practice for midwives practising in E n g l a n d and Wales defines duties d u r i n g the postnatal period for the care of mothers and their babies. This period is a m i n i m u m of 10 days, and up to 28 days. Visits after the 10th d a y are at midwives' discretion, b u t a survey of heads o f midwifery services suggests that most midwives would extend postnatal care b e y o n d the 10th d a y if the baby's umbilicus was not healed. M e t h o d s used for routine t r e a t m e n t o f the umbilical cord in the n e w b o r n babies v a r y widely. Previous studies suggest t h a t the rate of healing depends on the t r e a t m e n t m e t h o d used. This, in turn, can affect the workload o f midwives responsible for the care of n e w b o r n babies. Babies b o r n in the R o y a l Berkshire Hospital in the s u m m e r of 1984 were allocated at r a n d o m to have their cords treated by one of four dusting powders, one o f three cleansing methods and one of two frequencies o f t r e a t m e n t , in a trial with a factorial design. T h e effect o f t r e a t m e n t on the time to separation o f the cord and the n u m b e r o f midwives' visits was estimated. It was f o u n d that the t r e a t m e n t m e t h o d used could significantly affect the healing process and therefore the n u m b e r of visits m a d e b y midwives after the 10th day, a n d that the choice o f cord p o w d e r could significantly affect the midwifery workload in the district. T h e difference would be e n o u g h to a c c o u n t for the work of one whole-time e q u i v a l e n t c o m m u n i t y midwife for every 3000-5000 births.

INTRODUCTION After mothers and their newborn babies are discharged from hospital in the UK, community midwives visit them at home. The Midwives' Miranda Mugford BA (Hons) Economist, National Perinatal Epidemiology Unit, Oxford. Malinee S o m c h i w o n g BSc MSc British Council Research Fellow, National Perinatal Epidemiology Unit, Oxford (1984-85). Isobel Waterhouse SRN SCM Director of Nursing Services (Midwifery), West Berkshire Health Authority, Royal Berkshire Hospital, Reading. RePrint requests to Miranda Mugford Manuscript accepted 23 July 1986

Rules require that a mother and baby must receive 'continued attendance' by a midwife during the postnatal period, that is, 'not less than ten and not more than twenty-eight days after the end of labour' (UKCC, 1986). The interpretation of this policy in the West Berkshire Health District means that midwives will continue daily visits up to the 28th day (and sometimes longer) as long as the mother or baby continues to need care. In particular, a midwife would continue to visit after the 10th day if the umbilical cord stump was not separated and/or the umbilicus healed. To find out whether the West Berkshire practice had broader implications, one of us (IW) wrote to the head of midwifery services in all 177

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English health districts in 1985, asking about policies for postnatal visiting and methods of treatment used for cord care. We had 104 responses from 93 health districts (some districts have more than one policy, for example, if there are two maternity units). In this survey, we ascertained that the West Berkshire practice is common throughout England. In a few districts (3 % of responses), the midwife discharges mother and baby to the health visitor on the 10th day post partum whatever the state of the baby's umbilicus, and in 12 districts, the policy is that all mothers are routinely visited up to the 28th day. However, the majority of respondents (85%) said that it was policy to visit after the 10th day until the cord was separated, and 34 said visits continue until the umbilicus is healed. Community midwives are under increasing pressure from the increasing numbers of domiciliary visits as mothers are discharged earlier from hospital. Table 1 summarises some of the results from published research. The studies quoted did not all follow the same research design, and so the

results of each study are not directly comparable. However, the research indicates that the time to cord separation is consistently affected by choice of cord treatment, and thus the choice of an appropriate cord treatment might relieve the pressure of work for community midwives where they are not already using the 'best' method. (Of course, midwives may need to continue visiting after the 10th day for other reasons, including breast feeding advice and other postnatal problems.) As we could not find a clear answer about the best method of treatment to follow, we planned and conducted a randomised controlled trial to compare some of the different treatments used routinely in maternity units in England. Use of randomised design ensures that differences in outcomes between treatment groups are indeed the effect of the treatment and are not likely to be the result of other factors. The trial was designed to study the effect of different cord treatment policies on midwifery resources, in particular, the work of community midwives. To throw light on

Table 1 C o r d t r e a t m e n t and m e a n t i m e t o c o r d s e p a r a t i o n : s u m m a r y o f research

First author Country Year of of Research study

Method of allocation

Bhalla India

"Randomly selected"

1974/5

Lawrence England Alder England

1978/9

Arad Israel

1980/1

Barr N. Ireland

1981/2

Schuman USA

1980

1985

Treatment

Number Mean time to in study separation (days)

1. Mercurochrome 77 paint 2, Spirit & sterile 763 antiseptic powder Treatment 1, Sterzac & spirit 100 by ward 2. Sterzac alone 100 "Random 1. Spirit+l% chlor87 selection of hexidine+3% zinc cases from oxide 2 wards" 2. Spirit+Sterzac 87 Random 1. Triple dye 36 allocation 2. 1% Neomycin 26 3. 1% Silver sulphur25 diasine 4, Bismuth subgallate 34 Consecutive 1. Spirit daily, 83 groups cicatrin if necessary 2. Cord untouched 34 unless soiled Random 1. Triple dye 35 allocation 2. Isopropyl alcohol 36

6.4 5.9 7.1 6.6 6.0 5.9 7.7 12.0 10.6 6.4 8.1 6.2 15.7 10.7

MIDWIFERY the relationship between workload and clinical effects, time to cord separation and problems arising during the healing period were also studied. Possible treatments for the umbilical cord The range of treatments that have been or are used for routine cord treatment extends from items available in every kitchen cupboard to preparations available on presciption only. Traditional practice throughout the world varies widely (Edouard & Gregory, 1985). In Britain both whisky and butter have been recommended (Farr, 1863), but more recently preparations containing neomycin (cicatrin), hexachlorophane and chlorhexidine have been recommended. Routine care of the cord usually includes cleaning it with spirit or water and dusting with a cord powder. A variety of methods has been used for cleaning the cord or stump, including antiseptic solutions, soap and water, water alone, and spirit (with or without other antiseptic additives). Treatments also vary in the use of powder. Powders currently used include varying proportions of zinc oxide, alum, talc, starch, hexachlorophane, chlorhexidine and other ingredients. Finally, the frequency of treatment varies. In some cases the cord stump is cleaned and/or treated only at the time of delivery; in others, care is repeated daily or more often until the umbilicus heals. One method of care which is often forgotten is to leave the cord alone, only keeping it dry and free from dirt. This has been common practice in the past (Farr, 1863), is still practised in some places and has been compared with alternative policies in published research (Barr, 1984). Our survey of current policy in English health districts shows that the 'no treatment' option is seldom practised (Table 2). The most common reported method of care was to use spirit for cleaning the cord and Sterzac powder for dusting. Nearly three-quarters of respondents said it was policy to treat the cord at least daily. The West Berkshire Cord Trial

The West Berkshire Cord Trial was designed in

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an attempt to provide a practical guide for cord treatment policy in the West Berkshire Health District. A previous study, comparing practice in different maternity units in the District, had led to the adoption of spirit swabs with Cordocel powder (see Table 3) as the district policy for cord treatment. When Cordocel disappeared from the market following a company take-over, an alternative policy had to be implemented. During the period after Cordocel was withdrawn, community midwives became concerned that their workload had increased markedly, and there was further pressure to find out whether there was a method of cord care that could alleviate the problem. Published research gave no clear guidance about the range of possible treatments, nor was it clear how cord healing is affected by the frequency of care, by the method of cleansing the cord and by the use of dusting powder. We therefore decided to mount a randomised controlled trial to compare cord treatment methods that are available and widely used in Britain.

Table 2 Policies for cord care reported by senior midwives in English health districts Heads of service responses N umber

Per cent

76 4 6 14 4 N = 104

73.0 3.8 5.7 13.5 3.8 100.0

79 11 6 7 N = 103

76.7 10.7 5.8 6.8 100.0

14 58 24 3 1 N = 1 00

14.0 58.0 24.0 3.0 1.0 100.0

Powder Routine: Sterzac Routine: Chlorhexidine Routine: other powder Only if necessary Other treatment

Cleaning method Spirit Water Nothing

Other

Frequency Every napkin change Daily or more often As necessary Once only Not at all

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Table 3 Details of the factors of treatment compared in the West Berkshire trial Contents

(Proportion)

Dusting powder Zinc Oxide Starch

(0.25) (0.25) Sterilised talc (0.5) Hexachlorophane (0.0033) Zinc Oxide (0.03) Starch (0.08) Talc (0.8867) Zinc Oxide (0.2) Alum (0.4) Purified Talc (0.4)

Zinc starch and talc dusting powder BP

Sterzac powder

Cordocel powder

No powder

Method of cleansing Spirit (Mediswabs) Water No cleansing agent

Isopropyl alcohol

Frequency Once only in the first twenty-four hours) Daily

Materials and methods The trial was designed as a factorial experiment (Cochran & Cox, 1957) to estimate the effects of three main factors (powder, cleansing method, and frequency of treatment) on midwives' postnatal visiting patterns, in particular, the number of visits after 10 days post partum. The factors of treatment were combined so that all possible combinations of the powders, cleansing methods and frequency were tested. This factorial design makes it possible to estimate the separate effects (main effects) of the different factors and to find out whether combining two or more factors has an e}tkct beyond that of the individual factors alone (interaction effects). Table 3 describes the different factors of cord treatment in the West Berkshire cord trial. The choice of powders to be compared was determined as follows. Previous experience of using Cordocel powder in the West Berkshire District had provided data against which other powders could be compared. The size of the trial was calculated so that it would show a difference from this standard, and thus it was necessary to include Cordocel in the trial. The powder was

therefore supplied under a special licence for this purpose. Zinc, starch and talc dusting powder BP was chosen as a powder which is easily available and which had ingredients most closely corresponding to Cordocel. Sterzac powder was chosen because it is so widely used throughout England (as is indicated in Table 2). The study was carried out in the West Berkshire Health District. In the last trimester of pregnancy, a letter was given to all mothers booked to deliver in the Royal Berkshire Hospital during the study period, asking for their collaboration in research assessing routine cord care. All babies born in the labour ward were eligible for entry into the study if they were likely to receive normal postnatal care from West Berkshire midwives, that is, if they were singletons, their mother was resident in the West Berkshire District, they were transferred directly to the postnatal wards following delivery, and their mother had not opted out of the study. The primary hypothesis of the trial was that Cordocel powder would reduce the number of postnatal visits after the 10th day. The number of babies to be included in each group was calcu-

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lated so that the trial would have a power of 80% to show a 5 0 % reduction with 95% confidence (from 40% in 20%) in the numbers of babies visited after the tenth d a y post delivery. This also ensured the trial w o u l d show a difference in the n u m b e r of visits m a d e after the 10th d a y (assuming a similar distribution of visiting for the groups compared). T h e trial was also designed to look at interactions between powders used with methods of cleansing a n d frequency of t r e a t m e n t . A secondary hypothesis of the trial was that the p a t t e r n of visiting would be d e t e r m i n e d b y the length of time to cord separation, a n d by a n y subsequent 'stickiness' or infection of the u m b i l i c a l area. As we were testing t r e a t m e n t policies, we were p r e p a r e d for midwives to use their clinical j u d g e ment in deciding w h e t h e r to deviate from the r e c o m m e n d e d t r e a t m e n t , a n d we asked them to record any a d d i t i o n a l or different treatments used. Between J u n e 19 a n d S e p t e m b e r 15, 1984, 1170 babies were born in the R o y a l Berkshire Hospital. O f these, 921 met the criteria for entry. O f these, 124 were not recruited to the trial either because entry was occasionally overlooked when babies were b o r n at night or at p a r t i c u l a r l y busy times, or because some new staff on the l a b o u r w a r d did not know a b o u t the trial. A further 16 babies were excluded because their mothers did not wish to participate, so in all, 781 babies were recruited. In the study period, unit policy was followed for c l a m p i n g a n d cutting the c o r d at delivery and for b a t h i n g babies. T h e policy was to c l a m p the cord a b o u t 2 cm from the umbilicus with a Hollister c l a m p i m m e d i a t e l y following delivery. T h e cord c l a m p m a y be removed at the third day, but not before. A t delivery, the b a b y is 'gently cleaned and need only be b a t h e d i f . . . c o n t a m i n a t e d with blood or m e c o n i u m . ' I n order to ensure that allocation to treatments was as n e a r l y as possible the result of chance a n d not biased in any way, certain precautions h a d to be observed. E n t r y to the trial took place in the l a b o u r ward, after delivery, when the midwife took a sealed envelope c o n t a i n i n g the allocated treatment, wrote the trial n u m b e r in the delivery register and then o p e n e d the envelope. T h e trial c o o r d i n a t o r checked t h a t envelopes were used in

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the same o r d e r as the trial numbers. 781 eligible babies were allocated at r a n d o m to one of 23 m a n a g e m e n t policies. These policies resulted from c o m b i n a t i o n s of four kinds of dusting powder, three kinds of cleansing methods a n d two different frequencies of treatment. T h e r e were 24 possible c o m b i n a t i o n s of the factors at different levels. T w o of these combinations a m o u n t e d to the same t r e a t m e n t ('no powder, no cleansing, once' and 'no powder, no cleansing, daily') a n d so babies were, in fact, allocated to one of 23 different t r e a t m e n t s in terms of powder, cleansing a n d frequency of treatment. A further g u a r d against bias from t r e a t m e n t preference was to use ' b l i n d ' packaging. T h e envelopes c o n t a i n i n g the treatments were packaged so t h a t it was not possible to guess the allocation before entry of a b a b y to the trial. This m e a n t t h a t p a d d i n g h a d to be a d d e d to the 'no t r e a t m e n t ' envelopes. A further measure taken was to have the different powders p a c k a g e d in plain wrappers, with coded labels, so that all concerned with t r e a t m e n t should be blind to the a c t u a l p o w d e r being used. O b v i o u s l y it was impossible to provide a blind 'no p o w d e r ' group, as a n y p l a c e b o p o w d e r might have h a d similar ingredients to those being tested. F o l l o w i n g specific instructions on the trial record card, each b a b y was given her or his first t r e a t m e n t within 2-3 h of delivery, either in the l a b o u r w a r d or in the p o s t n a t a l ward. T h e t r e a t m e n t was continued in the p o s t n a t a l w a r d by the staff on d u t y and at h o m e by c o m m u n i t y midwives until the umbilicus was healed. T h e midwives responsible for p o s t n a t a l care m a d e a d a i l y assessment of the cord until they decided t h a t visits were no longer necessary. T h e y recorded d a i l y w h e t h e r the cord was separated, moist, sticky or infected, and described the actual t r e a t m e n t given to the cord if it differed ti~om the allocated t r e a t m e n t . C o m p l e t e d cards were then sent to the trial co-ordinator. T h e G L I M statistical system (Baker & Nelder, 1978) on the O x f o r d University V A X C o m p u t e r was used to e x a m i n e the m a i n effects a n d interaction effects of the three factors of dusting powder, cleansing m e t h o d a n d frequency, on the n u m b e r o f midwives' visits a n d the state of the cord.

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Findings Comparison of the babies allocated to each main factor of treatment shows (Table 4) that the groups are comparable in respect of distributions by sex, birthweight and mode of delivery. This reassures us that the randomisation did work. We are therefore confident that the process of chance had (through the randomisation) formed treatment groups that were similar in any other respect that could affect the outcome measures used. Therefore, observed differences in outcomes are indeed likely to be treatment effects, and not the result of differences in the characteristics of those treated. The trial compared different cord treatment policies, and in practice, as expected, there were deviations from the recommended treatments. Overall, extra spirit swabs were used for 31% of babies in the trial and 13% of babies were given other additional treatments. These included: talc and other home remedies used by the mother, some use of Cicatrin (neomycin powder) by midwives, and occasionally, treatments prescribed by general practitioners. Compliance with the allocated treatments was analysed by allocated factor of treatment (Table 5) and for each factor we found that the 'no treatment' group received a higher proportion of

'extra' treatment, which meant that where the policy was no treatment, over 20% of babies' cords were actively treated by midwives in spite of the instruction to the contrary. The effect of the different treatment policies on the work of midwives was analysed by main factor, and the results are shown in Table 6. The factor which shows the clearest difference is the powder, and this was confirmed to be a statistically significant effect from a Z2 test on estimates of goodness of fit using the G L I M analysis of factorial experiments. The policies of using either Cordocel or zinc, starch and talc BP were associated with fewer visits than use of Sterzac powder or no powder at all. Choice of cleansing method did not have a significant effect on midwives' visits. However, the X2 test for goodness of fit showed that babies allocated to daily treatment had fewer postnatal visits than those allocated to treatment only once. The effects of the three factors of treatment were found to be independent of each other, with one exception. The frequency with which powder was used was found to have a significant effect over and above the main effect of powder. It was found that powder used daily reduces the number of visits compared to powder used once only (Table

7). The effect of powder on length of time to cord

Table 4 Descriptive statistics for babies in the W e s t Berkshire cord trial by main factor of t r e a t m e n t

Factor of treatment

Number of babies Mean Mode of allocated to birthweight Sex delivery treatment factor ~SD % Male % Normal

Powder Zinch, Starch &talc BP 203 Sterzac 204 Cordocel 202 No Powder 203

3364=~448 3388±501 3329~=423 3355±491

52.2 50.0 46.6 52.0

83.3 84.8 83.3 87.3

Cleansing method Water Spirit No routine cleansing

272 271 272

3347:~470 3373~-473 3357±457

50.0 50.2 50.4

84.2 83.4 86.4

Frequency of treatment Daily Once only

407 408

3357~=481 3361 ±452

52.1 47.9

85.3 84.1

No significant differences at 95 per cent level (Student's t test)

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Table 5 Use of additional cord t r e a t m e n t s by allocated method of care

Factor of treatment

Valid N

Babies with with extra spirit swabs No. (Percent)

Babies with other additional treatment No. (Percent)

Powder Zinc starch & talc BP Sterzac Cordocel No powder

196 202 193 200

56 59 64 70

(29) (29) (33) (35)

26 27 11 41

(13) (13) (6) (21)

268 262 261

80 50 119

(30) (19) (46)

31 36 38

(12) (14) (1 5)

397 394

81 168

(20) (43)

41 64

(10) (16)

Cleansing method Water M ediswa b No routine cleansing

Frequency Daily Once only

Table 6 Midwives" visits after the 10th day by allocated factor of cord t r e a t m e n t

Valid N

Mean visits after day10 per baby

Standard error

197 202 193 200

0.97 1.59 1.01 1.57

0.22 0.31 0.31 0.31

268 264 260

1.26 1.34 1.27

0.19 0.27 0.27

398 394

1.03 1.56

0.1 5 0.22

Table 7 Postnatal visits after day 10 by p o w d e r and frequency of t r e a t m e n t Number of visits per baby Frequency of treatment

Powder* Zinc, starch & talc BP Sterzac Cordocel No powder

Cleansing Water Mediswab No routine cleansing

Zinc, starch & talc B P Sterzac Cordocel No powder

Valid N

Once only

Daily

197 202 193 200

1.26 2.19 1.26 1.51

0.66 1.09 0.75 1.64

P<0.001 (•2 test for goodness of fit using G LI M statistical system)

Frequency* Daily Once only

*P<0.001 (Z2 test for goodness of fit using GLIM statistical system)

separation was not exactly the same as the effect on numbers of visits (Table 8), but the a m o u n t of moisture and stickiness recorded for each powder group m a y explain differences in midwives continued visiting after cord separation (Table 9). Although there were differences between the

powders used in their effect on the incidence of recorded stickiness and moistness, there was no significant difference in infection, but this was not surprising as the overall incidence of infection was very low. O n l y for less than one per cent of babies in the trial did the midwives observe clinical signs of infection. Interestingly, the cleansing method used had a statistically significant effect on cord separation (Table 8), but this is a difficult result to interpret, as midwives treated such a large proportion of the 'no routine cleansing' group with extra spirit swabs (Table 5).

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Table 8 Cord separation by main factor of t r e a t m e n t

Factor of treatment

Valid N

Days to cord separation Mean4-SD

Powder* Zinc, starch and talc BP Sterzac Cordocel No powder

199 202 197 202

6.29±1.73 6.93~1.95 7.19±1.75 8.11 =~2.37

269 267 264

6.99:~2.05 7.14~=2.09 7.27±2.09

401 399

7.1 24-2.07 7.144-2.08

Cleansing methodt Water Mediswab No routine cleansing

Frequency Daily Once only

*P<0.001 (Z2 test for goodness of fit using GLIM statistical system) 1-<0.005 (Z2 test for goodness of fit using G LIM statistical system)

DISCUSSION Published research has shown that the method of care for the umbilical cord in normal newborns has an effect on the healing process and, in particular, on time to cord separation and rate of infection (Bhalla et al, 1975; Speck et al, 1977; Barrett et al, 1979; Alder et al, 1980; Arad et al, 1981; Lawrence, 1982; Barr, 1984; Schuman & Oksol, 1985). None of these studies assessed the effects of treatment on the work of midwives. The results of the studies are summarised in Table 1. Some of the studies were not randomised controlled trials and therefore the observed differ-

ences in those studies are more likely to reflect selection bias; however, the research results appear to suggest that use of spirit delays cord separation (Lawrence, 1982), that antiseptic treatment may delay separation (Arad et al, 1981), and that no treatment at all may be better than daily use of spirit (Barr, 1984). Where two antiseptic powders were compared (Alder et al, 1980), Sterzac (containing hexachlorophane) was found to be associated with similar time to separation as a chlorhexidine powder, Hibitane. Our results confirm that the method of treatment used affects the healing process. We distinguish between cord separation and healing because English midwives continue to be concerned about babies whose cord stump has separated, but where the umbilicus is moist, sticky or infected. Most importantly, we have confirmed the finding that although cord separation time is shorter for the antiseptic powder (Sterzac), this powder is also associated with longer time to healing and, therefore, more visits after the 10th day by midwives. We were surprised, in view of previous evidence, to find the 'no treatment' group and those with 'once only' treatments required a longer period of midwife's visits than those treated routinely every day. However, when we look at the actual treatments given (Table 5), it becomes clear that the interpretation of 'no treatment' and 'once only' was very flexible, and that midwives felt it necessary to use spirit or other treatment more often for these groups of babies. This divergence from the treatment instructions does not invalidate the results of this trial, as the trial was designed to compare the results of treatment policies as they are actually carried out.

Table 9 Moisture and stickiness in the umbilical cord or stump by powder

Mean days Moisture Valid N • (SD) Zinc, starch &talc BP 195 Sterzac 202 Cordocel 194 No powder 200

3.10 3.86 3.21 3.60

(2.78) (3.35) (2.60) (2.83)

Mean days Stickiness Valid N =L (SD) 194 202 194 200

0.64 0.90 0,60 1.06

(1.18) (1.69) (1.20) (1.66)

MIDWIFERY

O n e j u s t i f i c a t i o n t h a t has b e e n p u t f o r w a r d for r o u t i n e c o r d t r e a t m e n t is for c o n t r o l o f h o s p i t a l infection. T h e u m b i l i c u s has b e e n i d e n t i f i e d as a reservoir o f s t a p h y l o c o c c a l a n d o t h e r o r g a n i s m s ( J e l l a r d , 1957) a n d is thus seen as a source o f cross-infection in the h o s p i t a l e n v i r o n m e n t . T h e W e s t Berkshire c o r d trial was n o t d e s i g n e d to address this q u e s t i o n , a n d r o u t i n e swabs w e r e n o t taken. R a t e s o f o b s e r v e d i n f e c t i o n w e r e l o w in all t r e a t m e n t g r o u p s , n o t o n l y in those w i t h antiseptic t r e a t m e n t s , a n d t h e r e f o r e o u r results do n o t s u p p o r t the c h o i c e o f one p a r t i c u l a r p o w d e r for p r o t e c t i o n o f i n d i v i d u a l b a b i e s f r o m the effects o f infection. H o w e v e r , as w e d i d n o t take swabs, we c a n n o t rule o u t the possible d i f f e r e n t i a l r e d u c t i o n in c o l o n i s a t i o n by b a c t e r i a . I f this, in turn, has a n effect on o v e r a l l i n c i d e n c e o f clinical infection in a hospital, it m a y be t h a t the c h o i c e o f an a n t i s e p t i c p o w d e r is justified. H o w e v e r , the cost o f this policy is significant. I n a district w i t h a r o u n d 4000 deliveries a y e a r , we e s t i m a t e f r o m o u r trial results t h a t the c h o i c e o f S t e r z a c p o w d e r c o u l d m e a n t h a t one e x t r a w h o l e - t i m e m i d w i f e w o u l d be t a k e n u p w i t h the i n c r e a s e d c o r d care, a n d t h e r e f o r e p e r h a p s less staff t i m e w o u l d be a v a i l a b l e for o t h e r aspects o f m i d w i f e r y care. T o p u t this c o n c l u s i o n i n t o a n a t i o n a l c o n t e x t , in E n g l a n d in S e p t e m b e r 1983, g o v e r n m e n t statistics tell us t h a t t h e r e w e r e the e q u i v a l e n t o f just o v e r 19 400 w h o l e t i m e m i d w i v e s in the N H S (excluding administrators, but including SCBU staff a n d tutors, a n d c o u n t i n g students as w o r k i n g o n l y 5 0 % o f full time). T h e s e m i d w i v e s g a v e c a r e d u r i n g p r e g n a n c y , l a b o u r , d e l i v e r y a n d the p u e r p e r i u m to 590 933 w o m e n w h o g a v e b i r t h in t h a t year. T h u s if no m i d w i f e w o r k e d o v e r t i m e , there w o u l d h a v e b e e n a r o u n d 64 h o f m i d w i f e t i m e for e a c h w o m a n . T h i s w o u l d be r e d u c e d to a b o u t 52 h if we a s s u m e d t h a t 2 0 % o f total m i d w i f e r y t i m e is a b s o r b e d b y such factors as holidays, a b s e n c e for a d v a n c e d t r a i n i n g , m a t e r n i t y or sick leave. C l e a r l y E n g l i s h m i d w i v e s a r e h a r d pressed, a n d if there is a n y ineffective p r a c t i c e or policy w h i c h m a y be i n c r e a s i n g t h e w o r k l o a d , c h a n g i n g it c o u l d l e a d to a m o r e a p p r o p r i a t e use o f m i d w i v e s ' time. M i d w i v e s in o v e r 7 5 % o f districts in E n g l a n d use S t e r z a c for c o r d care. I n W e s t Berkshire we f o u n d t h a t use o f S t e r z a c p o w d e r was associated w i t h 0.61 e x t r a h o m e visits p e r

185

b a b y . E v e n if the m i d w i f e ' s visit o n l y lasts 10 rain, this w o u l d a d d to the a v e r a g e t i m e she m u s t give e a c h b a b y , b u t in m a n y areas t r a v e l t i m e w o u l d a d d to this c o n s i d e r a b l y . P u t t i n g this a n o t h e r w a y , at least 45 000 English m i d w i f e h o u r s a y e a r m a y be the cost to the N H S o f c u r r e n t c o r d t r e a t m e n t policies in English h e a l t h districts.

Acknowledgements We would like to thank all the following for their help: Mrs. Anne Medd for data collection during the trial; all the West Berkshire midwives and nursery nurses for filling in and returning such a high proportion of cards, especially the senior nurses who helped us follow up the stragglers; all the babies, and their mothers, for letting us do the study; other staff of the R.B.H. who made room for us while the trial was in progress; the R.B.HI pharmacist for advice about treatments and costs; Regent Pharmaceuticals for packaging the cord powders in plain sachets: Irene Stratton and Hazel Ashurst for computing help and advice; Klim Macpherson for statistical advice; Lesley Mierh, Kate Targett and Jini Hetherington for typing, and our colleagues at the National Perinatal Epidemiology Unit for advice and encouragement. Malinee Somchiwong was funded by the British Council. Miranda Mugford is funded by the Department of Health and Social Security, but this study was not supported by the Department.

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maternity hospital, British Medical Journal 94(8): 925928 Lawrence C 1982 Effect of two different methods of umbilical cord care on its separation time, Midwives Chronicle and Nursing Notes June 1982, pp 204-205 Schuman A J, Oksol B A 1985 The effect ofisopropyl alcohol and triplet dye on umbilical cord separation time, Military Medicine 150:49-51

Speck W T, Driscoll J M, Polin R A, O'Neill J, Rosencranz H S 1977 Staphylococcal and streptococcal colonization of the newborn infant: effect of antiseptic cord care, American Journal of Diseases of Children 131: 1005-t 008 United Kingdom Central Council for Nursing Midwifery and Health Visiting 1986 Handbook of Midwives Rules, UKCC, London: 5