Bacteriologic studies in ligated and nonligated umbilical cords

BACTERIOLOGIC NONLIGATED

STUDIES UMBILICAL 1. BERNARD M~YANN

(From

the Department

of

Obstetrics

IN LIGATED CORDS* BERNSTINE, FRITZ,

and

M.S.,

Gynecology,

M.D.,

AND

ABRAHAM

Jeferson

LUDMIR,

M.D.,

AND

PA.

PHILADELPHIA,

Medical

College

and

Hospital)

T

IIJS study was undertaken with the aim to note the relationship and role played by the umbilical cord in staphylococcic infection in the newborn and the puerperal mother. Edmunds and associates1 noted in their studies a relationship between the staphylococcic-positive swabs taken from the umbilical There were 40 per cent region and the maternal staphylococcic infections. positive Staphylococcus aureus swabs on the eighth day in the newborn, and OII the same day the maternal nasal swabs for Staph. aureus were 30.7 per cent and the vaginal IO.8 per cent for A’taph. aureus. ForfaP found 60 per cent positive Staph. a1Lreu.s on routine swab studies of the newborn, after the cord had separated. ?Jellard3 noted a relationship with the umbilical cord as a reservoir of infection. It has also been noted that a thick, moist cord offers a more favorable medium for bacteria to propagatee4

Material

and Method

Sixty-three cases of ligated cords and 88 cases of nonligated cords were investigated for bacteriologic study. The patients employed in this study were delivered by the resident staff of the hospital and included those registered Sor the maternity ward. All patients in the study, which included both primipOS these, 88 per cent were aras and multiparas, were delivered vaginally. Negroes and 12 per cent white; 93 per cent delivered spontaneously and 7 per ecnt by low forceps. The patient was prepared for delivery with green soap, sterile water, and Zephiran, 1 :l,OOO; the bladder was emptied by catheter and sterile drapes The operator and assistants scrubbed and wore operating suits. were applied. sterile gowns, and gloves. Whether the cord was to be ligated or not, after delivery the baby was permitted to rest below the level of the clelivery table. Ligated Cases.-The cord was severed 5 minutes after delivery of the baby, Tr. benzalkonium chloride, 1 :l,OOO, and alcohol,. 70 per cent, were applied to the cord, which was then tied with a clouble ligature. Following this, the above preparations were again applied and a piece of sterile gauze was loosely placed over the umbilical corcl stump. Nonligated Cmes.-The cord was not severed until one hour following delivery of the child. During that period the placenta had already been delivered and cord pulsations hacl ceased. The placenta was kept at a higher level than the baby during this time. The cord was cut obliquely, using scissors, and in

70

BERNSTINE,

LUDMIR,

AND

FRITZ

most c:Hes of the unligated group, the cord was put under tension before it was cut; in some, tension was also applied following severcnce of the cord. Thw Tr. benzalkonium chloride, 1 :l,OOO, and alcohol, 70 per ant, wvw a,p~)ii~~(l, .I small piece of gauze was placed loosely over the umbilical stump. In both groups the umbilical cord was cleansed with Zcphiran, I :l,OOO, and alcohol 24 hours after delivery. The operator, using sterile gloves an(l instrllmerits, cut obliquely a piece from the cord, permitting a segment about $ inch to remain attached to the baby. The severed piece of cord was further divided by cutting one segment. The proximal piece was used for histologic study am1 placed in 10 per cent formalin; the other segment was immediately placed in a test tube which contained sodium ~~hioglycollatc and was used for bact~t*iologic study. iOO% 95% 50% .35% aa 75% 70% 65% to% 55%

-

50% u% AC!%

cord

wab

cord

bhek: widte:

mmb

cord

II

I

Lietad Non Ligated

swab

cord

III 151 c*ses 63 ligated 88 non li&.ad

swab

IV I-staph. Aureus (coAg.+) II-Intc&.iMl typa mr. III-Respirator IV-Amembic

Fig.

I.-Relationship

of

cases,

ligated

and

nonligated,

to

the

four

bacteriologic

gruups.

Procedure Bacteriologic studies were carried out by inoculating sodium thioglycollate medium with the most distal portion of the remaining umbilical corcl taken 24 The tissue was incubated at 3F C. for 12 to 24 hours, hours after delivery. then inoculated on differential solid media, including MacConkey’s, tellurite glycine agar,5 and sodium azide, and on two plates of 7 per cent blood agar, one of which was incubated anaerobically for 72 hours. In many instances, distinctive biochemical reactions were utilized to identify further a particular organism. Animal inoculations were not done. In addition, swabs were takep at the umbilicocutaneous junction of the cord and from the cut end of the stump approximately 72 hours after delivery. Bacteriologic procedures were similar to those previously described.

Groups of Organisms In an effort to determine the general pattern isms were arbitrarily placed into 4 categories :

of flora present, the organ-

Vdme Numlxr

i8 I

BACTERIOLOGIC

STUDIES

IN

LIGA4TED,

NONLIGATED

CORDS

71

I. Cougulase-Positive Staphylococci. II. “Intestinal Type.“-These organisms included lactose-fermenting gramnegative rods such as; Escherichia coli and Aerobacter aerogenes. Nonlactosefermenting or late lactose-fermenting bacilli included Bacillus proteus species B. proteus tettgeri, Paracolon species, Pseudomonas species, and HereUea *vaginicoZa. Gram-positive streptococci, which grew in broth containing 6.5 per cent XaCl, were considered to be enterococci and were included in the category, “Enterococci (alpha, beta, gamma hcmolytic) Lancefield Group 11.” III. Respiratory Type.-Organisms cultured included Neisseria catawhalis, N. sicca, Hemophdus, iylfluenzae, Diplococcus pneumoniae and B. streptococci unable to grow in 6.5 NaCl broth and falling in Lanrefield Group A. IV. Anaerobes.-Anaerobes cult,ured were Clostridium species, Bacteroidcs species, and anaerobic micrococci. The Clostridia showed a double-zoned hemolysis on blood agar and produced st,ormy fermentation in lit,mus milk in I I isolations. I,actobacilli, diphthcroids, and coagulase-negative staphylococci were isolated from the large majority of specimens and wcrc not included under an> category because of their ubiquitous nature. The predominant organisms cultured in the 4 gro~~ps were as follows : Group I, Staphylococcus auw us,; (iroup 11, EschetGhia coli; Group III, Strepto(*occi (alpha, gamma liemolytic) ; f iroup lV, Clostridium species (proteolyt,ic) .

Results Group I&a”ted:

I.

~oay~Ll~i.~e-Po.~itil~e ~~~t(li)l~~l(~(~o~~,i.24

Positke

HOURS

Negative

SWABS

Total

Positive

(72 HOURS) Negative Total

&J & l&h &O l&S & In this series, 11 cases primarily positive (within 24 hours) remained as SLIC~I 72 hours after delivery (37 per cent), 1 case became negative (3 per cent), 8 cases primarily negative (24 hours) became positive 7’2 hours lat,er (27 per cent), and 10 cases remained negat.ive in both instances (33 per cent,). No,digated: 24 HOURS SWA4BS (72 HOURS) Positive Negative Total Positive Neg&ve Tot01 99 27 ssyo &h &o *Eye ii% it0~ In this series, 20 cases (41 per cent) primarily positive remained positive for 72 hours, 9 cases primarily positive (18 per cent) became negative within 72 hours, 2 cases (4 per cent) negative became positive within 72 hours, and 18 cases (37 per cent) remained negative in both instances. Group II. “Ivbtestinal Type” Flora.Ligated: 24 HOURS SWABS (72 HOURS) Positive Negative Total Positilje Negatbe Total 7 30 ii% l&h l& t&h 23% 100% Twenty-one cases were positive at 24 hours and remained positive 72 hours later (70 per ent), 4 cases were positive and became negative at 72 hours (13 per cent), 2 cases were negative and became positive at 72 hours (7 per cent), 3 cases were negative and persisted negat,ive at 72 hours (10 per cent).

72

TWRNWTNE,

T,TlT~MlR

ANl)

FR,l’l’Z

h,

1 ,!I?>1 a c;v,E-c i.,ll,, ,Cl
Nodigat~d: 24 FXOURS Sw.wS (72 HOURS) Negative Total Positi~~(, ~Vwative Totat 26 31 18 49 (j:35Jh 30% &% 37% loo:h Twenty-seven cases positive remained so at 72 hours (55 per cent), 7 cases positive became negative (14 per cent), 4 cases negative became positive (8 per cent), 1.1 cases negative remained so at 72 hours (23 per cent). Positive 6’) 7;s

Goup III. Ligated:

Respiratory

Type Orgunisvns.-

SWABS (72 HOURS) 24 HOURS Positiljp Negative Total Posit& Negative T&l7 9 14 49 30 2zr.c & 30g 78% l&% 1oov;, / Six cases positive remained positive at, 72 hours (20 per cent), 2 cases positivc became ncgativc at, 72 hours (7 per cent ), 3 casts ncbgative brcame positiv(b at 72 hours (10 per cent,), 10 cases nrgative remain(~d so at 72 hours (63 per cent,) .

Nonligated: Positilje 26 30%

24 HOURS Negative fj’? 7&G

Total 88 100%

SWABS ( 72 HOURS) Positive Yegative To ta7 .5 44 49 1OY 90% LOO%’

Two cases positive remained so at 72 hours ( 4 per cent ) , 13 cases positive became negative at 72 hours (27 per ccrd) with a st,atistical significance of P rz 0.02, 3 cases negative became positive at 72 lio~m (6 per cent 1, 31 casts negakr remained so at 72 hours (63 per cent). Group IV. Ligated: Positive 15 247;

2lnaerobic Orga~~is~ns.-24 EIOIJltS ,Vega,tilw 48 7676

SWABS

Total 63 IOOyJJ

Positive 5 7YA

(72 HOURS) AVegative Totul 25 30 83$J loo~:l

Three cases positive remained positive at. 72 hours (10 per cent) ~ 4 cases positive became negative at 72 hours (13 per cent), 2 cases negative became positive at 72 hours (7 per cent,), 21 pases negative remained ncgat,ivp at ‘72 hours (70 per cent,). Nonliguted: &j HOURS SWABS (72 HOURS) Positit!e Negatit!e Tota Total Positke Negatiue 15 73 4 45 49 83y4l G&l 8 76, 92% J00 y; 17% None of the primarily positive remained positive at, 72 hours (0 per cent J, 6 cases positive became negative at 72 hours (12 per cent), 4 cases negative be came positive at 72 hours (8 per cent), 30 cases negative remained negative at 72 hours (80 per cent). It may be observed that the percentage of coagulase-positive staphylococci as illustra’ted in Fig. 2 was as follows: Within 24 hours the ligated group showed 35 per cent, the nonligated group showed 57 per cent; within 72 hours

~hmr7,8

l3ACTE:RIOLOGIC

STUDIES

IN

LIGATED,

NONLIGATED

73

CORDS

there was a decline in the nonligated group to 45 per cent and a rise in the ligated group to 63 per cent. We feel these results may prove of clinical significance in future studies.

Comment This study was undertaken to investigate the role of the umbilical cord in infections occurring in the newborn and the puerperal mother. Although we were interested in the coagulase-positive staphylococcic infections, we also studied other organisms, which we divided into four groups as mentioned before, i.e., T. Coagulase-Positive Staphylococci, II. Intestinal Types, III. ReThe patients studied were spiratory Types, and IV. Anaerobic Organisms. divided into t,wo groups: (1) umbilical cord ligated in t,he newborn, (2) umbilical cord was not ligated in the newborn. The methods employed in handling the cord were mentioned under Procedure. The reason for dividing

Wig.

2, -Graphic

representation anrl

of coagulase-positive nonliga,ted groups

from

staphylococci showing 24 to 72 hours.

variation

in

liwkcd

t)he study into those babies having the cord ligated and those where nonligation was employed, was as follows: It was noted in previous studies0 that in the nonligated cords desiccation started immediately following severance and the average time before separation was 72 hours, as compared with the ligated cords where desiccation was much slower and separation occurred, on the average, in from 7 to 9 days. Morison4 felt that with a large, moist cord the reaction to infection may be poor. It is interesting that in the Coagulase-Positive Staphylococci Group bacteriologic studies revealed, within 24 hours, in the ligated group 35 pc~ cent positive and in the nonligated group 57 per cent positive; yet within 72 hours bacteriologic studies showed that the incidence of. positive results rose from 35 per cent to 63 per cent in the ligated group and that there was a drop in the nonligated group from 57 per cent to 45 per cent. We feel that t,hc original higher incidence shown by bacteriologic study within 24 hours in the nonligated group as comparecl to the ligated, was probably due to the grcatcr and more frequent observation and contact in the nonligated group within the first 24 hours (i.e., house physicians, interns clerks, and nurses checking for evidence of bleeding). Hayhoe? in his study of nurses and doctors, in rela,tion to penicillin-resistant staphylococcic infection in a maternity hospital, showed

that t,he nose was responsible in 68.75 per cmt, ant1 the skin in 51.6 1~41~ ~tli. and in the resident physicians studied, the nosy was the responsible WII~W in 53.2 per cent. Concerning bacteriologic observations ~na(l(h in (iroup 11 J organisms ill the nonligatcd group, 13 casts that lv~re posiCvc within 2-L hours brcam(i negative at 72 hour+s,+and in Group JV in thtx nonligatcd group, all the organisms that, were positive within 24 houm b~a~nc n~gaGv(~ wiUlin 72 hours. WC feel at, the prcsmt timp that it may 1~ som(>what prematut*~~ 10 tllitk(l a definite statement or draw definite conclusions, but, as Fig. 2 in(li(aat.es, t,hcre is a (lifference bctw~~t~nthe ligatecl ilTj(l nonliga,tt>(l groups. The results as reported by our st,aGsGcian art’ of intt>rcst. As of 24 hours, the incidence of coag~~las~-l~ositi~~e s~ilphyloco~ci was 3.5 pi (*thnt in th(s ligated, and 57 per cent in the nonligatc(l grouJ1. This diff(~rcn(~~* \\zils statistically significant (probability of chi-scluarc 1~s than 0.02). The inGdenec in thp ligat,cl(l group rostx t’rom 15 pew CY~Il~ to cc< IM’V W~Ilt at 72 hours. This rise \v>ls s~~aGsti~:llly significi\Ttt with prnl)ability ot f*bisquare less than 0.05. On thcx other han~l, th(~rc xv;~s:I drop) in in&-l(~n(*(~ i~~~~ot~~ the nonligatp
Summary A bacteriologic study was conductc(l on newborns, ettlploying two groul)s : (1) 88 cases of nonligated cords, and (2) 63 casts of ligated cords. The method has been describetl in &+ail, inclu(ling thtx handling of t,he .umbilicai finclc0rc1 a,nd that employed in t,he ba~~(~~*iologi~~stuclics. The bacteriologic St~~J~llylo(.o(.(,i~ ings were divided into four groups : ( 1 ) ( ‘(Ji~~l~li~S~-l’~~Siti~~f~ (2) Int,estinal Type Organistns, (3) I~(~s~Gra~ory Type Organisms, iIn< [41 Ana(lrobic organisms. Th(J incidence of (~roul) J wit,hin 24 hours was :5 pcbt’ (*tbnt, in t,h(> ligated group anal 57 per ~~atlt in the nonligatpd group, l)~t within ‘72 hours t,hc incidence in the ligated grout) rose from 35 per cent to 6:; lx&r Toni, anal in the nonligaM group dropped from 57 per (sent to 45 per ecnt.. J3i~~~teriologic observations on Group 111, in nonligated cords, showed t,hat. Iii cask which were positive within 24 hours b~~~a~~~c negative within 72 hours, anal in (troup IV in nonligated group), all organisnls that wcrc lmsitive within 24 hours bcca,me ncgativtx within 72 hours. WC feel that a cord that desicca,tes rapidly. and separates early seems to lx less favorable to the growth an{1 maint(lnancc of bacteriologic flora, and finally WC feel that the amount of han~lli~~~ 1~anal contacts to which the severed cord is cxpose
References 1. Edmunds, I?. N., Elias-cJones, T. I?., Forfar! J. 0. and Balf, C. L.: Brit. M. tJ. 1: 990, 1955. 2. Forfar, J. O., Balf, c:. L., Elias-