European Journal of
Eur J Pediatr (1987)146:387-389
The time of separation of the umbilical cord
A. M. Oudesluys-Murphy 1, G. A. M. Eilers2, and C.J. de Groot 1
1Department of Paediatrics, Zuiderziekenhuis, Groene Hilledijk 315, and
2Department of Biostatistics, Erasmus University, 3075 EA Rotterdam, The Netherlands
Abstract. The time of separation of the umbilical cord was
studied in 911 neonates. The mean time of separation was 7.4
days (SD 3.3, range 1-29 days). We sought a possible relation-
ship between the time of cord separation and various factors
in the perinatal period. Cord separation was delayed when
antibiotics needed to be administered to the neonate because
of 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. None
of the infants studied suffered from omphalitis and it would
appear that "delayed" separation of the cord is not always
necessarily accompanied by severe leucocyte dysfunction.
Key words: Umbilical cord - Leucocyte function
Introduction
The time of separation of the umbilical cord was the subject of
little interest until Hayward et al. [11] reported a possible
relationship between "delayed" separation of the cord and de-
fective neutrophil function. This was followed by other re-
ports [1, 3, 6, 7, 8]. However, there is no clear definition of the
normal time of cord separation, nor of when this may be said
to be delayed. No studies have been reported investigating
other factors apart from leucocyte function that may also be
related to the time of cord separation.
A search of the recent literature reveals only two studies
that investigate the time of cord separation on a large scale.
T6tterman et al. [13] report the findings in 600 Finnish neon-
ates. Bhalla et al. studied 840 Indian infants [51. Smaller
studies have been reported by A r a d et al. [4] and Wilson et al.
[14] among others.
We studied 911 infants to determine the normal time of
cord separation and to investigate the possible presence of a
relationship between the time of cord separation and the sex,
gestational age, birth weight, method of delivery, need to be
admitted to the special care baby unit, as well as specific prob-
lems such as jaundice of the newborn treated with photo-
therapy and treatment with antibiotics for suspected or con-
firmed sepsis.
Subjects and methods
A card was given to each mother who was delivered of a live
born infant in the maternity unit of our hospital requesting her
Offprint requests to: A. M. Oudesluys-Murphy
P e d i a t r i c s
9 Springer-Verlag 1987
to return the card stating the exact time at which she found the
cord stump separated from the infant. Other data including
the hour and date of birth, gestational age and birth weight
were recorded from the mother's medical records and infor-
mation concerning those infants who were admitted to the
special care baby unit was recorded from their own records.
Cards were returned for 911 of the 2369 infants born
during the study period. There was no reason to suspect that
the time of cord separation was earlier or later in those infants
for whom no cards were returned than in those for whom
cards were returned. The 911 infants reflected the general
population regarding gestational age, birth weight and meth-
od of delivery.
Of the 911 infants, 517 were male and 394 were female.
The gestational age ranged from 28-43 weeks, with a mean of
38.6 weeks (SD 2.6). The birth weight ranged from 950-5490 g
with a mean of 3050 g (SD 710). Delivery was by spontaneous
vaginal delivery in 754 infants, forceps or ventouse in 72 and
Caesarean section in 85. Of the 911 infants, 379 were term,
appropriate-for-gestational-age, healthy infants who needed
no special care. There were 532 infants admitted to the special
care baby unit because of various problems including pre-
mature birth, low birth weight, jaundice of the newborn, con-
firmed or suspected sepsis or other infections and other prob-
lems including asphyxia of the newborn, hypolgycaemia,
hypocalcaemia etc. Two hundred and forty-six infants were
treated with phototherapy for jaundice of the newborn. Anti-
biotics were administered to 174 infants because of confirmed
or suspected sepsis or infection.
During the study period there was no change in the cord
care regime, which is that commonly used in the Netherlands.
A dry gauze dressing was applied around the umbilical stump
and an umbilical binder was then used. No creams, dyes or
ointments were used. The infants were bathed daily fi'om the
age of 12 h. The umbilicus was inspected three-hourly at each
feed. No infant suffered from omphalitis and no infant had an
umbilical catheter.
The results were analysed statistically by stepwise multiple
regression using the computer programme GLIM.
Results
The time of separation of the umbilical cord in these 911 in-
fants ranged from 1-29 days with a mean of 7.4 days (SD 3.3).
When analysed by stepwise multiple regression a significant
relationship was found between the time of cord separation
and some of the factors studied. The results may be expressed
most easily "centred" for a male infant of 40 weeks gestation
388
Table 1. Stepwise multiple regression analysis of the factors influencing the time of umbilical cord separation
Factor Cord separation time
(days)
m (SE)
"Centred" infant ~ 6.2 (0.39)
Infection - confirmed or suspected (n = 174)
Gestational age in weeks
Delivery by Caesarean section (n = 85)
forceps or ventouse (n = 72)
Birth weight (g)
Female sex (n = 394)
Admission to special care unit (n = 532)
Jaundice of newborn with phototherapy (n = 246)
a Centred for male infant, 40 weeks gestation, birth weight 3000 g, unassisted vaginal delivery, without infections or jaundice and not admitted to
the special care unit
with a birth weight of 3000 g, delivered by spontaneous vaginal
delivery who did not need to be admitted to the special care
baby unit nor to receive any therapy such as phototherapy or
antibiotics. The mean time of cord separation in such an infant
was calculated to be 6.2 days (SE 0.39). This result corre-
sponds well to the findings in the subgroup of 379 healthy
term, appropriate-for-gestational-age infants where the mean
time of cord separation was also 6.2 days (range 1-17 days, SD
2.1).
A significant relationship was found between the time of
cord separation and the need for treatment with antibiotics for
confirmed or suspected sepsis. It is impossible to say which is
the most important - the effect of the antibiotics or the effect
of the infection. Cases with confirmed sepsis are grouped to-
gether with cases of suspected sepsis because when an infant
clinically appeared to have a sepsis and this was accompanied
by a toxic blood picture and raised CRP, antibiotics were
given immediately after cultures were taken. Sometimes the
results of the cultures were negative in these cases. The mean
time of cord separation in these infants was delayed by 2.95
days (SE 0.26) (Table 1).
A significant relationship was also found between the ges-
tational age and the time of cord separation - it separated
later in the prematurely born infants. The mean time of cord
separation in days could be expressed by the formula 0.17
multiplied by the difference between 40 and the gestational
age in weeks added to 6.2. Thus when the infant is delivered
after 30 weeks' gestation the time of cord separation is delayed
by 1.7 days and occurs at 7.9 days.
Delivery by Caesarean section was also related to a signifi-
cant delay in the time of cord separation. This delay was 2.01
days (SE 0.33). All Caesarean sections were grouped together
- whether performed for maternal or fetal reasons, with or
without the presence of labour and with broken as well as in-
tact membranes. Delivery with the aid of forceps or ventouse
did not significantly affect the time of cord separation.
The relationship with birth weight was also significant -
the lower the birth weight the later the cord separated. The
effect of birth weight could be calculated by multiplying the
difference between 3000 and the birth weight in grams by
0.0005. For example when the infant weighs 1000 g the mean
time of cord separation is delayed by 1 day and is then 7.2
days.
Delay or acceleration Z-value Two sided
P value
m (SE) SE/m
+ 2.95 (0.26) 11.25 < 0.001
+ 0.17 (0.05) 3.i9 0.001
x (40 - gestational age)
+ 2.01 (0.33) 6.02 < 0.001
+ 0.35 (0.35) 1.00 0.32
+ 0.0005 (0.0002) 2.56 0.01
x (3000 - birth weight)
- 0.50 (0.19) - 2.61 0.01
+ 0.32 (0.25) 1.26 0.21
+ 0.01 (0.26) 0.04 0.97
There was also a significant relationship between the sex of
the infant and the time of cord separation. The mean time of
cord separation was 0.5 days earlier in female than in male in-
fants.
No significant relationship was found between the time of
cord separation and the other factors studied - treatment
with phototherapy for jaundice of the newborn or admission
to the special care baby unit for any other reason.
Discussion
It is important to know when the umbilical cord normally
separates. Parents may be advised when to expect this occur-
rence. The knowledge may also be used to judge when the
time of cord separation falls outside the normal range. Recog-
nition of a severe delay in the time of cord separation may
make one suspicious of an otherwise yet unmasked immuno-
logical disorder.
In our study of the mixed group of 911 infants we found a
mean time of cord separation of 7.4 days (SD 3.3). A slight
delay may occur when the infant is delivered by Caesarean
section, is born prematurely, has a low birth weight or needs
to be treated with antibiotics for suspected or confirmed
sepsis. Cord separation may be said to be delayed when it
occurs later than 14 days (that is mean plus twice the standard
deviation). It is clearly outside the normal range when it
occurs after 21 days.
Despite varying geographical locations, race and differing
methods of cord care, the normal time of cord separation falls
within a fairly narrow time limit. In 1970 T6tterman and Autio
[13] reported a mean time of 6.3 days for cord separation in
600 Finnish neonates. The umbilical stump was cared for with
povidone-iodine and most of the infants they studied were
term infants weighing more than 2500 g. In 1975 Bhalla et al.
[5] reported a mean time of cord separation of 5.8 days in 840
Indian infants. The time of cord separation was also slightly
delayed following delivery by Caesarean section. The cord
care consisted of dressing with mercurochrome or sterile anti-
septic powder. A r a d et al. [4] studied the time of cord separa-
tion in 121 infants in Jerusalem in 1983. They found mean
times of cord separation varying with the method of cord care
from 6.4-12 days. Triple dye, 1% neomycin, 1% sulphadi-

azine ointment or bismuth subgallate powder were used in
caring for the cord in their study. Wilson et al. [14] reported a
later mean time of cord separation of 15 _-+ 7.2 days in their
study of 245 American infants. The cord care in these infants
consisted of application of triple dye.
The precise mechanism of cord separation is not known.
Drying, necrosis, collagenase activity [12] and granulocyte
activity are all thought to play roles. There are no studies re-
ported of factors influencing the timing of cord separation.
The only literature on delayed cord separation reports it in
association with recurrent infections and leucocyte dysfunc-
tion. These included defects of chemotaxis [11], diminished
oxidative response [1] and failure of adherence [8]. A defi-
ciency of a high molecular glycoprotein has been described
[3]. Hayward et al. [11] suggest that a primary defect of a
contractile protein could explain the association between de-
layed cord separation and the leucocyte dysfunction.
In our study we found a relationship between the time of
cord separation and various factors in the perinatal period,
but we do not know the exact way in which these factors affect
the mechanism of separation. The factors which we found to
delay cord separation - premature birth [9] and clinically
apparent infection [2] have been found to be associated with
leucocyte dysfunction. The method of delivery also affects
leucocyte function [10].
In all the reports of delayed cord separation accompanied
by leucocyte dysfunction the time of cord separation was later
than 21 days and often nearer to 6 weeks. In some cases the
cord did not separate spontaneously but needed to be surgi-
cally excised [11]. Those infants also suffered from recurrent
severe infections. We agree with Wilson et al.'s [14] view that
when delayed cord separation is associated with severe leuco-
cyte dysfunction, it is generally accompanied by severe recur-
rent infections. No one has reported delayed cord separation
in the presence of normal leucocyte function, but, it is quite
possible that is frequently the case.
The precise timing of cord separation is probably the result
of a complex interaction of many factors and further studies
will be necessary before attempting to interpret the time of
cord separation as an indication of the leucocyte function in
the neonate.
Conclusion
It is important to know the time at which the umbilical cord
normally separates so that parents may be advised when to
expect this occurrence. In our study of 911 infants we found a
mean time of cord separation of 7.4 days (SD 3.3). There was
a slight but significant delay when the infant was born pre-
maturely, delivered by Caesarean section, needed to be
treated with antibiotics for possible infections or had a low
birth weight. The cord separated slightly earlier in female than
in male infants.
Reports from the world literature do not vary greatly from
our findings in spite of differences in cord care as well as the
obvious differences in climate and race.
389
The time of cord separation may be regarded as being de-
layed when it occurs after 2 weeks and as being outside the
normal range when it occurs after 3 weeks. However it would
seem that when delayed cord separation is accompanied by
leucocyte dysfunction that the time of cord separation is very
much later than this and there are recurrent infections.
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Received July 17, 1986 / Accepted August 6, 1986