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obstruction, which usually is not amenable to nonoperative measures. Evidence-Based Research
Laparotomy and lysis/excision of the adhesions are usually required. Table 20.1 presents an overview of an evidence-based study on early
Any ischaemic intestinal segment needs to be resected. antisepsis with chlorhexidine.
Prognosis and Outcome Table 20.1: Evidence-based research.
Promptly treated uncomplicated omphalitis usually resolves without
Title Topical applications of chlorhexidine to the umbilical cord
serious morbidity. However, when presentation and treatment are for prevention of omphalitis and neonatal mortality in
delayed, mortality could be high, reaching 7–15%. 1,7,13,17 southern Nepal: a community-based, cluster-randomised
trial
Serious morbidity and mortality may occur from complications
6
such as NF, peritonitis, and evisceration. Portal vein thrombosis Authors Mullany LC, Darmstadt GL, Khatry SK, Katz J, LeClerq
18
may be fatal. Mortality may reach 38–87% following NF and SC, Shrestha S, Adhikari R, Tielsch JM
myonecrosis. 1,19,20 Also, certain risk factors such as prematurity, small Institution Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, USA
size for gestational age, male sex, and septic delivery are associated
with poor prognosis. Reference 21 Lancet 2006; 367(9514):910–918
Prevention Problem Omphalitis contributes to neonatal morbidity and mortality
in developing countries. Umbilical cord cleansing with
The incidence of omphalitis is low in well-resourced countries and antiseptics might reduce infection and mortality risk, but
for those born in hospital. For these, there is probably little benefit of has not been rigorously investigated.
prophylactic measures to reduce the incidence. In developing countries, Intervention In this community-based, cluster-randomised trial, 413
and especially after home birth, however, the incidence is high enough communities in Sarlahi, Nepal, were randomly assigned
to one of three cord-care regimens: 4,934 infants were
to consider prophylaxis to prevent the morbidity and mortality associ- assigned to 4.0% chlorhexidine, 5,107 to cleansing with
ated with late presentation of the disease. Access to proper maternity soap and water, and 5,082 to dry cord care.
and delivery services helps reduce the incidence. Comparison/ Cluster-randomised control study
Teaching safe cord-care practice to mothers as well as using control (quality
traditional birth attendants and primary-care workers are of utmost of evidence)
importance in the prevention of omphalitis in Africa. Vigilance is also Outcome/effect The frequency of omphalitis was reduced significantly
important to identify major complications and refer patients early for in the chlorhexidine group. Severe omphalitis in
chlorhexidine clusters was reduced by 75% (incidence
prompt intervention. In most African hospital settings, methylated spirit rate ratio, 0.25, 95% CI 0.12-0.53; 13 infections/4839
and gentian violet are commonly used for cord care. In other parts neonatal periods) compared with dry cord-care clusters
of the world, betadine, bacitracin, silver sulfadiazine, or triple dye is (52/4930). Neonatal mortality was 24% lower in the
chlorhexidine group (relative risk, 0.76 [95% CI 0.55-
recommended. Currently, not using any medicinal washes on the cord 1.04]) than in the dry cord-care group. Within the first 24
but just simply allowing the cord to dry and fall off is being advocated hours, mortality was significantly reduced by 34% in the
in developed parts of the world. There is little data to support any one chlorhexidine group (0.66 [0.46-0.95])
cord care or lack thereof over the other. Historical Early antisepsis with chlorhexidine of the umbilical
In one report, a simple clean delivery kit produced by the significance/ cord reduces local cord infections and overall neonatal
comments
mortality
United Nations Population Fund (UNFPA) was found to reduce cord
infections.1 Babies of mothers who did not use the kit were 13 times
more likely to develop cord infection than babies of mothers who used
the kit. The same report also noted that babies of mothers who did
not bathe before delivery were 3.9 times more likely to develop cord
infection than babies of mothers who bathed.

Key Summary Points

1. Omphalitis is a common problem in resource-limited settings 3. Prompt recognition of complications and treatment is
and is related to unhygienic cord practices. necessary to avoid morbidity and mortality.
2. Although a simple infection, life-threatening complications may 4. Omphalitis is easily preventable by clean and safe delivery and
occur if presentation and treatment are delayed. cord-care practices.

References
1. Gallagher PG, Shah SS. Omphalitis: Overview. Available at http:// paediatric wards at Kenyatta National Hospital. East Afr Med J
emedicine.medscape.com/article/975422-overview (accessed 15 2003; 80:611–616.
December 2008).
5. McClure EM, Goldenberg RL, Brandes N, Darmstadt GL, Wright
2. Sawardekar KP. Changing spectrum of neonatal omphalitis. LL. The use of chlorheidene to reduce maternal and neonatal
Pediatr Infect Dis J 2004; 23:22–26. mortality and morbidity in low-income settings. Int J Gynaecol
Obstet 2007; 97:89–94.
3. Mullany LC, Darmstadt GL, Katz J, et al. Risk factors for umbilical
cord infection among newborns of southern Nepal. Am J Epidemiol 6. Winani S, Wood S, Coffey P, Chirwa T, Mosha F, Changalucha J.
2007; 165:203–211. Use of clean delivery kit and factors associated with cord infection
and puerperal sepsis in Mwanza, Tanzania. J Midwifery Womens
4. Simiyu DE. Morbidity and mortality of neonates admitted in general
Health 2007; 52:37–43.