Meconium Stained Liquour, Delivery Room Management

Introduction
Management
Areas of Uncertainty in Clinical Practice

Introduction

Meconium staining of the liquor complicates approximately 15% of live births. Meconium aspiration syndrome (MAS) may complicate up to 5% of births through meconium stained liquor. MAS carries a significant respiratory morbidity and may be fatal.

Management

Sucking out the infant’s mouth and pharynx before the delivery of the shoulders makes no difference to the outcome of babies with meconium stained liquor and is no longer recommended.
Transfer the infant to the resuscitation area and assess infant vigour. A vigorous infant has

good muscle tone
active breathing efforts
HR>100BPM

IF VIGOROUS - provide standard care (see guidelines for resuscitation)

IF NOT VIGOROUS — when the operator present is able to perform intubation

place infant under radiant warmer while avoiding stimulation

insert laryngoscope

suction mouth and pharynx with 12 or 14 Fr catheter (set at —100 mmHg)

insert either 3.0 or 3.5 ET into trachea, attach meconium aspirator, apply suction while withdrawing ET
or
pass suction catheter directly through the vocal cords and apply suction while gradually withdrawing catheter

intubation and suctioning must be brief and should not compromise the infant

IF NOT VIGOROUS - when the operator present is unable to perform intubation

place infant under radiant warmer —avoid stimulation

suction mouth and pharynx with 12 or 14 g catheter (set at -100mmHg)

commence positive pressure ventilation with a neopuff or other hand ventilating device

Ongoing care

Provide continued resuscitation as indicated by condition.
If apnoea or respiratory distress develops subsequently, perform intubation and tracheal suctioning before commencing assisted ventilation
Aspiration of the stomach to prevent risk of aspiration of swallowed meconium is not part of the initial resuscitation since passage of the tube can cause a vagally induced apnoea. Subsequent aspiration of the stomach is recommended after resuscitation is complete.
Admission to SCN for observation is required when there is
- meconium below the cords
- ongoing respiratory distress or oxygen requirement
- need for active resuscitation involving CPR or prolonged IPPV

Areas of Uncertainty in Clinical Practice

There is no evidence that management should be based on consistency of meconium.

There is no evidence that techniques used to inhibit gasping after delivery are effective in reducing the incidence of MAS.

References

Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term Halliday HL http://www.cochrane.org/reviews/en/ab000500.html

Neonatal Resuscitation Textbook, 5^th Edition Editor Kattwinkel J.

Delivery Room Management of the Apparently Vigorous Meconium-stained Neonate: Results of the Multicenter, International Collaborative Trial WiswellT.E. et al Pediatrics 205(1) Part 1of 3, 2000, 1-7

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics. 2006 May;117(5):e978-88. Epub 2006

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