What to do when meconium is present in amniotic fluid

How aggressively do you handle meconium when detected in the amniotic fluid. I was surprised to find that my OB considers it a medical emergency and immediately after the baby is born, they would intubate the baby and perform deep tracheal suctioning. Is this necessary? I did read your response on terminal meconium but I'd like more info from a medical management standpoint. I will be having a homebirth and the midwife is not that aggressive (she'll Delee while the baby is on the perineum but does not feel that intubation is warranted unless respiratory distress is apparent), is this reasonable? Thanks so much!

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

Dear Sheila,

As you know, in my previous answer on meconium, I discussed the importance of meconium and the descriptive terms (i.e. thick, thin, and terminal) used to describe it when present during delivery. As I said before, the presence of meconium in the amniotic fluid most often causes no problems for the baby. However, it can be inhaled either prior to delivery or during the delivery process. Sometimes this inhalation causes little or no problems. But sometimes, it can cause rapid deterioration of the newborn being able to breathe in enough oxygen. Because of the possibility of life-threatening complications meconium can cause, a couple of interventions have been employed to attempt to prevent meconium aspiration or the inhaling of meconium once the baby is delivered.

The first is to have the mid-wife or OB adequately suction the mouth and nose prior to the baby taking its first breath. This can only be done sufficiently with what is called a delee suction. The other is to have the pediatrician, mid-wife, or OB place a tube into the trachea and suction out any meconium that may have gone done the baby's windpipe. The first intervention has little controversy associated with it because studies have shown that adequate suctioning before the first breath by the person delivering the baby can decrease (although not entirely prevent) the risk of serious complications due to meconium. The second intervention, however, has some controversy because there has never been a study that proved without a doubt that suctioning the trachea prevented meconium aspiration. And so, different physicians have different opinions as to when to perform this procedure. Therefore, let me attempt to outline the rationale behind a couple of the factors that influence the decision of when to suction out the trachea, and then I will give you my opinion.

Distress in the Baby

There are many things that can happen prior to delivery and during delivery which cause stress on the baby such as having the umbilical cord wrapped around the neck, being in a position which makes delivery more challenging (e.g. breech position), and infection. Stress on an infant can cause the gastrointestinal tract to expel meconium prior to delivery. In addition, certain stresses such a compression on the cord can cause a gasp reflex in the infant presumably making it more likely to inhale the meconium. Therefore, stress on the baby is an important factor in causing the events leading to meconium aspiration.

Thick or Thin Meconium

To all appearances, thick meconium would be more troublesome than thin. Unfortunately, there are no studies that show this is the case. And in fact, there are numerous cases of life threatening complications with both thick and thin meconium. Nonetheless, many health care providers use the consistency or "how it looks" to help base a judgment as to whether to suction the trachea or not.

Sheila, my opinion lies somewhere between your OB and your mid-wife. First of all, while meconium can cause problems, it usually doesn't. Therefore, I would disagree with your OB if he suggests that any presence of meconium is an emergency. There are many instances in which the presence of thin meconium does not necessitate tracheal suctioning. Secondly, meconium can only be removed if it isn't first inhaled far down the trachea. Unfortunately, this sometimes occurs before the baby is even delivered. However, the first few breaths of an infant are very powerful, so any meconium that is lying in the trachea becomes increasingly hard to reach with each cry. Therefore, I would argue that waiting for respiratory distress to suction the trachea as your mid-wife suggests is fruitless in trying to prevent serious complications. By then, the horse is out of the barn. My decision to suction the trachea is quite similar to the recommendations put forth by the American Academy of Pediatrics. If any of the following factors are present, I usually elect to suction:

  1. Thick meconium
  2. Any signs of distress in the infant before it is born - Now, this implies the mother is in the hospital and on monitors which would detect any distress.
  3. Any signs of distress in the baby as he is being delivered - This usually comes in the form of an infant who is floppy and not interested in taking that first breath
  4. If suctioning of the mouth was not adequately performed by the mid-wife or OB as the head was being delivered - This occurs when there is a malfunction in the delee or the delee is unavailable.

Sheila, I hope this answers some of your questions. Congratulations for your impending new arrival, and the best of luck with the rest of your pregnancy and delivery!

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