Management

Seek expert advice.

The aim is prevention; firstly obstetric management to prevent the baby from passing meconium, then paediatric management to prevent aspiration.

Presence of meconium

When assessing risk at any time during labour, be aware that the presence of meconium:

• can indicate possible fetal compromise, and
• may lead to complications, such as meconium aspiration syndrome

Be aware that meconium is more common post-term, but should still trigger a full risk assessment and discussion with the woman about the option of CTG monitoring

Resuscitation of babies with meconium-stained liquor (1):

• Pinciples of care of babies in the presence of meconium
  • if presence of any degree of meconium:
    • do not suction the baby's upper airways (nasopharynx and oropharynx) before birth of the shoulders and trunk
    • do not suction the baby's upper airways (nasopharynx and oropharynx) if the baby has normal respiration, heart rate and tone
    • do not intubate if the baby has normal respiration, heart rate and tone
  • if there has been any degree of meconium and the baby does not have normal respiration, heart rate and tone, follow nationally accredited guidelines on neonatal resuscitation
  • if there has been significant meconium staining (defined as dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium) and the baby is in good condition, the baby should be closely observed for signs of respiratory distress. These observations should be performed at 1 and 2 hours of age and then 2-hourly until 12 hours of age, and should include:
    • general wellbeing
    • chest movements and nasal flare
    • skin colour including perfusion, by testing capillary refill
    • feeding
    • muscle tone
    • temperature
    • heart rate and respiration
  • if there has been non-significant meconium, observe the baby at 1 and 2 hours old in all birth settings
  • if any of the following are observed after any degree of meconium, ask a neonatologist to assess the baby. Transfer both the woman and baby if they are at home or in a freestanding midwifery unit:
    • respiratory rate above 60 breaths per minute
    • the presence of grunting
    • heart rate below 100 or above 160 beats per minute
    • capillary refill time above 3 seconds
    • body temperature of 38°C or above, or 37.5°C on 2 occasions 15 to 30 minutes apart
    • oxygen saturation below 95% (measuring oxygen saturation is optional after non-significant meconium)
    • presence of central cyanosis, confirmed by pulse oximetry if available

Occassionally meconium has been inhaled deep into the bronchial tree and cannot be sucked out. In this instance supportive measures may be needed - starting with oxygen and progressing to ventilation under sedation and paralysis. High pressures are needed to ventilate these neonates, and the risk of secondary complications such as pneumothorax is great. There is relative pulmonary hypertension and persistant fetal circulation may be a problem. In addition the meconium itself acts as a chemical irritant, causing a pneumonitis.

Occasionaly the situation is severe enough to require extracorporeal membrane oxygenation.

Reference:

1. NICE (September 2023). Intrapartum care