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Brief Reports

Indian Pediatrics 2000;37: 1251-1255.

Delivery Room Management of Neonates Born Through Meconium Stained Amniotic Fluid


Pushpa Chaturvedi
Balraj Yadav
M.S. Bharambe*

From the Departments of Pediatrics and Community Medicine*, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra 
442 103, India.

Reprint requests: Prof. P. Chaturvedi, Head, Department of Pediatrics, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra 442 103, India.

Manuscript received: October 6, 1988;
Initial review completed: November 19, 1998;
Revision accepted: May 29, 2000

Meconium aspiration syndrome (MAS) occurs most frequently in term and post term infants who have passed meconium in utero. It causes respiratory morbidity and high mortality ranging from 28-40%(1,3). The current approach to prevent MAS is oropharyngeal suctioning by the obstetrician on delivery of the head followed by immediate postnatal endotracheal suctioning(1,4). However, whether all babies born through thin meconium should undergo immediate postnatal endotracheal suctioning is a point of controversy. The present study was conducted to find out the incidence of MAS in neonates born through Meconium stained amniotic fluid (MSAF) and to evaluate the usefulness of intubation and intratracheal suctioning in vigorous neonates born through thin MSAF.

 Subjects and Methods

This study was conducted in the Neonatal Unit, Department of Pediatrics Kasturba Hospital attached to Mahatma Gandhi Institute of Medical Sciences. All deliveries with MSAF were prospectively enrolled in the study and evaluated and managed as per the management protocol (Fig. 1). In addition to routine perinatal data, the consistency of meconium (thick or thin), color of meconium, presence of meconium staining of the cord/skin/nails/vernix, occurrence of respiratory distress and seizure were recorded. Gestation was assessed by last menstrual period (LMP) where known, and correlated with clinical criteria of Dubowitz(s). Where LMP was not known, Dubowitz criteria were used. Those neonates with thin meconium and depression were excluded (one case in whom intubation and intratracheal suction was done had no MAS). Group I consisted of 75 neonates with thick meconium and Group II consisted of 108 apparently vigorous neonates with thin meconium. All study neonates underwent intrapartum suctioning of oropharynx on delivery of head, before the delivery of the shoulders and immediate oropharyngeal suction at birth.

Alternate neonates in Group II were assigned to subgroups II-A (no intubation or intratracheal suctioning done) and subgroup II-B (intubation and intratracheal suctioning carried out). Neonates in Group I and in Group II-B underwent chest splinting intuba-tion and direct intratracheal suctioning which was repeated till trachea was cleared of meconium.

The following definitions were used:

1. Thin meconium: Very light green staining of amniotic fluid.

2. Thick meconium: Thick greenish meconium with particulate matter in amniotic fluid

3. Meconium Aspiration Syndrome (MAS): Development of respiratory distress soon after birth with radiological evidence of aspiration pneumonitis in presence of meconium staining of liquor, staining of nails or staining of umbilical cord or skin(6).

4. Asphyxia was diagnosed when Apgar score at 5 minutes was less than 7(7).

Statistical analysis was done using Chi-square test and "Z" test.

Fig 1. Management Protocol

Table I__Comparison of Baseline and Outcome Variables Between Groups

Variables

 Group I
(n=75)

 Group II-A
 (n=54)

 Group II-B
 (n=54)

Birth weight (g)
Mean ± SD

 2599 ± 438.99

 2608 ± 439.94

 2639 ± 430.39

Gestation (wk)
Mean ± SD

 38.9 ± 2.44

 39.0 ± 1.95

 38.7 ± 1.96

Apgar

  1 min*

 6.5 ± 2.5

 8.8 ± 0.63

 8.4 ± 1.31

  5 min*

 8.4 ± 1.30

 9.0 ± 0

 8.9 ± 0.45

Mode of delivery No. (%)

 Vaginal

 35 (46.7)

 38(70.4)

 35 (64.8)

  Instrumental
    and LSCS

 40 (53.3)

 12 (22.2)

 13 (24.0)

MAS* No. (%)

 14 (18.7)

 1 (1.9)

 1 (1.9)

* P <0.001

 Results

Of the 1109 live births, 184 (16.5%) were born through MSAF of which 16 (18.7%) developed MAS bringing the incidence of MAS to 1.44% of all live births. Of the 75 neonates born through thick MSAF, 14 (18.6%) had MAS whereas amongst the 108 born through thin MSAF only 2 (1.8%) had MAS. This difference was statistically significant (p <0.001). Table I compares the baseline variables in the study groups. The mode of delivery did not influence the occurrence of MAS. Cases of thin meconium who underwent intratracheal suctioning (Group II-B) did not show any difference in the development of MAS as compared to cases of thin meconium in whom no intratracheal suctioning was done (Group II- A). There were 2 deaths in Group I due to severe MAS, occurring at 12 h and 4 h after birth, respectively and 1 death in Group II B who had no evidence of asphyxia or MAS at birth and died due to culture proven sepsis on day 6.

  Discussion

Current obstetric and neonatal practices are not able to eliminate MAS which is an important cause of neonatal morbidity and mortality. Moreover, there is no clear consensus regarding management of apparently vigorous babies born through thin meconium. Our incidence of MSAF (16.5%), MAS (8.7%), MAS in all live births (1.44%) and mortality due to MAS of 12.5% falls within the ranges cited by other workers(1,8-11).

Meconium passage is rare before 37 weeks but occurs more often in pregnancies of more than 42 weeks of gestation(8). A rising incidence of meconium passage is seen with increasing gestation(10), a finding which was also seen in the present study. MAS can occur even when Caesarian section is done(12) and normal vaginal delivery does not increase the incidence of MAS unless fetal distress is present. In this series, the mode of delivery did not influence the occurrence of MAS. A recent study reported that MAS developed in all babies with severe or moderate asphyxia as opposed to only 41% in those with mild or no asphyxia (1 min Apgar <7)(13). In another study, 33.8% of neonates with asphyxia (1 min Apgar <7) developed MAS(10). In the present study 45.5% of neonates with asphyxia (5 min Apgar <7) had MAS.

Thick meconium is associated with increased incidence of MAS, reported as 21%(10) and 35.2%(11). Our incidence was 18.6% whereas the incidence of MAS in thin meconium was reported as 2.9%(10) and 16.1%(11) being 1.8% in the present study. Thin meconium was responsible for 12.4% cases of MAS whereas others report an incidence of 15.4%(10) and 19.4%(11). The consistency of meconium has also a direct bearing on neonatal outcome(10,14) which is borne out by the present study as well. We lost 2 neonates due to MAS, both had thick meconium and severe asphyxia at birth. Asphyxia was more often seen in neonates with thick meconium.

There in no consensus about which neonate will be benefited from subsequent intubation and suctioning. Most authors advise intratracheal intubation and suctioning of all meconium stained neonates (3,11,15). Some maintain that intubation should be performed only if heavy, particulate meconium is present(14,16). Finally, others have suggested that if neonate is vigorous and apparently healthy, intubation may not be neces-sary(10,17). Thus it remains unclear whether or not all vigorously active meconium stained neonates should be intubated and suctioned. In the present study we found that the incidence of MAS in vigorously active neonates delivered through thin meconium whether suctioned intratracheally or not was the same. A study stated reduction in the incidence of MAS due to thin meconium from 26% to 16% by combined intrapartum and endotracheal suctioning(11). However, a very well con-ducted recent study concluded that intra-tracheal suctioning of apparently vigorous meconium stained infants does not result in decreased incidence of respiratory distress compared with expectant management (no intubation and intratracheal suctioning)(18).

The frequency of adverse complications from intubation procedure appears to be very low. Approximately 1% of intubated infants developed transient stridor(16), whereas only one such incident occurred among several thousand intubated neonates(19). In another study it was found that 2 of 306 intubated infants had persistent stridor(17). A recent study on complications of intubation in vigorous meconium stained neonates found that 3.8% neonates developed mild and transient complications(18). However, in our series no neonate developed stridor or any other complication related to intubation.

The present study concludes that thick meconium is more often associated with MAS as compared to thin meconium. Asphyxia is a significant risk factor for the development of MAS in neonates born through MSAF. The outcome of active and vigorous neonates born through thin MSAF is not altered by intubation and suction after birth provided oropharyngeal suction has been done by the obstetrician on delivery of the head. Larger studies are required to prove this point further.

Contributors: PC designed, coordinated and interpreted the study and drafted the manuscript. She will act as a guarantor for the paper. BY collected the data and helped in the drafing of the paper. MSB helped in the perception of the study, statistical analysis and revision of the manuscript.

Funding: None.
Competing interests:
None stated.

Key Messages

  • Thick meconium and asphyxia are significant factors for the occurrence of MAS.

  • Intubation and intratracheal suctioning in apparently vigorous babies born through thin MSAF does not result in decreased incidence of MAS provided they have undergone intrapartum suctioning.

  References
  1. Carson BS, Losey RW, Bowes WA, Simmons MA. Combined obstetric and pediatric approach to prevent meconium aspiration syndrome. Am J Obstet Gynecol 1976; 126: 712-715.

  2. Vidyasagar D, Yeh TF, Harris V, Pildes RS. Assisted ventilation in infants with meconium aspiration syndrome. Pediatrics 1975; 56: 208-213.

  3. Davis RO, Philips JB, Harris BA. Wilson ER, Huddelston JF. Fetal meconium aspiration syndrome occurring despite airway manage-ment considered appropriate. Am J Obstet Gynecol 1985; 151: 731-736.

  4. Wiswell TE, Henley MA. Intratracheal suctioning, systemic infection and the meconium aspiration syndrome. Pediatrics 1992; 89: 203-206.

  5. Dubowitz LMS, Dubowitz V, Goldberg C. Clinical assessment of gestational age. J Pediatr 1970; 77: 1-10.

  6. Narang A. Definition of major illnesses as applicable at different levels of the health care delivery system. In: Neonatal Nomenclature and Data Collection. Eds. Singh M, Paul VK, Bhakoo ON. Delhi, Vani Press 1989; pp 27-35.

  7. Ellis M, Costello A. Birth asphyxia, Apgar score and neonatal encephalopathy. Indian Pediatr 1997; 34: 975-978.

  8. Usher RH, Boyd ME, McLean FH, Kramer MS. Assessment of fetal risk in postdate pregnancies. Am Obstet Gynecol 1988; 158: 259-264.

  9. Locus P, Yeomans E, Crosby U. Efficacy of bulb versus De Lee suction at deliveries complicated by meconium stained amniotic fluid. Am J Perinatal 1990; 7: 87-91.

  10. Narang A, Nair PMC, Bhakoo ON, Vasishta K. Management of meconium stained amniotic fluid: A team approach. Indian Pediatr 1993; 39: 9-13.

  11. Suresh GK, Sarkar S. Delivery room management of infants born through thin meconium stained liquor. Indian Pediatr 1994; 31: 1177-1181.

  12. Sashikala A, Raghav S, Mishra N, Khatoon S, Bupathy A, Rani R. Perinatal outcome in relation to mode of delivery in meconium stained amniotic fluid. Indian J Pediatr 1995; 62: 63-67.

  13. Gupta P, Faridi MMA, Behl D, Agarwal KN. Clinical and biochemical asphyxia in meconium stained deliveries. Indian Pediatr 1998; 35: 353-357.

  14. Gregory GA, Gooding CA, Phibbs RH, Tooley WH. Meconium aspiration in infants - A prospective study. J Pediatr 1974; 85: 848-852.

  15. Falciglia HS. Failure to prevent meconium aspiration syndrome. Obstet Gynecol 1988; 71: 349-353.

  16. Hageman JR, Conely M, Grancies K. Delivery room management, meconium staining of amniotic fluid and the development of meconium aspiration syndrome. J Perinatol 1988; 7: 127-131.

  17. Linder N, Aranda JV, Tsur M. Need for endotracheal intubation and suction in meconium-stained neonates. J Pediatr 1988; 112: 613-615.

  18. Wiswell TE, Gannon CM, Jacob J. Delivery room management of the apparently vigorous meconium stained neonate: Results of the multi center international collaborative trial. Pediatrics 2000; 106: 1-7.

  19. Kresh MJ, Brion LP, Fleishman AR. Delivery room management of meconium stained neonates. J Perinatol 1991; 11: 46-48.

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