Meconium

Dr .Ashraf Fouda
Ob/Gyn. Consultant
Damietta General
Hospital
E. mail :
 INTRODUCTION

The detection of meconium

stained amniotic fluid during
labour often causes
anxiety in the delivery room
because of its association with
increased perinatal mortality
and morbidity.
 INTRODUCTION
 Meconium is composed of :
2. Small dried amniotic fluid debris,
3. Bile pigment and
4. The residue from intestinal secretions.
 It is a sterile compound made up
primarily of water (75 %), with mucous
glycoproteins, lipids and proteases.
 INTRODUCTION
Although meconium is sterile,
its passage into amniotic fluid
is important because
of the risk of
meconium aspiration
syndrome (MAS)
and its sequelae.
 INTRODUCTION
Infants delivered through
meconium-stained amniotic
fluid are more likely to be
depressed at birth
and to require
resuscitation and
neonatal intensive care.
 INCIDENCE
Meconium-stained liquor is rare
in premature infants
(<5 % of preterm
pregnancies); if it does
occur, there is an association
with infection and
chorioamnionitis.
 INCIDENCE
Passage of meconium is increasingly
common in infants >37 weeks'
gestation and occurs in up to 50 %
of post-mature infants ( >42 weeks).
The incidence of MAS varies between
1 and 5 % of all deliveries
where there has been meconium-
stained liquor.
 INCIDENCE
 There are a number of factors associated with
an increased risk of developing MAS; these
include a:
 Lack of antenatal care,
 Black race,
 Male fetus,
 Abnormal fetal heart rate monitoring,
 Thick meconium,
 Oligohydramnios,
 Operative delivery,
 Poor Apgar scores,
 No oropharyngeal suctioning and
 The presence of meconium in the trachea.
 AETIOIOGY
Many theories have been
proposed to explain the passage
of meconium in utero; however,
the precise mechanisms remain
unclear.
The fetal bowel has little
peristaltic action and the anal
sphincter is contracted.
It is thought that hypoxia and
 PATHOPHYSIOLOGY
Meconium aspiration syndrome is a
disease of term and post-term infants
and its severity is linked to co-existing
fetal asphyxia.
Aspiration of meconium into
the distal airways can occur either
antenatally or postnatally,
but in the majority of
affected infants
 PATHOPHYSIOLOGY
Aspiration is known to occur
prior to delivery, as
meconium has been found in
the lungs of stillbirths and in
infants delivered pre-labour
by caesarean section without
evidence of fetal distress.
 PATHOPHYSIOLOGY
Postnatal inhalation
can occur
late in the second stage or
immediately after delivery
if the infant
gasps or makes breathing movements
while the
oropharynx, nasopharynx or trachea
contains meconium-stained
liquor.
 PATHOPHYSIOLOGY
Meconium has a number of
adverse effects on
the neonatal lung,
which may
ultimately lead to the
respiratory failure (and
hypoxaemia)
which characterizes MAS.
 PATHOPHYSIOLOGY
Meconium:
 Causes mechanical blockage of the
airway,
 Acts as a chemical irritant causing
pneumonitis, alveolar collapse and cell
necrosis
 Although initially sterile, predisposes to
secondary bacterial infection
 PREVENTION OF MECONIUM
ASPIRATION SYNDROME
Because of potential morbidity and
mortality from MAS,
prevention would clearly be
beneficial.
This has led to a number of
antenatal, intrapartum and postnatal
preventative therapies,
with a varying degree of success.
 Antenatal therapies

1. Amnioinfusion
2. Delivery by caesarean
section
3. Maternal sedation
 Amnioinfusion
 The idea behind amnioinfusion
is that by increasing the liquor volume,
meconium will be diluted.
 In addition, in cases of oligohydramnios,
the increased volume will prevent :
 cord compression,
 subsequent hypoxia,
 fetal gasping and
 passage of meconium.
 Amnioinfusion
A meta-analysis of amnioinfusion
trials showed that this therapy has a
role in the prevention of
MAS.
However, the use of amnioinfusion
requires further evaluation, as the
therapy is associated with a number
of complications, including a
higher incidence of instrumental
delivery and endometritis.
 Delivery by caesarean
section
Although most studies suggest
that infants with MAS are more
likely to be delivered by
caesarean section than by vaginal
delivery, this is largely due to the
suspicion or confirmation
of fetal distress.
 Delivery by caesarean
section
 There is currently no evidence to suggest
that MAS would be prevented by elective
delivery by caesarean section of infants
with meconium-stained liquor;
 Perhaps this is not surprising, as neither
 The conditions for nor
 The timing of aspiration
can be predicted.
 Maternal sedation
 Ithas been suggested that the
administration of narcotics to laboring
women will prevent fetal gasping in utero
by suppressing fetal breathing.
 Although there has been success in the
prevention of MAS in animal models,
there are no data to support this therapy
in humans.
 Moreover, the likely
maternal and neonatal complications
would preclude its use .
 Intrapartum/postpartu
m management

1. Oropharyngeal suctioning
2. Physical manoeuvres
 Oropharyngeal suctioning
Suction of the oropharynx
and nasopharynx before
delivery of the shoulders and
trunk is a
well-established practice that
has been used since the 1970s.
Oropharyngeal suctioning
It seems reasonable that
suctioning in this way would
minimize the amount of
meconium in the upper airway
and thus reduce
the amount aspirated
during the onset of
respiration.
Oropharyngeal suctioning

The evidence relating to routine

suctioning of the oropharynx as a
preventative measure is conflicting.
What is clear, is that meticulous
cleaning of the upper airway after
delivery is beneficial in reducing MAS

EVIDENCE l a
Physical manoeuvres
It has been suggested that
MAS may be prevented
if the infant is
prevented from
breathing after delivery.
 Physical manoeuvres
 Methods advocated include:
 Thoracic compression, in which the
thoracic cage of the infant is compressed
by a healthcare professional in order to
prevent respiration and subsequent
aspiration of the contents of the upper
airway, and
 Cricoid pressure, in which external
pressure is applied to the cricoid, thus
preventing aspiration.
 Physical manoeuvres
Itis suggested that if used, these
interventions be continued until
a second resuscitator
undertakes oral and/or
endotracheal suctioning.
There is no evidence supporting the
use of either of these methods in
preventing MAS.
Physical manoeuvres
In fact, both
Thoracic compression
and Cricoid
pressure are
potentially dangerous
and cannot be recommended
EVIDENCE IV
 Postnatal
intervention
Intratracheal
suctioning
 Intratracheal suctioning

Untilrelatively recently,
all infants with meconium-
stained amniotic fluid underwent
endotracheal intubation
and suction,
as this was known to reduce
the incidence of MAS.
Intratracheal suctioning
More recently, evidence
has suggested a
change in practice
depending on whether or
not an infant is deemed
vigorous.
Intratracheal suctioning
A recent meta-analysis
suggests that
routine intubation of vigorous
term infants in order to
aspirate the lungs should be
abandoned
EVIDENCE l a
Intratracheal suctioning

 Suctioning of the oropharynx may

be beneficial, but endotracheal
suctioning should be reserved for:
 Depressed or
 Non-vigorous infants or
 Those who deteriorate following
initial assessment.
 Aspiration of gastric
contents
 Aspiration of gastric contents to
remove swallowed meconium is still
done in many centers.
 The passage of an orogastric tube is
likely to cause apnoea and/or
bradycardia and is potentially
harmful.
This practice should be
EVIDENCE
abandoned IV
 Saline lavage
 Saline lavage is used in order to loosen
meconium.
 Saline lavage is potentially harmful,
as saline will displace endogenous
surfactant, which could in turn
worsen the respiratory illness.
 In cases where saline lavage has been
used, infants developed respiratory
distress secondary to 'wet lung'.
 DELIVERY ROOM MANAGEMENT OF
INFANTS BORN WITH MECONIUM-STAINED
LIQUOR

Itis important that a

person experienced in
neonatal resuscitation
attends the delivery of all
infants in whom
thick meconium-
stained liquor is noted,
particularly if accompanied by
suspected fetal compromise.
 DELIVERY ROOM MANAGEMENT OF
INFANTS BORN WITH MECONIUM-
STAINED LIQUOR
 The Neonatal Resuscitation Program of the
American Academy of Pediatrics incorporates
guidelines for the management of these
infants
 If an infant is vigorous after delivery:
3. No tracheal suctioning should be undertaken,
4. Secretions should be cleared from the mouth
and nose using a wide-bore suction catheter,
5. Routine care should be given.
DELIVERY ROOM MANAGEMENT OF INFANTS
BORN WITH MECONIUM-STAINED LIQUOR

 However, if an infant is not vigorous

afterbirth (defined as :
 depressed respirations,
 decreased muscle tone and/or

 heart rate < 100 beats per minute):

 Direct endotracheal suctioning should
be undertaken as soon as possible,
 Suction should be applied for no more
DELIVERY ROOM MANAGEMENT OF INFANTS
BORN WITH MECONIUM-STAINED LIQUOR

 If meconium is aspirated from below the

cords, the infant should be reintubated and
the process repeated,

 Unless the infant has a profound

bradycardia, in which case:
 Resuscitation should proceed with
intermittent positive pressure ventilation
(IPPV) without suctioning,
 Further suctioning can be attempted at
a later stage.
 DELIVERY ROOM MANAGEMENT OF
INFANTS BORN WITH MECONIUM-STAINED
LIQUOR

 If after the first suctioning

no meconium is aspirated :

2. No further suctioning should be

attempted and
3. The infant should be resuscitated
using IPPV via an endotracheal tube.
 IS MENONIUM PRESENT
NO YES

SUCTION MOUTH,NOSE AND POSTERIOR

PHARYNX AFTER DELIVERY OF HEAD
BUT BEFORE DELIVERY OF SHOULDERS

IS THE BABY
?VIGOROUS
YES NO

CONTINUE WITH RESUSCITATION SUCTION

CLEAR MOUTH AND NOSE FROM MOUTH AND
SECRETIONS TRACHEA
 DRY,STIMULATE AND REPOSITION
 GIVE OXYGEN AS NECESSARY
 KEY POINTS
Meconium-stained liquor is
associated with increased
morbidity and mortality in babies.
MAS is linked to perinatal
asphyxia.
Good neonatal resuscitation skills
reduce the incidence of MAS
 KEY POINTS

 In the prevention of MAS ,

there is no evidence supporting
the use of:
 Saline lavage,
 Gastric aspiration or
 Thoracic compression
 KEY POINTS

The evidence relating to

routine suctioning of the
oropharynx as a preventative
measure is conflicting.
Intratracheal suctioning
should be reserved for the
non-vigorous baby.