MECONIUM STAINED AMNIOTIC FLUID

DELIVERY.
TO INTUBATE OR NOT ?
Dr Rhishikesh Thakre
DM(Neo),MD(Ped),DNB,FCPS,DcH.
INTRODUCTION :
Meconium aspiration syndrome ( MAS ) remains one of the most common
causes of neonatal respiratory distress. Meconium is more potent and toxic
than we previously have appreciated. The vicious cycle of hypoxemia,
shunting, acidosis and pulmonary hypertension is frequently associated with
MAS and may be difficult or impossible to treat successfully. Therefore the
aim of intervention in the delivery room should be directed to reduce the
incidence and severity of meconium aspiration. On the basis of evidence from
non randomized studies, it has been recommended that all babies born
through thick meconium should have their trachea intubated so that
suctioning of their airways can be performed. With growing research there is
ongoing debate concerning universal versus selective intratracheal suctioning
in MSAF deliveries.
This article reviews the current evidence for babies born through meconium
stained amniotic fluid and their need for intubation for suctioning the airways.
UNIVERSAL INTRATRACHEAL SUCTIONING :

Intubation of the treacheas of meconium stained babies at birth has been

advocated as a means of preventing or ameliorating severe meconium aspiration
syndrome based on three non-randomized studies. The rationale was careful
aspiration of the airway at birth reduces both the incidence and severity of
meconium aspiration syndrome.
These studies 1,2,3. have suggested that when thick meconium staining has
occurred the obstetrician should suck out the mouth as the head crowns, using
either a suction catheter or a bulb suction. Gregory et al1 found that 56% of
meconium stained infants had meconium in the trachea and in 10% there was
meconium below the cords despite it being absent from the mouth or pharynx.
1.Gregory GA, Gooding CA, Phills RH, et al Meconium aspiration in infants: a
prospective study. J Pediatr 85: 848-852,1974.
2.Ting P, Brady JP. Tracheal suction in meconium aspiration. Obstet Gynecol 122
: 767-771,1975.
3.Carson BS, Losey KW, Bowes WA et al. Combined pediatric and obstetric
approaches to prevent meconium aspiration syndrome. Am J Obst Gynec 126:
712-715,1976.


All recent reports concerning the role of endotracheal intubation in MSAF
babies have found a substantial proportion of infants who developed MAS (26% 96%) had not been intubated and suctioned in the delivery room .4,5,6,7,8,9.
4.Usta IM, Mercer BM, Aswad NK et al : The Impact of policy of amnoinfusion of
meconium stained ammiotic fluid. Obstet Gynecol 85: 237, 1995.
5. Bhutta JA, Jalil S : Meconium aspiration syndrome : the role of resuscitation
and tracheal suction in prevention. Asia Oceania J Obstet Gynecol 18:13; 1992.
6.Chistly AL, Alvi Y, Iftikhar M et al : Meconium aspiration in neonate combined
obstetric and pediatric intervention improves outcome. J Pakistan Med Assoc 46:
104, 1996.
7.Erekkola R, Kero P, Sucbhonen Polvi H et al : Meconium aspiration syndrome.
Ann Chir Gynecol 83: 106, 1994.
8.Halliday HL, Speer CP, Roberton B, et al : Treatment of severe meconium
aspiration syndrome with porcine surfactant . Eur J Pediatr 155: 1047, 1996.
9.Manickam D : A retrospective review of tracheal suction at birth in neonates
with meconium aspiration syndrome. Med J Malaysia 47; 60, 1992.

The current guidelines of the American Academy of Pediatrics and

American Heart Association recommend intubation of all infants born through
moderately thick or thick consistency MSAF10.
10.Committee on neonatal ventilation meconium / chest compression. Guidelines
proposed at the 1992 National Conference on Cardiopulmonary Resuscitation and
Emergency Cardiac Care; Dallas 1992.JAMA 268; 2276, 1992.
SELECTIVE INTRATRACHEAL SUCTIONING :

Several authors11,12,13 have retrospectively reviewed delivery room

management in their institutions and concluded that a selective approach to
intubation, generally restricted to depressed infants is justified.
11.Gupta V, Bhatia BD, Mishra OP. Meconium stained amniotic fluid : Antenatal,
Intrapartum and neonatal attributes. Ind Ped 33: 293; 1996.
12.Peng TCC, Gutcer CK, VanDorsten JP. A selective aggressive approach to
neonate exposed to meconium stained ammotic fluid.Am J Obst Gynecol 175: 296,
1996.
13.Yoder BA : Meconium Stained amniotic fluid and respiratory complications.
Impact of selective tracheal suction. Obstet Gynecol 83; 77: 1994.

Linder et al 14 (1988) studied 572 meconium stained babies which were

divided into intervention group and control group. Suction of the babys mouth
and nose was performed while the head was on perineum in all. Half of the team

of pediatricians who participated in the study were to intubate and suction all
MSAF babies during their attendance at birth whilst the other half was instructed
to restrain from doing so. There were no respiratory complications in the
conservatively managed meconium stained infants born at term.
14.Linder N, Aramda JA Tsur M et al : Need for endotracheal intubation and
suction in meconium stained neonate. J Pediatr 1988; 112: 613-615

Daga et al 15 examined the outcome of 49 babies born with thick

meconium staining of the amniotic fluid. These were randomly allocated to either
oropharyngeal suction or combined oropharyngeal suction and tracheal suction.
The outcomes studied were pneumothorax, convulsions, HIE, duration of oxygen
administration and mortality. Three babies developed pneumothorax requiring
intercostal drainage, one in the tracheal suction group and two in oropharyrngeal
suction group.
15.Daga SK, Dave K, Mehta V et al : Tracheal suction in meconium stained
infants : a randomized controlled study. J trop Pediatr 1994; 40: 198-210.

Liu 16 (1998) studied whether intubation of the low risk newborn through
meconium affects the incidence of respiratory symptoms or not. 2 of the 77 infants
in the intubation group developed respiratory symptoms and one of these needed
oxygen compared to 1 of 92 infants in the non intubated group who developed
symptoms but did not need oxygen.
16.Liu WF. Delivery room intubation of thin meconium in the low risk newborn :
a clinical trial. Paediatr Res 1998; 43: 182A

Wiswell et al 17(2000) studied the delivery room management of the

apparently vigorous meconium stained neonate in a multicentre, international
collaboration trial involving 1051 infants. 34 of 7051 infants in the intubation
group developed meconium aspiration syndrome compared to 28 of 1043 in the
expectant management group. There were no significant differenes between
groups in the occurrence of MAS or in the development of other respiratory
disorders. They concluded Compared with expectant management intubation and
suctioning of the apparently vigorous meconium stained infant does not result in a
decreased incidence of MAS or other respiratory disorders. Complications of
intubation are infrequent and short lived.
17.Wiswell JE, Gammon CM, Jacol J et al ; Delivery room management of the
apparently vigorous meconium stained neonate. Results of the multicentre
international collaborative trial. Pediatric Vol 105, No l, Jan 2000, 1-7.
Meta-analysis of these studies does not support routine use of endotracheal
intubation at birth in vigorous meconium stained babies.

DISCUSSION
Meconium first appears in the fetal ileum between 10 and 16 weeks of gestation as
a viscous, green liquid composed of gastrointestinal secretions, cellular debris,
bile and panrcreatic fluid, mucous, blood, lanugo, and vernix. Meconium is
approximately 72% to 80% water. MSAF rarely occurs before 38 weeks of
gestation. The increased incidence of MSAF with advancing gestational age
probably reflects the maturation of peristalsis in the fetal intestine. Intestinal
parasympathetic innervention and myelination also increase throughout gestation
and may play a role in the amplified passage of meconium in late gestation. Most
infants with MSAF do not have lower Apgar scores, more acidosis or clinical
illness than infants born with clear amniotic fluid. Perinatal morbidity is increased
in newborns with abnormal fetal heart rate patterns in the intrapartum period.
Before the late 1970s it was thought that aspiration of amniotic fluid and
meconium occurred during the first few breaths after delivery. Meconium
aspiration syndrome continues to occur in those who are adequately suctioned in
the delivery room indicating that in some infants, especially those with asphyxia,
in-utero aspiration takes place. Clinically fetal lung fluid flows outward from the
lungs into the amniotic sac. However studies with radioopaque contrast and Cr
labelled erythrocytes injected into the amniotic sac demonstrated that some
amniotic fluid enters the fetal lung in the nonasphyxiated human fetus. Gasping
associated with inhalation of amniotic fluid or meconium occurs in fetal lambs,
rhesus monkeys, and humans in response to fetal asphyxia induced by
compression of the umbilical cord or aorta.
FETAL GASPING MAY BE A CRITICAL FACTOR IN THE ENTRY OF
MECONIUM INTO THE LUNG BEFORE BIRTH. ANTENATAL DIAGNOSIS
AND TREATMENT OF ASPHYXIA IS CRITICAL FOR PREVENTION OF
MAS.
Clinical studies support the use of intrapartum amnioinfusion, particularly in cases
of oligohydramnios to decrease the rate of emergency cesarean section as well as
to decrease morbidity related to MAS.
Routine oropharyngeal suctioning before delivery of the infants shoulders has
long played an important role in preventing MAS.
However following additional methods have been tried in an effort to prevent
MAS.
1.
Cricoid pressure involves applying pressure to the infants airway to
prevent in intratracheal meconium from descending into the lungs.
2.
Epiglotic blockage entails insertion of one or two fingers into infants
airway to manually close the epiglottis and block the entry of meconium.
3.
Thoracic compression consists of encircling the childs chest with ones
hands and applying pressure before endotracheal cleansing .

All these are potentially dangerous and should be abandoned.

There is ongoing debate concerning universal versus selective intratracheal
suctioning in meconium stained infants .With growing body of knowledge and our
understanding, it is now clear that the management of MSAF babies is not decided
by the consistency of meconium (thick or thin ) as was previously thought, but by
the state of the neonate.
If the neonate born through MSAF is depressed at birth, irrespective of the
consistency of meconium he in addition to the oropharyngeal suction at the
perineum warrants intubation for intratracheal suctioning .Otherwise a vigorous
neonate born through MSAF should not undergo intubation irrespective of the
meconium consistency.
With the meta-analysis of trials it is now clear that the outcome of babies
born though MSAF at term and who are vigorous is not different in the intubated
versus the conservatively managed group in terms of mortality, meconium
aspiration syndrome, other respiratory symptoms or disorders, pneumothorax,
oxygen need, stridor, HIE or convulsions
ROUTINE ENDOTRACHEAL INTUBATION AT BIRTH IN VIGOROUS
TERM MECONIUM STAIED BABIES HAS NOT BEEN SHOWN TO BE
BENEFECIAL AND SHOULD BE ABONDONED.
PRACTICAL POINTS :
1.
Passage of meconium is physiological in breech deliveries and postdated
babies, but would be considered pathological any time if the fetal heart rate
monitoring is associated with non reassuring fetal heart rate pattern.
2.
Passage of meconium is extremely rare in preterms and its presence
should consider diagnosis of listeria sepsis.
3.
Majority of MSAF babies have uneventful course unless complicated by
abnormal fetal heart rate patterns.
4.
Yellow meconium is usually old, while green meconium suggests a more
recent insult.
5.
The indication for intubation in MSAF babies is only for those who are
depressed at birth irrespective of the consistency of meconium.
6.
For infants requiring endotracheal suctioning, vigorous stimulation and
drying maneuvers are delayed until intubation is performed to avoid initiation of
respiration. After clearance of the airway usual steps of resuscitation are
performed.
7.
Bag and mask ventilation is contraindicated in MSAF babies who are
depressed at birth and intubation for intra tracheal suctioning takes precedence for
airway clearance.
8.
To date there are no data verifying the efficacy of chest physiotherapy
either in preventing MAS or in treating the disorder.

9.
To date there have been no prospective randomized controlled trials
assessing the potential benefits of cesarean versus vaginal delivery in preventing
MAS.
10.
Negative pressure during suctioning of airway should not exceed 120mm of Hg. It should be applied continously and not intermittently for optimal
retrieval.
11.
An intriguing therapy is that of dilute surfactant lavage which has been
found to be beneficial in human infants with established MAS.
PROTOCOL FOR MANAGEMENT OF MSAF BABIES
MSAF baby.
Suction oropharynx at perineum

Active Depressed
No ET
Intubation
-SKIP INITIAL STEPS OF STABILIZATION.
(DRYING/STIMULATION)
-INTUBATE THE BABY, SINGLETIME.
-SUCTION AIRWAY WITH CONTINOUS PRESSURE NOT
EXCEEDING 120 mm of Hg TO RETREIVE AS MUCH
MECONLUM AS POSSIBLE
-APPLY SECOND INTERVAL OF NEGATIVE PRESSURE IF
MECONIUM IS STILL RETRIEVED.
- ASSESS FOR BREATHING AND HEART RATE TO DECIDE
FURTHER RESUSCITATION.
- DO NOT BAG THE BABY UNLESS AIRWAY IS CLEARED.
-ATTEMPTS AT INTUBATION SHOULD NOT TAKE MORE
THAN 20 SECONDS.
-SUPPLEMENT WITH OXYGEN AT TIME OF INTUBATION.
-DO NOT OVERLOOK THE INFANTS GENERAL CONDITION.
-IF UNSUCCESSFUL THE CHILDS CONDITION SHOULD BE ASSESSED
AND MANEUVERS SUCH AS STIMULATION AND POSITIVE PRESSURE
VENTILATION BE UNDERTAKEN IF NEEDED.

Dos
1.

Oropharyngeal suction at perineum in all MSAF babies.

2.
Intraparttum fetal heart rate monitoring in all MSAF
babies.
3.
Anticipate passage of meconium or MAS during birth of
all IUGR babies in the labor room.
4.
Skillfull resuscitation and assistance are keypoints in
management.
5.
Do intubate neonates born through MSAF who are
depressed at birth irrespective of consistency of meconium.
6.
Do intubate neonates born through MSAF who are
depressed at birth irrespective of consistency of meconium.
7.
Do intubate neonates born through MSAF who are
depressed at
birth irrespective of consistency of meconium.
8.
Do intubate neonates born through MSAF who are
depressed at
birth irrespective of consistency of meconium.

Donts
1.
Do not go by the consistency of meconium in
management for intubation.
2.
Do not apply cricoid pressure, chest compression or
occlude airway by fingers to prevent initation of respiration in
MSAF babies.
3. Do not ignore the general condition of baby during
intubation.

Conclusions :
1.
ROUTINE INTUBATION OF VIGOROUS TERM MECONIUM
STAINED BABIES TO ASPIRATE THE LUNGS SHOULD BE ABANDONED.
2.
SUCTIONING OF THE OROPHARYNX MAY BE BENEFICIAL BUT
ENDOTRACHEAL INTUBATION SHOULD BE RESERVED FOR
DEPRESSED OR NON VIGOROUS INFANTS.

Email : rhishikeshthakre@hotmail.com
References
*Cleary GM, Wiswell TE: Meconium Stained amictic fluid and the meconium
aspiration syndrome : An Update. Pediatr Clin North Am 45: 511, 1998.