Reminders from Karen Strange's class: Neonatal
Resuscitation class with Karen Strange, (And you get 11.0
CEUs for the online course and 5 (BRN) or 5.5 (MEAC) CEUs for the
live class.):
Color, consistency, and amount of meconium do not matter. These
characteristics are all completely irrelevant to the clinical
picture. Meconium is always a warning flag and a risk factor.
Meconium typically results from prolonged hypoxia. Inhalation of
meconium happens from gasping in utero, more than from the first
breath.
Even with non-vigorous babies and meconium, you don't need to
suction before PPV.
Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI.
Lancet. 2004 Aug 14-20;364(9434):597-602.
"Interpretation Routine intrapartum oropharyngeal and
nasopharyngeal
suctioning of term-gestation infants born through MSAF does not
prevent
MAS. Consideration should be given to revision of present
recommendations."
Recommendations
for
management of the child born through meconium-stained amniotic
fluid.
[Free
extract]
Keenan WJ.
Pediatrics. 2004 Jan;113(1 Pt 1):133-4.
Lead study author Dr. Edgardo Szyld, of the Hospital Diego Paroissien in Buenos Aires, Argentina, believes that "we should consider revising the current recommendations" of suctioning these infants during delivery.
A total of 2514 infants with meconium-stained amniotic fluid were randomized to oro- and nasopharynx suctioning or to no suctioning just before delivery of the shoulders. Of those infants suctioned, 3.5% developed meconium aspiration syndrome (MAS), as did 3.6% of those not suctioned. Five newborns died in the suctioned group, and three in the group not suctioned.
No differences between the two groups were observed in the frequency of thick meconium, C-sections or need for resuscitation.
A single study back in the 1970s was the foundation for the recommendation of suctioning when meconium staining is evident, Dr. Szyld said. Recommendations to suction, set forth by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) makes the practice "widespread--and it's done around the world."
However, he said, the current study shows that suctioning before the shoulders are delivered does not prevent meconium aspiration or its complications.
"The data presented by Dr. Szyld's team provides convincing evidence that suctioning probably does not" alter outcomes, Dr. Laura E. Riley, chair of ACOG's Committee on Obstetric Practice, told Reuters Health.
"Because suctioning has been beaten into clinicians for so many years, I'm not sure the current findings are really going to change clinical practice," Dr. Riley said. "Still, I think the findings may provide some reassurance to clinicians that when meconium aspiration syndrome occurs it probably didn't have anything to do with how adequately the infant was suctioned."
While Dr. Riley believes that the researchers succeeded in showing that suctioning is probably unnecessary, she said they didn't address "whether suctioning may actually have harmful effects, such as causing facial trauma."
Delivery
room
management of the apparently vigorous meconium-stained neonate:
results
of the multicenter, international collaborative trial.
Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K,
Schutzman
D, Cleary GM, Filipov P, Kurlat I, Caballero
CL, Abassi S, Sprague D, Oltorf C, Padula M
Pediatrics 2000 Jan;105(1 Pt 1):1-7
Conclusions. 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.
Amnioinfusion
May
Not Be Helpful for Meconium Staining CME
[Medscape
registration is free]
Amnioinfusion
for
the prevention of the meconium aspiration syndrome.
Fraser WD, Hofmeyr J, Lede R, Faron G, Alexander S, Goffinet F,
Ohlsson
A, Goulet C, Turcot-Lemay L, Prendiville W, Marcoux S, Laperriere
L, Roy
C, Petrou S, Xu HR, Wei B; Amnioinfusion Trial Group.
N Engl J Med. 2005 Sep 1;353(9):909-17.
CONCLUSIONS: For women in labor who have thick meconium staining
of
the amniotic fluid, amnioinfusion did not reduce the risk of
moderate or
severe meconium aspiration syndrome, perinatal death, or other
major maternal
or neonatal disorders. Copyright 2005 Massachusetts Medical
Society.
About the Neonatal Resuscitation Program (NRP 2000) from the American Academy of Pediatrics
International
Guidelines
for Neonatal Resuscitation: An Excerpt From the Guidelines 2000
- Of particular note is the change in guidelines for meconium - "
Meconium-stained
amniotic fluid: If the newly born infant has absent or depressed
respirations,
heart rate <100 beats per minute (bpm), or poor muscle tone,
direct
tracheal suctioning should be performed to remove meconium from
the airway.
" and "There is evidence that tracheal suctioning of the
vigorous
infant with meconium-stained fluid does not improve outcome and
may cause
complications"
NPR Instructor Update Vol. 7 . No. 3 . October 1998 - Delivery Room Management of the Apparently Vigorous Meconium-Stained Neonate: Results of the Multicenter, International Collaborative Trial [It's also available from the AAP web site.]
Intubation of the apparently vigorous meconium-stained neonate
does
not result in a decreased incidence of MAS or other respiratory
distress
compared to expectant management.
Wiswell, T. (1998). Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. NRP Instructor Update 7(3):1-3. (Oct)
They looked at 2094 vigorous babies born at 37 weeks or more with mec stained fluid (any consistency - as it worked out, there were 43% with thin mec, 29% moderately thick, and 28% thick, similar in both groups). Babies were randomized to be intubated or not. There were no significant differences in the rate of occurrence of MAS (3.2% of the intubation group, and 2.7% of the expectant management group). 3.8% of the intubated babies had complications related to the procedure, all transient (bradycardia, hoarseness/stridor, laryngospasm, apnea, bleeding at the vocal cords, and cyanosis). One minute APGARs were significantly lower in the intubated group due to the intubation procedure. Approximately 7% of infants in both groups subsequently developed respiratory distress. The thicker the mec, the more likely the development of distress.
What was most interesting to me was their relaxed definition of
vigorous:
HR >100, any spontaneous respirations, and "reasonable" tone (I
took that
to mean a one on the APGAR scoring for tone - some flexion, even
without
movement).
Significance
of
meconium staining of the amniotic fluid.
Kariniemi V, Harrela M.
J Perinat Med 1990;18(5):345-9
The study was conducted to determine the significance of meconium staining and more specifically its association with fetal heart rate patterns. Five hundred and one patients in labor were examined, 106 of whom had meconium stained amniotic fluid. A multivariate analysis of the data was performed by logistic regression analysis using meconium staining as the dependent variable. The determinants of meconium in the amniotic fluid were gestational age, base deficit, calcified placenta, late decelerations and placental weight. The following variables had no effect on the occurrence of meconium: maternal age, type of risk, parity, fetal sex, duration of labor, duration of the second stage of labor, entanglement of the umbilical cord, FHR variability, variable decelerations, oxytocin usage, type of anesthesia, maternal smoking and alcohol consumption habits. In conclusion, meconium in the amniotic fluid seems to be associated with placental rather than with umbilical insufficiency.
From a doula's letter at OnHealth.com:
I'm a doula, providing professional labor support, typically for
first-time
moms. A lot of my clients go somewhat past their due date,
which
is normal for first babies, but this also tends to increase the
incidence
of meconium that I see, since it's more commmon in postdates
babies.
My question concerns routine procedures for babies born with
meconium,
which recently came up on a doula list. The
recommendations
from the American Academy of Pediatricians and the
NPR
Instructor Update for 1998 both say that research now shows
that the
deep suctioning/lavage of a vigorous baby's lungs causes more
problems
than it prevents. Yet the hospitals where I work are still
following
the old protocols. When can we expect their practices to catch up
with
research? It's just awful to have that newborn taken right
away from
the mother and "worked on" for ten minutes with tubes down the
throat and
pounding on the back. It's bad enough when it's necessary,
but it's
truly horrible when you know the research says it's no longer
necessary.
The Medscape summary of the issue at: "Aggressive Management of
Vigorous
Meconium-Stained Neonates Unnecessary "
(http://pediatrics.medscape.com/reuters/prof/2000/01/01.11/cl01110a.html)
implies
that these changes may not show up in hospital protocols until
around October, 2000.
Any hints on what parents can do to ensure that their baby is
treated
according to the most recent research and protected from
unnecessary and
dangerous intubation?
So, why does meconium cause problems, after all? Over the years, I've heard a few different explanations - the meconium physically coats the lungs and prevents the transfer of oxygen; the meconium is an irritant that causes a chemical pneumonia.
Here's an article that explores the issue:
Morphology
and
function of pulmonary surfactant inhibited by meconium.
Bae CW, Takahashi A, Chida S, Sasaki M
Pediatr Res 1998 Aug;44(2):187-91
The pathophysiology of neonatal meconium aspiration syndrome (MAS) is related to mechanical obstruction of the airways and to chemical pneumonitis. It has also been suggested that meconium causes inhibition of surfactant function. . . . These results suggest that meconium inhibits surfactant function by altering surfactant morphology. Our morphologic and functional findings support the new concept that surfactant inhibition may play a role in the pathophysiology of MAS.
Meconium
Aspiration
Syndrome from picuBOOK-
an on-line resource for pediatric critical care
Abstract of Study that Meconium Aspiration
Syndrome
not Caused by Meconium
From A Guide to Effective Care in Pregnancy & Childbirth
by Enkin, Keirse, Renfrew and Neilson:
For infants who have passed meconium before birth, suctioning the nostrils, mouth and pharynx before delivery of the chest may prevent postnatal aspiration of meconium in the pharynx. This procedure is sufficiently safe to be recommended even though its effectiveness in preventing severe meconium aspiration is unproven.Notes - The pharynx is the back of the throat.Tracheal suctioning for infants who passed meconium before birth is a more hazardous procedure which has been introduced into practice without testing in randomized trials. The apparently low rate of morbidity following intubation reported by very experienced resuscitators is not likely to be achieved by persons who only occasionally perform the procedure. The potential hazards of intubation include trauma, hypoxia, and bradycardia. The increase in blood pressure that regularly occurs during intubation may increase the risk of intracranial hemorrhage in preterm infants. Severe pulmonary artery vasospasm may occur in babies with pre-existing pulmonary artery hypertension, particularly in meconium-stained babies. Other risks include cross-contamination of bacteria or viral infection between newborns and caregivers.
Because of these risks, and because there are no demonstrated benefits, it would seem unwise to perform tracheal intubation for infants who are not depressed simply because they have been born following meconium passage in utero. Careful tracheal suctioning should be carried out only for infants who are depressed at birth (heart rate less than 80-100 beats/minute at birth) and have meconium in the pharynx.
If the baby looked pink, conscious and alert when born, it's
likely
the heart rate was completely normal, and taking the baby to the
warmer
to do tracheal suctioning is not recommended because the medical
risks
outweigh the benefits. When you add in the immediate separation of
the
newborn from the mother, I'd say the overall risks far outweigh
the benefits.
True meconium aspiration is often a prenatal/prelabour event. There are several documented cases where babies were born with MAS after elective sections. Both the meconium and the aspiration are usually related to hypoxic events in utero. The baby, if subjected to severe enough an hypoxic insult in utero, will gasp (sort of a last-ditch reflexive effort to get oxygen) and will then get the meconium down below the vocal cords.
This is why there is some question as to how useful it is to suction babies on the perineum with mec (although everyone I work with still does it) with respect to preventing MAS. And why many babies, despite lots of mec at birth, will be vigorous with no problems.
The worst MAS case I encountered was in my labour-support, premidwifery days. The baby crashed in latent labour (about 3-4 cm, contrx q 10 and mild), with a sustained bradycardia (for at least five minutes) at 50. (Fortunately, I had already heard one significant decel at home, which was why we were in the hospital so early.) When the membranes were ruptured by the (idiot) resident who thought she should put on a scalp clip, the fluid was basically thick, old mec. The OB ran in, tore a large strip off the resident, did the fastest informed consent for a section I've ever seen, and they had the baby out in 10 minutes. He'd aspirated, was in the NICU for about a week and a half, ended up okay.
I, on the other hand, sprouted many more grey hairs and quickly
understood
the responsibility I was taking on doing this work!
I suspected that "suctioning for meconium" wasn't necessary when
I began
working with docs trained in Germany, Russia, and Japan, and the
UK midwives.
They rolled their eyes and went along with our "Yank" protocol,
but thought
it wasn't necessary. Then several years ago I heard a
controversial
OB doc, Vern Katz, do a persuasive presentation on the idea that
severe
MAS occurs in utero, as evidenced by smooth muscle hypertrophy
around the
airways of deceased infants. I haven't searched the
lit but
his article shouldn't be hard to find. And you know those
tissue
changes didn't get there from poor management of mec at birth,
they were
there long before. Interesting.
Meconium
aspiration
syndrome: reflections on a murky subject.
Katz VL, Bowes WA Jr
Am J Obstet Gynecol 1992 Jan;166(1 Pt 1):171-83
Meconium-stained amniotic fluid occurs in approximately 12% of live births. In approximately one third of these infants meconium is present below the vocal cords. However, meconium aspiration syndrome develops in only 2 of every 1000 live-born infants. Ninety-five percent of infants with inhaled meconium clear the lungs spontaneously. Recent investigations have suggested that a reexamination of our assumptions about the etiology of meconium aspiration syndrome is in order. Several authors have provided evidence that support the hypothesis that it is not the inhaled meconium which produces the primary pathologic condition of meconium aspiration syndrome but rather it is fetal asphyxia that is the etiologic agent. Asphyxia in utero produces pulmonary vasospasm and hyperreactivity of the pulmonary vessels. With severe asphyxia the fetal lungs undergo pulmonary vascular damage with pulmonary hypertension. The damaged lungs are then unable to clear the meconium. In the most severe cases there is right-to-left shunting and persistent fetal circulation with subsequent fetal death. The incidence of meconium aspiration may thus be essentially unaffected by current obstetric and pediatric interventions at birth. For the asphyxiated or distressed infant we recommend suctioning at birth and tracheal intubation. In the healthy fetus observation may be sufficient.
Abstract - Equivalence of Bulb Suctioning and DeLee Suctioning for Meconium
I taught neonatal resus when I worked in the OB dept in our local
hosp.
and still get instructor update materials. One the updates I just
got said
DeLee's are no longer recommended for suctioning meconium! The
rationale
is that the tubing is too fine to be very effective on particulate
mec.
What is being recommended instead? I have tried to suction thick
mucus
or mec with a deLee and had very little success. I have had a lot
of success
by having someone hold the baby by it's feet upside down while I
suction
with a 3 oz. bulb syringe......works great. It's amazing how much
you can
get out with the help of gravity. (Of course I have only done this
with
babies who are needing help.....I am not into holding poor, sweet
newborns
upside down by their feet!)
For all of you who asked me what the NRP recommends rather than the deLee, I finally found my newsletter.
Recommendations are to use a large caliber suction device to
remove
large quantities of thick, particulate mec. They recommend a large
bore
catheter connected to wall or portable suction or a bulb syringe
to clear
mec while the head is on the perineum. After birth, the
recommendation
is use suction applied directly to an endotracheal tube and a
meconium
aspirator.
When I did hospital births, the recommendation (or at least what the local hospitals did) was deLee for light-mod. mec, and then have peds present to visualize cords and suck mechanically if thick mec was present. In the last year or so, I heard that even with thick mec, one should leave vigorous babies alone and stop trying to visualize cords if they're obviously breathing and crying.
Now, this new recommendation in which they want mechanical
suction with
large-bore catheter and straight ET tube suction - is this just
for thick
mec? Tell me that I don't have to worry about this at home with
the light-mod
mec and no evidence of fetal distress. And does this also means
that bulb
suction on the perineum for light mec is now considered adequate -
no deLee
required?
Interestingly, the newsletter didn't say much about kids that were crying. But when I was in midwifery school, I did see studies that supported leaving the baby alone who was already crying.
A bulb is considered adequate on the perineum, no deLee required.
They
say they no longer recommend them. Interestingly, they hedged on
OOH births
with things like mechanical suction and actually said their
recommendations
applied primarily to in hospital births. It doesn't sound like you
need
to change anything.
Yes, it's my understanding that bulb suction on the perineum is
adequate
for light-mod mec and no evidence of fetal distress.
To me, light meconium is thin and fluid. If it were put in a jar and held to the light it would be transparent. It is just fluid with a little green or yellowish-brown color. Moderate meconium is a little thicker, but still watery. Thick meconium is pasty and sticky, more like thin mud. Particulate meconium is anything chunky or stringy floating in the fluid.
I consider thick meconium an indicator of long-term insult to the fetus. Those babies often don't have good reserves and run into problems in labor. Amnioinfusion during labor for thinning out the mec and "cushioning" these babies inside the uterus seems to improve their outcomes. Particulate meconium is said to be riskier in terms of meconium aspiration, as those chunks can get lodged in the baby's airways and cause respiratory distress.
With any meconium I deLee suction on the perineum. With thick or
particulate
meconium I have a pediatrician present at the birth to make sure
there
isn't any meconium below the vocal cords. With moderate meconium I
use
my judgment. If I have an uneasy feeling about things or if there
have
been any decels during pushing, I have the pediatricians there for
the
birth. If the baby's looked and sounded great all along, with good
variability
and no decels, I usually won't call the pediatrician to be there.
How a homebirth midwife handles meconium is directly related to
her
experience level. This a compliment!!!!!!!! When I first started
my "practice"
meconium scared the meconium outa me! Now, I rarely transport for
meconium.................cause...........I
am better able to evaluate FHT and interpret if there is any true
difficulty
with the unborn baby. In the presence of light to moderate
meconium and
FHT's that are reactive, no significant decels, also taking into
account
where mom is in her labor, I make sure everyone at the birthing is
aware
of the possibilities, parents are fully informed and the ultimate
decision
about transport rests with them. The resus table is always set up
at any
birth. You can have a compromised baby during any birth. In the
presence
of thick meconium, the birth team is on alert for a depressed baby
and
if there is no time to transport, this assures that no one will
panic and
further compromise the infant or scare the mom during resus
efforts. The
presence of mec. and a truly sick baby are extremely rare in the
home due
to the lack of so many interventions incurred in the hospital
setting the
aggravate or even precipitate mec. because the baby is put into
stress.
The women I choose to work with during births are drug free, do
not smoke,
(with rare exception) are well nourished and very well informed.
They are
about as low risk as you can get, and yes I do realize how
fortunate and
spoiled I am to have them as clients. I am also VERY picky about
who I
chose to have as a partner for assisting at births. The best
partner works
with you like hand in glove I think it, she's already doing' it.
This is
the best safeguard you can have to ensure a smooth response to an
emergency
situation.
Several years ago I had an identical situation with a Hx. of mec.
and
with the birth I was helping with, she again had mec. We
transported and
baby came rapidly after arrival and the only complication was the
doc SCREAMING
at us cause I caught the baby...........well he said "call me when
the
head is on the perineum", and WE DID!!!!!!!!!!!!! So the next time
around
she was willing to give me a second chance IF I got my act
together about
this meconium stuff. So I read and read and read and at this
birthing,,,,,,,,,,,,,,yup
meconium. I was much better prepared and more confident about my
ability
to evaluate a true need for transport..........and all went
well..........................along
with the last four births I have done with this same family and
almost
always with mec!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I am not
foolhardy..........If
there is a need.......we GO............ and the families know I
hold veto
power in the true emergency.
Per College of Pediatrics (Neonatology?) - Visualizing the cords
was
only to be done when the baby needed resuscitation, that is, if
there was
no spontaneous cry. When I questioned him, he agreed that if I
deLee'd
the baby on the perineum and the baby cried before I could cut the
cord,
I would not cut the cord, hand the baby to the mother and there
would be
no further concern. This is whether there is light or pea soup
meconium.
In other words, like any resuscitation, intubation is used to
clear the
airway. I stopped handing the baby off for light mec at Baylor and
UT-Houston.
I only deLee'd. The neonatologist, said that the studies showed
more damage
to the baby with intubation and no decrease in mec aspiration
syndrome.
I place a gauze or some other barrier in front of the infants
face to
prevent a gush of fluids from covering the face but have found
that more
babies have more fluids etc. accumulated in the nasopharynx after
the HK
position and MAY need to be suctioned.
We use a wash cloth for HK's and OP's. The wash cloth provides a
much
thicker and more absorbent barrier for hind waters. I agree with
the fact
that those babies still have a greater chance of having to be
suctioned,
but we usually don't do it on the perineum.
Speaking of suctioning.... One of the local hospitals has new
protocol
for meconium for babies with normal fht's. At delivery the baby is
suctioned
on the perineum, delivered, then stimulated. If the baby starts
crying
they do not intubate regardless of the amount of meconium.
Basically the
midwives are just placing the baby up to the mom and stimulating
the baby
to cry. I reckon someone there finally read one of Dr.
Mendelsohn's books.
I am a 20-years-in-practice mostly hospital midwife with a
question
for home birth experts: How do you decide how to "manage"
meconium
at home when NALS says the choice to do endotracheal suctioning in
moderate
to heavy mec depends on the condition of the baby at birth?
It seems
like most midwives wait for spontaneous rupture (which could be
too late
to make a transport decision), and just keep everyone at
home. I
guess most home birth attendants don't "do" ET suctioning. Is
hospital
routine regarding meconium completely ridiculous? Can we get
some
data from home birth management of meconium to show this? Or
are
midwives taking unnecessary risks?
In my practice, if membranes are not ruptured, we wait for a sign
in
the fhr that tells us if the baby is having a problem with
meconium.
(or anything else, for that matter). It doesn't matter
that
I cannot visualize mec, if the FHR is normal, then we trust that
all is
OK. If FHR is abnormal, and cannot be resolved with position
changes,
whether it's mec or not, we transport unless the birth is
imminent.
If it is imminent, we're ready with syringe or delees on the
perineum and
bag and mask if necessary.
We practice fairly similarly - I pay a lot of attention to how
diluted
the mec is, and how much amniotic fluid there is, if there is
ROM.
If not, we pay attention to heart tones, and how reactive the baby
is.
I am always more attentive, if it is a postdates baby. We
are careful
in setting up for a resuscitation. We use a res-q-vac, which
is a
hand held deep suctioning device. I've had lots of mec, never a
transport
or sick baby.
I've practiced both in and out of the hospital and treat MSAF the
same
in both settings. Just look at the whole picture. Have
you
got a good FHT patttern? How about variables? That's
highly
unlikely to cause aspiration. If I'm at home I'd transport
if the
babe was persistantly tachycardic, without alot ofvariability, or
if there
are lates. And this all can be done with a doppler and some
patience.
In 19 years of practice I've only taken one lady in for
MSAF. She
was a prime with PROM, thick meconium, no labor, and a high
baseline.
This birth ended well. I've only had one case of aspiration
and that
was on a serious abruption, in a hospital birth. I think all this
suctioning
on the perineum is overrated. The vast majority of aspiration
occurs
in utero. I'm more nervous not doing the whole intubation
trip in
the hospital for all the obvious political reasons; but I stil
won't do
it unless it's called for.
The Guide To Effective Care In Pregnancy And Childbirth says:Because of these risks [trauma, hypoxia, bradycardia, increase of BP leading to increased risk of intercranial haemorrhage in preterm infants, severe pulmonary artery vasoplasm in babies with pre-existing pulmonary artery hypertension-particularly in mec-stained babies, cross-contamination of bacteria or viral infection between newborns and care givers] and because there are NO DEMONSTRATED BENEFITS, it would seem unwise to perform tracheal intubation for infants who are not depressed simply because they have been born following meconium passage in utero.
So as you can see home birth midwives are yet again ahead of the
science
and are practising more safely than the hospitals.
The studies support this -cesarean babies have "aspiration" -mec
inhaled
before birth -- has nothing to do with suctioning. My
postdates son
who was stillborn was full of mec, and he did not ever inhale at
all.
Our new state protocols don't give us a lot of room re THICK meconium.
They read we must transfer with "Amniotic fluid with thick or moderate.thick meconium and birth not imminent" -- --- This is a change from an earlier version which included "in the presence of worrisome heart-tones"
Not all midwives are statelicensed of course. I think most are still following the old OMC protocols which read like the earlier version (meconium PLUS poor heat tones, and birth not eminent).
Thick mec at the time of rupture might be at the time of birth too. As you say, no time for transport. Any attendant at a birth should know how to drain and suction a baby in order to minimise after-birth inhalation of meconium. But suctioning on the perineum doesn't help to prevent MAS due to the baby who inhaled in the womb -- so we aren't able to help those baby's after the fact.
THICK mec is not often a good thing though... Most folks would transport if there looked like time, since THICK mec is a "pretty" reliable sign of fetal distress. If they transfered it would be for possible distress -- not because of lacking ability to suction meconium.
I think most home birth attendants carry delee or other suction
devices.
Most (in this region of my state) have been through NALS. Most
feel that
deep suctioning is required in preparation for resuscing a
depressed baby
---- not for a vigorous baby.
Nearly all respondents would do one or two things before delivery of the chest, combined with one or two things after delivery.
Of these, DeLee suction of the mouth/nose on the perineum got 15 votes, bulb suction only 1, with 3 people indicating both. (I'm not sure if this means both for any one case, or use either one that happens to be available.)
After delivery, 6 said that they would DeLee the stomach, 5 of which were in combination with another post-delivery maneuver.
Only one person would bulb suction after delivery; 3 would DeLee mouth/nose, 2 of which were to be in combination with laryngoscopy.
18/20 said that they (or an assistant) would do a laryngoscopy.
Of these,
8 were suction if meconium seen at or below the cords, and 10 were
tracheal
suction regardless of what's seen.
And now for a few comments from the literature. (I don't pretend to have done a thorough review, just have a few articles that are interesting. Contrary findings in other papers are, of course, welcome.)
Bulb and DeLee catheter are equally effective at suctioning the pharynx on the perineum in terms of frequency and amount of mec seen in the trachea, risk of meconium aspiration syndrome, and mortality: Cohen-Addad et al., Journal of Perinatology.
DeLee suction works as well after delivery of the chest works as well as before. Falciglia, "Failure to prevent meconium aspiration syndrome", green journal 1988; 71:349. And Falciglia, "Does DeLee suction at the perineum prevent meconium aspiration syndrome?" gray journal 1992; 167:1243-9.
Laryngoscopy and tracheal suctioning can safely be reserved for only depressed neonates. Cunningham, "Tracheal suction and meconium: a proposed standard of care," Journal of Pediatrics, Jan 1990; 116:153-4. Also Peng et al, "A selective aggressive approach to the neonate exposed to meconium-stained amniotic fluid," gray journal 1996; 175:296-303. Seems to be confirmed indirectly by the experience of Sepkowitz, "Influence of the legal imperative and medical guidelines on the incidence and management of the meconium-stained newborn," Am J Dis Child 1987; 141:1124-7.
So, to answer my own survey, I would either bulb or DeLee suction on the perineum, or DeLee after delivery of the chest, depending on what was most readily available and could be accomplished most easily. (Slipping that DeLee in when only the head is out can be difficult.) Laryngoscopy only if the baby is depressed enough to need either bag-mask ventilation or intubation, and then suction only if intubated.
Best general review of the etiology of MAS and whether
obstetricians
can do anything to prevent it: Katz and Bowes, "Meconium
aspiration syndrome:
Reflections on a murky subject," gray journal 1992; 166:171-83.
Abstract - Equivalence of Bulb Suctioning
and
DeLee Suctioning for Meconium
I heard a grand rounds two years ago by one of the people who did
the
original study showing that suctioning on the perineum improved
outcomes.
He had done a more recent study which looked at lungs of infants
who had
died of overwhelming sepsis, mec aspiration, and other
non-infectious causes,
and did special studies on the tissue looking for signs of
infection. The
babies who died of sepsis obviously had large amounts of bacteria,
etc,
and the non-infectious causes, like heart problems, had none. The
surprising
discovery was that the mec babies had moderate signs of infection,
including
changes in the blood vessel structure which take weeks to develop.
His
theory was that the initial results were somehow entirely wrong.
He now
believes that mec is only a marker for some intrauterine infection
which
happens weeks before birth, and causes irreversible changes to the
lung
tissue. Like any other intrauterine stress it also causes
premature passage
of meconium. Unfortunately I have no references, nor do I remember
the
man's name. I keep hoping I will see something published, as it
made a
great deal of sense to me. It certainly would take the pressure
off transports
for meconium, peds present at deliveries, aggressive suctioning of
healthy
kids, etc.
He has shown that all babies who die of mec asp. have lung changes which are too chronic to be all postpartum, such as arteriolar hypertrophy. A fellow of his studied lungs of babies who died of many causes, and found low grade signs of bacterial infection in the lungs of only mec asp babies, consistent with mid pregnancy in utero infection. His theory now is that meconium is a marker for intrautero stress caused by infection, and not the cause of the problem.