26 yoF 36 weeks by dates presents to the ED in labor, and has a precipitous birth in the resus area. The infant is covered with a greenish liquid the consistency of split-pea soup.
How do you address this?
A) If the baby is vigorous, proceed with routine care. No intervention needed.
B) If the baby is depressed, prior to stimulation, generally accepted care is to intubate and perform direct tracheal suction via ETT/meconium aspirator, followed by removal of the ETT, then routine neonatal care/resuscitation PRN.
Meconium aspiration syndrome (MAS) occurs when the infant passes meconium prior to or during delivery, subsequently aspirates the material, and develops related clinical sequelae. Aspirated meconium is inflammatory, decreases surfactant, and causes direct airway obstruction, all of which can lead to decreased gas exchange, pneumonitis, pulmonary hypertension, hypoxic injury, and asphyxia.
For some time, standard care for meconium staining in any neonate was to suction the oropharynx prior to delivery of the shoulders, and then to proceed with intubation and meconium suctioning.
A RCT published in Pediatrics in 2000 randomized 2094 neonates with meconium staining who were vigorous at birth to either tracheal suctioning or expectant management. They found no significant difference in respiratory outcomes or MAS between the two groups.
A subsequent Cochrane review in 2001 concluded that there was not sufficient evidence to support routine endotracheal suctioning in vigorous meconium stained neonates.
For depressed neonates with meconium staining, standard care is to intubate and suction. This is supported by the American College of Gynecology and hesitantly by the American Academy of Pediatrics. There is not yet randomized trial data supporting or refuting this indication, and it remains an active topic in the literature. While the AAP notes that case-control studies supporting suctioning were affected by selection bias, “there is insufficient evidence to recommend a change in the current practice of performing endotracheal suctioning of nonvigorous babies.”
For the EM physician attending to a meconium stained neonate, data and consensus driven care would support expectant care for the vigorous neonate, and endotracheal suctioning of the nonvigorous neonate.
Halliday HL. Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term. Cochrane Database Syst Rev. 2001;(1)
Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 379: Management of delivery of a newborn with meconium-stained amniotic fluid. Obstet Gynecol. 2007 Sep;110(3):739.
Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon WM, Weiner GM, Wyckoff M, Zaichkin J; American Heart Association. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010 Nov;126(5):e1400- 13
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. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000;105(1 Pt 1):1–7