How to manage meconium stained liquor during labor?

Management of Meconium-Stained Liquor During Labour

For vigorous infants born through meconium-stained amniotic fluid, allow the baby to stay with the mother for routine newborn care without intervention; for nonvigorous infants, proceed immediately with positive pressure ventilation rather than performing routine intubation and tracheal suctioning. 1, 2

Preparation and Anticipation

• Ensure a resuscitation team skilled in tracheal intubation is present at delivery when meconium-stained amniotic fluid is identified, as these infants have increased risk of requiring resuscitation 1
• Prepare equipment for potential advanced resuscitation, including intubation supplies, though routine use is not indicated 1
• Meconium-stained amniotic fluid occurs in 5-15% of all deliveries, with approximately 3-5% of these infants developing meconium aspiration syndrome 1, 2

Assessment-Based Management Algorithm

For Vigorous Infants (Good Respiratory Effort, Good Muscle Tone, Heart Rate >100/min)

• Allow the infant to remain with the mother for initial newborn care 1
• Gentle clearing of meconium from mouth and nose with bulb syringe may be performed if necessary 1
• Do not perform routine oropharyngeal or tracheal suctioning, as vigorous infants do not benefit from this intervention and it carries risks of bradycardia and delayed ventilation 1

For Nonvigorous Infants (Poor Muscle Tone, Inadequate Respiratory Effort, Heart Rate <100/min)

• Initiate immediate positive pressure ventilation without performing routine laryngoscopy or tracheal suctioning 1
• Begin with bag-mask ventilation or T-piece resuscitator with positive end-expiratory pressure (PEEP) to establish functional residual capacity 2
• Use pulse oximetry to guide oxygen therapy, starting with room air for term infants and titrating based on preductal oxygen saturation 1, 2
• Target oxygen saturation should approximate the interquartile range of healthy term infants (starting around 60% at birth, reaching 90% by 10 minutes) 1, 2

When to Consider Intubation and Suctioning

Reserve intubation for specific circumstances only 1, 2:

• Failure to respond to adequate bag-mask positive pressure ventilation
• Evidence of airway obstruction from meconium (rare)
• Need for prolonged mechanical ventilation due to persistent severe respiratory failure
• If attempted intubation is prolonged and unsuccessful, return to bag-mask ventilation, particularly if persistent bradycardia develops 1

Evidence Context and Paradigm Shift

The 2020 International Consensus on Cardiopulmonary Resuscitation represents a significant departure from historical practice 1. For over 25 years, routine tracheal suctioning was standard practice, but evidence from randomized controlled trials involving 680 newborns demonstrated no benefit in survival to hospital discharge, neurodevelopmental outcomes, or reduction in meconium aspiration syndrome 1. The task force weighted harm avoidance heavily, as laryngoscopy and suctioning delay ventilation—the most critical intervention for nonvigorous infants 1, 2.

Critical Pitfalls to Avoid

• Delaying positive pressure ventilation to perform suctioning leads to prolonged hypoxia and worse outcomes 2, 3
• Routine suctioning procedures can cause vagal-induced bradycardia, deterioration of pulmonary compliance, reduced cerebral blood flow velocity, and increased infection risk 1, 2
• Unnecessary suctioning of the nasopharynx should be avoided even when amniotic fluid is clear, as it provides no benefit and carries risks 1
• Do not perform cesarean section solely for the presence of meconium-stained amniotic fluid, as this increases maternal morbidity without providing neonatal benefit 3

Escalation Criteria

If heart rate remains <60 beats per minute despite adequate ventilation 2:

• Verify effective ventilation technique (chest rise, bilateral breath sounds)
• Consider increasing oxygen concentration
• Initiate chest compressions at 3:1 ratio with continued ventilation
• Prepare for advanced resuscitation measures including medications if needed

Monitoring and Documentation

• Use continuous pulse oximetry when resuscitation is anticipated or positive pressure ventilation is administered 1
• Attach the pulse oximetry probe to a preductal location (right upper extremity) before connecting to the instrument for fastest signal acquisition 1
• Document infant's vigor status at birth (respiratory effort, muscle tone, heart rate) to guide management decisions 1