Most Appropriate Action During Delivery: Proceed with Standard Resuscitation
For a term infant born through dark green (thick) meconium-stained amniotic fluid, the most appropriate action during delivery is to have a skilled resuscitation team ready and proceed with immediate resuscitation based on the infant's vigor, WITHOUT performing routine oropharyngeal suctioning before delivering the shoulders or routine endotracheal intubation. 1, 2, 3
Why Option C (Oropharyngeal Suction Before Delivering Shoulders) is INCORRECT
Routine intrapartum oropharyngeal and nasopharyngeal suctioning is no longer recommended for infants born through meconium-stained amniotic fluid of any consistency, as demonstrated by a large randomized controlled trial of 2,514 patients showing no reduction in meconium aspiration syndrome (4% in both suctioned and non-suctioned groups). 1, 4
This practice was abandoned after evidence showed it provides no benefit in preventing meconium aspiration syndrome, reducing need for mechanical ventilation, or improving mortality. 4
Suctioning procedures can cause vagal-induced bradycardia, deterioration of pulmonary compliance, and reduced cerebral blood flow velocity, potentially harming the infant. 1, 3
Why Option B (Immediate Endotracheal Intubation) is INCORRECT
Routine endotracheal intubation and tracheal suctioning is no longer recommended for nonvigorous infants born through meconium-stained amniotic fluid, as it delays ventilation without improving outcomes. 1, 2, 3
The 2020 International Consensus on Cardiopulmonary Resuscitation, based on randomized controlled trials involving 680 newborns, demonstrated no benefit in survival to hospital discharge, neurodevelopmental outcomes, or reduction in meconium aspiration syndrome from routine tracheal suctioning. 1, 3
Meta-analysis showed no significant difference in mortality (RR 0.99,95% CI 0.93-1.06), meconium aspiration syndrome (RR 0.94,95% CI 0.67-1.33), or need for mechanical ventilation (RR 1.00,95% CI 0.66-1.53). 1
The CORRECT Approach: Assessment-Based Algorithm
Step 1: Preparation (Before Delivery)
Ensure a resuscitation team skilled in tracheal intubation is present at delivery, as infants born through meconium-stained amniotic fluid have increased risk of requiring resuscitation. 2, 3
Have equipment ready for potential advanced resuscitation, including intubation supplies, though routine use is not indicated. 3
Step 2: Immediate Assessment After Birth
For VIGOROUS infants (good respiratory effort, good muscle tone, heart rate >100):
- Allow the infant to remain with the mother for routine newborn care. 2, 3
- Gentle clearing of meconium from the mouth and nose with a bulb syringe may be done if necessary. 2
For NONVIGOROUS infants (poor respiratory effort, poor muscle tone, or heart rate <100):
- Proceed immediately with positive pressure ventilation without performing routine laryngoscopy or tracheal suctioning. 2, 3
- Initiate resuscitation with room air for term infants, using pulse oximetry to guide oxygen therapy. 2, 3
Step 3: When to Consider Intubation
Reserve intubation for specific circumstances only: failure to respond to adequate bag-mask positive pressure ventilation, prolonged unsuccessful ventilation attempts, or persistent bradycardia. 3
If there is evidence of airway obstruction from meconium blocking the trachea, intubation and suctioning using an endotracheal tube with meconium aspirator may be effective in relieving the obstruction. 1, 2
Why Options A and D Are Not "During Delivery" Actions
Option A (NICU transfer arrangement) is a post-delivery consideration, not an action during delivery. 1
Option D (IV antibiotics) has no role in the immediate management of meconium-stained amniotic fluid during delivery and is not supported by any guidelines. 1
Critical Pitfall to Avoid
The single most important pitfall is delaying positive pressure ventilation to perform suctioning, as this leads to prolonged hypoxia and worse outcomes. 3 The paradigm has shifted from "clear the airway first" to "ventilate first" because meconium aspiration often occurs in utero due to fetal asphyxia, not during resuscitation. 5, 6
Supporting Care During Resuscitation
Use pulse oximetry to guide oxygen therapy when resuscitation is anticipated or positive pressure ventilation is administered. 2, 3
Maintain normothermia, as hypothermia increases mortality risk. 2
Consider positive end-expiratory pressure (PEEP) for ventilated infants to assist in establishing functional residual capacity. 2