In a 39‑week pregnant woman with meconium‑stained (dark green) amniotic fluid, what is the most appropriate action to take during delivery?

Management of Meconium-Stained Amniotic Fluid During Delivery

The most appropriate action during delivery is to proceed with standard neonatal resuscitation based on the infant's clinical status at birth—none of the listed options (oropharyngeal suction before shoulder delivery, immediate intubation, or IV antibiotics) are indicated as routine interventions. 1

Why Traditional Interventions Are No Longer Recommended

The 2020 International Consensus on Cardiopulmonary Resuscitation fundamentally changed delivery room management by demonstrating that routine airway interventions provide no benefit and may cause harm: 1

• No survival benefit: RR 0.99 (95% CI 0.93-1.06) 1
• No reduction in meconium aspiration syndrome: RR 0.94 (95% CI 0.67-1.33) 1
• No reduction in hypoxic-ischemic encephalopathy: RR 0.85 (95% CI 0.56-1.30) 1

Specific Reasons Each Option Is Incorrect:

Option C (Oropharyngeal suction before shoulder delivery) is explicitly contraindicated because routine suctioning before delivering the shoulders does not improve outcomes and is no longer recommended. 2, 3

Option B (Immediate endotracheal intubation) is contraindicated because it delays the initiation of positive-pressure ventilation without improving outcomes, thereby prolonging hypoxia. 1, 4

Option D (IV antibiotics) is not a standard delivery room intervention for meconium-stained fluid alone, though some evidence suggests antibiotics may reduce clinical chorioamnionitis risk postnatally. 5

Option A (Arrange NICU transfer after delivery) may be appropriate after initial assessment but is not an action taken during delivery itself. 1

The Correct Approach During Delivery

For Vigorous Infants (good respiratory effort, good tone, HR >100 bpm):

• Allow the infant to stay with the mother for routine care 1, 2
• No additional airway interventions are needed 1

For Non-Vigorous Infants (poor respiratory effort, poor tone, or HR <100 bpm):

1. Place under radiant warmer immediately 1, 4
2. Position head in "sniffing" position 1
3. Dry and provide tactile stimulation 1, 4
4. Initiate positive-pressure ventilation WITHOUT DELAY if the infant shows poor respiratory effort, poor tone, or HR <100 bpm 1, 2

Reserved Indications for Endotracheal Intubation

Intubation should be performed only when: 1, 2

• The infant fails to respond to adequate bag-mask positive-pressure ventilation
• There is clear evidence of airway obstruction from thick meconium
• Prolonged mechanical ventilation is required

Critical Pitfalls to Avoid

Delaying positive-pressure ventilation to perform suction or intubation is the most harmful error, as it prolongs hypoxia and worsens outcomes. 1, 2, 4

Additional risks of routine suctioning include: 1, 2

• Vagal-mediated bradycardia
• Increased infection risk
• Lower oxygen saturation in the first minutes of life

Essential Preparation

Despite the recommendation against routine intubation, a skilled resuscitation team capable of performing endotracheal intubation must be present at every delivery with meconium-stained fluid, as approximately 3-5% of these infants will develop meconium aspiration syndrome and may require advanced interventions. 2, 4, 3

Strength of Evidence

These recommendations are based on low-certainty evidence from randomized controlled trials, but the task force placed strong emphasis on harm avoidance given the lack of demonstrated benefit and the known risks of delayed ventilation. 1 This represents a major paradigm shift from historical practice where routine tracheal suctioning was standard for 25 years. 4