In a 39‑week pregnant woman with meconium‑stained amniotic fluid, what is the most appropriate intra‑delivery maneuver?

No Routine Oropharyngeal Suction During Delivery

The most appropriate action during delivery is to proceed with standard resuscitation based on the infant's clinical status at birth, without performing oropharyngeal suction before delivering the rest of the body. 1, 2, 3

Evidence Against Routine Intrapartum Suctioning

The 2020 International Consensus on Cardiopulmonary Resuscitation explicitly recommends against routine oropharyngeal or nasopharyngeal suctioning for infants born through meconium-stained amniotic fluid, even when the meconium is thick (dark green). 1 This represents a major paradigm shift from historical practice:

• Oropharyngeal suctioning does not remove liquid from the lungs or prevent meconium aspiration syndrome. 1
• Systematic review data demonstrate that routine suctioning provides no survival benefit, no reduction in meconium aspiration syndrome (RR 0.94,95% CI 0.67-1.33), and no reduction in hypoxic-ischemic encephalopathy (RR 0.85,95% CI 0.56-1.30). 2, 3

Documented Harms of Routine Suctioning

The procedure carries significant risks that outweigh any theoretical benefit:

• Vagal-induced bradycardia from nasopharyngeal stimulation 1
• Lower oxygen saturation through the first 6 minutes of life, with delayed time to reach normal saturation 1
• Increased risk of iatrogenic infection from mucosal irritation 1
• Delays initiation of positive-pressure ventilation in nonbreathing infants, prolonging hypoxia 1, 2
• Potential for hypercapnia, impaired cerebral blood flow regulation, increased intracranial pressure, and subsequent brain injury 1

Correct Management Algorithm

For Vigorous Infants

• If the infant has good respiratory effort, good muscle tone, and heart rate >100 bpm, routine care may continue with the mother without any airway interventions. 2, 3

For Nonvigorous Infants

• Place under radiant warmer, position head in "sniffing" position, dry, and provide tactile stimulation. 2, 3
• Immediately initiate positive-pressure ventilation if poor respiratory effort, poor tone, or heart rate <100 bpm—do not delay for suctioning. 2, 3
• Reserve endotracheal intubation only for: (1) failure to respond to adequate bag-mask ventilation, (2) evidence of airway obstruction from thick meconium, or (3) need for prolonged mechanical ventilation. 2, 3

Why the Other Options Are Incorrect

Option A (NICU transfer arrangement): While infants with meconium-stained fluid may require NICU care, this is a post-delivery decision, not an intra-delivery action. 2

Option B (Immediate endotracheal intubation): The 2020 International Consensus explicitly recommends against routine immediate intubation, as it delays ventilation without improving mortality (RR 0.99,95% CI 0.93-1.06) or reducing meconium aspiration syndrome. 1, 2, 3

Option C (Oropharyngeal suction before delivering shoulders): This outdated practice was abandoned after the 2005 guidelines and definitively rejected in 2015 and 2020 guidelines based on evidence of harm without benefit. 1, 4

Option D (IV antibiotics): Prophylactic antibiotics during delivery are not indicated for meconium-stained fluid alone and represent an inappropriate intervention. 2

Essential Preparation

A resuscitation team skilled in tracheal intubation must be present at delivery when meconium-stained amniotic fluid is identified, even though routine intubation is not performed, to manage the subset of infants who fail to respond to bag-mask ventilation. 2, 5