Delivery Room Management

1. The Paediatric Resident (SHO, Registrar, or NS-ANP) should be called if there is thick meconium staining or light meconium plus fetal distress.
2. There is no advantage in oral and pharyngeal suction as the head delivers and this is no longer indicated. ¹ 
   Suctioning does not alter the chance of developing respiratory distress or symptomatic meconium aspiration syndrome, even in sub-groups with thick meconium, fetal distress or delivered by Caesarean section.
3. If the baby is apparently vigorous at birth (heart rate >100, spontaneous respiration, reasonable tone), intubation and tracheal suction is not indicated, unless the baby subsequently has poor respiratory effort or early respiratory distress. ²
   Intubation of vigorous babies does not improve respiratory outcomes and can result in trauma to the infant.
4. Intubation and tracheal suction should be performed if the baby has moderate or thick meconium and depression at birth.

• Laryngoscope and suction the pharynx under direct vision. Intubate and suction the trachea with a meconium aspirator tube, applying suction as it is withdrawn. Use a pressure of -100mm Hg or -13Kpa for 1-5 seconds, with withdrawal of the tube ².
• If meconium is present in the trachea, consider repeating ET suction.
• Resuscitate infant appropriately. If the heart rate is low, the infant should be ventilated after the first intubation (bag and mask) or on the second intubation.

5. Assess the infant.
   Arrange for cord blood gas (arterial if possible) to be taken from a double clamped section of cord.

Further Management

• All infants with meconium stained liquor must be well observed. For most babies this is with their mothers.
• If there is thick meconium or any worrying clinical features, the paediatric resident staff should review the baby at an hour of age.
• All babies should have AC temperature and respiration recordings with instructions to call the paediatric resident if there is any respiratory distress. ³

Criteria for Admission to NICU

• Symptomatic meconium aspiration syndrome.
• Meconium in trachea with significant asphyxia
  (> 10 minutes to establish spontaneous ventilation or cord pH < 7.2).
• Other significant risk factors for infection.

Management of the Symptomatic Infant

• Assess the infant.
• Give enough oxygen to maintain SpO₂ >95% initially. Put on CPAP to deliver oxygen.
• CXR if significant respiratory distress or tachypnoea persists.
• Consider antibiotics:
  1. if unwell
  2. if persistent symptoms
  3. if other risk factors for infection
• Take blood culture if treating with antibiotics.

Complications of Meconium Aspiration

1. Infection: Uncommon unless sepsis was the stimulus to make the infant pass meconium. Consider LISTERIA, especially if preterm. Meconium is a good culture medium so secondary infection may occur.
2. Pneumothorax: May occur at any stage (MAS is an air-trapping disease). So consider this any time from resuscitation onwards if there is unexpected deterioration or significant disease.
3. Respiratory Failure: Can occur because of respiratory obstruction, inflammation, infection or shunting.
4. Persistent Pulmonary Hypertension: Is common in severe MAS and can be very difficult to treat. Early assessment and avoidance of hypoxaemia, hypothermia, hypoglycaemia are important to avert PPHN.

References