Q: If the waters break during pushing and there is thick meconium, is it
better to try to get the baby out quickly or allow it to stay inside mom?
-Belinda, apprentice
A: It has been my experience that if she is pushing she's usually fully
effaced and dilated. If at that time the meconium is observed the baby is
"more out than in." Delivery is imminent. We have let the woman deliver on
her own, but avoiding a prolonged [second] stage. If the mec is observed
with very little dilation and effacement, measures are taken to deliver
that baby, depending on the situation. . . a C/S is performed.
-M.B.
====
The danger of meconium other than indicating possible fetal distress is
aspiration upon delivery. How has the fetus appeared up until the point of
rupture? Any indications of distress? Apparently, the fetus passes meconium
in utero all the time and macrophages "clean up" the amniotic waters. As
the fetus gets older, the macrophages decrease, thus leaving meconium in
the waters.
Meconium in and of itself does not always mean distress (pathology). Many
times when the pressure on the head becomes "severe" as in pushing and
birth the baby may pass meconium. What is the whole picture telling you?
Does the maternal history make you think the baby may have experienced
stress? Any other stressors? If there's no indication of distress and heart
tones are reactive with good variability I don't see what speeding up the
birth will do.
The concern at birth is when the baby takes the first breath and aspirates
meconium. Better to have a Delee trap or suction ready to clear the mouth
and throat, then nose, right as the head delivers. In some facilities all
babies with meconium are intubated to visualize the vocal cords. I don't
think this is really necessary with thin meconium. You might want to take a
NALS class to familiarize yourself with distress, apnea and meconium
staining.
-Harriet Kaufman
====
I have had a few situations like this--meconium so thick it plops out after
the bag breaks. If heart tones stay strong even with some bradycardia we
just keep pushing to get baby out. Mom works hard and baby is constantly
monitered with a Doppler. I will call for an ambulance in this situation in
case baby does not do well. Thankfully in each situation the babies have
done very well with stimulation and we have not needed to transport.
-Linda
====
Approximately 500,000 infants are born through meconium-stained waters each
year, and of those, 10% develop meconium aspiration syndrome (MAS). Many
practitioners choose to intubate and suction these infants despite lack of
proof that this intervention is beneficial.
A randomized, controlled, international, multicenter trial that involved
2,094 full-term, vigorous infants, compared intubation and intratracheal
suctioning with expectant therapy. The infants were equivalent in all
infant and maternal antenatal and intrapartum characteristics. There was
little difference in outcome between the groups (including infants born
through the thickest meconium) in MAS incidence (intubation group, 3.2%;
expectant group, 2.7%) or in other respiratory disorders (3.8% and 4.5%
respectively). Infants in the intubation group were significantly more
likely to have 1-minute Apgar scores of less than 7 (17% vs. 6%), and 51
complications of intubation were noted, including bradycardia, hoarseness,
or laryngospasm.
-Pediatrics, 2000 Jan; 105:1-7.
Reprinted from Midwifery Today E-News (Vol 2 Issue 17 April 28, 2000)
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