Meconium stained liquor (MSL) management

Management includes:

• Prepare and check resuscitation equipment in advance.
• Transfer the infant to the resuscitation area immediately and without stimulation.
• Assess the infant's vigour, which will determine further management.

Assessing infant vigour

A vigorous infant has:

• good muscle tone
• active breathing efforts
• HR >100 BPM.

If vigorous provide standard care (see resuscitation).

If not vigorous and the attending operator is able to perform intubation:

1. Place infant under radiant warmer while avoiding stimulation.
2. Insert laryngoscope.
3. Intubate with an appropriate size ET tube (3.0 or 3.5 for an average term baby), attach the meconium aspirator (if available), then apply suction whilewithdrawing ET tube.
             or
   Pass suction 12 or 14 G suction catheter directly through the vocal cords and apply suction (pressure 100 mmHg) while gradually withdrawing the catheter. (This is easier if the catheter has not become limp from becoming warm under the radiant heater).
4. Intubation and suctioning must be brief and should not compromise the infant.
5. Proceed with standard resuscitation, including positive pressure ventilation with a neopuff or other hand ventilating device as necessary. Higher pressures than usual may be required, but keep in mind the increased risk of an air leak.

If not vigorous and the attending operator is not able to perform intubation:

• Place infant under radiant warmer avoiding stimulation.
• Suction mouth and pharynx with 12 or 14 G catheter (suction pressure set at 100 mmHg).
• Commence positive pressure ventilation with a neopuff or other hand ventilating device.

Please note: Sucking out the baby’s mouth and pharynx on the perineum before the delivery of the shoulders makes no difference to the outcome of babies with meconium stained liquor and is no longer recommended.

Infants born through meconium-stained liquor require the following ongoing care:

• Provide continued resuscitation as indicated by infant condition.
• If apnoea or respiratory distress develops subsequently, perform intubation and tracheal suctioning before commencing assisted ventilation.
• Aspiration of the stomach to prevent risk of aspiration of swallowed meconium is not part of the initial resuscitation since passage of the tube can cause a vagally induced apnoea.
• Subsequent aspiration of the stomach is recommended after resuscitation is complete.
• Admission to special care nursery (SCN) for observation is required when there is:
  • meconium below the cords
  • ongoing respiratory distress or oxygen requirement
  • need for active resuscitation involving CPR or prolonged IPPV.

• There is no evidence that management should be based on consistency of meconium.
• There is no evidence that techniques used to inhibit gasping after birth can be effective in reducing the incidence of MAS.

Clinical

• Australian Resuscitation Council
• NeoResus (2012) Newborn resuscitation training program

References

• Neonatal Resuscitation Textbook, 5th Edition Editor Kattwinkel J.
• Delivery Room Management of the Apparently Vigorous Meconium-stained Neonate: Results of the Multicenter, International Collaborative Trial WiswellT.E. et al Pediatrics 205(1) Part 1of 3, 2000, 1-7
• The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics. 2006 May;117(5):e978-88. Epub 2006