Caring For A Delivery Complicated By Meconium

TRANSCRIPT

Meconium is excreted into the amniotic fluid in approximately 10% of births. Up to 5% of these babies develop meconium aspiration syndrome when meconium is inhaled into the baby’s lungs. A delivery complicated by meconium requires only routine newborn care if a baby has strong respiratory efforts, good muscle tone, and a heart rate above 100 beats per minute.

However, if the baby is not vigorous due to decreased muscle tone, poor respiratory effort, or a heart rate less than 100 beats per minute, it may be helpful to intubate and suction the trachea in order to prevent meconium aspiration syndrome.

In this case, treat the baby using the following steps:

1. The obstetrical team will notify you, the team leader, of the meconium-stained amniotic fluid. Immediately confer with the equipment person to decide which of you will apply suction and remove the endotracheal tube.
2. Determine if the baby is non-vigorous by evaluating them for decreased muscle tone, poor respiratory effort, or a heart rate less than 100 beats per minute. If these symptoms are present, tell your team loudly: “Don’t stimulate the baby.”
   
   The equipment person must not dry or touch the non-vigorous baby until you tell them to do so.
3. The equipment person should be preparing an endotracheal tube with or without a stylet, depending on your pre-delivery huddle with them. This team member should also have a suction catheter ready to attach to the suction tubing in case you need to clear secretions and meconium from the hypopharynx in order to see the vocal cords. The equipment person should also prepare a meconium aspirator to attach to the suction tubing when you call for it to be connected to the recently inserted endotracheal tube.
4. The medication nurse should be available to stabilize the baby’s head with her hand if you ask her to do so.
5. Request the regular suction catheter first to clear the hypopharynx and see the vocal cords.
6. Insert the endotracheal tube as described in the “Intubating and Securing an Endotracheal Tube” segment of this program.
7. During the intubation attempt, the cardiac team member should monitor the heart rate and keep the team informed by calling out the rate after multiplying the number of beats in 6 seconds by 10. He should also alert the team to the heart rate visually by either opening and closing his hand over the baby’s umbilicus in time with the baby’s heart rate, or loudly tapping it out on the radiant warmer. The cardiac person must be prepared to provide cricoid pressure using one finger. This team member must also keep track of the time spent attempting to intubate, loudly notifying the team when it’s taking longer than 30 seconds, and when the heart rate is less than 100.
8. After inserting the endotracheal tube, direct the equipment person to connect the meconium aspirator and suction tubing. The equipment person should not let go of the meconium aspirator-endotracheal tube assembly until you grasp it and say, “I have it.”
9. Apply suction to the trachea for a few seconds by covering the meconium aspirator’s side suction port. You should note if meconium was obtained before you pull the meconium aspirator-E.T. tube assembly out of the trachea and into the hypopharynx. While using a circular motion to pull the assembly out, apply suction in order to remove additional meconium and secretions.
10. If no meconium is aspirated below the vocal cords, proceed with positive pressure ventilation using a flow-inflating bag and mask.
11. If meconium is aspirated, decide whether or not to repeat the intubation and meconium aspiration process. If the baby is tolerating the intubation attempts with a heart rate above 100 and you suspect there is more meconium in the trachea, then re-intubate using a new endotracheal tube. Do not reuse an endotracheal tube with meconium in it. One helpful technique is to discard meconium-filled endotracheal tubes onto the floor so they are not accidentally reused.
12. After multiple intubations, proceed with positive pressure ventilation using the flow-inflating bag mask until the infant regains spontaneous respirations with a heart rate above 100 beats per minute.

Deliveries complicated by meconium are a common occurrence in regular obstetrical practice. Knowing how to treat a non-vigorous baby using a meconium aspirator to clear the trachea may prevent respiratory failure, pneumothoraces, or even death from meconium aspiration syndrome.

*Per the seventh edition of the Newborn Resuscitation Program (NRP), a non-vigorous baby, whose delivery is complicated by meconium, does not require intubation for meconium aspiration below the vocal cords. Instead, follow the steps that are laid out in the Running a Neonatal “Mega-code” video for a non-vigorous baby.