Mec Aspiration

[berrymama]

Since meconium stained fluid seems to be one of those gray areas in terms of transfer during a homebirth, I was wondering if anyone has any personal experience or knows of any studies about the incidence of mec aspiration during homebirths and neonatal outcomes. I am an OB nurse and this is probably one of my biggest areas of concern. With DS (natural hospital birth), I had thick mec when my water broke, which was also my first sign of labor. I went on to deliver in the tub just 3 hours later with a midwife and telemetry monitoring. DS cried right away, no problems. BUT I also know of cases where everything appears to be fine, clear fluid right up until delivery and then baby comes out with terminal mec and needs intubation. Of course, it is hard to compare homebirths with hospital births that are probably full of interventions, but my birth was also free of interventions and we could have easily had mec aspiration problems. So...Any insights, stories, studies you know of regarding mec and homebirth?

[Lovemy3babies]

OH oh me me me

I can only tell you my expirience, I dont have any statistics.

My son was born last august (so over a year ago) attempted homebirth. My water never broke. But after contractions all night that did nothing and heavy bleeding, I transferred. His heart rate indicated stress, so we did a emergency section. As soon as they cut in and saw my waters, they were thick mec. Everyone started screaming and freaking out. They stopped pulling him out so they could suction him before he breathed. They showed him to me and took him away, said they just wanted to watch him. this was a thrusday.

I was a homebirth transfer and as such you get treated like GARBAGE, so I was put on mag for pre e which I didnt have. I couldnt see him for 30 something hours. When I did, he was on a ventilator, couldnt be touched, make noise, pictures, fed, nothing. He was on 100 percent oxygen and nitric oxcide, ventilated with arterial line and umbilical line.

On Saturday night I was in my room and they came to me to tell me that he was VERY sick. The sickest baby on the floor, 1st priority, doctors never left his room. They said even though the baby next to him was 1 lb, he was sickerat nearly 9 lbs.. he had respiratory failure and pulmonary hypertension cause by meconium aspiration syndrome. They said if he got any worse throughout the night, they would have to transfer him to U of M. And he wouldnt survive the ride, because he couldnt bring all the machines with him that were keeping him alive. They would transfer him for ECMO, which is heart lung bypass.

My church prayed and fasted, my husband fasted for a week. Finally after 10 days, I got to hold him. He started to turn around. He came off the vent, then off oxygen, and is so perfect now the doctors call him a miracle baby. I asked them his chance of survival and they wouldnt tell me. They were grim. He had a scare one night while I was there that last hours and the doctors though that was it. But he is here. 16 months old. And healthy. Unfortunately, that isnt the story with most as severe as he was.

He was in mec for 8 hours they said. my water never broke, so we didnt know. I had a neglectful prideful midwife on top of it who never counted the heart rate and refused to admit I needed to transfer (I had a placental abruption, and all the classic signs, but pride didnt want me to transfer).

It can be serious, and life threatening.

That said, I am pregnant again, after 3 sections, planning ANOTHER homebirth My midwife will be monitoring, and knows what happened, and will be on top of things unlike last time. ANy sign of stress, and we will transfer. This time I feel good about, this time it is going to happen. As scary as last time was, to me it scarier giving birth in a hospital.

[Sojourner]

Have you seen this? http://www.gentlebirth.org/archives/meconium.html Are you planning a homebirth? You may want to post this question in the birth professions forum as well.

[berrymama]

Originally Posted by Sojourner

Have you seen this? http://www.gentlebirth.org/archives/meconium.html Are you planning a homebirth? You may want to post this question in the birth professions forum as well.

Thanks for the link, and I am planning a homebirth. I am also aware (and see everyday at work) that many, many babies are born with mec stained fluid and do fine. I guess I am wondering what other moms have done when their water breaks at home and there is mec. Do you/would you stay home? Base it off of how baby is doing? What has your midwife recommended? I guess it just bothers me because with my first birth (planned hospital birth), if I would have been planning on homebirth, I may have had to transfer right away due to thick mec at SROM, but my baby was fine. It just seems to be such a gray area. My midwife recommends transfer with mec, but takes all other factors into consideration and ultimately it would be my decision.

[Lovemy3babies]

Originally Posted by berrymama

Thanks for the link, and I am planning a homebirth. I am also aware (and see everyday at work) that many, many babies are born with mec stained fluid and do fine. I guess I am wondering what other moms have done when their water breaks at home and there is mec. Do you/would you stay home? Base it off of how baby is doing? What has your midwife recommended? I guess it just bothers me because with my first birth (planned hospital birth), if I would have been planning on homebirth, I may have had to transfer right away due to thick mec at SROM, but my baby was fine. It just seems to be such a gray area. My midwife recommends transfer with mec, but takes all other factors into consideration and ultimately it would be my decision.

I am planning a homebirth this time also. Most midwives I have talked to dont transfer automatically for mec, it depends on how dark. And of course, listening to the baby, varience in heart rate to make sure there isnt stress going on in there. Mec honestly, is one of my last worries. I wouldnt worry to much.

[cileag]

I'm also an OB nurse and just gave birth at home in October. I had planned on transferring for anything more than "light mec" for my own comfort--my midwives were comfortable with moderate or even thick depending on fhts. As it turned out, everything went perfectly and fluid was clear (at 41 and 3 even!).

[Juvysen]

My first baby - born in a hospital had light mec staining when they broke my water (at 2 cm) after inducing me. It was light yellow fluid. she was 9 days overdue when she was induced. They didn't bother suctioning her or anything.

Ds was a homebirth. I was terrified of the same thing, really. I got to about 7 cm and asked for them to break my waters... when they did two llittle blurps of mec came out - like in a slug-form, not throughout the waters. I was worried that they would suggest transfer (our area doesn't have great transfer records, really), though I knew I would go if they really felt something was wrong. They just started watching his heartrate a bit more, and encouraged me to get in positions that would push things along. They also recommended against getting back in the birth tub because they didn't think it was necessarily the best place for a baby that might not be doing perfectly. 20 minutes after they broke my waters, he was on my chest, pink and beautiful, although when his head was out and he was turning for his body to come out he managed to turn his face directly into a pool of fluid and do a little inhale-ish move... that is, he got some fluid in his nose after being smushed out, I guess. He was fine for his apgars, but there was a minute or so in between that he turned sorta purple (we have a picture of his little purple feet). He was fine again after some rubbing (and encouragement to cry - he was breathing some but not really crying, just sorta mellow), though his respirations were sorta high for an hour or so after. He had calmed down by the time the midwives left and I was watching him closely for the rest of the night, but he was fine after that.

[erin_brycesmom]

I don't have any research on me since I'm on dh's laptop and not my desktop but there are a lot of studies here on MDC if you do a search. Sometimes the search function is sucky but you can do an advanced search on google and put mothering.com/discussions in to read previous threads on this topic.

For personal experience, my 2nd (hospital birth) and 3rd (homebirth) babies both had meconium stained fluid. Luckily, no AROM either time and my waters did not break until late in labor. With my hospital birth, my baby's cord was cut right away where he was whisked off for suctioning and intubation which they found no meconium in there so it was all for nothing...other than disrupting our bonding and causing a traumatic scene to what would have been a gentle birth. With my homebirth, I continued on with my waterbirth and my baby came out just fine. I pulled him from the water and he never left my arms for over hour and the only for dh to hold him while I went to the bathroom, lol. No suctioning, no separation...it was wonderful!

[JennTheMomma]

My son was born in a birth center and had mec. stained fluid when my water broke. He was 7 days over due and my OB wasn't concerned at all because his heart seemed fine. My Ob told me that when he is born they will suction him out and put him on oxygen, but he shouldn't have to leave the room. DH cut the cord and he was placed in a heating crib next to me with oxygen, he was fine in a few minutes. We're planning a homebirth this time and with good monotoring, I'm not really worried.

[womenswisdom]

IIRC, NRP guidelines state that suctioning is not needed for even with mec stained fluid if baby is vigorous at birth. If resusitation was necessary, suctioning would need to be done before an ambubag was used. I'd have to go check that though to be sure.

ETA: This appears to support what I remember from the course: http://pediatrics.aappublications.or...full/113/1/133. However, I am aware that many/most providers still do suctioning anyways. But the most recent studies and recommendations show that it has no effect on meconium aspiration syndrome. My understanding is that it occurs in utero and suctioning at birth has no effect. It's not something I would personally be comfortable being transported for in the absence of other issues.

[pamamidwife]

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Edited by pamamidwife - 9/10/11 at 11:23am

[MsBlack]

I agree with pamamidwife. And I have to think that one of 2 things is true about the neonate who was intubated, from berrymama's first post:

A) that neonate had already experienced sufficient hypoxia IN UTERO for breathing to be initiated (quite possibly days or more prior to labor's onset), thus causing the mec aspiration. In a case like this you do usually see thick mec during labor, but also evidence of 'aged' mec--maybe what you see in the waters is dark, but what is jammed into baby's ears, nose and all folds and wrinkles is yellow (old) mec. In this sort of case, suctioning has to happen prior to intubation because there may be no airway at all.

B) The 2nd possibility I can think of with that baby, is that it was hospital staff response to the mec that caused the need for intubation (as pam suggested) That is, that deep vigorous suctioning was done even though baby did have an airway (albeit a possibly decreased airway if mec was present beneath vocal cords); that instead of following NRP guidelines NOT to suction if there is an airway, staff went ahead with the older protocols and suctioned the heck out of a baby, cutting cord immediately, removing baby from mom's skin--and thus pushed a distressed, possibly depressed baby a bit further toward collapse and the need for intubation.

Thing is, both suctioning and intubation can push mec further into the lungs. They also cause trauma to delicate mucus membranes, causing swelling in the airway that makes breathing even more difficult. Immediate cord cutting can rob a baby of a precious few minutes of oxygenation while s/he gathers energy to come around if stressed/depressed. We tend to assume that if it's done by medical people, it is truly 'needed' and truly 'the best thing possible to do' to save a life. But I have not seen this to be true, at least not in the very earliest moments of such a baby's life outside the womb.

Basically, I think we have to rethink mec in the amniotic fluid, and mec possibly in baby's airway.

[SwanMom]

My waters broke after a long first stage at home. The midwife found meconium, and immediately got ready for an emergency if need be. He was born after 18 minutes of pushing (partly because they said, "If the head doesn't come on this push, we're transfering" and I was determined to have him at home, I guess!). He couldn't breathe well, wasn't crying, and we tranfered immediately. The midwives/hospital staff were amazing. He was in bad shape, and doctors say he was a miracle baby. NICU, Ventilator, etc. It was 5-6 days of uncertainty before they said he was becoming more stable (he took a turn for the worse at 4 days--it was horrible). I was able to hold him again when he was 9 days old. He came home at 3 weeks (took awhile for him to learn to eat after all the morphine, etc.).

He wasn't in distress till the very end (they checked often), but the midwife thinks the meconium was there awhile (his fingernails were stained, etc.). I'm pregnant again, with the same midwives, and I know that what happened was a fluke and statistically uncommon. My midwife suggested we could break the waters earlier if that made me/DH more comfortable. She said if they had seen that, we would have transferred sooner.

In retrospect, DS (almost 3) is fine. He breastfed for 28 months & hasn't had any meds since he was in the hospital. I didn't have a C-section, but if we could have avoided the trauma of it all, we would have, of course. It's hard to know what we could have done differently. If I had been in the hospital, I'm sure I would have had a C-section. I also wouldn't have been free to go immediately to the hospital with a NICU (where my son ended up--25 miles away from our local hospital). I never was a patient at either hospital, and it was nice to be a free woman.

I believe in birth & have read statistics (google it) showing that most of the time the baby is fine when there is mec in the waters. I'm planning another home birth. I was at my sister's home birth & her baby was unaffected (light mec).

[SwanMom]

Also, one perk of having a home birth: I got to hold my son (while giving him oxygen) from a few moments after birth, in the ambulance, and for a few minutes at the hospital. If I had had him in the hospital, he would most likely have been whisked right away from me, and I'm not sure if it would have made a difference--the meconium aspiration happened in utero, and there would have been roughly an equal amount of time between birth & the arrival of the ventilator (from another hospital) either way.

I treasure those first memories of getting to hold him (even while in transit), and look into his dark eyes.

[mwherbs]

so I think neonatal resuscitation has the info about suctioning - doesn't matter unless there is no breathing then what you are doing is trying to clear an airway - we did have a baby with terminal mec, chunky particles- Tachypnea with slight retractions- that would smooth out with blowby heart tones stayed good but the baby would not nurse- and we could not successfully wean the baby off the blow by- deep suctioning is not going to alter what has happened to the surfaces of the lungs it is just going to irritate the airway more and with mec aspiration what you already have is chemical pneumonia- mec disolving surfactant and adding a pathway for infection - and the longer the mec has been there you could be dealing with established infection anyway- so yes it is risky to have potential mec aspiration at home and we do not have epinephrine to give ASAP. Don't have studies about those kidos at born at home but those numbers would be part of any of the overall studies on homebirth and transfers -

here is a discussion we had in April on mec aspiration
http://www.mothering.com/discussions...=#post13579281

[finn'smama]

Originally Posted by berrymama

Thanks for the link, and I am planning a homebirth. I am also aware (and see everyday at work) that many, many babies are born with mec stained fluid and do fine. I guess I am wondering what other moms have done when their water breaks at home and there is mec. Do you/would you stay home? Base it off of how baby is doing? What has your midwife recommended? I guess it just bothers me because with my first birth (planned hospital birth), if I would have been planning on homebirth, I may have had to transfer right away due to thick mec at SROM, but my baby was fine. It just seems to be such a gray area. My midwife recommends transfer with mec, but takes all other factors into consideration and ultimately it would be my decision.

I transferred to a hospital last time with mec stained water with particles. Midwives here (Ontario) have to recommend transfer for mec. When I talked about it at my last appt. my mw said it no longer matters whether it's thick or thin, mec is mec. If we noticed mec too late at home, paramedics would be called who could intubate and would wait outside the door.
I had a completely natural birth last time, with intermittent monitoring and baby was fine. He was not suctioned right away or taken from me, and was checked by a pediatrician eventually. He was totally fine.
I honestly am not sure what I would choose to do this time. I have had both a homebirth and a hospital birth and my hospital experience was great. Other than the pediatrician, I never saw any hospital staff and I was home 3 hours after the birth, so for me, it might just be better to be there in case. But I really don't know yet...