Would you transfer for meconium?

[babymango]

With my past midwife (in another country) there were some well defined guidelines for transfers. The mom could always refuse, obviously, but they had some well established protocols. Any meconium was a reason for transfer to a hospital (but NOT transfer of care, the midwife continued to assist the mom once in the hospital, after a consultation with a physician)
This time, it feels pretty wishy-washy. My current midwives have never transfered anyone for meconium and kind of looked at me like I was crazy when I asked about it. Their guidelines say recommend to transfer in cases of fetal distress (well, that on its own is a good enough reason for transfer to me, mec or no mec!)
I am trained in neonatal rescussitation, I was even an instructor for that course before going on mat leave with #1. It has been hammered into my brain that a non vigorous baby born with meconium in the water needs to get endotracheal suction, which my midwives cannot do at home.
I tried to find litterature on the subject, but didn't find much (most is about whether or not to suction at the perineum, which is not so much an issue)
I would like to hear opinions about this... What would you do if your water broke spontaneously (we're not going to go looking for mec, but in case it happens to be there...) and there was mec? Thick or thin? What about a very mature baby (like 42ish weeks), that is more likely to have mec as a sign of maturity, not distress?
Obviously, this question only applies if there is time to transfer... This is my second baby so it's very possible that once the water breaks, the baby just "falls out" and this whole discussion is irrelevant!
If it makes any difference, I would love a HB, but im not dead set on it. I would be very dissappointed to have to transfer, but I will do what it takes to birth my DD in the best situation/location for her.

[HappyMommy2]

I am planning my second HBAC now, and yes, I would transfer for meconium. I read about it in "Baby Catcher" ... but now I think I will def ask my midwife for more info about it.

[jljeppson]

I've never transferred someone for mec, and never seen it happen either. Now if mec was accompanied by heart tones I didn't like that wasn't resolved by position change... There are new studies on endotracheal suction with mec that state it causes more harm than good and does not prevent MAS, in a vigorous infant. Hospitals that have stopped suctioning vigorous infants have seen their pneumonia rates drop as well. Here's a link to an abstract for a controlled study that came to that conclusion. http://www.ncbi.nlm.nih.gov/pubmed/1...?dopt=Abstract As for depressed infants current recommendation is the suctioning, but I believe that will be changing in the future. Some studies have been done, after the study of deceased infants that were diagnosed as having passed due to MAS, showing that ALL the infants have lung changes which are too advanced to be postpartum and all of them had infections indicating that the mec was the result of an intrauterine infection that happened mid-pregnancy. In other words, it was a symptom, and not the actual cause of death. For me, I wouldn't transfer myself (going on baby #7 here) or a client just for mec, certainly not for light or moderate mec. With heavy mec staining it would depend on the case. And of course it wouldn't matter what degree of mec there was if the mother had problems with heart tones that I couldn't resolve, I'd transfer no matter what. Hope this helps.

[AnneCordelia]

It would depend on the meconium. How much is there? How much fluid? Is the mec particulate or well-mixed?

I did transfer with my first child for mec. It was thick, gloopy and there was next to no amniotic fluid. I would absolutely transfer in that case again. But, I doula'd at a birth with thin, well-mixed mec and we didnt' transfer. Baby was born screaming and fine, and it was the right decision not to transfer.

[Banana731]

Probably not. ACOG changed it's SOP along with the AAP in 2007. They don't do anything for mec anymore, unless it's present and the baby's breathing is depressed. So unless your baby needs to be intubated, they would just watch and wait at the hospital. If your lo needs to be intubated, your going to the hospital anyway!

http://www.ncbi.nlm.nih.gov/pubmed/17766627

[babymango]

jljeppson: Do you have any references for those upcoming changes (about mec being a symptom of something from mid pregnancy)? The link you gave is about oro/nasal suctionning, which is not an issue.
And I agree that endotrach suctionning is not for vigorous babies, but how do you know ahead of time... I know there are signs, but i've seen my share of babies who were born non-vigorous without a clear warning, especially in second time moms who had a very quick labor (maybe a little shell shock?)... Those babies are probably healthy, hence the lack of signs, but they would still have all the criteria for endotrach suctionning in case of mec

[erin_brycesmom]

I wouldn't transfer for MSAF unless there were non-reassuring FHR but would transfer for the later any how. So it's mostly a non-issue for me. I read some research lately that even thick mec is no more of a risk factor than thin mec. 2 out of 3 of my babies had MSAF. One was a hospital birth and one was a homebirth. It was handled *way* better at home and was actually one of the things that led me to homebirth in the first place.

I would think that you'd have signs of distress with FHR monitoring if the baby is going to be born non-vigorous. If not, then what caused that to happen? I don't believe that MAS happens during birth but rather before birth. I don't know about mid pregnancy but certainly before the baby comes out. There are studies to that effect, here is one:

http://www.ncbi.nlm.nih.gov/pubmed/1442972
CONCLUSIONS: We concluded that "early" oronasopharyngeal DeLee suctioning at the perineum does not affect the rate of meconium aspiration syndrome. We speculate that meconium aspiration syndrome is predominantly an intrauterine event associated with fetal distress and that meconium in the airways is merely a "marker" of previous fetal hypoxia.

[jljeppson]

Sorry about that, I should have checked my link before posting and made sure it was working properly. As for the changes, I'd say it's light years away. The medical community doesn't work swiftly and the papers on the findings I was talking about haven't been published yet (and maybe not even written). You can check out Ronnie Falcao's site and it has a deep discussion of this topic, along with a few people that mention the research I was talking about. One midwife states that in her area of Massachusetts even the hospitals don't deep suction anymore and that their levels of caustic pneumonia have gone down. She does state that no study has been done, that it was a change in practice implemented by Dr's and CNM's trying to be a little more gentle with their newest patients. I'd say shell shock is an adequate description of the babies you mentioned; it's not unusual for precipitous labor babies to take a little while to breathe. I'm not advocating no suctioning at all, but I think it's a case by case basis how MUCH suctioning you do. Just like most things to do with labor and delivery, each mom and baby isn't cookie cutter type, and in some cases I don't feel that they are best served by a "We ALWAYS do this in this instance mindset". Plus, the medical community in the US is far too willing to take studies at face value and implement them without enough research to back them up. We know now that it harms vigorous babies to be trach suctioned and that suctioning before the shoulders are delivered does not prevent MAS (this from a study presented in 2003 by a Dr. Szyld from Argentina), but there are still doc's and hospitals out there doing it based on a single study from the '70's. ACOG even admits that they don't believe the findings will cause any significant change in clinical practices because doc's have had it drummed in their heads for so long to suction, suction, suction. We're quick to jump on the band wagon and slow to get off. So- to summarize I agree with suctioning, but feel in most cases that going further than the pharynx is counter productive and harmful. Midwives can definitely suction that far back with a DeLee (though those are starting to fall out of favor) or with a res-q-vac.

[Sijae]

I would not transfer for presence of mec alone.

[Sfcmama]

Just to share our experience...
Mec was a non-negotiable transfer condition at our birth center, which meant we ended up transferring even though there were no other signs of distress. DD was almost 42w so it ended up being due to maturity I was completely comfortable playing it safe. The peds team did not do an endotracheal suction because she was active and our mw continued care while in the hospital so we really didn't feel like we'd lost anything.
However, that was our first and I wonder if the mw would have stuck to that rule if things had been moving quicker...?
Best of luck, mama!

[etsdtm99]

I just had my baby yesterday - meconium was present, but not thick when my water broke at the beginning of labor.. it got worse later on in labor but heart tones were good or improved with position change.. baby is/was fine.. labor was pretty quick (10 hours total) .. my midwife never mentioned transferring she did keep a doppler on me almost constantly though but that was to make sure i was staying in a good position due to cord compression issues due to lack of fluid .. i would have been crushed had my homebirth been 'canceled' due to the meconium alone. .

[mrsdewees]

Depends on a few things. One - how much meconium and how thick and two- fetal heart tones. If baby has a little meconium and the heart rate is fine - no need to transfer. If baby is born with "pea soup" and is in distress - then a transfer.

Also, midwives do bring DeLees with them. I took my NRP certification with an instructor who is also a homebirth midwife - so she tailored the class to those of us in the homebirth setting and meconium was not need for transfer. Especially if it's not super-thick and the baby is doing just fine

[mrsdewees]

Originally Posted by babymango

jljeppson: Do you have any references for those upcoming changes (about mec being a symptom of something from mid pregnancy)? The link you gave is about oro/nasal suctionning, which is not an issue.
And I agree that endotrach suctionning is not for vigorous babies, but how do you know ahead of time... I know there are signs, but i've seen my share of babies who were born non-vigorous without a clear warning, especially in second time moms who had a very quick labor (maybe a little shell shock?)... Those babies are probably healthy, hence the lack of signs, but they would still have all the criteria for endotrach suctionning in case of mec

"International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 - Of particular note is the change in guidelines for meconium - "There is evidence that tracheal suctioning of the vigorous infant with meconium-stained fluid does not improve outcome and may cause complications" "

Personally, I'd rather use a DeLee.

[Youngfrankenstein]

I had mec in the water when it broke over the toilet. I told the mw, she looked at it and said "no problem" and we ignored it. Baby was totally fine and pooped over and over after coming out. No problems. I can't say when or how she may have transfered for what "kind" or mec present.

[babymango]

Originally Posted by mrsdewees

"International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 - Of particular note is the change in guidelines for meconium - "There is evidence that tracheal suctioning of the vigorous infant with meconium-stained fluid does not improve outcome and may cause complications" "

Personally, I'd rather use a DeLee.

Yes, I think we all agree that a vigorous infant doesnt need suctioning. Im just still not sure if i would be comfortable to stay home in the case the baby comes out non vigorous, be it because of last minute distress with no time to transfer, or a "shell shock" baby, or whatever else.

[mrsdewees]

I suppose it depends on your level of trust with your midwife, then. Most midwives are capable of handling a non-vigorous baby. (It's why we bring DeLees and oxygen) Like I said though, in the case of meconium - thin meconium with good FHTs? I can't imagine transferring for that. If it were pea soup? Then, yeah. Probably.

[babymango]

Thanks for all the replies. It gave me a lot to think about and to discuss with my midwives. I've done a lot of reading and not finding much about the usefulness of tracheal suctioning (even in depressed babies!) It sounds more and more like one of those things that we've been doing forever and the medical world is hesitant to revisit. Im still not sure on what im going to do, but I have definately gained better understanding of the issues.