What to do if meconium is present...

[mariamamaof5]

I haven't searched the threads for this so sorry if this is a repeat post but my hubby and I were just talking about our UC and this just came to my mind. Has anyone experienced this? And what should we do?

[sharita]

I am not sure what the exact protocol is but I just wanted to share that with my first HB my water broke and there was light meconium (very watered down) and my midwife didn't panic, heart tones were fine, no other sign of anything amiss, we just kept on laboring and he was fine.  She didn't even suction him which I thought was weird but she didn't think it nessesary.  I have a pic of him crowning and you can see the light green mec and it makes me shiver thinking how gross, haha.  We didn't do anything different though. 

I red one birth story a while back (written by the midwife) where upon water breaking, there was lots of heavy and thick mec and she interpreted that to be a sign of distress and that mama needed immediate transport.  Baby was indeed in trouble.  I have heard light mec isn't nessesarily a sign anything is wrong though it just depends.  Sometimes if you are post dates like 42 weeks plus, I think there is increase of chances of meconium passage in utero, With a breech, with super short fast labors (I think the theory is that the contractions are more intense and can cause baby to expell a little).  All these reason would be the ones that may not be of worry. 

As to what you should do I am not 100% but what I personally would do would just go by how much and how heavy it was, if its really light like water is just slightly greenish but no real thick stuff coming out with water, Id just suction baby after birth and pay close attention to respitory stuff with him/her.  REally thick, I think I wouldn't be able to help but worry and would transport if I had time, if not and he was already being born, I may call EMTs so that baby can be assessed or helped if needed.

This is a good question and now I want to research it a bit more.

Update: found this site to have a bit of info you may find useful:

http://www.homebirth.org.uk/meconium.htm 

[mariamamaof5]

Thanks Sharita!

[dayiscoming2006]

Thank for the link Sharita. I had 2 babies and both times there was some meconium and they were both born a bit before their due date. With my first they took him to suction him but he was fine. With my second, I was in a country without resources - like fetal monitoring. Might as well have been at home, but didn't have any home to birth in. Oh well. Anyway, he was fine too. I don't think I'll go rushing to a hospital if I notice meconium again. I'll just suction baby and make sure they are breathing well after the birth. 

[sosurreal09]

I have read some things about suctioning actually making it worse. Anyone else heard that?

[sharita]

Yes, I think it was the deep suctioning where the tube is pushed down the nose and stuff.  I think I read that they no longer recommend that unless the airway is actually blocked from meconium which would be a very rare thing.  I probably wouldn't worry too much about it unless there was obvious mec in the nostrils then if it was thin, Id just suction with bulb syringe because more than likely, baby didnt breath it up in the nostrils it just got there when baby passed through it. 

[AutumnAir]

DD2 passed mec at some point - I think during the pushing stage.  She came out covered in thick mec, though my mom (who caught her) said that the very top of her head, as she was crowning was clear, which is why I think it happened around that time.  She was born at 43+6 weeks and it was a super fast labour - about 45 minutes.  

Because of the post-dates thing I had done some thinking and research about mec.  My conclusions were that mec, esp. light mec on its own was no evidence of distress - there would need to be other signs for me to worry enough to transfer.  Most of my reading seemed to point to MAS (Meconium Aspiration Syndrome) as something that almost always happened in utero, well before labour/birth, and so not something that much could be done about at the time of the birth anyway.  And in fact, the usual hospital policies of routine deep suctioning in the presence of mec. can cause more problems than it solves, so I was very wary of that. I was prepared to use my little nasal suctioner and/or my mouth to do suctioning myself if I thought it necessary, and obviously to transfer in case of any breathing problems.

In the event, it was very straightforward.  DD2 was born in a couple of pushes, covered thick mec. She was completely alert from the beginning, looking around and not crying.  I checked her mouth and nose and both were totally clear of any signs of mec, so I felt comfortable skipping any kind of suctioning, and just keeping her under observation for a while to make sure I hadn't missed anything - but really, who's not going to be paying close attention to their newborn right after the birth anyway??  (We did end up transferring to the hospital for a few hours of obs - just to keep DH happy.  Mec was one of those things that had him totally freaked out, and I was okay with snuggling in a hospital room instead of at home for a few hours to assuage his fears.)

[greenmama66]

With my third he had very light mec and was born in my tub- I just lifted him up out of water and that was it. I had a midwife and she didn't do anything (suctioning) she just let us be and then helped me out of the tub. he was fine. If I was UCing I'd access how much mec there was and decide from there is baby's breathing was off etc; There is a UC video where a mama had heavier mec (baby born in water) and I don't think she did anything.

[hereyes]

Originally Posted by sharita 

Yes, I think it was the deep suctioning where the tube is pushed down the nose and stuff.  I think I read that they no longer recommend that unless the airway is actually blocked from meconium which would be a very rare thing.  I probably wouldn't worry too much about it unless there was obvious mec in the nostrils then if it was thin, Id just suction with bulb syringe because more than likely, baby didnt breath it up in the nostrils it just got there when baby passed through it. 

During consult with MW she just said that MWs have a saying (and bumper stickers): "meconium happens". She also said that if neonates were meant to have suctioning due to mec that one day a woman would give birth to a bulb syringe first, followed by baby...and it ain't happenin'.

I ended up in the hospital because of my husband and I did have meconium. The OB and nurses made a big stink about it when they noticed it. I made a big stink back, and they said that if DD seemed alright they would give her to me right away. In hindsight, I'm pretty sure they just told me that to get me to shut up. The OB ended up suctioning with bulb syringe once DD's head was out, DD cried instantly after being born--a nice, robust, healthy cry--, the OB immediately cut the cord (despite the fact that I told her NOT to cut or clamp the cord until it stopped pulsating), and then DD was passed off to the nurses where she received supplemental oxygen and endotracheal suctioning...she was crying--ahem, screaming--the whole time...

They worked on DD and did her newborn exams for probably 30+ minutes (I'm not sure how long, I was too busy crying because the whole experience was terrible). When they finally gave her to me (for some reason my husband held her first?!), I held her skin-to-skin. The nurse said that DD had "shallow breath sounds" and they would monitor that, but that the skin-to-skin with mother should aid in slowing her breathing down. It did just that.

Okay, so...based on what I know and what I was informed by the MW...all that was not necessary.

http://www.nlm.nih.gov/medlineplus/ency/article/001596.htm states:

Treatment

The delivering obstetrician or midwife should suction the newborn's mouth as soon as the head emerges during delivery.

Further treatment is necessary if the baby is not active and crying immediately after delivery. A tube is placed in the infant's trachea and suction is applied as the endotracheal tube is withdrawn. This procedure may be repeated until meconium is no longer seen in the suction contents....If there have been no signs of fetal distress during pregnancy and the baby is an active full-term newborn, experts do not recommend deep suctioning of the windpipe, because it carries a risk of causing a certain type of pneumonia.

Outlook (Prognosis)

Meconium aspiration syndrome is a leading cause of severe illness and death in newborns.

In most cases, the outlook is excellent and there are no long-term health effects.

In more severe cases, breathing problems may occur. They generally go away in 2 - 4 days. However, rapid breathing may continue for days.

In fact, DD's shallow breath sounds were more likely an adverse affect of the endotracheal suctioning (which has been associated with a plethora of adverse events and unpleasant side effects--as if hearing your baby gagging on a tube isn't bad enough) than meconium aspiration. DD did have a tight nuchal cord which is probably what caused the fetal distress leading to the meconium being eliminated during long labor/2 hours of pushing.

If your LO is born and is active and vigorous with a healthy cry and breath sounds, don't do squat. Even that preliminary suction once the head out seems a little excessive...just another thing that westernized medicine thought up to fix something that isn't broken.

[sosurreal09]

TY hereyes for sharing. Your poor baby. Glad it is all ok now.

[~~Sarah~~]

More important than what to do if, is what to consider as it is happening... IMNSHO meconium aspiration syndrome is exceedingly rare and over-diagnosed for no reason. No bulb syringe or even deep suctioning device will get meconium out of the baby's lungs - a baby must be intubated to accomplish this. So, what can you do? SFA.

More importantly, what does is mean if meconium is present in the waters? It could mean pretty much nothing, but it could also mean that the baby is in distress. Is the "greenness" getting worse? Better? What other signs are there?

[ElizabethE]

Hereyes and Sarah are right!

Meconium is not always aspirated and MAS is not the expected outcome. Like most things medical, it's blown out of proportion and most things are done *just in case*. Hello, rough treatment.

MAS can be dangerous but any attentive mother will see the signs of a problem in her baby. Difficulty breathing, strange noises, strange coloring (not to be mistaken with skin staining!)... a concerned mother would take her infant in to get checked out if she saw these types of signs. Then, if a baby truly does have MAS, they can be treated accordingly at the hospital/doctor for it just like any other hospital born baby. MAS would not kill your baby unless you are ignoring it and the signs for an extended period of time.

In short, meconium is nothing to panic about.

[phathui5]

Put down that bulb syringe.

I took neonatal resuscitation last Saturday with Karen Strange. The new guidelines are that if a baby is born and is vigorous (defined as breathing, good heart rate color and muscle tone) that you do not suction the baby.

Meconium aspiration syndrome isn't going to be prevented by sucking goop out of baby's nostrils. In fact, it's thought that it often happens before the baby is out.

[phathui5]

And as a side note, if you insist on suctioning even though it isn't recommended, always, always suction the baby's mouth before their nose. The thinking on this is that if you suction their nose first, they're going to gasp and inhale whatever was in the mouth.

[Shonahsmom]

Even though MAS is rare and not the expected outcome, it can be pretty damn serious when it does occur.

My eldest baby was a homebirth transfer. When my water broke, there was moderate meconium, enough that my midwives felt it no longer appropriate to be at home. I went to the hospital and had a lovely, unmedicated birth, attended by my HB MW, who also had hospital privileges. My baby tolerated the pretty short labor very well and we expected a healthy outcome. My MW did have a NICU team waiting outside the door as my baby was crowning, just in case.

My baby had aspirated severely and she was not able to breathe. She had no tone and turned blue and then purple. The NICU team had to resuscitate and then ultimately intubate her. She had to be intubated for 24 hours and then struggled with breathing for another couple of days.

I feel comfortable saying that if she had been born at home she likely would have died of suffered severe brain damage. Even born at the hospital, with a NICU team at our immediate disposal, there was still some concern about brain damage because she was oxygen deprived for several minutes while they worked on her. She was ultimately okay. I went on to homebirth my next baby and am planning to homebirth the one I have on the way. But, at the firt sign of anything other than really light meconium, I will high tail it to the hospital without thinking twice.

[savithny]

Originally Posted by ElizabethE 
Meconium is not always aspirated and MAS is not the expected outcome. Like most things medical, it's blown out of proportion and most things are done *just in case*. Hello, rough treatment.

MAS can be dangerous but any attentive mother will see the signs of a problem in her baby. Difficulty breathing, strange noises, strange coloring (not to be mistaken with skin staining!)... a concerned mother would take her infant in to get checked out if she saw these types of signs. Then, if a baby truly does have MAS, they can be treated accordingly at the hospital/doctor for it just like any other hospital born baby. MAS would not kill your baby unless you are ignoring it and the signs for an extended period of time.

In short, meconium is nothing to panic about.

Actually, respiratory distress in a newborn isn't that obvious, and even an attentive, unmedicated, mother may not readily recognize the signs.

Respiratory distress in the newborn is characterized by one or more of the following: nasal 
flaring, chest retractions, tachypnea, and grunting. Nasal flaring is a relatively frequent 
finding in an infant attempting to decrease airway resistance. Suprasternal retraction 
indicates upper airway obstruction. Subcostal retraction, on the other hand, is a less specific 
sign that may be associated with either pulmonary or cardiac diseases. Normally, the 
neonate takes 30 to 60 breaths/min. The infant breathes at a faster rate to maintain 
ventilation in the face of decreased tidal volume. An infant in respiratory distress may try to 
maintain lung volume with adequate gas exchange by partially closing the glottis during 
expiration. This is the mechanism responsible for the audible grunting in these infants. An 
infant who has an advanced degree of respiratory distress may exhibit additional signs, such 
as cyanosis, gasping, choking, apnea, and stridor. The managing physician should consider 
these additional signs to be “alarming.”

THe signs you mention are actually advanced signs of respiratory distress, signs that indicate the baby is having serious difficulties.   The earliest signs of distress are much harder for a novice, even an attentive mother, to catch.    I've been reading parenting boards and blogs for 12 years now, and in that time I've read quite a few birth stories in which the mother was totally unaware that her newborn was struggling to breathe until a midwife, doctor, or nurse, said something like "She's grunting a little," or noticed a nostril flare.    I don't think I've ever read one where the mother was the one to say "Wow, that chest retraction doesn't look normal."   In fact, when my 2nd was an infant, she got a respiratory infection and was retracting, and I didn't even know that *that* was what "retracting" was.    

I'm a big advocate of being as knowledgable as possible about birth and babies going into labor, birth, and parenting -- but we can't all be content experts in everything, and maternal intuition is not some kind of panacea, or replacement for the knowledge that comes from having watched dozens or hundreds of newborns breathe in all their various healthy or unhealthy ways -- and it is disingenuous to argue that every birthing woman will automatically just *know* what respiratory distress looks like.   I teach my kids that one of the most important things to know in this world is what we *don't* know (See also the "Kruger-Dunning effect" http://en.wikipedia.org/wiki/Dunning–Kruger_effect).   

That said, it is true that mec is not some kind of automatic problem.  There was mec staining when my water broke with my first birth, and when I expressed concern, the midwife reassured me that it was no big deal, that there's some mec at many births, and while we'd watch the baby a bit more closely, it wasn't going to change the birth at all.

[leahsmama]

First thing: I am not totally comfortable with UC's but I don't begrudge anyone who wants one as long as they are aware of signs and symptoms of problems and are willing to get support if problems arise.

Originally Posted by phathui5 

Put down that bulb syringe.

I took neonatal resuscitation last Saturday with Karen Strange. The new guidelines are that if a baby is born and is vigorous (defined as breathing, good heart rate color and muscle tone) that you do not suction the baby.

Meconium aspiration syndrome isn't going to be prevented by sucking goop out of baby's nostrils.

You are right about the standards about *when* to suction, but if a meconium baby needs to be suctioned, you are supposed to be doing deep suction with a meconium aspirator to get the meconium out of the trachea. This is why someone with training and equipment needs to be present if there is meconium present. Yes, there is a good chance the baby will come out vigorous, but if he/she doesn't, you need to have proper suction tools. That's why, in my mind, serious staining is a reason to transfer or at least call for assistance just in case the baby need assistance. If you wait to see how the baby is when he/she comes out, and he/she does NOT come out vigorous, the baby needs intervention IMMEDIATELY. As Shonahsmom said, even with an NICU team, it can sometimes be difficult to recover a baby with serious aspiration.

Originally Posted by savithny 

Actually, respiratory distress in a newborn isn't that obvious, and even an attentive, unmedicated, mother may not readily recognize the signs.

THe signs you mention are actually advanced signs of respiratory distress, signs that indicate the baby is having serious difficulties.   The earliest signs of distress are much harder for a novice, even an attentive mother, to catch.    I've been reading parenting boards and blogs for 12 years now, and in that time I've read quite a few birth stories in which the mother was totally unaware that her newborn was struggling to breathe until a midwife, doctor, or nurse, said something like "She's grunting a little," or noticed a nostril flare.    I don't think I've ever read one where the mother was the one to say "Wow, that chest retraction doesn't look normal."   In fact, when my 2nd was an infant, she got a respiratory infection and was retracting, and I didn't even know that *that* was what "retracting" was.    

I'm a big advocate of being as knowledgable as possible about birth and babies going into labor, birth, and parenting -- but we can't all be content experts in everything, and maternal intuition is not some kind of panacea, or replacement for the knowledge that comes from having watched dozens or hundreds of newborns breathe in all their various healthy or unhealthy ways -- and it is disingenuous to argue that every birthing woman will automatically just *know* what respiratory distress looks like.   I teach my kids that one of the most important things to know in this world is what we *don't* know (See also the "Kruger-Dunning effect" http://en.wikipedia.org/wiki/Dunning–Kruger_effect).   

That said, it is true that mec is not some kind of automatic problem.  There was mec staining when my water broke with my first birth, and when I expressed concern, the midwife reassured me that it was no big deal, that there's some mec at many births, and while we'd watch the baby a bit more closely, it wasn't going to change the birth at all.

Excellent, excellent post savithny . Serious respiratory distress is usually easy to spot, but the early signs are not. I work in NICU and I cannot count the number of times I have had parents comment about the "cute" sounds their baby is making when the baby is in distress. A grunty baby is definitely something that takes practice to recognize. I forget who said it but this is so true: "The more I learn, the more I learn how little I know".

Originally Posted by ElizabethE 
.......but any attentive mother will see the signs of a problem in her baby. Difficulty breathing, strange noises, strange coloring (not to be mistaken with skin staining!)... a concerned mother would take her infant in to get checked out if she saw these types of signs. Then, if a baby truly does have MAS, they can be treated accordingly at the hospital/doctor for it just like any other hospital born baby. MAS would not kill your baby unless you are ignoring it and the signs for an extended period of time.

In short, meconium is nothing to panic about.

ElizabethE, I think saying "....but any attentive mother will see the signs of a problem in her baby" is unfair to women who have not noticed problems with their baby. As I said, respiratory distress in a newborn can be very subtle and I wouldn't be at all surprised if a woman who had just given birth missed it. Frankly, even being an NICU nurse, I would not trust my self to spot a problem with my own baby. I was so blinded by the whole birth experience and the sheer joy at having my baby, I probably would have missed the early signs of distress.

Originally Posted by ElizabethE 
MAS would not kill your baby unless you are ignoring it and the signs for an extended period of time.

This is misleading. MAS is not often fatal with treatment, but if you are at home, without the proper training and equipment, if most certainly can kill your baby. If there is heavy staining and the baby comes out flat, it may be too late to get to a hospital.

So all said and done, light meconium can probably be managed with close observation of the baby after birth (so long as you know what you are looking for), but heavy meconium should be managed by someone with equipment to suction and intubate if necessary.

*Edited because I messed up the quotes*

[jeminijad]

Originally Posted by savithny 

Actually, respiratory distress in a newborn isn't that obvious, and even an attentive, unmedicated, mother may not readily recognize the signs.

THe signs you mention are actually advanced signs of respiratory distress, signs that indicate the baby is having serious difficulties.   The earliest signs of distress are much harder for a novice, even an attentive mother, to catch.   it is disingenuous to argue that every birthing woman will automatically just *know* what respiratory distress looks like.   I teach my kids that one of the most important things to know in this world is what we *don't* know (See also the "Kruger-Dunning effect" http://en.wikipedia.org/wiki/Dunning–Kruger_effect).   

That said, it is true that mec is not some kind of automatic problem.  There was mec staining when my water broke with my first birth, and when I expressed concern, the midwife reassured me that it was no big deal, that there's some mec at many births, and while we'd watch the baby a bit more closely, it wasn't going to change the birth at all.

Thank you for this. Some of the most troubling stories I've read are those where even the midwife did not diagnose breathing problems after apparently healthy births, with bad outcomes several hours later. It is simply false that an attentive mother will pick up on the beginnings of respiratory distress in the neonate.

[~~Sarah~~]

Originally Posted by jeminijad 


Thank you for this. Some of the most troubling stories I've read are those where even the midwife did not diagnose breathing problems after apparently healthy births, with bad outcomes several hours later. It is simply false that an attentive mother will pick up on the beginnings of respiratory distress in the neonate.

Yes. I totally agree. Sometimes respiratory distress takes on very mild symptoms that can lead to very bad outcomes. But what does it have to do with mec in the waters? It is still an incredibly rare occasion that meconium in the fluid leads to respiratory distress. Respiratory distress in and of itself is not rare. It's one of those things - it. just. happens. If you are comfortable UCing you need to be comfortable with that fact.

The original question is "what to do if meconium is present". The very real likelihood is not MAS but that the baby is showing a sign of distress that should be taken seriously. Whether that means more frequent monitoring or a straight transfer or nothing at all - is up to you.

[savithny]

Originally Posted by ~~Sarah~~ 

Yes. I totally agree. Sometimes respiratory distress takes on very mild symptoms that can lead to very bad outcomes. But what does it have to do with mec in the waters? It is still an incredibly rare occasion that meconium in the fluid leads to respiratory distress. Respiratory distress in and of itself is not rare. It's one of those things - it. just. happens. If you are comfortable UCing you need to be comfortable with that fact.

The original question is "what to do if meconium is present". The very real likelihood is not MAS but that the baby is showing a sign of distress that should be taken seriously. Whether that means more frequent monitoring or a straight transfer or nothing at all - is up to you.

To the bolded:  Exactly.   If you plan to UC, part of the process of coming to that decision needs to be knowing that it does happen, and being honest about how much you can do about it.    Being honest with yourself includes not pretending that every reasonably attentive mother will be able to recognize very subtle indicators.

That honesty is vital, because a realistic assessment of your own capacities is the foundation of your last statement.  In deciding what to do when a situation arises, you need to recognize both what you are and are not capable of, and not make your decision based on on overly-optimistic self-image.     Thus, the idea that a "reasonably attentive mother" will obviously spot problems right away really needs to be questioned, lest someone take it as a given and make their decisions based on it.