breaking water to check for meconium?

[beachmommy5]

I thought I would get the opinion of you wonderful ladies since I had a concern about something my midwife said....

I found a mw practice I like and the two out of four mw's that I have talked to thus far have no problem with my natural/non intervention birth plan, and as far as I know the other two are on the same page as well. My concern is that when I asked about all the "routine" interventions usually done in labor the mw said they do none of them except that they do break the water before birth to check for meconium and if it is present that a NICU team must be present in the room, not necessarily wisk the baby off but do the initial check to make sure everything is ok and that if present it would necessitate immediate cord cutting ( I want to delay cord cutting). I know that meconium inhalation can cause serious problems although it does not always happen, especially if the baby is suctioned before it is stimulated to breath.

My question is does this policy of breaking the water before birth to check for meconium seem reasonable to you and not a sign of mw's who are not as pro natural and non intervention as they seem? Also if meconium is present does this really mean that the cord has to be cut right away or can they do the initial check while baby is on my chest? I don't have a problem with taking extra care if meconium is present but I don't want to get set up with a bunch of interventions either.

TIA!

[onelilguysmommy]

thats not reasonable for a step for every woman. Also, no they wouldnt necessarily *have* to cut the cord either... just makes everything easier on them.

(and you dont have to stimulate a baby to breathe either, in most cases unless they have an issue...)

[onlyboys]

I think this is a silly reason to break a bag of waters and potentially introduce bacteria to the uterus. I would refuse it. If, when your water breaks there is mec staining, you can deal with it then.

[BirthFree]

Not only bacteria problems but then it's less cushioned for baby, sticks baby in a potentially bad position, messes with the natural birth process and usually adds more intensity/pain for Mom.

No need to do it in my opinion...

[Jane]

Are they talking about breaking it 5 minutes before birth or when you arrive at the hospital?
I have worked with midwives who routinely break the water bag if it's still intact at pushing saying that the bag has already done it's job if the mama is completely dialated. Evidence says it doesn't make pushing faster. But I've seen it make mamas more comfortable (removes the bulging bad in the vagina) and seem to push more effectively (get more feedback without the bag).
Breaking water at admission is a silly, outdated, non-evidence based practice.

[BrooklynDoula]

My birth with my bag intact was amazing and I'd never let someone break it after that experience (with the first they broke it at 9.5 cm because of a lip). I see no good reason to routinely break the bag just to check for mec staining.

[pamamidwife]

even if there is meconium, in a baby that has done beautifully throughout labor there should be no need to have a NICU team standing by. the evidence clearly shows that suctioning of any kind on a vigorous, healthy newborn is not beneficial and could even be harmful.

[maxmama]

Voice of dissent here.

Yes, as a labor nurse I like to know if there is mec. A vigorous NB does not need assistance. Not all mec babies (or any babies) are vigorous, and for nonvigorous NBs visualization of the cords and deep suction are still NRP standard. I don't intubate, because I don't do it enough to be good at it. I want to have RT there to do that.

What we will generally do is break the bag during pushing if it hasn't SROMed. Minimal risk of infection, since the baby generally is born within 10 minutes. I am comfortable with this, though clearly some are not.

[BirthFree]

I have to also add that my MW breaking my bag of water in my first two births robbed me of that experience as well as the other reasons outlined above - it was HER routine way of practicing, but not one I appreciated or would have someone do in the future. My last birth my bag broke just before he was born and it was awesome.

If the bag has done it's job and WE know better than nature, then why don't we decide when we feel baby is done cooking? It all has a purpose down to the very last minutes - be it empowerment to the mother or comfort for both - it should not be taken away by a MW or other provider for their convenience when like Pamela has said above:

in a baby that has done beautifully throughout labor there should be no need to have a NICU team standing by. the evidence clearly shows that suctioning of any kind on a vigorous, healthy newborn is not beneficial and could even be harmful.

[mwherbs]

I think that there is a big difference between ROM at pushing and ROM at the onset of labor . Rupturing membranes just to see if there is mec, we don't do but often at pushing you get a big bubble of forewaters that if ruptured will give mom a bit of relief from the pressure.

[pamamidwife]

Originally Posted by maxmama

Voice of dissent here.

Yes, as a labor nurse I like to know if there is mec. A vigorous NB does not need assistance. Not all mec babies (or any babies) are vigorous, and for nonvigorous NBs visualization of the cords and deep suction are still NRP standard. I don't intubate, because I don't do it enough to be good at it. I want to have RT there to do that.

What we will generally do is break the bag during pushing if it hasn't SROMed. Minimal risk of infection, since the baby generally is born within 10 minutes. I am comfortable with this, though clearly some are not.

The presence of meconium isn't a clue on whether or not a baby will be compromised.

Poor fetal heart tones will offer that information.

Intubation of nonvigorous babies is sometimes needed for resus - whether there is mec or not. I still argue with the idea that nonvigorous babies with mec need deep suction. I disagree. We know that deep suctioning causes a vagal response in babies, often further complicating resuscitation efforts with severe bradycardia on top of what compromise you already have. If you can get an airway, that's what is important - not meconium. There is more and more research to show that mec aspiration does not happen with the first breath, but likely happens in utero. Suctioning is not something that will help make an unresponsive baby better, mec or no.

[maxmama]

Originally Posted by pamamidwife

The presence of meconium isn't a clue on whether or not a baby will be compromised.

Poor fetal heart tones will offer that information.

Intubation of nonvigorous babies is sometimes needed for resus - whether there is mec or not. I still argue with the idea that nonvigorous babies with mec need deep suction. I disagree. We know that deep suctioning causes a vagal response in babies, often further complicating resuscitation efforts with severe bradycardia on top of what compromise you already have. If you can get an airway, that's what is important - not meconium. There is more and more research to show that mec aspiration does not happen with the first breath, but likely happens in utero. Suctioning is not something that will help make an unresponsive baby better, mec or no.

PPV will often help make a floppy baby better. PPV can be done more efficiently, if needed for a long period of time, with an ET tube.

I am aware of the mec research and love the changes to NRP, because it put an end to suctioning on the perineum. But if I have a potentially compromised baby, I want to have everyone there. If they don't need to be there -- fabulous, they leave. But it's my responsibility to plan for worst-case scenarios as well as most likely scenarios. It's not the job of the provider, of the baby nurse or anyone else. So damn straight -- it is policy in my hospital that we have RT there for mec deliveries, and I want to make sure they actually are there. I like my job, you know. I like having my job. I want to continue to have my job.

[nadine]

to the op, i would ask the midwives when they break the water, do they break it right at the end just to see if there is meconium? or do they break it earlier on admission?

where i work (hospital L&D), they like to know if there is meconium. if there is mec, peds do come for delivery. if baby is not vigorous and mec present, deep suctioning is done (nrp guidelines are followed).

that being said, i have seen moms decline arom and have their babies born on caul. and i have seen doctors not even offer to rupture either and have babies born on caul.

[pamamidwife]

Originally Posted by maxmama

PPV will often help make a floppy baby better. PPV can be done more efficiently, if needed for a long period of time, with an ET tube.

I do not - and did not - disagree with this. What I do disagree with is visualizing the cords of any baby with mec for suctioning. I've seen this done numerous times on vigorous babies with mec and it causes major issues. When you're intubating a baby for resus, that is definitely different.

[nurnur]

so if they need to have the rt team there and ready in case then they must arom before the very end....oh but that is why they always find a reason to do it before we even get to 2nd stage. Can you imagine all the intact bags bulging into 2nd stage, the RT teams would have to be scrambling like crazy at the drop of a hat.

[doctorjen]

Hmm. I don't break water to check for mec at all, 2nd stage or 1st. Birthing with membranes intact is rare, even when you don't do AROM (I've only had 4 ever in my career - and 2 of them were this week!) so usually you know about mec to begin with. I follow the new NRP guidelines, if the baby is vigorous at birth, I do nothing. If baby is not vigorous, or especially if not making respiratory efforts or in respiratory distress, I suction. Perhaps the difference is that I practice in a rural setting, and *I* would be the one doing any intubating, so having to get someone else there isn't an issue. I think the chance of having to intubate a baby due to meconium is remote enough that I'm not willing to routinely AROM for it.
I've had one baby in my career with meconium aspiration syndrome (in almost 400 births) and that baby was actually quite vigorous at birth, and developed respiratory distress within the first hour. He was the most deeply stained baby I've ever seen - had yellow fingernails, deep yellow cord, and looked almost jaundiced, and was IUGR most likely due to his mother's continued drug use and severe, poorly controlled asthma. This baby also had non-reassuring fetal heart rate tracing and we were getting ready to move to cesarean when his mom progressed suddenly and birthed him quickly, so he had every risk factor for doing poorly. He came out squalling and with APGARs of 9 and 10, though, and didn't get suctioned.

[mothercat]

alternative to AROM

In Birth Reborn Michel Odent discusses this very point. His suggestion: if you really need to know if there is mec, don't break the bag. Use a little periscope device to view the bag through the vagina. He describes one that he has seen used this way.

This could be a really good use for those flexible endoscopes that are used for GI and bronchial procedures in the hospital. And they are a lot smaller than a hand holding an amnio hook.

Either way, no AROM for mom and baby and the staff still gets the info they need to prepare for birth.

[lunaliss]

AROM to check for mec?
sure, if you're bound to hospital protocol.
If you trust birth and baby and the clues of a healthy birth... no need.
If you have respect for mama's wishes and she opts for low intervention, it serves no purpose and has the potential to invite infection, poor fetal positioning, possible operative assist... there IS NO INTERVENTION WITHOUT POTENTIAL ADVERSE EFFECT.
Look at the evidence and if your hospital's protocols are not up to date, work on that. Don't take it out on the babies we are trying to gently birth.