MECONIUM STAINED LIQUOR (MSL) IN LABOUR AND

MANAGEMENT OF THE NEWBORN - CLINICAL GUIDELINE

1. Aim/Purpose of this Guideline
1.1. This guideline gives guidance to midwives, obstetricians and neonatal staff
on the management of meconium stained liquor in labour and the initial
management of a baby born through meconium. This does not cover care on the
neonatal unit or the management of Meconium Aspirate Syndrome (MAS).

2. The Guidance
2.1. Introduction
Between 15%-20% of term pregnancies are associates with meconium stained
liquor (MSL), which, in the vast majority of labours, is not a cause for concern.
However, in some circumstances, the passage of meconium in utero is
associated with significant increases in perinatal morbidity and mortality. The
aspiration of meconium into the lungs during intrauterine gasping, or when the
baby takes its first breath, can result in a life-threatening disorder known as
meconium aspiration syndrome (MAS) and this accounts for 2% of perinatal
deaths.
2.2. Identification and management in labour of MSL
Pre labour rupture of membranes: Any woman that makes contact with
the maternity service and reports spontaneous rupture of membranes with
any meconium staining should be advised admission to the consultant led
unit for assessment. If MSL is confirmed, continuous electronic fetal
monitoring (CEFM) should be commenced and a plan made for Induction
of labour (IOL).
Low risk intrapartum woman in the community setting: If during
labour, MSL becomes evident, a risk assessment should be undertaken to
include, the stage of labour, parity, whether the meconium staining is
significant (significant is described as either dark green or black amniotic
fluid that is thick or tenacious or contains lumps of meconium) or light,
current fetal well being and transfer time. If transfer to a unit with neonatal
facilities can be achieved before delivery, the woman should be advised to
transfer, by ambulance, to a consultant lead unit. If birth is expected before
transfer can be facilitated, preparations should be made for resuscitation of
the newborn and consideration given to calling an ambulance for transfer
of the baby, following birth.
Intrapartum women in the consultant lead unit: If the woman is being
cared for as a low risk woman on delivery suite and MSL is identified, the
woman should be informed of the significance of MSL and that CEFM is
indicated and that the presence of a member of the neonatal team will be
called for delivery, and observation of the baby will be advised in the post
natal period. The white board should be updated and the coordinator and
obstetrician informed of the presence of meconium, and care transferred to
consultant lead care.
High risk intrapartum woman on delivery suite: If the woman already
has risks factors requiring CEFM and MSL is identified, the white board

should be updated and the coordinator and obstetrician should be

informed of the presence of MSL, the woman should be informed of the
significance of MSL and that a member of the neonatal team will be called
for delivery, and observation of the baby will be advised in the post natal
period.
2.3. Management of a baby born through MSL
Suctioning of the nasopharynx and oropharynx prior to the birth of the
shoulders and trunk should not be carried out.
Resuscitation equipment should be checked and available in the delivery
room/area
If in the consultant unit a member of the neonatal team should be called for
delivery
A baby born through meconium should not be stimulated in any way,
however, if the baby is vigorous and breathing at birth with no signs of
airway obstruction, no action is required and baby can remain skin to skin
with its mother.
The upper airways should only be suctioned, by a healthcare professional
trained in advanced neonatal life support, if the baby has thick or tenacious
meconium present in the oropharynx
If the baby has depressed vital signs, laryngoscopy and suction under
direct vision should be carried out by a healthcare professional trained in
advanced neonatal life support. If in the community setting basic life
support should be commenced and immediate transfer by ambulance to a
unit with neonatal facilities should be facilitated.
2.4. Ongoing care of a baby born through meconium
If the baby is vigorous at birth, a plan should be made and documented by
the attending neonatologist for observation to be carried out at 1hour and 2
hours of age for signs of respiratory distress. The observations must be
documented on a neonatal early warning score (NEWS) chart. These
observations must be commenced in the delivery setting. Provided the
baby remains well these observations can be carried out in the community
setting.
For any baby born though meconium with signs of initial depression but
responds rapidly to suction and has no ongoing abnormal respirator signs,
the attending neonatologist must make and document a plan for the baby
to be admitted to the post natal ward/area and observed for signs of
respiratory distress at 1 hour and 2 hours of age and then 2 hourly until 12
hours of age. These observations must be commenced in the delivery
setting.
Any baby with initial depression requiring more prolonged resuscitation or
meconium is aspirated from below the cords should be assessed by the
neonatal team and admission to the neonatal unit considered.
2.5. Documentation: All observations must be completed and documented in
a timely manner not to exceed 15 minutes of the required time. Observations
should be recorded on a neonatal early warning score (NEWS) chart, CHA
3296 V1 Observations include: temperature, respiration, grunting, heart rate,
colour and circulation and neuro and scored and the scores must be
Meconium Stained Liquor (MSL) In Labour And Management Of The Newborn - Clinical Guideline

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responded to appropriately. Once observations have been commenced the

NEWS chart should be filed and remain in the neonatal notes.
2.6. Neonatal referral: If the babys condition causes concern at any time a
review by the neonatal team should be requested. This should be
documented on the intrapartum record if still on delivery suite or in the
neonatal notes section of the hand held notes. If in the post natal period, the
documentation of the review of the baby by the neonatal team will be in the
baby notes.

3. Monitoring compliance and effectiveness

Element to be
monitored

Lead
Tool

Frequency

Reporting
arrangements

Acting on
recommendations
and Lead(s)

Change in
practice and
lessons to be

The audit will take into account record keeping by obstetricians

and midwives
The results will be inputted onto an excel spreadsheet
The audit will be registered with the Trusts audit department
Maternity Risk Management Midwife
Was the NEWS chart filed in the neonatal notes
Was a plan documented by the neonatologist
If baby born in good condition and required no resuscitation,
were observation documented on the observation chart at 1
hour and 2 hours of age
If baby required suction at birth but no ongoing signs of
respiratory depression were observation documented on the
observation chart at 1 hour and 2 hours of age and every 2
hours until 12 hours of age
Were observations performed within a 15 minute window
If there were concerns about the babys condition were the
actions taken documented in the appropriate section of the
notes
1% or 10 sets, whichever is greater, of all health records of
newborns with MSL present at delivery, will be audited over a 12
month period
A formal report of the results will be received annually at the
Maternity Risk Management and Clinical Audit Forum, as per
the audit plan
During the process of the audit if compliance is below 75% or
other deficiencies identified, this will be highlighted at the next
Maternity Risk Management and Clinical Audit Forum and an
action plan agreed.
Any deficiencies identified on the annual report will be
discussed at the Maternity Risk Management and Clinical Audit
Forum and an action plan developed
Action leads will be identified and a time frame for the action to
be completed by
The action plan will be monitored by the Maternity Risk
Management and Clinical Audit Forum until all actions complete
Required changes to practice will be identified and actioned
within a time frame agreed on the action plan
A lead member of the forum will be identified to take each

Meconium Stained Liquor (MSL) In Labour And Management Of The Newborn - Clinical Guideline

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shared

change forward where appropriate.

The results of the audits will be distributed to all staff through
the Risk Management Newsletter/Audit Forum as per the action
plan

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement which can be found in the 'Equality, Diversity &
Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information

Document Title

MECONIUM STAINED LIQUOR (MSL) IN

LABOUR AND MANAGEMENT OF THE
NEWBORN - CLINICAL GUIDELINE

Date Issued/Approved:

1st May 2014

Date Valid From:

1st May 2014

Date Valid To:

1st May 2017

Directorate / Department responsible

(author/owner):

Sarah Hadfield, Women and Childrens

and Sexual Health Division

Contact details:

01872 252879
This guideline gives guidance to
midwives, obstetricians and neonatal staff
on the management of meconium stained
liquor in labour and the initial
management of a baby born through
meconium. This does not cover care on
the neonatal unit or the management of
meconium aspirate syndrome (MAS).
Meconium, meconium stained, liquor,
MSL, aspiration, new-born, observation,
RCHT
PCH
CFT
KCCG

Brief summary of contents

Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:

Medical Director

Date revised:

1st May 2014

This document replaces (exact title of

previous version):

Management of infants born through

meconium stained liquor (MSL)
Maternity Guideline Group,
Obs and Gynae Directorate Meeting
Divisional Board

Approval route (names of

committees)/consultation:
Divisional Manager confirming
approval processes

Head of Midwifery

Name and Post Title of additional

signatories

Not Required

Signature of Executive Director giving

approval
Publication Location (refer to Policy
on Policies Approvals and

{Original Copy Signed}

Internet & Intranet

Meconium Stained Liquor (MSL) In Labour And Management Of The Newborn - Clinical Guideline

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Intranet Only

Ratification):
Document Library Folder/Sub Folder

Clinical/Midwifery and Obstetrics

Links to key external standards

CNST 5.4
NICE (2007) Intrapartum Care Care
of healthy women and their babies
during childbirth. NICE, London

Related Documents:

RCHT (2012) Clinical guideline for

the management of pre labour
rupture of membranes at term
(TermPROM).

Training Need Identified?

No

Version Control Table

Date
August
2005

Version
No
1.0

Summary of Changes
Initial document

Changes Made by
(Name and Job Title)
Paul Munyard
Consultant
Neonataoligist
Paul Munyard
Consultant
Neonataoligist
Jan Clarkson
Maternity Risk
Manager

September
2009

1.1

Updated to include NICE guidance

September
2012

1.2

Reviewed and updated, compliance

monitoring added

1.3

Updating use of NEWS chart and reinforcing

timeliness of observations:
a) Observations commenced in delivery
setting
Sarah Hadfield
b) NEWS chart to be used for recording
Midwife
observations and filed in neonatal notes
c) Observations to be recorded in a timely
manner not not exceeding 15 minutes of
required time

1st May
2014

All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing

Meconium Stained Liquor (MSL) In Labour And Management Of The Newborn - Clinical Guideline

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Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

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Appendix 2.Initial Equality Impact Assessment Screening Form

Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Clinical guideline for the management of meconium stained liquor in
labour and management of the newborn.
Directorate and service area:
Is this a new or existing Procedure?
Obs and Gynae
Existing
Name of individual completing
Telephone:
assessment: Elizabeth Anderson
01872 252879
1. Policy Aim*
This guideline gives guidance to midwives, obstetricians
and neonatal staff on the management of meconium
stained liquor in labour and the initial management of a
baby born through meconium.
2. Policy Objectives*
Safe, evidenced based management of meconium stained
liquor in labour and initial management of the new-born.
3. Policy intended
Outcomes*

Good outcome for a baby born through meconium.

5.
How will you
measure the outcome?

Compliance Monitoring Tool.

5. Who is intended to
benefit from the Policy?

Pregnant Women and their new-born babies

6a. Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around this
policy?

No

b. If yes, have these

groups been consulted?

N/A

c. Please list any groups N/A

who have been consulted
about this procedure.

7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Sex (male, female, trans-

Yes

No
X

Rationale for Assessment / Existing Evidence

gender / gender
reassignment)

Meconium Stained Liquor (MSL) In Labour And Management Of The Newborn - Clinical Guideline

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Race / Ethnic
communities /groups

Disability -

learning
disability, physical
disability, sensory
impairment and
mental health
problems

Religion /
other beliefs

Marriage and civil

partnership

Pregnancy and maternity

Sexual Orientation,

Bisexual, Gay, heterosexual,

Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
You have ticked Yes in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
X

9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director
Sarah Hadfield
Midwife
Names and signatures of
1. Elizabeth Anderson
members carrying out the
2.
Screening Assessment

Date of completion and submission

1st May 2014

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trusts web site.
Signed: Elizabeth Anderson
Date: 1st May 2014

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Appendix 3: Flowchart for the management of a baby born through

meconium

Identification of MSL in labour, assess for

transfer to consultant led care, CEFM,
prepare for possible resuscitation

Do not stimulate the baby,

but if baby born with no signs
of respiratory depression and
vigorous, remain skin to skin
with mum

Do not stimulate the baby, if baby born

with initial respiratory depression (at 1015 seconds heart rate < 100bpm, no
spontaneous breathing, poor muscle
tone), take to resuscitation area

Trained professional to inspect

airways under direct vision, if
meconium seen aspirate with a
large bore sucker. If in community
setting commence basic life
support and transfer.

No resuscitative action
required

Observations at 1 hour
and 2 hours of age as
per NEWS chart. (Can
be carried out in
community setting, if
baby remains well)

Baby responds
rapidly to suction
and no further
abnormal respiratory
signs
.

Admit to post natal

ward for
observations at 1
hour and 2 hours
and then every 2
hours until baby 12
hours old

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Baby has
meconium below
the cords or
continuing
depressed vital
signs
Consider
intubation and
direct tracheal
suction, if infant
deteriorating (HR
<60bpm) suction
should be
discontinued and
inflation breaths
delivered