SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
S.Y. 2018-2019

A Case Study on Meconium Staining:

Introduction

Meconium is a dark green liquid normally passed by the newborn baby, containing
mucus, bile and epithelial cells.

However, in some cases the meconium is passed when the baby is still in the womb,
staining the amniotic fluid. This can vary from light to heavy staining. It is considered significant
if dark green or black, with a thick, tenacious appearance.

Components of the meconium, especially the bile salts and enzymes, can cause serious
complications if they are inhaled by the fetus at any stage of labour. This can result in meconium
aspiration syndrome (MAS). There are several pathological mechanisms participating in MAS,
particularly airway obstruction, surfactant dysfunction, inflammation, lung oedema, pulmonary
vasoconstriction and bronchoconstriction.

Meconium staining often occurs in conjunction with other causes of fetal distress. It is
rare in babies born at <34 weeks of gestation.

Etiology

Deliveries complicated with meconium-stained amniotic fluid are associated with

additional adverse pregnancy outcomes (eg, increased rates of labour dystocia, delivery by
caesarean section and fetal distress).
Risk factors include:

 Placental insufficiency.

 Maternal hypertension and pre-eclampsia.

 Oligohydramnios.

 Smoking.

 Cocaine abuse.

 Increased maternal age.

Meconium-stained amniotic fluid is really worrisome from both the obstetrician's and the
pediatrician’s point of view, as it increases the caesarean rates, and causes birth asphyxia, MAS
and an increase in neonatal intensive care unit admissions.

Signs and Symptoms

Each baby may experience symptoms of meconium aspiration differently, but the following are
the most common signs:
 Rapid or labored breathing
 Retractions, or pulling in of the chest wall
 Grunting sounds with breathing
 Bluish skin color, called cyanosis
 Low apgar score, a rating of a baby's color, heartbeat, reflexes, muscle tone and respiration
just after birth
 Limp body
 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
S.Y. 2018-2019

Exposure to meconium in the amniotic fluid for a long time may cause yellowed skin and nails.

Management

These recommendations are from the National Institute for Health and Care Excellence
(NICE), 2014.

Intrapartum
 If significant meconium staining is noted in labour, there should be continuous electronic fetal
monitoring.

 This is defined as dark green or black amniotic fluid that is thick or tenacious, or any amniotic
fluid that contains lumps of meconium.

 Transfer mother to obstetric-led care, if it is safe to do so and delivery is not imminent.

 If there are signs of fetal distress, a fetal blood sample should be obtained. If pH is <7.21,
there should be emergency delivery.

 Ensure that the advanced resuscitation unit and appropriately trained staff are available.

 There should be no suction prior to delivery.

At delivery - healthy neonate

 If the baby is in good condition (Apgar score >5, based on colour, tone, heart rate and
breathing), there should be no suction.

 The baby should be observed for signs of respiratory distress in the first hour of life, in the
second hour and then two-hourly until 12 hours old.

 If there is blood or if there are lumps of meconium in the oropharynx, suction should be used
in the upper airways.

 Endotracheal intubation at birth in otherwise healthy, term meconium-stained babies, is no

longer recommended.

At delivery - sick neonate

 Therapeutic interventions in severe MAS include airway suctioning, oxygen delivery, or
ventilatory support

 Suction - the National Institute for Health and Care Excellence (NICE) does not recommend
routinely suctioning the nasopharynx and oropharynx prior to birth of the shoulder and trunk.
However, it advises that the upper airways may be suctioned after the shoulders are delivered,
if thick or tenacious meconium is present in the oropharynx. If the baby has depressed vital
signs after delivery, laryngoscopy and suction under direct vision should be carried out by a
healthcare professional trained in advanced neonatal life support.

 Oxygen should be given to keep oxygen saturations at 95-98%. Ventilation may be necessary.
Pneumothoraces will need chest drain insertion.

 High-frequency oscillation ventilation may be given in some cases.

 Giving prophylactic antibiotics to neonates born through meconium-stained amniotic fluid has
not been shown to reduce the incidence of MAS (or other complications).
 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
S.Y. 2018-2019

 Surfactant - meconium flowing into the lung deactivates the activity of surfactant, causes a
rise in surface tension and presages the onset of respiratory distress. Surfactant replacement
can be beneficial for babies with MAS, as it can rapidly improve oxygenation.

 Surfactant replacement by bolus or slow infusion in infants with severe MAS has also been
shown to reduce the need for extracorporeal membrane oxygenation.

 The development of active synthetic surfactants is very complicated.

 Anti-inflammatory drugs may be given to diminish the adverse action of products of

meconium-induced inflammation on both endogenous and exogenously delivered surfactant.

 Inhaled nitric oxide can be useful in the management of pulmonary hypertension associated
with MAS. It is thought to act by relaxing smooth muscles in the pulmonary vessels, causing
vasodilatation, as well as promoting bronchodilation.

 Enteral sildenafil may be used for the treatment of persistent pulmonary hypertension resulting
from MAS.[17]
 Extracorporeal membrane oxygenation (ECMO) may be needed in those babies who
deteriorate.

 Steroids - inhaled or systemic - have been used to good effect in some studies. Budesonide has
been shown to improve the effects of exogenous surfactant in experimental MAS.

Complications

Infant respiratory distress syndrome

 Respiratory distress that usually occurs within four hours of birth and becomes persistently
worse for 48 to 72 hours is known as infant respiratory distress syndrome. If not fatal, it
resolves by 72 hours.
 A deficiency of surfactant produces high alveolar surface tension. The baby must re-inflate the
collapsed alveoli with every breath. Thus, every breath takes a lot of effort for relatively poor
expansion.

 Surfactant replacement therapy has shortened the duration of the disease and significantly
reduced mortality.[6]It is treated with administration of synthetic or animal surfactant.

Persistent pulmonary hypertension of the newborn

 Babies may have persistent pulmonary hypertension of the newborn, as a consequence.

 This occurs where the fetal circulation persists with blood being shunted away from the lungs
through the foramen ovale and a patent ductus arteriosus.
 It is a consequence of raised pulmonary vascular resistance. Clinical features include cyanosis,
tachypnoea and the murmur of patent ductus arteriosus.

Treatment

This includes:

 Supportive measures, including ventilation.

 Prostacyclin infusion.

 Extracorporeal membrane oxygenation (ECMO).

 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
S.Y. 2018-2019

 Several promising therapeutic modalities for this condition: these include oxygen
supplementation, mechanical ventilation, nitric oxide, phosphodiesterase enzyme inhibitors,
endothelin receptor antagonists, and ECMO.

Chronic lung disease

 Children with meconium aspiration may develop chronic lung disease as a result of intense
pulmonary intervention.

 Infants with meconium aspiration have a slightly increased incidence of infections in the first
year of life because the lungs are still in recovery.

Prognosis

 Up to 10% of cases of meconium staining develop MAS.

 Nearly all infants with MAS have complete recovery of pulmonary function.

 Initial hypoxic events may cause the infant to have long-term neurological problems,
including seizures, general learning disability and cerebral palsy.

Prevention

Elective induction of labour for pregnancies at or beyond 41 weeks has been shown to be
associated with significant reduction in the incidence of MAS and fewer perinatal deaths
compared to expectant management.
 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
S.Y. 2018-2019

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM 102

Submitted to:

Mrs. Erika B. Yap, RN, MAN

Submitted by:

Jam Mikka G. Rodriguez

Date Submitted:

September 22, 2018