Meconium during delivery: A sign of

compensated fetal distress

H. ABRAMOVICI, M.D.
J. M. BRANDES, M.D.
K. FUCHS, M.D.
I. TIMOR-TRITSCH, M.D.
Haifa, Israel

The fetal scalp pH was examined in 80 parturients in whom meconium

appeared during the first stage of labor. These were matched with 80 control
patturients in whom the amniotic fluid was clear. No significant differences
were found between the two groups in fetal outcome, Apgar score,
or number of interventions during delivery. The meconium group was subdivided
into two groups: (1) thin and watery and (2) thick and solid. No differences
were found between the two subd~oisions in fetal scalp pH, fetal outcome,
Apgar score, or the number of interventions during delivery. Our data support
the assumption that the passage of meconium during delivery could be a
state of compensatory fetal distress.

T H E A P P E A R A N c E of meconium dur- there is no connection between the appear-

ing any stage of labor has long been con-
sidered a clinical sign of fetal distress. Ac-
cording to the classical conception, this is
an indirect sign representing the response
of the fetal gastrointestinal tract to hypoxic
conditions: Any decrease in the oxygen con-
centration in the fetal blood induces hyper-
peristalsis of the fetal gut and relaxation of
the anal sphincter. As a result, the fetus
passes meconium into the amniotic fluid. 1
Lately, the appearance of meconium as a
sign of fetal distress has been questioned.
Clinical experience shows that in many cases
From the Department of Obstetrics
and Gynecology, Rambam Government
Hospital, The Aba Khoushy Medical
School.
Received for publication March 26,
1973.
Revised june 13, 1973.
Accepted july 6, 1973.
Reprint requests: Dr. H. Abramovici,
Department of Obstetrics and
Gynecology, Rambam Government
Hospital, Aba Khoushy Medical School..
Haifa, Israel.
251
ance of meconium during labor and the fetal
outcome. On the other hand, there are many
cases of evident fetal distress, even of fetal
death, without evidence of meconium. In
this respect the series of Wood and Pinker-
ton2 and Leslie 3 clearly show that there is no
difference in the fetal outcome when cases
in which meconium appeared during de-
livery are compared to cases in which the
amniotic fluid remains clear. There is am-
bivalence concerning the appearance of me-
conium during delivery as being an ominous
sign.
During the last few years, the relatively
new biochemical and electronic methods of
direct fetal monitoring during labor have
allowed a more accurate analysis of the fetal
condition and a re-evaluation of the old
classical indirect signs of fetal distress (me-
conium, fetal heart rate changes, etc.) . How-
ever, at the time of this study only bio-
chemical monitoring was available to us. The
purposes of this article are: ( 1) to establish
the correlation between the appearance of
meconium alone during labor and fetal
 January 15, 1974
252 Abramovici et al.
Am. J. Obstet. Gynecol.

Table I. The one-minute Apgar scores in the and 45 were multiparas. In 50 cases the me-
meconium group as compared to the conium was thin, watery, and green or yel-
control group low. In 30 cases the meconium was thick,
firm, and sometimes included pieces of solid
Apgar I Meconium Control
meconium.
score group group Total
One minute after delivery the condition
0- 3 1 1 2
4- 6 5 6 11 of the fetus was evaluated by Apgar's scor-
7-10 74 73 147 ing method.
Total so 80 160 To each parturient in our series, a control
subject was matched by stage of labor, age,
and parity, and in whom the amniotic fluid
Table II. The pH values and Apgar scores was clear. In this control group the new-
in the 80 babies who passed meconium born infant's condition was evaluated by the
during delivery Apgar score.

Apgar
score I pH< 7.20 I pH > 7.20 1 Total
0- 3 1 0
4- 6 2 3
7-10 0 74
- -
Total 3 77
acidemia, ( 2) to determine whether the ap-
pearance of meconium during labor can be
used as a clinical prognostic sign for fetal
outcome, and ( 3) to check if there is any
connection between the type of meconium
(thin and watery or thick and solid) , fetal
acidemia, and fetal outcome.
Material and methods
In 80 parturients who were in a progres-
sive first stage of labor and in whom me-
conium appeared after the rupture of the
membranes (surgical or spontaneous) , the
fetal scalp pH was examined.
The mean cervical dilatation when the
meconium was diagnosed was three fingers
and from this stage the mean duration of
labor was three hours and 20 minutes. The
fetal scalp sampling was performed immedi-
ately after the membranes ruptured and me-
conium was diagnosed. The acid-base bal-
ance was examined according to Saling's4
method; pH values above 7.20 were con-
sidered normal and values below 7.20 were
considered as pathologic, showing fetal
acidemia. All the cases were vertex presen-
tations and the fetal heart beats were normal.
Of the 80 parturients, 35 were nulliparas
Results
The 80 parturients with evidence of me·
1
5 conium were delivered of live-hom babies.
74- Out of these 80, 76 (95%) were delivered
80 spontaneously and four were delivered by
operative procedures (two cesarean sections,
one forceps, and one vacuum extractor). All
the babies were mature, weighing over 2,500
grams (more than 36 weeks from last men-
strual period). Table I, shows the one-minute
Apgar scores at delivery for the 80 babies
who passed meconium during delivery as
compared to the 80 control babies in whom
the amniotic fluid was clear.
The 74 babies who passed meconium and
73 babies with clear amniotic fluid (control
group) were vigorous at delivery and had
Apgar scores of 7 or more. Only six babies
in the meconium group and seven babies
in the control group were depressed at de-
livery (Apgar scores below 7) and required
resuscitation (0 2 ; suction) . As this table
shows, there were no significant differences
in the Apgar scores between the two groups.
Table II shows the pH values and Apgar
scores for the 80 babies who passed mecon-
ium during delivery. In 77 out of these 80
the fetal pH values during delivery were
normal (pH above 7.20) and acidemia was
found only in three (pH values below 7.20).
The Apgar scores in the 77 babies with
normal pH values were 7 or above in 74
and low (between 4 and 6) only in three,
but the babies recovered well after resuscita-
tion (0~: suction) . The three babies in whom
Volume 118 Meconium during delivery 253
Number 2

acidemia was found (pH less than 7.20) had Table III. The fetal outcomes, mean Apgar
low Apgar scores (below 7). scores, and number of interventions in the
Table III shows a comparison between meconium group as compared to the
the fetal outcomes, mean pH values, mean control group
Apgar scores, and number of interventions
during delivery of the 50 patients with
I
Meconium Control I
.! group . group . Total
watery (yellow or green) meconium and No. of ca.ses 80 80 160
the 30 with thick meconium. In the group Live-born infants 80 80* 160
with watery meconium (50 babies) the mean No. of interventions
during delivery 4 4 8
pH value was 7.30 (range, 7.18 to 7.43). In 8.58 8.57 8.58
Mean Apgar score
this group the mean Apgar score was 8.66 *One baby in this group died immediately after delivery
(range, 6 to 10). In 48 out of 50 patients of as a result of severe congenital malformations.
this group (96 per cent) the pH values were
above 7.20 and only in two were pH values Table IV. The fetal outcomes, mean pH
of 7.18 found. One of these two mothers values, mean Apgar scores, and number of
was delivered by vacuum extractor and the interventions during delivery in the infants
second gave birth spontaneously while prep- with thin and watery meconium as
arations for forceps delivery were being compared to those with thick and solid
made. One cesarean section was performed meconium
in this group in a case of posterior asynclitism Thick,
without clinical evidence of fetal distress. firm,
In the group with thick meconium during Thin solid
watery me co-
delivery ( 30 babies), the fetal pH values meconium nium Total
were normal (above 7.20) in 29 (96.6 per
No. of cases 50 30 80
cent); in only one the pH was 7.19 and the Live-born infants 50 30 80
patient was delivered by forceps. The mean pH> 7.20 48 29 77
pH value in this group was 7.31 (range, pH< 7.20 2 1 3
Mean pH 7.30 7.31 7.30
7.19 to 7.40) and the mean Apgar score was Mean Apgar score 8.66 8.56 8.58
8.56 (range, 3 to 10) . One cesarean section No. of interventions
was performed in this group in a case of ce- during delivery 2 2 4
phalopelvic disproportion which was diag-
nosed early in labor and no evidence of fetal thick meconium (Table IV) no difference
distress was found. As Table IV shows, when was found concerning the fetal outcomes,
the two groups with thick solid and thin fetal pH values and Apgar scores.
watery meconium are compared, no signif- We assume that the type of meconium de-
icant differences can be found between the pends on the water absorption capacity of
two groups concerning the mean Apgar the fetal gut. When the fetal gut absorbs
scores, mean pH values, fetal outcomes, and more water from its contents, the meconium
the number of interventions during delivery. passed by the fetus will be firm or solid; if
the fetal gut absorbs less water, the me-
Comments conium passed by the fetus will be loose and
The traditional VIew concerning the dif- watery.
ferent types of meconium is that the green Since in a mature baby the gallbladder
or yellow watery meconium means an old and the biliary tract are anatomically and
meconium which was passed by the fetus functionally well developed, it is logical to
and became mixed with the amniotic fluid. assume that the color of the meconium will
In contrast, the thick solid meconium means depend on the bile pigments it contains. 5
a fresh meconium, indicating a recent pas- We therefore feel that the physical properties
sage due to actual fetal distress. When we of the meconium do not have a definite value
compared the two groups with watery and in the estimation of fetal distress.
254 Abramovici et al.
Schwartz 6 was the first to show (in 1858)
that the appearance of meconium during
labor meant impending fetal death. Walker's 7
basic assumption, according to which the
fetus passes meconium when the oxygen con-
centration in the umbilical cord blood falls,
has not been confirmed by any other author.
On the contrary, there are experiments dem-
onstrating that there is no connection be-
tween the fetal oxygen concentration and
the fetal peristalsis. Speert8 demonstrated
that induced hypoxia and/or oxygen admin-
istration to pregnant monkeys does not affect
the fetal peristalsis. Clinical experience clear-
ly shows that newborn infants with hypoxia
due to respiratory or cardiac insufficiency do
not pass meconium in greater amounts or
more frequently than normally oxygenated
babies. These observations seem to indicate
that during labor other influences besides
hypoxia can cause the passage of meconium.
According to Fenton and Steer9 the passage
of meconium represents a normal physiologic
intra-amniotic defecation; certain fetuses be-
gin this function just before instead of just
after birth. The fetus in utero swallows
amniotic fluid, vernix caseosa, and desqua-
mative cells-substances which form the
meconium. These substances begin to ac-
cumulate in the fetal gastrointestinal tract
in the fourth month of pregnancy and, close
to delivery date, when the gastrointestinal
tract is functionally mature, the fetus de-
fecates the meconium into the amniotic fluid
as a normal physiologic process.
Another explanation for the appearance
of meconium was given by Hon, 10 who sug-
gested that the passage of meconium is due
to a vagal reflex more frequent in postmature
cases (vagal dominance) .
According to Saling, 11 the vital organs of
the fetus receive normal blood supply during
hypoxia while the rest of the fetal nonvital
organs (skin, gut, etc.) do not receive oxy-
genated blood as a result of vasoconstriction.
REFERENCES
1. Barham, A. K.: J. Obstet. Gynaecol. Br.
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January 15, 1974
Am. J. Obst•t. Gynecol.
The vasoconstriction followed by hypoxia of
the fetal gut induces hyperperistalsis and
sphincter relaxation and as a result the fetus
passes meconium. What Saling's explanation
really shows is that a mature fetus has the
capacity of adaptive mechanism against hy-
poxia (peripheral vasoconstriction) in order
to supply oxygenated blood to the vital
organs. It is our opinion, therefore that the
fetuses who have passed meconium during
labor are in a state of temporary compen-
sated fetal distress (well-oxygenated vital
organs and peripheral hypoxia) . The fetal
blood pH at this stage will show no aci-
demia; if the fetus is delivered within a
reasonable period of time the Apgar score
will be good. Our results confirm this pre-
sumption: in only three of our 80 cases of
meconium during labor was there a slight
fetal acidemia; the great majority of the
babies had good Apgar scores.
Saling12 found slight acidemia in only
three out of 176 cases of meconium and the
same low percentage of acidemia in cases
of meconium during delivery was found by
Coltar and associates 13 and Garud and as-
sociates.14
Our results confirm these observations and
we feel that during progressive labor the
appearance of meconium with normal fetal
heart beats and nonnal pH may be a tem-
porary compensated state of fetal distress
because in our cases the appearance of me-
conium did not change the prognosis of the
fetuses and the Apgar scores of the me-
conium group and the control group were
comparable. We could assume that for short
periods the state of compensation would
persist. Perhaps a change in the fetal heart
beats or a fall in the fetal scalp pH would
suggest the end of the compensatory equilib-
rium and a state of decompensated fetal
distress in which intervention should be per-
formed. Continuous fetal monitoring is es-
sential in these cases.
2. Wood, C., and Pinkerton, J. H. M.: J. Obstet.
Gynaecol. Br. Commonw. 68: 427, 1961.
3. Leslie, D. W.: Br. Med. J. 2: 612, 1959.
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Number 2
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Meconium during delivery 255
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