Joseph Hageman, MD, Mitchell Goldstein, MD, MBA, CML, Walid Hussein, MD

The management of meconium-staining of the amniotic fluid (MSAF) in newborns in the delivery room has evolved significantly over the years. In the past, the approach was relatively straight-forward, with neonatologists, neonatal fellows, and pediatric residents frequently performing endotracheal intubation, especially in cases where the meconium was thick and quick suctioning was deemed necessary (1,2). It was commonly believed that meconium aspiration occurred during the intrapartum period before the obstetrician and neonatology team could intervene with suctioning and delivery (see figure) (1,2).

Interestingly, examining the literature spanning the last 50 years reveals substantial changes in management practices on the obstetrical side. No longer is oropharyngeal or nasopharyngeal suctioning routinely performed before the delivery of the shoulders, nor is amnioinfusion commonly used to dilute the meconium (1-5). This shift underscores the dynamic nature of medical practices in response to evolving evidence and advancements.

On the neonatal side, recent updates from the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) textbook, along with insights from prospective randomized studies involving both vigorous and non-vigorous newborns with MSAF, have led to changes in recommendations. Tracheal suctioning is no longer the default approach unless there is a clear indication of airway obstruction due to thick meconium (3-5). It is important to note that while this approach is recommended, the level of certainty attached to the recommendation is considered low, supported by some available data (3).

Conversations with practicing obstetricians and neonatologists corroborate this changing landscape. Obstetricians now tend to avoid suctioning before the delivery of the shoulders, and the neonatology team rarely resorts to intubation for tracheal suctioning. This transformation in clinical practice highlights the impact of research, collaboration, and evolving guidelines on the ground level of medical care (WH).

The references provided offer further insight into this evolution, such as the combined obstetrical and pediatric approach proposed by Carson et al. in 1976 (1), Cleary and Wiswell’s comprehensive exploration of meconium aspiration syndrome in 1998 (2), Wiswell et al.’s pivotal collaborative trial on delivery room management of meconium-stained neonates in 2000 (4), and more recent studies like Kalra et al.’s investigation into neonatal outcomes in cases of non-vigorous neonates with MSAF (5). These references underscore the progression of medical knowledge and the adaptive nature of medical practitioners in response to emerging evidence.

In conclusion, managing meconium-stained amniotic fluid in newborns has undergone substantial changes. While the approach to obstetrical and neonatal care has evolved, these changes are rooted in ongoing research, collaborative efforts, and evidence-based updates to clinical guidelines. This dynamic process reflects the commitment of healthcare professionals to provide the best possible care to newborns and their mothers.

References:

1. Carson BS, Losey RW, Bowes WA, et al. Combined obstetrical and pediatric approach to prevent meconium aspiration syndrome. Am J Ob Gynecol 1976;126(6):712-715.
2. Cleary GM, Wiswell TE. Meconium-stained amniotic fluid and the meconium aspiration syndrome. Pediatric Clinics of North America 1998; 45(3):511-529.
3. Chiruvolu A, Wiswell TE. Appropriate management of the nonvigorous meconium stained newborn. NeoReviews 2022;23(4):e250-e261., https://doi.org/10.1542/neo.23-4-e250
4. Wiswell TE, Gannon CM, Jacob J et al. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multi-center, international collaborative trial. Pediatrics 2000;105(1 pt 1):1-7.
5. Kalra V, Leegwater AJ, Vadlaputi P et al. Neonatal outcomes of non-vigorous neonates with meconium stained amniotic fluid between and after change in tracheal suctioning recommendation. J Perinatol 2022;42:769-774. https://doi.org/10.1038/s41372-021-01287-0

Disclosures: There are no reported disclosures