Meconium-stained amniotic fluid is common complication, seen in 1 out of every 5 pregnancies.Golden rule for management of MSAF is Foetal Heart Monitoring

1. MECONIUM STAINED
AMNIOTIC FLUID

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. MECONIUM – A MURKY SUBJECT
Parkland Hospital, Katz & Bowes, 1992

4. INTRODUCTION
• Meconium is the earliest stool of an infant.
• Meconium is composed of materials ingested during
the time the infant spends in the uterus:
intestinal epithelial cells, lanugo, mucus, amniotic
fluid, bile, and water.
• When Baby passes Meconium in utero, making
Amniotic fluid light to dark green, it gives rise to a
condition of Meconium Stained Liquor.
• It is rare in babies born at <34 weeks of gestation.

5. HISTORY
• Aristotle coined the word
‘Meconiumarion’, a greek word for
Meconium.
• John Williams in 1903 1st observed and
attribute Meconium Passage to “relaxation
of the Sphincter Ani muscle induced by
faulty aeration of foetal blood”.

6. INCIDENCE
• Meconium-stained amniotic fluid is a
common obstetric situation, occurring
in 12–22% of women in labour.*
• < 5 % in preterm.
• Up to 20% in term.
• > 20 % in post term.
* ACOG Committee opinion, number 346, October 2016

7. CAUSES: MATERNAL
• Placental insufficiency
• Maternal hypertension
• Pre-eclampsia
• Oligohydramnios
• Maternal drug abuse (tobacco, cocaine)
* Shaikh EM, Mehmood S, Shaikh MJ. Neonatal outcome in meconium stained
amniotic fluid- One year experience. J Pak Med Assoc. 2010;60(9):711–14.

8. CAUSES: FOETAL
• Response to acute hypoxic events
• Relaxation of anal sphincter
• Increasing the production of motilin,
which promotes peristalsis.

9. PATHOPHYSIOLOGY
• Foetuses pass meconium in response to
hypoxia and that meconium therefore
signals foetal compromise (Walker, 1953).
• The physiological explanation is that in
utero passage of meconium represents
normal gastrointestinal tract maturation
under neural control (Mathews, 1979).
• Meconium passage follows vagal
stimulation from common but transient
umbilical cord entrapment with resultant
increased bowel peristalsis (Hon, 1961)

10. CONSISTENCY OF MECONIUM
Thin meconium:
• Yellow to light green and is watery (
Hagemanet al, 1988 ).
• 10% to 40% of the cases of meconium passage.
• Passed as a maturational event in most cases.
• Infants are more likely to be healthy at birth.
• 10% to 20% of cases of MAS occur with thin
meconium.

11. CONSISTENCY OF MECONIUM
Thick or particulate meconium:
• Is pasty or granular ( Meis et al, 1978 ).
• The risk of perinatal death is increased (5-7times).
• Early in labour generally reflects:
a. Oligohydramnios
b. Risk factor for neonatal morbidity and mortality

12. MECONIUM ASPIRATION SYNDROME
• Presence of meconium below vocal cord is
known as meconium aspiration.
• Meconium aspiration syndrome (MAS) is
defined as a respiratory distress that
develops shortly after birth, with
radiographic evidence of aspiration
pneumonitis and presence of meconium
stained amniotic fluid.
• Meconium aspiration syndrome occurs in
up to 10% of infants who have been
exposed to meconium-stained amniotic
fluid.

13. • Ramin and associates (1996) studied almost 8000 pregnancies
with meconium-stained amniotic fluid delivered at Parkland
Hospital.
• They suggested that Meconium aspiration syndrome was
significantly associated with foetal acidaemia at birth.

14. PATHOLOGY OF MECONIUM ASPIRATION SYNDROME
FETAL HYPERCARBIA AND ACIDAEMIA
STIMULATES FOETAL RESPIRATION, CAUSING GASPING
ASPIRATION OF MECONIUM INTO THE ALVEOLI
MECHANICAL BLOCKAGE OF THE AIRWAY
CHEMICAL IRRITANT CAUSING PNEUMONITIS

15. MECONIUM IN AMNIONIC FLUID IS A
FETAL ENVIRONMENTAL HAZARD
RATHER THAN A MARKER OF
PREEXISTENT COMPROMISE.

16. MANAGEMENT
• ANTEPARTUM
• INTRAPARTUM
• POSTPARTUM

17. ANTENATAL MANAGEMENT
• Prevention of post mature (>41 or 42 weeks
gestation) delivery.
• Anticipation of MSAF in high risk cases, like
1. Pre eclampsia
2. Chronic hypertension
3. Oligohydramnios
4. IUGR
5. Maternal Fever
6. PROM

18. INTRAPARTUM MANAGEMENT
• Foetal heart monitoring
• Improve foetal oxygenation and
uteroplacental blood flow.
• Take steps to diminish uterine activity.
• Relieve umbilical cord compression.

19. FOETAL HEART MONITORING
• Intermittent Auscultation
• Continuous Electronic Foetal Monitoring
• MONICA: WIFI enabled Wireless foetal
heart rate monitor

20. INTERMITTENT AUSCULTATION
• Every 15 to 30 minutes in active phase of first
stage of labour; every 5 minutes in second
stage of labour with pushing.
• Differentiate maternal pulse from foetal pulse.
• Palpate for uterine contraction during period
of FHR auscultation to determine relationship.
• Count FHR between contractions for ≥ 60
seconds to determine average baseline rate.

21. ELECTRONIC FOETAL MONITORING
• Electronic Foetal Monitoring is a method of
choice for foetal monitoring in high risk
pregnancies, like
Preeclampsia
Type 1 diabetes
Preterm birth
IUGR
MSAF
* ACOG 2013

22. BEAT TO BEAT VARIABILTY
• Baseline variability is an important
index of cardiovascular function and
appears to be regulated largely by the
autonomic nervous system.
• Sympathetic and parasympathetic
“push and pull” mediated via the
sinoatrial node.
• Normal variability of 5 -20 bpm with
accelerations , indicates a healthy
foetus.

23. MINIMAL VARIABILITY
• <5bpm
• Represents foetal hypoxia and
maternal acidaemia.
ABSENT VARIABILTY
• Ominous sign indicating a
seriously compromised foetus.
• Loss of variability in combination
with decelerations was
associated with foetal acidaemia

24. MODERATE (NORMAL)
VARIABILITY
• 6 to 25 bpm
MARKED VARIABILITY
• > 25 bpm.
• During foetal breathing and
body movements.

25. SINUSOIDAL HEART RATE
• Stable baseline heart rate of 120 to 160 bpm with regular oscillations
• Amplitude of 5 to 15 bpm.
• Long-term variability frequency of 2 to 5 cycles per minute
• Oscillation of the sinusoidal waveform above or below a baseline
• Absent acceleration
• Observed with foetal intracranial haemorrhage, with severe foetal asphyxia, and
with severe foetal anaemia from Rh alloimmunization, fetomaternal
haemorrhage, twin-twin transfusion syndrome, or vasa previa with bleeding.

26. FETAL TACHYCARDIA
• Tachycardia > 180 bpm
• Hypoxia is a well-known cause of
tachycardia.
• Also seen in Foetal Anaemia,
maternal fever and thyroid storm.
• foetal cardiac arrhythmias, especially
those associate with clear amniotic
fluid and no hydrops foetalis, are
managed conservatively.

27. EARLY DECELERATIONS
• Gradual decrease and return to
baseline associated with a
contraction.
• Rarely falls below 100 to 110 bpm
or 20 to 30 bpm below baseline
• Caused by Head compression.
• Not associated with foetal
hypoxia, acidaemia, or low Apgar
scores.

28. LATE DECELERATIONS
• Gradual, symmetrical decrease in
FHR beginning at or after the
contraction peak and returning to
baseline only after the contraction
has ended.
• The interval or lag from the
contraction onset until the late
deceleration onset was directly
related to basal foetal oxygenation.
• SYNONYMOUS TO POOR PLACENTAL
FUCTION.

29. VARIABLE DECELERATIONS
• Attributed to umbilical cord occlusion.
• Abrupt decline in the FHR varying
contractions.
• The decelerations measure ≥ 15 bpm
for ≥ 15 seconds and have an onset-to-
nadir phase of < 30 seconds. Total
duration is < 2 minutes.
• ACOG(2013a), recurrent variable
decelerations with minimal to
moderate variability are
indeterminate, whereas those with
absent variability are abnormal.

30. PROLONGED DECELERATIONS
• Isolated deceleration greater than 15
bpm lasting 2 minutes or longer but <
10 minutes from onset to return to
baseline.
• Epidural, spinal, or paracervical
analgesia may induce prolonged
deceleration.
• Also seen in cervical examination,
uterine hyperactivity, cord
entanglement, maternal hypotension,
Abruption and Foetal hypoxia.
• Recurrent prolonged decelerations
may lead to Foetal death.

32. AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
GUIDELINES (2013b,c)

33. MONICA : WIRELESS NST
• It records Wireless FHS , Maternal
Heart Sound and Uterine contractions
simultaneously upto 10 patients on a
single workstation.
• The tracings can be monitored and
send in real time to the Lecturer on
call, Senior consultant for his opinion
and advice on a smart phone , laptop.
• Started on 8/4/2015 in Sion Hospital.

34. MONICA : WIRELESS NST

35. IMPROVE FOETAL OXYGENATION
• Moving the mother to the lateral
position.
• Intravenous hydration—500 to 1000 mL
of lactated Ringer solution given over 20
minutes.
• Administer supplemental oxygen at 10
L/min.
Simpson KR, James DC. Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor.
Obstet Gynecol. 2005 Jun;105(6):1362-8

36. TOCOLYSIS
• A single intravenous or subcutaneous
injection of 0.25 mg of terbutaline sulphate
given to relax the uterus has been described
as a temporizing manoeuvre in the
management of nonreassuring foetal heart
rate patterns during labour. *
• Small intravenous doses of nitro-glycerine 60
to 180 μg also have been reported to be
beneficial.
* American College of Obstetricians and Gynaecologists (2013b)

37. RELIEVE UMBILICAL CORD COMPRESSION
• Changing maternal position.
• Tocolysis.
• A physician may slip his/her
finger through the cord and
unwrap it if it’s wrapped around
the infant’s neck.
• Amnioinfusion.

38. AMNIOINFUSION
• Amnioinfusion, the instillation of
isotonic fluid into the amniotic cavity,
has been advocated to improve neonatal
outcome in women labouring with thick
meconium in the amniotic fluid.
• The proposed benefits of amnioinfusion
include dilution of thick clumps of
meconium by the instilled fluid, and
possible prevention or relief of cord
compression.

39. INDICATIONS OF AMNIOINFUSION
• Treatment of variable or prolonged
decelerations.
• Prophylaxis for women with oligohydramnios,
as with prolonged ruptured membranes.
• Attempts to dilute or wash out thick
meconium

40. PROPHYLACTIC ANTIBIOTICS BEFORE
AMNIOINFUSION
• A randomized trial showed that
prophylactic use of cefazolin in the
infusate (1 g/1000 mL of normal saline)
did not significantly reduce rates of
maternal or neonatal infection.*
* Edwards RK, Duff P. Prophylactic cefazolin in amnioinfusions administered for meconium-stained amniotic
fluid. Infect Dis Obstet Gynecol 1999; 7:153.

41. TECHNIQUE OF AMNIOINFUSION
• After rupture of the foetal membranes, an
intrauterine pressure catheter is inserted using
standard technique and attached to intravenous
extension tubing.
• A paediatric nasogastric feeding tube or IV set can be
used if an intrauterine pressure catheter is not
available.
• The catheter is used to infuse Lactated Ringers
solution without dextrose into the amniotic cavity.
• Lactated Ringers is preferred to normal (0.9 percent)
saline because the latter may cause small changes in
the concentration of foetal electrolytes.

42. PROTOCOLS OF AMNIOINFUSION
• A fluid bolus (50 to 1000 mL) followed by a constant
infusion
• A serial boluses (200 to 1000 mL administered every
20 minutes to four hours).
• Constant infusion (15 to 2250 mL/hour)
A randomized trial found that continuous and
intermittent infusions were similarly effective.*
* Rinehart BK, Terrone DA, Barrow JH, et al. Randomized trial of intermittent or continuous amnioinfusion for variable
decelerations. Obstet Gynecol 2000; 96:571.

43. AMNIOINFUSION IN MSAF
Cochrane analysis of 14 major papers
published on Role of Amnioinfusion in MSAF,
in 2014 concluded that:
• Reduction in caesarean sections (CSs) for
foetal distress.
• Reduction in neonatal intensive care unit
admission.
• Reduction in Meconium below the vocal
cords diagnosed by laryngoscopy

44. VIDEO

45. AMNIOINFUSION IN MSAF
Cochrane Analysis also concluded that:
• There was no significant reduction in the primary
outcomes meconium aspiration syndrome,
perinatal death or severe morbidity, and
maternal death or severe morbidity.
• The American College of Obstetricians and
Gynaecologists (2012a, 2013c) does not
recommend amnioinfusion to dilute meconium-
stained amniotic fluid.

46. COMPLICATIONS OF AMNIOINFUSION

47. INTRAPARTUM SUCTIONING
• In this study, 2514 infants of at least 37 weeks gestation with
cephalic presentation and MSAF of any consistency were randomly
assigned to suctioning of the oropharynx, nasopharynx, and
hypopharynx or no suctioning before delivery of the shoulders.
Suctioning was performed with a 10- to 13-Fr suction catheter
connected to negative pressure of 150 mmHg.

48. INTRAPARTUM SUCTIONING: Result of the Trial
• The incidence of MAS did not differ between groups.
• There were no significant differences between the control and
suction groups detected in any of the secondary outcomes: the
need for mechanical ventilation for MAS, mortality, duration of
mechanical ventilation, duration of oxygen therapy, or length of
hospital stay.
• No complications of suctioning were noted.
The American Academy of Paediatrics, and the Neonatal Resuscitation
Program Steering Committee, no longer recommend routine intrapartum
suctioning of the oropharynx and nasopharynx of neonates delivered
following labours complicated by meconium.

49. POSTPARTUM MANAGEMENT
Meconium stained liquor
No sign of depression
No resuscitation required
Observe for 2 hours
Do not vigorously stimulate the baby , if
born with respiratory depression
Dry and assess airway, breathing and heart rate.
Inspect airway direct vision, if meconium seen,
aspirate with a large bore sucker.
Baby has meconium below the cords or continuing depressed vital signs
Intubation and direct tracheal suction.
Suction should be discontinued and inflation breaths delivered after 1 minute

50. CONCLUSION
• Meconium stained amniotic fluid is common complication, seen in
1 out of every 5 pregnancies.
• Golden rule for management of MSAF is Foetal Heart Monitoring.
• An alert and vigilant Obstetrician can reduce foetal mortality and
morbidity.
• NST should be used in all high pregnancies.
• Neonatologists should be alerted in every case of MSAF in labour,
under vision suctioning should be done to prevent MAS.

51. REFERENCES
• Williams Obstetrics 24th Edition
• American College of Obstetricians and Gynaecologists (2013)
• Shaikh EM, Mehmood S, Shaikh MJ. Neonatal outcome in meconium stained amniotic fluid- One year
experience. J Pak Med Assoc. 2010;60(9):711–14
• Rinehart BK, Terrone DA, Barrow JH, et al. Randomized trial of intermittent or continuous amnioinfusion
for variable decelerations. Obstet Gynecol 2000; 96:571.
• Simpson KR, James DC. Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status
during labor. Obstet Gynecol. 2005 Jun;105(6):1362-8
• Ramin KD, Leveno KJ, Kelly MA, Carmody TJ. Amniotic fluid meconium: a fetal environmental hazard.
Obstet Gynecol. 1996 Feb;87(2):181-4.
• Katz VL, Bowes WA Jr. Meconium aspiration syndrome: reflections on a murky subject. Am J Obstet
Gynecol 1992;166:171–83.
• Puertas A, Paz Carrillo MP, Molto L, Alvarez M, Sedeno S, Miranda JA. Meconium-stained amniotic fluid in
labor: a randomized trial of prophylactic amnioinfusion. Eur J Obstet Gynecol Reprod Biol 2001;99:33–7.