3. Introduction of
meconium
The first intestinal discharge from newborns is
meconium, which is a viscous, dark-green substance
composed of intestinal epithelial cells, lanugo, mucus
and intestinal secretions( eg. bile).
Meconium is typically passed for 2-3 days after birth.
Sometimes, the fetus passes the meconium while it is
still in the womb.
Intestinal secretions, mucosal cells and solid elements
of swallowed amniotic fluid are the major solid
constituents of meconium.
4.
5. Definition of
MAS
Meconium aspiration syndrome( MAS) is a
respiratory distress in a newborn who has
breathed( aspirated) meconium into the lungs
before or around the time of birth.
6.
7. Incidence:
A study conducted in Australia and New Zealand in infants
who were intubated and mechanically ventilated with a
primary diagnosis of MAS between 1995 and 2002
showed that MAS occurred in 0.43 of 1,000 live births.
The possibility of inhaling meconium occurs in about 5-
10% of births.
Not all infants with meconium aspiration will develop
MAS. Features of MAS develop immediately after birth
only in 5-10% infants.( Dutta 2006)
8. Finding from a study at Manipal College of Medical
Science, Pokhara, Nepal showed that: incidence of
meconium stained amniotic fluid( MSAF) was 13.97%
and that of MAS was 8.57%.
Most common and significant risk factor associated with
MAS were increased gestational age, increased cesarean
section(LSCS) and low apgar score at 1min & 5 min.
( Swain & Thapalial, 2008)
9. Incidenc
e
It occurs approximately in 8-15% of live births.
Approximately 5% of neonates born through meconium stained amniotic fluid
develop MAS
OF MEC stained infants:
30 % depressed at birth
10 % meconium aspiration syndrome (range 2-36 %)
OF infants with MEC aspiration syndrome
17 % deliver through thin meconium (range 7-35 %)
35 % need mechanical ventilation (range 25-60 %)
12 % die (range 5-37 %)
Frequency of Mec stained amniotic fluid = 10-25%
10.
11. Causes of
MAS
Hypoxia in distressed baby
Meconium Stained Liquor
Uterine Infections
Difficulty during labour process
12. Factors that promote the passage of meconium in utero
includes the following:
Placental insufficiency
Post dated pegnancy
Maternal hypertension
Pre-eclampsia
Oligohydramnios
Maternal drug abuse, especially of tobacco and cocaine
Maternal infection/ chorioamnioitis
Fetal gasping secondary to hypoxia( fetal distress)
Inadequate removal of meconium from the airway prior to
the first breath.
16. Airway
Obstruction
Complete obstruction of lungs may result in
atelectasis.
Partial obstruction cause: air trapping and
hyperdistension of alveoli, commonly called ball-valve
effect.
19. History
Presence of meconium in amniotic fluid.
Green urine may be observed in newborns with
meconium aspiration syndrome less than 24 hours
after birth. (Meconium pigments can be absorbed
by the lungs and can be excreted in urine).
Signs:
Severe respiratory distress may be present.
20. Symptoms include the following:
Cyanosis
End-expiratory grunting
Nasal flaring
Breathing problems like( difficulty in breathing,
no breathing and rapid breathing)
Intercostal retractions
Tachypnea
Barrel chest in the presence of air trapping
Auscultated rales and rhonchi ( in some cases).
Yellow-green staining of fingernails, umbilical cord
and skin my be observed.
21. Diagnosis of
MAS
High risk infants may be identified by
fetal tachycardia
bradycardia or
absence of fetal accelerations (upon CTG ) in utero
At birth, the infant may look cachexic and show signs
of yellowish meconium staining on skin, nail and the
umbillical cord.
These infants usually progress onto Infant Respiratory
distress syndrome within 4 hours.
22. Investigations which can confirm the diagnosis are :
Fetal chest x-ray, which will show hyperinflation,
diaphragmatic flattening, cardiomegaly, patchy
atelectasis and consolidation.
ABG samples, which pH, partial pressure of
oxygen( p02), partial pressure of CO2 ( pCO2) and
continuous measurement of oxygenation by pulse
oximetry are necessary for management.
23. Complete blood count: hemoglobin & hematocrit
level must be sufficient to ensure adequate oxygen-
carrying capacity.
Serum electrolytes: obtain sodium, potassium and
calcium concentration when the infants with MAS
aged 24 hrs because the syndrome of inappropriate
secretion of antidiuretic hormone( SIADH) and
acute renal failure are frequent complications of
perinatal stress.
24. Preventive measures of
MAS
MAS is difficult to prevent.
When there is meconium stained liquor, careful suctioning
of posterior pharynx after delivery of head decreases the
potential for aspiration of meconium.
immediate
of aspirated
When aspiration occurs, intubation and
suctioning of airway can remove much
meconium.
Do not perform the following harmful techniques in an
attempt to prevent aspiration of meconium- stained liquor:
- Squeezing of the chest of baby
-Inserting a finger into the mouth of baby.
25. Management of
MAS
Prenatal:
1. Identification of high risk pregnancies
- recognition of predisposing maternal factors
- post dates pregnancy inductions as early as 41 weeks
2. Monitoring
- careful observation and fetal monitoring during labour
- corrective measures should be undertaken in identifies
compromised fetus.
3. Amnioinfusion
-relieved umbilical cord compression during labor ->
reducing occurrence of variable fetal heart rate decelerations
- efficiency not well demonstrated.
27. Immediate
Management
The American Academy of Pediatrics Neonatal Resuscitation
Program Steering Committee guidelines are as follows
If the baby is not vigorous:
Suction the trachea immediately after delivery
Suction for no longer than 5 seconds
If no meconium is retrieved, do not repeat intubation and suction
If meconium is retrieved and no bradycardia is present, reintubate
and suction
If the heart rate is low, administer positive pressure ventilation and
consider suctioning again later.
If the baby is vigorous:
Do not electively intubate
Clear secretions and meconium from the mouth and nose with a
bulb syringe or a large-bore suction catheter.
Dry, stimulate, reposition, and administer oxygen as necessary.
Transfer ill newborns with respiratory distress to NICU
28. General
management
Continued care in the neonatal ICU (NICU)
Maintain an optimal thermal environment
Minimal handling to reduce agitation thus pulmonary
hypertension and right-to-left shunting causing hypoxia and
acidosis
Insert umbilical artery to monitor blood pH and blood gases
without agitating the infant.
Continue respiratory care: oxygen therapy via hood or positive
crucial in maintaining adequate arterial
Oxygen saturation ( 90-95%) should be
pressure is
oxygenation.
maintained.
Newborns are treated with antibiotics because of risk of
infection( eg. Gentamycin)
29. Supportive treatment
o IV Dextrose to prevent hypoglycemia.
o Fluid restriction (60-70 mL/kg/d) to prevent cerebral
and pulmonary edema
o Electrolytes to correct metabolic acidosis
o Protein, lipids, and vitamins to prevent deficiencies
For treatment of persistent pulmonary
hypertension of newborn( PPHN), inhaled nitric
oxide is the pulmonary vasodilator of choice.
30. Surfactant Therapy: Replace displaced or inactivated
surfactant and as a detergent to remove meconium, may reduce
the severity of disease, progression to extracorporeal
membrane oxygenation and decrease length of hospital stay.
May decrease respiratory failure with MAS within 6 hrs of 3
doses
ECMO: Extracorporeal membrane oxygenation is the last
option focused on the function of oxygenation and CO2
removal. Effective but associated with a high incidence of poor
neurologic outcomes.
ECMO is done using only cervical cannulation, which can be
performed under local anesthesia used for longer-term support
ranging from 3-10 days.Allow time for intrinsic recovery of the
lungs and heart. Survival rate 93-100%
32. Complications of
MAS
In mild cases, respiratory distress usually subsides in
2-4 days although tachypnea can persist for longer.
Cerebral hypoxia may lead to long term neurological
damage.
Aspiration pneumonia
Brain damage due to lack of oxygen
Collapsed lung
Persistent pulmonary hypertension of newborn.
34. Nursing care of an infant with meconium aspiration
syndrome include the following:
Nursing Assessment
Assessment of an infant with meconium aspiration
syndrome include:
•History. The presence of meconium in amniotic fluid is
required to cause meconium aspiration syndrome (MAS), but
not all neonates with meconium-stained fluid develop this
condition.
•Physical exam. The diagnosis of MAS requires the presence
of meconium-stained amniotic fluid or neonatal respiratory
distress, as well as characteristic radiographic abnormalities.
35. NURSING MANAGEMENT
• During labor, continuously monitor the fetus for signs and symptoms of distress.
• Immediately inspect any fluid passed with rupture of the membrane.
• Assist with immediate endotracheal suctioning before the first breaths, as
indicated.
• Monitor lung status closely, including breath sounds and respiratory rate and
character.
36. Assessment of neonate:
• Monitor and maintain temperature and monitor vital
signs for change in condition or status such as
decreased cardiac output (poor perfusion, mottling,
deteriorating ventilation status).
• Closely monitor for deviations from desired breathing
pattern—pulse oximetry, arterial blood gases, clinical
signs of poor oxygenation, grunting, nasal flaring,
apnea, tachypnea, retractions, and cyanosis.
37. . Airway clearance
• Suctioning should be performed only when necessary and
should be based on individual neonate assessment, which
includes auscultation of the chest, evidence of decreased
oxygenation, excess moisture in the ET tube, or increased
infant irritability.
• When nasopharyngeal passages, the trachea, or the ET tube
is being suctioned, the catheter should be inserted gently but
quickly; intermittent suction is applied as the catheter is
withdrawn.
• Suctioning should not be done for more than 5 seconds , as it
causes vagal stimulation and then bradycardia and continuous
suction removes air from the lungs along with the mucus
38. Maintainance of respiration
• The most advantageous positions for facilitating an
infant’s open airway are on the side with the head
supported in alignment by a small folded blanket or,
when on the back, positioned to keep the neck
slightly extended.
• With the head in the “sniffing” position, the trachea is
opened at its maximum; hyperextension reduces the
tracheal diameter in neonates.
• Facilitate proper oxygenation by implementing
appropriate therapy such as supplemental oxygen,
mechanical ventilation, or change of position
39. Thermo regulation
• Place warm blankets on scales, x-ray plates, or
other surfaces in contact with the baby
• Warm blankets and clothing before use
• Preheat incubators, radiant warmers, heat
shield
• Maintain room temperature at levels
adequate to provide a safe thermal
environment for neonate
41. Improve fluid volume level.
• Monitor and record vital signs to note for
alterations
• provide oral care by moistening lips & skin care by
providing daily bath
• administer IV fluid replacement as ordered to
replace fluid losses
42. •Improve frequency of breastfeeding
•. Demonstrate the use of manual piston-type breast
pump.;
• Review techniques for storage/use of expressed
breast milk;
• Provide privacy, calm surroundings when the
mother breastfeeds
• Recommend for infant sucking on a regular basis,
and encourage the mother to obtain adequate rest,
• Maintain fluid and nutritional intake, and
schedule breast pumping every 3 hours while
awake.
43. Maintain skin
integrity
• Inspection of the skin is part of routine neonate
assessment.
• Position changes and the use of water pillows
are helpful in guarding against skin breakdown.
44. • Mouth care is especially important when infants are
receiving NPO, and the problem is often aggravated
by the drying effect of oxygen therapy.
• Drying and cracking can be prevented by good oral
hygiene using sterile water. Irritation to the nares or
mouth that occurs from appliances used to
administer oxygen (e.g., nasal CPAP) may be
reduced by the use of a water- soluble ointment.
• Routine oral hygiene care in intubated neonate has
been shown to decrease the incidence of ventilator-
associated pneumonia.
45. • Watch for signs of complications such
as fever, vomiting, seizures, breathing
difficulties etc.
46. • Chest physiotherapy : Perform gentle chest
percussion, vibration, and postural drainage
based on assessed need and neonate's
tolerance.
47. Parental support:
Parents need reassurance concerning their infant’s
progress. All the procedures are explained to
familiarize them with the benefits and risks. It is
imperative that nurses remain sensitive to parents’
feelings and information needs during this process; an
important nursing intervention is assessment of the
parents’ understanding of the treatment involved and
clarification of the nature of the treatment..
48. Nursing Diagnosis
•Ineffective tissue perfusion related to impaired transport of
oxygen across alveolar and on capillary membrane.
•Hyperthermia related to inflammatory process/
hypermetabolic state as evidenced by an increase in body
temperature, warm skin and tachycardia.
•Fluid volume deficit related to failure of regulatory
mechanism.
•Interrupted breastfeeding related to neonate’s present
illness as evidenced by separation of mother to infant.
•Risk for Impaired parent/neonates attachment related to
neonates physical illness and hospitalization.
49. Prognosis of
MAS
The mortality rate of meconium-stained infants is considerably
higher than that of non-stained infants.
Meconium aspiration accounts for a significant proportion of
neonatal deaths.
Residual lung problems are rare but include symptomatic
cough, wheezing, and persistent hyperinflation for up to five to
ten years.
The ultimate prognosis depends on the extent of CNS injury
from asphyxia and the presence of associated problems such as
persistent pulmonary hypertension.
Mortality rate is approx 5%.
