Monday, October 13, 2014

MECONIUM STAINED INFANTS -- STUDIES SUPPORT A GENTLE APPROACH



Source Article by Gloria Lemay:
Meconium in the amniotic fluid
http://wisewomanwayofbirth.com/meconium-in-the-amniotic-fluid/

It’s estimated that about 10% of full term babies pass their first bowel movement while still in the womb. It can be a sign of distress or it can be a perfectly normal, physiological event. When a midwife sees meconium in the amniotic fluid, she usually increases her surveillance of the fetal heart rate. The meconium can be well mixed with the amniotic fluid giving the appearance of pea soup or brown gravy. If just meconium is pouring out like oil, the midwife will realize that the baby is presenting bum first (breech).

Babies with meconium who are born in the hospital can be at a disadvantage because the hospital routine involves cutting the cord immediately and passing the meconium stained baby over to the pediatric nurse or dr. Cutting the cord forces the baby to inspire into the lungs deeply and leads to induced fetal distress–the unwanted problem.

This photo is of baby Abigail who suffered meconium aspiration syndrome after her hospital birth. She now has cerebral palsy:



Medical professionals are starting to realize that many babies have been treated unnecessarily with harmful consequences. Leaving the umbilical cord to pulse, putting the infant skin to skin with the mother, allowing the vigorous baby to have time to pink up without suction—all these natural methods have science to show they work best with meconium stained infants. Here are some studies that support taking the more gentle approach:

M E C O N I U M

Research

Researchers reviewed records of 199 cesareans that were done for non-reassuring fetal condition and/or meconium stained amniotic fluid in a rural hospital to evaluate the effect on neonatal outcome. Apgars at one and five minutes were compared with those of 33 vaginal births after labour with meconium staining. Five babies out of the 232 (2.2%) had an Apgar score 7 at five minutes. Of those, one died shortly after birth. Of those born by caesarean section group for non-reassuring condition, two were stillbirths and one was an early neonatal death, giving a perinatal mortality rate of 15.1/1,000 births. Mode of delivery did not affect the five minute Apgar score in a statistically significant manner.

The researchers concluded that “caesarean delivery does not improve the neonatal outcome when the amniotic fluid is meconium stained.”

Journal of Obstetrics and Gynaecology 28(1): 56-59
Meconium aspiration syndrome: reflections on a murky subject.
Katz VL, Bowes WA Jr
Am J Obstet Gynecol 1992 Jan;166(1 Pt 1):171-83
Meconium-stained amniotic fluid occurs in approximately 12% of live births. In approximately one third of these infants meconium is present below the vocal cords. However, meconium aspiration syndrome develops in only 2 of every 1000 live-born infants. Ninety-five percent of infants with inhaled meconium clear the lungs spontaneously. Recent investigations have suggested that a reexamination of our assumptions about the etiology of meconium aspiration syndrome is in order. Several authors have provided evidence that support the hypothesis that it is not the inhaled meconium which produces the primary pathologic condition of meconium aspiration syndrome but rather it is fetal asphyxia that is the etiologic agent. Asphyxia in utero produces pulmonary vasospasm and hyperreactivity of the pulmonary vessels. With severe asphyxia the fetal lungs undergo pulmonary vascular damage with pulmonary hypertension. The damaged lungs are then unable to clear the meconium. In the most severe cases there is right-to-left shunting and persistent fetal circulation with subsequent fetal death. The incidence of meconium aspiration may thus be essentially unaffected by current obstetric and pediatric interventions at birth. For the asphyxiated or distressed infant we recommend suctioning at birth and tracheal intubation. In the healthy fetus observation may be sufficient.

Management of Infants With Meconium-Stained Amniotic Fluid

Treatments to prevent meconium aspiration syndrome have included amnioinfusion during labor, intrapartum suctioning, and endotracheal intubation and suctioning of infants with meconium-stained fluid. The most recent evidence suggests that these practices are not helpful and do not prevent meconium aspiration syndrome. Table 4 http://www.medscape.com/viewarticle/558124_Tables#T4 offers the current evidence about these practices.[54-56] A 2006 review[57] shows no benefit to infants from these practices.

Two classic nonrandomized studies done in the 1970s[58,59] suggested that suctioning the airway before the birth would decrease the incidence of morbidity and mortality associated with meconium aspiration syndrome.

Subsequent studies comparing DeLee suctioning with bulb suctioning found no differences in the incidence and severity of meconium aspiration syndrome, respiratory rates, or Apgar scores between the infants who had suctioning either before delivery of the head or after birth.[60-62] In 2004, the Meconium Study Network[55] conducted a large multicenter RCT comparing outcomes of vigorous infants with meconium staining, with or without suctioning on the perineum ( Table http://www.medscape.com/viewarticle/558124_Tables#T4

4 ). No difference was found between the two groups for any outcomes, even when analyzing the subgroup with thick meconium. This suggests that intrapartum suctioning does not prevent meconium aspiration syndrome. Similarly, no benefit for the prevention of meconium aspiration syndrome has been found following amnioinfusion[54] or from endotracheal intubation and suctioning of vigorous term infants.[56] These practices should not be used to prevent meconium aspiration syndrome.[57]

Gastric Suctioning


It has been suggested that gastric suctioning of the newborn might prevent regurgitation and aspiration of meconium or other stomach contents. A MEDLINE search on gastric suctioning of the newborn revealed only one study relevant to this review.

Widstrom[63] studied the effect of gastric suction on newborn circulation and subsequent feeding behavior. Healthy, term newborns were randomly assigned to have gastric suction (n = 11) or no gastric suction (n = 10). At birth, the newborns were dried and placed on the mother’s chest. No suctioning of the airway was done, and all infants began to breathe spontaneously. The umbilical cord was clamped and cut between 60 and 90 seconds after birth. Pulse and blood pressure were recorded every minute from 5 to 10 minutes of age. Between the first two blood pressure recordings, infants in the suction group had a #8 suction catheter inserted through the mouth into the stomach, and the contents were aspirated. The procedure lasted approximately 20 seconds. The infants were maintained in a prone position on their mother’s chests and were observed for 3 hours. While the two groups did not differ in average heart rate, one infant in the suction group had an episode of bradycardia, and infants in the suction group experienced an increased blood pressure when the catheter was withdrawn. Defensive motions were observed in nine of the suctioned infants.

Suckling was delayed until 62 minutes in the suction group versus 55 minutes in the no suction group. There was also a greater lag in hand-to-mouth movements in the suction group (P = .005). This small study found harm and no benefit from gastric suctioning, indicating that it should not be used in the routine care of the neonate.