Delivery Room Management of the Apparently Vigorous Meconium-Stained Neonate: Results of the Multicenter, International Collaborative Trial

Abstract

Of the approximately 13 percent of live-born infants born through meconium-stained amniotic fluid (MSAF), an estimated 5 to 12 percent develop meconium aspiration syndrome (MAS). Proper treatment of meconium-stained infants who remain vigorous is controversial. This prospective, randomized trial attempted to determine whether MAS can be prevented by intubation and suctioning. The 2094 infants enrolled in the trial, from 12 centers, had a gestational age of at least 37 weeks, were born through MSAF, and seemed to be vigorous immediately after birth. A total of 1051 infants were assigned to the intubation and suction (INT) group, whereas 1043 were managed expectantly (EXP group). Infants in the INT group were intubated immediately after birth and were suctioned using a Neotech aspirator for 1 to 5 seconds as the endotracheal tube was withdrawn. The two treatment groups were similar in prenatal care, the consistency of stained amniotic fluid, fetal heart rate monitoring, and amnioinfusion therapy. Gender, race, and 5-minute Apgar scores also were comparable. Sixty-two infants (3 percent of the total) developed MAS, and another 4.2 percent had different respiratory disorders, most often transient tachypnea. MAS developed in 3.2 percent of the INT group and 2.7 percent of the EXP group, and the rates of other respiratory conditions also were similar. The risk of either MAS or other respiratory problems increased with the thickness of the stained amniotic fluid, but, even with the thickest fluid, intubation conferred no obvious benefit. MAS was more frequent after cesarean delivery and when the mother had made five or more prenatal visits. On logistic regression analysis, other respiratory disorders were related to the same factors as well as to relatively thick amniotic fluid, a lack of oropharyngeal suctioning, no fetal heart rate monitoring or abnormal monitoring findings, and meconium in the trachea (Fig. 1). Low Apgar scores and oligohydramnios also correlated with these disorders. Nearly half of the infants with MAS required mechanical ventilation or continuous positive airway pressure, as did 15 percent of those with other respiratory disorders. Fig. 1: All factors, except for male gender, that were found to be significant independent predictors for the development of respiratory distress attributable to causes other than meconium aspiration syndrome (P < .05). Data are expressed as odds ratios and 95 percent confidence intervals. MSAF indicates meconium-stained amniotic fluid; and FHR, fetal heart rate. Reproduced by permission of Pediatrics.Tracheal suctioning does not limit the risk of respiratory distress in meconium-stained infants who remain vigorous after birth compared with expectant management. The procedure is quite innocuous, however, and still is recommended for infants who are not vigorous if they develop symptoms of respiratory distress or require positive-pressure ventilation. Pediatrics 2000;105:1–7