Does DeLee suction at the perineum prevent meconium aspiration syndrome?

Passage of fetal bowel movement (meconium) is common (in about one out of six births), and in some the staining of the amniotic fluid is a sign of fetal distress. Inhalation of meconium (aspiration syndrome, in upto one out of five to eight such births) just before or at birth may be preventable by a coordinated approach by well-trained and informed birth attendants. Respiratory failure secondary to meconium aspiration syndrome (MAS) remains a major cause of morbidity and mortality in the neonatal population. Infants with hypoxemic respiratory failure because of MAS, persistent pulmonary hypertension of the newborn and pneumonia/sepsis have an increased survival with extracorporeal membrane oxygenation (ECMO). Other treatment options earlier limited to inotropic support, continuous airway pressure (CPAP), conventional ventilatory management, respiratory alkalosis, paralysis and intravenous vasodilators have been replaced by synchronized intermittent mandatory ventilation (SIMV), high-frequency oscillatory ventilation (HFOV), surfactant and inhaled nitric oxide (iNO). HFOV has been advocated for use to improve lung inflation while potentially decreasing lung injury through volutrauma. Other reports describe the enhanced efficacy of HFOV when combined with iNO. Subsequent to studies reporting that surfactant deficiency or inactivation may contribute to neonatal respiratory failure, exogenous surfactant therapy has been implemented with apparent success. Recent studies have shown that iNO therapy in the neonate with hypoxemic respiratory failure can result in improved oxygenation and decreased need for ECMO. However, these innovative interventions are costly, require a sophisticated infrastructure and are not universally accessible. In this paper, a context of systems-approach for prenatal, natal and postnatal management of babies delivered through meconium stained amniotic fluid (MSAF) so that adverse outcomes are minimized and the least number of babies require innovative ventilatory support is described. Previously reported data from a single urban perinatal center (Philadelphia, PA, USA), over a 6-year period (1995)(1996)(1997)(1998)(1999)(2000), demonstrated that 14.5% (3370/23 175 of live births babies were delivered with MSAF. These data also showed that 4.6% of babies (155/ 3370) with MSAF sustained MAS. Overall, 26% of babies (40/155) with MAS needed ventilatory support (or 0.17% of all live births); of these, only 20% (8/40 or 0.035% of live births) needed innovative ventilatory support. None died or needed ECMO. These data describe the components for a systems approach to prevent and manage adverse outcomes related to MSAF at the regional level II or III perinatal center. Replication of a similar strategy may be more relevant to cost containment and be a safer approach for neonates at risk for MAS-related respiratory failure. This paper assess the evidence for pivotal steps needed to prevent MAS and ensuing neonatal death and disease in the context of diverse perinatal health services.

Section: Postnatal Management Decisionsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Developing a systems approach to prevent meconium aspiration syndrome: lessons learned from multinational studies

Bhutani

2008

“…This concept of routine intubation was challenged first by Faciglia using a concurrent observational study. 17,18 He showed no differences in outcome with and without routine intubation. Linder et al 19 in a prospective controlled trial, perhaps inadequately randomized, assessed the need for intubation of vigorous term meconiumstained infants.…”

Section: Extracorporeal Membrane Oxygenation and Masmentioning

confidence: 85%

Meconium aspiration syndrome: historical aspects

Fanaroff

2008

162

The meconium aspiration syndrome (MAS) is a common problem that continues to concern perinatologists and neonatologists. MAS is defined as respiratory distress in an infant born through meconium-stained amniotic fluid (MSAF) whose symptoms cannot be otherwise explained. This disorder may be life threatening, complicated by respiratory failure, pulmonary air leaks and persistent pulmonary hypertension. Approaches to the prevention of MAS have changed over time with collaboration between obstetricians and pediatricians forming the foundations for care. This report details the management of babies delivered with associated MSAF before the accumulation of evidence for best practice through appropriately powered, prospective randomized controlled trials.

“…Those factors are heavy MSAF, nulliparity, postterm delivery, fetal heart rate (FHR) abnormalities during labor, presence of meconium below the vocal cords, cesarean delivery and the low Apgar scores. 13,14,20,[25][26][27][28][29][30] It has been reported that there is an apparent relationship between maternal ethnicity and risk of MSAF, and the risk of MAS having been observed to be increased in black Americans, Africans and Pacific Islanders. [30][31][32] Intrapartum fetal monitoring The goal of continuous electronic fetal heart rate monitoring (EFM) is to detect fetal hypoxemia and therefore reduce the risk of adverse neonatal outcomes.…”

Section: Pathophysiology and Risk Factorsmentioning

confidence: 99%

“…The findings of observational studies remain conflicting. 20,26,61 -63 Falciglia et al 26 compared infants with meconium-stained fluid who underwent 'early' oronasopharyngeal DeLee suctioning with a similar group of infants whose airways were suctioned 'late' (after chest delivery). They found no evidence of benefit of oropharyngeal suctioning in the prevention of MAS.…”

Section: Pathophysiology and Risk Factorsmentioning

confidence: 99%

Obstetric approaches to the prevention of meconium aspiration syndrome

Wei

Fraser

2008

Meconium aspiration syndrome (MAS) is associated with increased risk for perinatal mortality and morbidities. To provide an overview of the advances in our knowledge concerning the obstetric approaches to the prevention of MAS. The evidence of the effectiveness of intrapartum surveillance, amnioinfusion, and delivery room management in the prevention of MAS are reviewed in the present paper. Meconium aspiration syndrome remains one of the most common but challenging conditions for obstetricians and pediatricians. The available evidence did not demonstrate a beneficial effect of either of obstetric strategies in the prevention of MAS.