Meconium stained liquor is common finding(40-50%) in this gestational age.But presence of meconium is assosiated with increased incidence of intra partum stillbirths, distress, Neonatal death, acidosis,low APGAR .These are more common if meconium is thick .If meconium is old and diluted risk is comparitively less than if it is thick ,fresh and associated with oligoamnios.this increases perinatal mortality by 5-7 fold.These should be taken into account while deceiding managemant aspects.SROM itself increase risk of infection to mother and fetus
Initially note history regarding duration of rupture of membranes,any pain abdomen suggestive of labour ,fever &rigors suggestive of infection , and her appreciation of fetal movemants.Review AN record for any risk factors that are missed and allowed pregnancy to continue till 41 weeks like IUGR,PIH ETC and also confirm dating from early scans.
Examine the woman - record PR,BP,TEMP, P/A any tenderness,contractions to note if she is in labour,presentation , Record fetal heart.If contractions are prasent note strength,duration of contractions.
P/S examination to note liquor wether thin or thick meconium stained
VE to note cervical findings(effacement ,dilatation), Bishop score to assess favourability for induction if not in labour.
Fetal wellbeing assessed by CTG .
HVS is taken and LVS & urethral swab for Group B streptococcus. WCC,CRP to note if there is any infection as evidence of infection needs immediate delivery.
Further management depends on fetal condition , maternal condition (she is in labour or not, cervical findings,)mother\'s wishes.
She is admitted ,explain her risk associated with her situation. Patient\'s wishes considered.
If there is evidence of fetal compromise ,infection, immediate delivery is advocated by quickest route possible based on examination findings.Most often it would be caesarean section unless women is already in late labour.Mal presentations require C.S
If women is in established labour and fetal condition is satisfactory on initial CTG assessment, labour is allowed to progress. continous EFM is recommended till delivery as these fetuses are at risk of hypoxia.If CTG trace is abnormal then FBS is done if feasible . Ph <7.2 needs immediate delivery by quickest route possible , If > 7.2 labour is allowed to progress.Monitor progress of labour, plot partogram, if necessary augmentation can be considered with syntocinon .
If woman is not in labour ,fetal condition reassuring then consideration should be given for induction of labour.This is favourable to expectant management is this woman with MSAF , as IOL is assosiated with lower rates of maternal and neonatal infection, no increase in C.S RATE.Infection further increases the risk assosiated with meconium.Oxytocin is preferrable as use of PG\'s is assosiated with increase in MATERNAL &neonatal infectioN. IOL if not acceptable by the mother respect her wishes , document the same , and subject her for surveillance. COntinous EFM , 4 th hrly temp,PR. Uterine tenderness .Most woman 92% of woman get into spn labour within 48 - 96 hrs. Deliver if fetal compromise ,e/o infection.
Amnio infusion with saline ,will reduse meconium concetration, relieve cord compression ,there by reduse fetal gasping. Cochrane review has showed that there is significant reduction in C.S rates specifically due to fetal distress, reduse incidence of MAS and so is beneficial to fetus.This shuold be considered if thick meconium assosiated with oligoamnois.
Intrapartum avoid events that precipitate hypoxia .eg - hyperstimulation, supine hypotension.
Neonatologist informed.Paediatrician be present at the time of delivery.Suctioning of oropharynx,is done gentle at delivery of head,before first breath.Unproven value of splinting of shoulders,adn routine suctioning of trachea.
Watch for development of MAS.
All events and discussions well documented as a risk management strategy.
