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:

Abigail meconium aspiration photo

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:

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 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

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.

30 thoughts on “Meconium in the amniotic fluid

  1. I think it’s interesting that there is still the belief that babies inhale meconium with that first breath. It makes more sense to understand that any severe lack of oxygen (hypoxia) will result in the baby’s last ditch effort for oxygen – even in utero – a gasp for breath.

    What has likely occurred is that the first serious hypoxic state released the meconium and subsequent episodes could result in that breath effort. Because the lungs cannot fully inflate in utero, particulates of meconium become lodged in the lungs and cause MAS/pneumonia.

    I cannot figure out why we’re still suctioning babies. It makes no sense – and deep intubation or suctioning triggers the vagal response, creating bradycardia (low heart rate) and compromising what could have been a normal newborn transition.

    Skin to skin, leaving the cord intact and diligent observation is the best treatment for meconium-stained births. The process of suctioning with the birth of the head, cutting the cord immediately and further suctioning baby deeply is invasive, scientifically and physiologically unsound and creates more problems than it solves.

    Thanks for posting this, Gloria. xo

  2. Wonderful, Gloria. You have really brought some heretofore practices and beliefs into question. You are stunning, and your work is decisive and brilliant.

    Shaking the medical world, and now the midwifery world, to the core is what is needed to shake down the truth… and usually that truth is that “Above all do no harm,” is the motto most needed to be remembered. Ah, the ego of us thinking our “doing” is “saving the baby.” It is usually not for poor intention, but once the wheel of intervention gets rolling, it is sure to pick up speed until finally it is somehow believed that without this wheel, there is certain to be misfortune.

    How many times have I suctioned babies? How many times was that not only unnecessary, but actual harmful??? Hm…

    Seems we are more like ducks than we know. Our training as fledglings influences all that we do and believe for years to come. It becomes frightening to do anything else, or especially to do anything “less”.

    You are challenging all of us.

    As I used to say about doctors’ beliefs about “once a cesarean, always a cesarean”: Imagine that you have been attending Catholic school for twelve long years, and finally today you are graduating. The speaker at the commencement exercises announces, “By thy way, there is no God.”

    This is the essential feeling we practitioners have when a practice has become so thoroughly engrained in us that it is no longer based on factual evidence, but rather a BELIEF SYSTEM. This is why presenting practitioners with new “facts” rarely changes their practices. To change a belief system requires an essential shock.

    I truly hope that we midwives can be more receptive to change our practices. After all, although the practices have been engrained in us as well, hopefully our essential BELIEF SYSTEMS were developed long before we were fledgling midwives. These prior-held beliefs about the nature of birth and the power of essential nature to bring forth healthy infants, CAN overcome the effect of training and rote practice. The question is, “How willing are we to be “true believers”? How willing are we to change our practices, when evidence is presented that would actually bring us back to our claimed beliefs?” To do so means that we confront our own fears of “what if…” What if I don’t suction? I can feel the knot in my stomach. The fear-base we have learned is the driving force from within, powered by the 365 horsepower engine revving us up from the external medical and legal pressures.

    Truthfully, there were times when for one reason or another, I just didn’t suction. I have no idea why. It just didn’t go that way. And despite my “failure to intervene” which might have produced that poor outcome everyone fears, these babies all did well. A gentle voice and a loving touch appeared to be all that they needed. As I said, I have no idea why I failed to do what was accepted and required. I didn’t think I was challenging anything, nor did I give it a moment of thought. It just happened.

    So maybe, we will begin to just let things happen again.

    And then, in the back of my mind, comes the whisper, “But death is natural, too.” And I return to the eternal connundrum of when to intervene and when to allow. To do no harm… hm.

  3. I just wish I had my old midwives email addresses so I could send them this . . . and show them how unnecessary disrupting my beautifully planed home water birth was . . .

    • midwives , too , learn every day ms,.peters.every birth i have ever been to has shown me one more thing i was taught, that needed to be relearned.

  4. Hello
    My daughter also had Merconium aspiration at birth and went 7 minutes and 45 minutes without oxegen. She lived for 20 months 17 days. I wrote this psalm for her. Feel free to share it with others!!

    The Psalm of Jennifer’s Mom’s Heart

    I praise you for my daughter Jennifer.

    Your name will be exalted over all nations and for all times for your great wonders

    astound me, they humble me and bring me to my knees.

    I call to you and you answer me, surely and quickly, always with love, abounding


    Before creation you knew Jennifer’s begriming from her end. The life saving machines

    sang your name. Their rhythmic beeping was a song to your glory. Each fine blond

    hair on her head, you numbered prior to knitting her together in my womb.

    No mistakes, divine perfection.

    Oh God of wonders, only you can create the heavens and silence the storms of a sea?

    You brought Jennifer forth from my womb to demonstrate your great, great glory.

    I love you as no other. My heart aches and longs to be in your presence.

    Jennifer loved with unconditional love.

    I worship you with all that I am.

    You were present when Jennifer first cried, not the cry of a normal child but a cry

    of deep morning, deep grief.

    Jennifer wept, I wept, you wept.

    Jesus, you are my greatest treasure.

    Jennifer smiled with the smile of a thousand angles sent directly from heaven.

    Thank you! My lord.

    She comforted me with tiny arms, hugging, clinging, tiny hands in mine – wingless,

    wanting to fly heavenward, but remaining, comforting, loving.

    She asked for nothing but gave everything.

    Jennifer was the air I breathed.

    Forgive me.

    Wondrous was your gift to me but you alone. I worship.

    You alone reach into the deepest place and heals my heart.

    I thank you for Jennifer.

    I thank you for taking her to live with you eternally in paradise.

    Patiently with great anticipation I wait and long for our reunion.

    No pain only love.

    I seek your face. I find comfort in your words.

    You make all things new. Deeper and deeper, you take me.

    Healing and restoring my soul.

    My heart adores you.

    Jennifer alive with angels.

    Jesus alive in Jennifer’s mom’s heart.

    • That is so beautiful! So right. So full of hope and truth. Thank you for sharing. On my blog, listed above, you can see some of the poems I wrote for my own beloved daughter, who suffered sever asphyxiation during my labour, and only lived on earth for 26 hours after her delivery.

  5. When my water broke during labour there was meconium in it (I was 1 week ‘overdue’) and my independent midwife advised me that I had to get out of the birth pool to birth as it was safer. Is this true? Is there any studies to say that birthing in water with meconium in the waters is riskier?

    • Michelle, there is no reason to get the woman out of the water. I find that, with babies who have passed meconium, you can clearly see them expelling the brown stained mucous under the water while their chests are being compressed by the mother’s intact vagina/perineum. That last squeeze of the chest is Mother Nature’s expeller of mucous. Then, leaving the cord alone means the baby’s CO2 levels remain low and they have time to “breathe off the cord” while they snort, spit, cough and otherwise get ready for lung breathing. I’m talking about unmedicated babies, of course.

      • My midwife actually preferred for me to stay IN the water when my son was born with meconium staining, so she could make sure his face was clear from “debris” before bringing up into the air to breathe for the first time.

  6. Just witnessed (in the role of doula) a really intense, quick hospital birth of a perfect boy this past weekend (JUST before the hurricane made its way through here). The baby had mec (the staff used the term “particulate” meconium) and the midwife in charge suctioned deeply on the perineum (w/Pediatrician on hand) AND cut the cord immediately against the wishes and despite the protestations of the mother AND myself. I kept thinking that it seemed foolish considering the baby cried vigorously and the APGARs were 8 and 9 (and I felt strongly that the latter score should have been 10 but that the nurse’s judgment was tainted by the unnecessary drama). NOW I see that cutting the cord immediately was even more unnecessary than I thought at first since this forces the baby to do exactly what needs to be prevented: breathe anything that might be in there down deeper causing a real problem. Oy vey. Well, despite this… as hospital births go (I was at the previous one for this mom too), it was good. I don’t know that I can do another hospital birth though. Thank you for the info as always, Gloria… much love and appreciation… Joyce

    • Joyce-I quit doing hospital births after a mother had been very adament about tearing naturally and the OB insisted the baby would come out faster and everything would be fine if she just cut. The mom said no again and the doc said “well, this baby is obviously stuck because you can’t seem to push her out so I’m going to have to cut you for the good of the baby” she then made a horrific fourth degree cut and there was so much blood and trauma to the mom, me, the father and the baby that I just felt like I couldn’t do it anymore. The mom SCREAMED that she had been ripped in half and was in complete shock and pain (natural birth) and was trying to move but the doc kept yelling at her to quit being dramatic, it would all be fixed soon enough. Afterward the doc actually came in and said- “see, if I hadn’t done that you might still be pregnant!” I was appalled and decided I couldn’t do hospital births anymore.

      • I was yelling at my computer screen as I read your horrific story of the mom being cut like that! I want to be that mom so I can KICK HER IN THE FACE!

      • Alicia, please please tell me that these parents are going to lodge a formal complaint, and will follow it up with legal action if they get fobbed off.

  7. At 42 weeks, I was ordered to the hospital for an OC T. Pitocin was administered by IV and external fetal monitoring was utilized. I was instructed to lie on my back. Our daughter’s FHR plummeted with every contraction. The OB arrived after several hours and said he had some bad news for us. The baby was not doing well and the induction was to continue, followed by a cesarean was the probable path we were destined to follow. Our OB was called out of the room, my husband and I discussed the situation rationally and decided without pitocin, our daughter was just fine and we would not proceed with any further intervention. Our OB returned and agreed with us! We suggested a repeat of the OCT. Two days later we repeated the test with one small difference, I laid on my side and refused to change position so the fetal monitor would have a better reading on our daughter’s response. Same OB, same nurse, same test-different results. Perfect! OB agreed to change by EDD so I could utilize the Birth Center. Four days later, our daughter was born with no intervention. An unfamiliar OB attended, I pushed one time and 9 lb. 1 oz. Stephanie was born. Just prior to her birth, my amniotic sac created a small water balloon, filled with tainted water from meconium staining. I felt it slip out, the nurse caught it and said, “Wait till the doctor sees this, he won’t believe it”. Stephanie was covered with meconium and the amniotic fluid was watery but green. Her Apgar was 8/10. OB attempted to DeLee, but Stephanie had other ideas and the OB tossed her on my chest saying, “Here, she is just fine”. I am convinced, the first OCT caused fetal distress, resulting in meconium staining. By the time of her birth, six days later, it had been filtered out by the placenta and Stephanie was not the worse for wear, thank God!

  8. Just remember that cerebral palsy is a long term collection of symptoms and cannot be diagnosed when a baby is being ventilated, as in the picture. The baby likely has Hypoxic Ischaemic Encephalopathy *HIE* which he may or not recover from. Cerebral Palsy cannot be diagnosed form “cutting a cord too early” and is often associated with an intrapartum insult ( A baby with thick pea soup meconium at birth with low apgars is likely to be an infant who suffered an intrapartum assault/stress and does not cope well with what would be the reasonable stress of labour and birth to a well baby. The etiology of cerebral palsy is therefore not dependent on delayed cord clamping and there is no known association in the evidence.

    • Marianne, spouting all that medical-ese doesn’t change the fact that cutting the cord is a further insult to a baby who already might have been through hell. Why would you add more insult to injury? Wouldn’t it just be common sense to help that baby adjust to extra uterine life in the most physiological way possible.

      The medscape articles which try to make Cerebral palsy seem to happen up in the mother’s womb where no doctor can be blamed and sued are fine but, come on, we all know that CP is clearly associated with forceps and vaccuum extraction. We can’t blame physicians for coming up with unsupported theories which get them out of the gunsites of lawyers but please don’t try to “sell” this kind of thinking on my blog. It just won’t go over. Gloria.

      • Gloria,
        I think this was an unnecessarily hostile response. Marianne didn’t say that delayed cord clamping was bad, only that clamping the cord can’t be blamed for CP. To say that she’s “spouting medical-ese” to support her point after you just discussed research is unfair. If you are able to believe the research that MAS happens in utero to support your point, why aren’t you also open to the research that CP most likely begins in utero? It’s easy to dismiss as conspiracy when it goes against your point. Your own article states that the baby in the picture developed CP after her MAS, which your research shows began in utero and was not the result of forceps.

        That being said, I agree with you that term, vigorous babies should not be suctioned even in the presence of mec (this practice is sloooooowly making it’s way into hospitals, even though it is part of the NRP guidelines). These babies should remain on the mother’s chest and the cord left intact until it has stopped pulsing (something that many OBs seem to completely disregard). However, a baby with meconium who is non-vigorous does need to be evaluated and most likely suctioned per intubation by peds. This is in accordance with NRP guidelines.

        Routine suctioning of mec babies (heck, some places still routinely DeLee every baby), immediate cutting of the cord, routine epistiotomies, etc… There are numerous practices in the OB world that are unnecessary, and even harmful. Please don’t take this post the wrong way Gloria, I love your blog. I just don’t want any parent to read the above and think that if only they had delayed clamping the cord, their baby would not have CP.

        • just re-read my hostile comment and you’re right it is pretty reactionary. Thanks for being the voice of moderation that I needed there, Anonymous. Point taken.

  9. “we all know that CP is clearly associated with forceps and vaccuum extraction.”

    Association does not equate causation. Perhaps the clinical evidence that led to the decision to perform a forceps or vacuum birth is the cause of CP.

  10. CP is in fact caused by trauma to the brain, it is not just related to forceps and vacuum extraction. It can (also) be caused by lack of oxygen, premature birth, (other) traumatic delivery, or even a trauma to the brain later in life.

  11. My daughter (born in 2005) was deep suctioned due to mec staining. This resulted in a traumatized baby who screamed every time my milk let down and sprayed in her mouth. I struggled for 4 months, ceaselessly searching for answers (colic? reflux?) before finally understanding she had been emotionally traumatized by what happened. I stumbled onto craniosacral therapy and that is what finally healed her, in a series of powerful, heart-wrenching sessions culminating in me snatching her off the table and sobbing that I was sorry, so sorry that I hadn’t protected her. She immediately stopped crying, looked up at me through tears in her eyes and smiled (4-5 months old).

    Reading this research (which is not new to me, as I researched this after her birth) makes me so sad that my baby had to endure such an awful thing for no good reason. I think how difficult it would be to go through that as an adult, even able to understand what is happening and why. But a baby? Suctioning her before her body was even out of mine? And taking her from me and continuing? And then again when the NICU doc arrived? (Her APGARs were fine and she was crying vigorously.) And there is near universal refusal by the medical profession (OBs) to acknowledge that the type of trauma she experienced is even possible.

    So I am sad, but have taken from it all I can. As a result of my daughter’s experience with CST, I started receiving treatment myself, which was simply amazing. So I started the training, and 7 years later I am a craniosacral therapist myself, hoping to give back in the ways I have received.

    I do hope and pray, however, that a day comes when this practice no longer occurs. I know of numerous other babies who were traumatized by suctioning (some even from the routine bulb suctioning done at all hospital births). I hope for a day when newborns are seen as actual, sentient humans, with a rich emotional life, and are treated as such.

  12. It saddens me to see the harm caused by lack of knowledge. I was very blessed when my youngest was born that even though she had passed meconium intrauterine that the midwife did not suction and left cord pulsating as I had requested. I wish people would not practice out of habit but from evidence based practice…. Less interventions usually equals healthier mothers and babies

  13. Thank you for posting this vital information. I will share it with my clients and students. Your posts are always fascinating and well-researched. I consistently look to your site for solid evidence-based information that puts moms and babies first.

  14. I would just like to ask Have people heard of and use Homeopathy ?
    It saddens me that people either do not know or are afraid of opening up to the help and support it can be in all are lives, From womb to the grave.

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  16. Dear Gloria and anonymous,
    My comment above was in no way meant to undermine your message Gloria, that not cutting the cord and (in most cases) not suctioning vigorously, are better ways of handling babies born with msl than ‘routine medical interventions’. Immediate Skin to skin in a prone position and delayed cord clamping should be the norm even if there is msl. If resuscitation and intubation are necessary, I always perform these before I attend to the cord and have neopuff and suction equipment ready at the bedside. Thank you for sharing and highlighting the pertinent research about msl.

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