Friday, 23 March 2012

Meconium stained liquor

In a note regarding last week’s OBEM I asked why it was that a multiparous woman being induced for postdates was being subjected to continuous monitoring,(EFM). It was clear that she had been induced by prostaglandin suppository alone and was not on a syntocinon drip. I had a discussion with an NHS labour ward colleague and was able to rule out that EFM, in this case, was linked to induction process so I was confused. However what I obviously missed and what was subsequently pointed out on Facebook page, One Born Every Minute-The Truth, was that there was meconium stained liquor seen during the birth. (note to self wear your glasses next time)

So I thought I would pose this question; is meconium stained liquor always a reason to constantly monitor a baby in labour? I think I am correct in saying that finding meconium in the amniotic fluid is a reason that is often cited to transfer from a home birth, midwifery led unit or birth centre to a consultant led unit and also to commence EFM (information taken from local trust guidelines). The labour therefore has shifted from a normal one to an abnormal one, from low risk to high risk and maybe the course of the woman’s birth and or birth plan completely changed because of the meconium alone.

There is plenty of information on what meconium is and what harm it can do (Google it) so I want to focus on the changes it brings to the course of labour and whether those changes are indeed always necessary.

According to the National Institute for Clinical Excellence, (NICE) continuous EFM should be ADVISED for women with significant meconium-stained liquor, which is defined as either dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium. Whereas continuous EFM should be CONSIDERED for women with light meconium-stained liquor depending on a risk assessment which should include as a minimum their stage of labour, volume of liquor, parity and the fetal heart rate. Nice also states that “significant meconium stained liquor” is an indication for transfer to an obstetric unit. It seems that NICE are definitely about defining and describing different categories of meconium which may change the advice given and or choice of care.

We can presume, from reading individual Trusts guidelines, listening to women’s stories and of course watching good old OBEM that labouring women are told that there IS meconium and therefore they need to be constantly monitored due to it being a risk factor for baby, but are they told ALL the details and given a choice?

Are women informed that the meconium in the water is light and that as they are having a 2nd or subsequent baby the labour may be quick and that if baby has no problems with his /her heart rate it is recommended that continuous EFM be only CONSIDERED? Are women told that the need for EFM is not absolute, and furthermore that in her particular case, it has been considered and there is no reason to constantly monitor the baby as long as all else stays well? Her birth plan does not have to change she can remain moving around and being intermittently monitored at home, in a birth centre or indeed in the hospital of her choice?

I have reviewed a very recent research paper (2012) which was published in the International Journal of Paediatrics and reviewed 133,000 births between 37 and 43 weeks complicated by meconium stained liquor. With a bit of mathematics I have changed the percentages into numbers and this is what the study found.

Meconium in the water is a relatively uncommon problem and in this study affected only 8 in every 100 births, and of those babies less than 7 in 10,000 became ill. In terms of mortality rates, the chances of meconium related death in childbirth was 2 in 100,000.

Other studies have quoted different statistics but in all recent evidence the incidence of meconium aspiration syndrome is similarly very low. That is not to say that it is to be dismissed lightly as it can cause extremely serious illness and fatalities in the extreme cases.

The issues once again are informed choice. Some parents would want to act on the chance they could be one of the 2 in 100,000 who child dies or even one of the 7 in 10,000 whose child is ill but equally importantly some would want to make choices based on the likelihood of them being one of the 998,000 or of the 9,993 who could continue with their plan of a normal non-medical birth.

Either way they should be given the facts in order to make a choice

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