Meconium Stained Liquor (MSL) in Labour and Management of the Newborn

Clinical Guideline

V2.1

June 2020

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 2 of 13

Summary

Flowchart for the management of a baby born through meconium

Identification of MSL in labour, assess for transfer to consultant led care, CEFM,

prepare for possible resuscitation

If baby born with no signs of respiratory depression vigorous, heart rate over 100bpm, remain skin to

skin with mum

Do not vigorously stimulate the baby if the baby is born with respiratory depression, heart

rate < 100bpm, or floppy. Take to the resuscitation area

Dry and assess airway, breathing and heart rate. Trained professional to inspect airway

under direct vision, if meconium seen, aspirate with a large bore sucker.

If in community setting, commence basic NLS life support, call for an ambulance communicate

with and transfer to delivery suite.

No resuscitative action required

Observations at 1 hour and 2 hours of age as per NEWS obs. (Can be

carried out in community setting, if baby remains

well)

Baby responds rapidly to suction and no further abnormal

respiratory signs

Admit to postnatal ward for observations at 1 hour and 2 hours

and then every 2 hours until baby 12

hours old

Baby has meconium below the cords or

continuing depressed vital

signs

Consider intubation and direct tracheal

suction. Suction should be

discontinued and inflation breaths delivered after 1

minute

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 3 of 13

1. Aim/Purpose of this Guideline 1.1. This guideline gives guidance to midwives, obstetricians and neonatal staff

on the management of meconium stained liquor in labour and the initial management of a baby born through meconium. This does not cover care on the neonatal unit or the management of Meconium Aspiration Syndrome (MAS).

1.2. This version supersedes any previous versions of this document.

1.3. This guideline makes recommendations for women and people who are pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals.

2. The Guidance

2.1. Introduction Between 15%-20% of term pregnancies are associates with meconium stained liquor (MSL), which, in the vast majority of labours, is not a cause for concern. However, in some circumstances, the passage of meconium in utero is associated with significant increases in perinatal morbidity and mortality. The aspiration of meconium into the lungs during intrauterine gasping, or when the baby takes its first breath, can result in a life-threatening disorder known as meconium aspiration syndrome (MAS) and this accounts for 2% of perinatal deaths.¹

2.2. Identification and management in labour of MSL

The presence of MSL makes pregnancy and labour high risk therefore the obstetric team must review the patient within 30 minutes of admission to delivery Suite and a minimum of 6 hourly thereafter. These reviews must be documented in the notes. If the obstetric team are unavailable, the reason must be clearly documented in the notes and when a review is expected. The co-ordinator should review the patient to assess the urgency. If a obstetrician is required urgently, immediate escalation to the Obstetric Consultant on call

Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation

The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We cannot rely on opt out, it must be opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the Information Use Framework Policy or contact the Information Governance Team rch-tr.infogov@nhs.net

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 4 of 13

should take place. Until the review happens the co-ordinator should be kept up to date with any changes (NEW 2020). 2.2.1. Pre labour rupture of membranes: Any woman that makes

contact with the maternity service and reports spontaneous rupture of membranes with any meconium staining should be advised admission to the consultant led unit for assessment. If MSL is confirmed, continuous electronic fetal monitoring (CEFM) should be commenced and a plan made for Induction of labour (IOL).²

2.2.2. Low risk intrapartum woman in the community setting: If during labour, MSL becomes evident, a risk assessment should be undertaken to include, the stage of labour, parity, current fetal well-being and transfer time. If transfer to a unit with neonatal facilities can be achieved before delivery, the woman should be advised to transfer, by ambulance, to a consultant led unit. The woman must be changed to Obstetric led care and the woman must have and obstetric review within 30 minutes of being on delivery suite as above (NEW 2020). If birth is expected before transfer can be facilitated, preparations should be made for resuscitation of the newborn and consideration given to calling an ambulance for transfer of the baby, following birth.

2.2.3. Intrapartum women in the consultant lead unit: If the woman is

being cared for as a low risk woman on delivery suite and MSL is identified, the woman should be informed of the significance of MSL and that CEFM is indicated and that the presence of a member of the neonatal team will be called for delivery, and observation of the baby will be advised in the post-natal period. The patient data Swiftplus screen should be updated and the coordinator and obstetrician informed of the presence of meconium, and care transferred to consultant led care. The obstetric team must be informed of the presence of MSL and a review undertaken within 30 minutes as above. 6 hourly reviews by the obstetric team should be undertaken and documented. If this timeframe cannot be achieved the reason why must be documented in the notes and the coordinator informed (NEW 2020)

2.2.4. High risk intrapartum woman on delivery suite: If the woman

already has risks factors requiring CEFM and MSL is identified, the patient data Swift plus screen should be updated and the coordinator and obstetrician should be informed of the presence of MSL. The woman should be informed of the significance of MSL and that a member of the neonatal team will be called for delivery, and observation of the baby will be advised in the post-natal period. The obstetric team must be informed of the presence of MSL, this must be documented in the maternal notes and an obstetric review undertaken within 30 minutes as above. 6 hourly reviews by the obstetric team should be undertaken and documented. If this timeframe cannot be achieved the reason why must be documented in the notes and the coordinator informed (NEW 2020).

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 5 of 13

2.3. Management of a baby born through MSL 2.3.1. Resuscitation equipment should be checked and available in the

delivery room/area

2.3.2. If in the consultant unit a member of the neonatal team should be called for delivery

2.3.3. Suctioning of the nasopharynx and oropharynx prior to the birth of

the shoulders and trunk should not be carried out. 2.3.4. If a baby born through meconium is vigorous and breathing at birth

with no signs of airway obstruction and a heart rate over 100bpm, no action is required and baby can remain skin to skin with the mother and delayed cord clamping.

2.3.5. If the baby is compromised at delivery with a low heart rate or ineffective/not breathing the baby’s cord should be cut but left long and baby transferred to the resuscitation area. The upper airways should be suctioned, by a healthcare professional trained in neonatal life support before inflation breaths are given. If the baby has depressed vital signs, laryngoscopy and suction under direct vision should be carried out by a healthcare professional trained in advanced neonatal life support. Inflation breaths should be commenced after 60 seconds even if tenacious meconium is apparent in the airway (NLS guidance 2016)

2.3.6. If in the community setting basic life support should be commenced

and immediate transfer by ambulance to a unit with neonatal facilities should be facilitated.

2.3.7. Emergency senior neonatal team help should be summoned using

the 2222 system in Hospital or 999 ambulance

2.4. Ongoing care of a baby born through meconium 2.4.1. If the baby is vigorous at birth, a plan should be made and

documented by the attending neonatologist for observation to be carried out at 1hour and 2 hours of age for signs of respiratory distress. The observations must be documented on a neonatal early warning score (NEWS) chart or electronic observation NEWS record. These observations must be commenced in the delivery setting. Provided the baby remains well these observations can be carried out in the community setting.

2.4.2. For any baby born though meconium with signs of initial depression who responds rapidly to suction and has no ongoing abnormal respiratory signs, the attending neonatologist must make and document a plan for the baby to remain in hospital and observed for signs of respiratory distress at 1 hour and 2 hours of age and then 2 hourly until 12 hours of age. These observations must be commenced in the delivery setting.

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 6 of 13

2.4.3. Any baby with initial depression requiring more prolonged resuscitation or if meconium is aspirated from below the cords they should be assessed by the neonatal team and admission to the neonatal unit considered.

2.5. Documentation:

All observations must be completed and documented in a timely manner not to exceed 15 minutes of the required time. Observations should be recorded on a neonatal early warning score (NEWS) chart, CHA 3296 V1 or electronically recorded with NEWS eObs Early warning scores must be responded to appropriately and escalated to the neonatal team. Once observations have been commenced the NEWS chart should be filed and remain in the neonatal notes.

2.6. Neonatal referral: If the baby’s condition causes concern at any time a review by the neonatal team should be requested. This should be documented on the intrapartum record if still on delivery suite or in the neonatal notes section of the hand held notes. If in the post-natal period, the documentation of the review of the baby by the neonatal team will be in the baby notes.

3. Monitoring Compliance and Effectiveness Element to be monitored

See Appendix 3 for the Auditing Tool

Lead Audit Midwives

Tool See Appendix 3 for Auditing Tool

Frequency 1% or 10 sets, whichever is greater, of all health records of newborns with MSL present at delivery, will be audited over a 12 month period

Reporting arrangements

A formal report of the results will be received annually at the Maternity Forum as per the audit plan

During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next Maternity Forum Meeting and an action plan agreed.

Acting on recommendations and Lead(s)

Any deficiencies identified on the annual report will be discussed at the Maternity Forum Meeting and an action plan developed

Action leads will be identified and a time frame for the action to be completed by

The action plan will be monitored by the Maternity Forum until all actions complete

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within a time frame agreed on the action plan

A lead member of the forum will be identified to take each change forward where appropriate.

The results of the audits will be distributed to all staff through the Patient Safety Newsletter as per the action plan

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 7 of 13

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 8 of 13

Appendix 1. Governance Information

Document Title Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1

This document replaces (exact title of previous version):

Management of infants born through meconium stained liquor (MSL) V2.0

Date Issued/Approved: May 2020

Date Valid From: June 2020

Date Valid To: September 2022

Directorate / Department responsible (author/owner):

Sarah-Jane Pedler, Practice Development

Contact details: 01872 255 019

Brief summary of contents

This guideline gives guidance to midwives, obstetricians and neonatal staff on the management of meconium stained liquor in labour and the initial management of a baby born through meconium. This does not cover care on the neonatal unit or the management of meconium aspirate syndrome (MAS).

Suggested Keywords: Meconium, meconium stained, liquor, MSL, aspiration, new-born, observation,

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route for consultation and ratification:

Maternity Guidelines Group Care Group Board PRG

General Manager confirming approval processes

Debra Shields, Care Group Manager

Name of Governance Lead confirming approval by specialty and care group management meetings

Caroline Amukusana

Links to key external standards CNST 5.4

Related Documents:

NICE clinical guideline Intrapartum guidance for healthy women and babies (cg190) 2014.updated November 2016 https://www.nice.org.uk/guidance/cg190/ifp/chapter/if-there-is-meconium-during-labour

RCHT (2012) Clinical guideline for the management of pre labour rupture of

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 9 of 13

membranes at term (Term PROM)

Resuscitation Council UK NLS guidance updated 2016 https://www.resus.org.uk/statements/rc-uk-resuscitation-guidelines-2015-published/

Training Need Identified? No

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet

Intranet Only

Document Library Folder/Sub Folder Clinical/Midwifery and Obstetrics

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

August 2005

V1.0 Initial version Paul Munyard Consultant Neonatologist

September 2009

1.1 Updated to include NICE guidance Paul Munyard Consultant Neonatologist

September 2012

1.2 Reviewed and updated, compliance monitoring added

Jan Clarkson Maternity Risk Manager

1st May 2014

1.3

Updating use of NEWS chart and reinforcing timeliness of observations: a) Observations commenced in delivery

setting

b) NEWS chart to be used for recording observations and filed in neonatal notes

c) Observations to be recorded in a timely manner not exceeding 15 minutes of required time

Sarah Hadfield Midwife

12th January

2016 1.4

Updated re new NICE guidance 2016, NLS guidance 2016 and electronic observation use. Flowchart moved to front of document

Judith Clegg ANNP, NNU

September 2019

V 2.0

Additions regarding changing to obstetric care following recommendations from the Health Safety Investigation Branch (HSIB). Removal of thick/thin meconium.

Sarah-Jane Pedler, Practice Development Midwife.

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 10 of 13

May 2020 V2.1

Addition of 1.4 – equality statement 2.2 paragraph, 2.2.2 and 2.2.3 30 minute reviews by the obstetric team on arrival on delivery suite or new MSL and 6 hourly reviews of high risk women

Julie Walton Audit Midwife

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 11 of 13

Appendix 2. Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1

Directorate and service area: Obs and Gynae

Is this a new or existing Policy? Existing

Name of individual/group completing EIA Sarah-Jane Pedler, Practice Development

Contact details: 01872 255 019

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

This guideline gives guidance to midwives, obstetricians and neonatal staff on the management of meconium stained liquor in labour and the initial management of a baby born through meconium.

2. Policy Objectives Safe, evidenced based management of meconium stained liquor in labour and initial management of the new-born.

3. Policy Intended Outcomes

Good outcome for a baby born through meconium.

4. How will you measure the outcome?

Compliance Monitoring Tool.

5. Who is intended to benefit from the policy?

Pregnant Women and their new-born babies

6a). Who did you consult with?

b). Please list any groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

X

Please record specific names of groups: Maternity Guidelines Group Care Group Board

c). What was the outcome of the consultation?

Guideline agreed.

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 12 of 13

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have a positive/negative impact on:

Protected Characteristic

Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Sex (male, female non-binary, asexual etc.)

X

Gender reassignment X

Race/ethnic communities /groups

X

Disability (learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions)

X

Religion/ other beliefs X

Marriage and civil partnership X

Pregnancy and maternity X

Sexual orientation (bisexual, gay,

heterosexual, lesbian) X

If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:

Sarah-Jane Pedler, Practice Development

If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead debby.lewis@nhs.net

Meconium Stained Liquor (MSL) in Labour and Management of the Newborn Clinical Guideline V2.1 Page 13 of 13

Appendix 3. Monitoring Compliance and Effectiveness

Guideline Audit Tool

Applicable Guideline MECONIUM STAINED LIQUOR (MSL) IN LABOUR AND MANAGEMENT OF THE NEWBORN - CLINICAL GUIDELINE

Audit Register Number (For audit use)

Process Retrospective

Audit Date (For audit use)

Auditor (For audit use)

Audit Questions

1 If prelabour SROM occurs and meconium is present was CEFM commenced and a plan made for IOL?

2 Was CEFM utilised if MSL was noted at any point during the labour and delivery?

3 Was the obstetrician informed of the presence of MSL?

4 If transfer to the DS was required was the woman reviewed within 30 minutes of being in delivery suite?

5 Were women who laboured for more than 6 hours with MSL reviewed a minimum of 6 hourly by the obstetric team?

6 Was a resuscitaire in the room for delivery?

7 Were the neonatal team called to attend the delivery?

8 Was the NEWS chart completed with the appropriate 1 hour old observations if the baby remained in midwifery care?

9 Does the NEWS chart show 12 hours of observations every 2 hours

10 Were any abnormal observations escalated to the ANNP or neonatal SHO appropriately?