Royal College of Surgeons Ireland

School of Nursing & Midwifery

Academic Year 2016-2017

Student ID Number 15111288

Programme: Post Graduate Diploma (Neonatal

Intensive Care Nursing)
Module: Core Module 2

Submission Date: 29th August 2017

Submission First, Repeat etc.: Repeat

Actual Word count (not inc. 3800

references)

Date Submitted: 28th August 2017

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submit for assessment for the module above is entirely my own work and has not been

submitted as an exercise for assessment at this or any other University”

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1
Contents
Introduction...........................................................................................................................................4
Epidemiology.........................................................................................................................................5
Pathophysiology....................................................................................................................................5
MAS Diagnosis and Management..........................................................................................................6
Conventional Mechanical Ventilation Respiratory Support...................................................................8
High Frequency Ventilation...................................................................................................................9
Inhaled Nitric Oxide (INO)....................................................................................................................10
Family Support....................................................................................................................................14
Conclusion and Recommendation.......................................................................................................15
References...........................................................................................................................................15

2
Aspiration of meconium produces a syndrome characterized by hypoxia,

hypercapnia, and acidosis…… (Yeh, 2010).

3
Introduction

Meconium aspiration syndrome (MAS) mainly affects term infants or post-term infants.

Since meconium is seldom found in the amniotic fluid earlier than 34 weeks’ gestation

(Wiswell & Cleary 1994). It is a condition afflicting infants who inhale or aspirate meconium

stained liquor throughout or thereafter labour. Perinatal hypoxia, obstruction of airway

proximately after birth, a significant pulmonary vasoconstriction and hypertension are the

three main causes of morbidity and mortality. Major risk factors for MAS includes post

maturity, caesarean birth and maternal ethnicity (Dargaville, 2012). The approach to

preventing MAS in the newborn changed distinctly over the last 30 years, this is due to

improve antepartum and intrapartum obstetrical management as well as post-delivery.

Resuscitation of the newborn (Whitfield et al, 2009). Although the incident decreases, MAS

continues to be a neonatal disorder with a high morbidity and mortality rate at 2 to 5 percent,

in spite of changes in obstetrical and neonatal care (Stenson & Smith, 2012). The disease is

characterized by early onset of respiratory distress in meconium stained infant with poor lung

compliance and hypoxemia (Dargaville, 2012). Health professionals play a major role in

implementing new modalities for the best interest of the patients as well as their families.

Management of such infants remain a major challenge for the health professionals. Newer

technologies and therapies such as high frequency ventilation, inhaled nitric Oxide and

surfactant bolus therapy have been used in the treatment of MAS (Stenson & Smith, 2012).

In this assignment, the writer will discuss on how to distinguish MAS, describe the

pathophysiology that may occur after meconium aspiration. Discuss the clinical

manifestation, management, treatment, and prevention of MAS, and will give importance of

parental support. A conclusion and recommendation will be presented at the end of this

assignment.

4
Epidemiology

Meconium aspiration is a dark green sticky vicious mixture of intestinal epithelial cells,

lanugo, water, mucus, and bile (Ross, 2005). The occurrence of MAS and meconium stained

amniotic fluid (MSAF) depend on such factors as the socioeconomic family status,

convenience to medical care, advance technology, and effectiveness of prenatal care of a

community, and maternal ethnicity whereby Pacific Islanders and Indigenous Australians had

higher risk of MAS (Vain et al, 2009). Factors that inhibits the meconium passage in utero

involves maternal hypertension, placental deficiency, drug abuse during pregnancy, mostly of

cocaine and tobacco. Factors causing the MAS development between infants with meconium

stain amniotic fluid (MSAF) consist of thick meconium, non-reassuring cardiotocograph

(CTG) recording foetal hearth beats, and uterine contractions (Devane et al, 2006), foetal

acidosis, meconium below the cords, caesarean delivery, low Apgar score (Velaphi et al,

2006) and infants needing intubation at birth. MSAF is present in 13% of all new borns

delivered (Askin, 2010). Almost 30% of babies born with MSAF requires resuscitation in the

delivery suite and will require intensive care (Wiswell, 2001). However, Dargaville &

Copnell (2006) stated that the incidence of MAS is low and decreasing in the developed

country. Vein et al, (2009) says that the decrease in the incidence is due to the advances in

practices such as amnioinfusion, electric foetal monitoring increase prenatal ultrasound,

increase caesarean section, and decrease in post term deliveries.

Pathophysiology

MAS pathophysiology is complicated. There are few pathophysiologic means of hypoxemia

in MAS such as acute airway obstruction, surfactant dysfunction, chemical pneumonitis with

release of vasoconstrictive and inflammatory mediators, and Persistent Pulmonary

Hypertension (PPHN), right-to-left extra pulmonary shunting. Intrapulmonary shunting

5
related to atelectasis, contributed to poor oxygenation. Meconium may result to complete

airway obstruction or partial airway obstruction. It depends on the amount and thickness of

aspirated meconium and this will lead to alveoli atelectasis or hyperinflation. Air leak

syndrome namely pneumothorax, pneumomediastinum and pulmonary interstitial

emphysema arises due to rapture of gas that is trapped. Once alveoli have filled with

aspirated meconium the function of surfactant will be inactivated, and will decrease

production, resulting to lung atelectasis and may cause more of ventilation perfusion

mismatch (Raju, 2010) Leading to respiratory failure. The degree of lung damage is

depending on the severity of hypoxia and present of acidosis at birth. (Yakoob et al,2011).

The severity of MAS may not be the cause of aspirated meconium but mostly caused of

multiple pathologic development which occurs in utero, namely chronic asphyxia, listeria,

infection or PPHN.

MAS Diagnosis and Management

It is essential that infants delivered with meconium stain amniotic fluid (MASF) are

monitored for any signs of respiratory distress, for at least 24 hours. MAS is a prominent

cause of respiratory distress in the term or post term new born contributing to morbidity and

mortality. However, MAS is a disorder that can be prevented (Whitfield et al, 2009). Over

the past decades plans and management for neonates born through meconium stain amniotic

fluid (MASF) has been changed (Vein et al, 2009). The possible of MAS has been credited to

preventing of postmaturity and caesarean delivery where foetal distress is distinguished

(Dargaville & Copnell, 2005). Antenatal findings of foetal compromise as evidence by late

decelerations, abnormal foetal heartbeats, early increase in amount of MSAF are vital to

prevent risk of morbidity or mortality (Lavery, 2004). Excellent care of a new born infant

through MSAF involves teamwork between obstetrician, paediatrician, neonatologist and

nurses, each with different special roles. Good communication, preparation and anticipation
6
of possible problems should always be initiated for a better outcome and improve the

condition of the new born infant (Walsh & Fanaroff, 2007). Suctioning is another progress in

the management of babies born through MSAF. The approach to the management of infants

with MSAF in the delivery suite (DS) has been reformed and changed. DS management of

infants born with MSAF according to the neonatal resuscitation program (NRP) depends if

the infant is vigorous or not. (American Academy of Paediatrics, 2016). A vigorous infant

has a heart rate of more than 100 beats per minute, good respiratory effort and good tone, no

intervention required. A non-vigorous infant does not require routine endotracheal and

tracheal suctioning unless there is a suspicious airway block. Additionally, delivery of infants

must be attended by at least one skilled health professional whose responsibility is only focus

to a new born infant, and additional health professional should be present in a high-risk

delivery. Infants delivered with MSAF must be observed closely due to risk of developing

MAS (Wiswell, 2006). Clinical Manifestation of MAS sometimes develop late, such as

increasing respiratory distress, cyanosis, unstable oxygenation, decrease breath sounds and

barrel chest appearance (Ross, 2005). Infant showing this clinical manifestation should be

transferred to NICU for close observation and management (Walsh & Fanaroff 2007). It is

vital to monitor oxygen saturation if infants show signs of oxygen desaturation, and must

receive oxygen therapy. Continues positive airway pressure (CPAP) for mild MAS has been

used for treatment (Brooke & Vincent, 2015). On the other hand, Stenson and Smith (2012),

stated that CPAP increases risk of airleak syndrome, Neonatologists are cautious to use

CPAP, they rely upon the severity of MAS. Oxygen saturation should be maintained close to

100% (Kamat et al. 2009). Chest X-ray must be performed immediately to access for the

presence of air leaks, pneumothorax, pneumomediastinum and plural effusion (Wiswell,

2006). Radiographic display of typical MAS might be diffused, consolidation with areas of

collapse, patchy infiltrates with areas of expansion. The primary nurse has the vital role in

7
giving he necessary care and immediate management for infant. Assessment of acid-base

status is crucial due to metabolic acidosis that may occur from perinatal stress and maybe

complicated by respiratory acidosis from persistent pulmonary hypertension (PPHN) (Clark

2010). Primary nurse must be organized in plan and priority of care. Make sure that

management and treatment is provided on time on a stress free surrounding. And reassure

minimal handling, and not to agitate infant easily (Nicolls, 2010). Radiographic changes for

some new born infants may continue for several weeks, but some resolves for seven to ten

days (Cleary, 1998).

Conventional Mechanical Ventilation Respiratory Support

As a Result of severe MAS, cautious management is vital. Mechanical Ventilation is required

in about 30% to 40% newborns in MAS (Edward et al, 2013), and 10% requires continuous

positive airway pressure (CPAP). The objective of mechanical ventilation is to provide

adequate ventilation and remove carbon dioxide (Fraser, 2010). Nursing role is concerned on

minimizing hypoxia and acidosis and optimizing oxygenation (Nicolls, 2012). Oxygen

saturation should be kept between 92-97%. Assisted Mechanical Ventilation should be

considered when infants manifesting respiratory acidosis with PH less than 7.25, hypoxemia,

with Pao2 less than 5 kpa, hypercarbia with Paco2 greater than 10 kpa, . The amount of

ventilator support need for MAS depends on the severity of infant’s respiratory distress.

Oxygenation is improving when positive end expiratory pressure (PEEP) is between 4.7

centimetres water (Wiedemana et al, 2008). On the other hand, administering high PEEP with

MAS on CPAP is not recommended, due to risk of air trapping causing pneumothorax (Vain

et al, 2009). Ventilator settings should be set appropriately, short inspiratory time are advised

to prevent over distension of alveoli. Time cycled and limited pressure ventilation mode are

used, to avoid lung injury. Hyperventilation is also advised to achieve respiratory alkalosis

and avoid lung injury, resulting to pulmonary vasodilation (Dargaville, 2012). However,
8
infants showed worse outcomes with hyperventilation compared to those managed with

designed strategies to normalise alkaline and carbon dioxide. (Wadsh et al, 2007).

Furthermore, hyperventilation appeared to have a higher risk of air leaks and changes in

cerebral blood flow and considered harmful. (Vain et al, 2009).

High Frequency Ventilation

High frequency ventilation (HFV) is the next step when conventional ventilation fails and newborn

infants with severe MAS needs increased ventilator support (Widemann et al, 2008). High frequency

ventilation uses low pressures and high frequency to recruit the collapse alveoli by providing

effective gas exchange at low tidal volume. The advantages in using high frequency ventilation are

less barotraumas, increased mobilization of airway secretions and quicker attainment of respiratory

alkalosis (Raju et al, 2010). Niccolls (2012), stated that humidification is vital with high flow

oscillators to prevent from having necrotizing trachea-bronchitis, this condition appears to relate to

a combination of dry gas and high inspiratory flow. The neonatal nurse should ensure that airway

temperature is kept at 37 degrees centigrade and the fluid level in the humidification chamber is

filled with sterile water. Disconnection of the endotracheal tube from the ventilator circuit should be

avoided, a closed system approach to endotracheal suctioning should be implemented to prevent

the loss of lung volume due to alveolar collapse (Niccolls, 2010). Equal chest wall vibration must be

assessed carefully, this indicates for hyper or under-inflation, a blocked or disloged ETT, and possible

pneumothorax. Clinical trials have shown that high frequency ventilation decrease the need for

extracorporeal membrane oxygenation treatment and decreased air leak in infants with pulmonary

hypertension (Stenson & Smith, 2012). Yeh T.F. (2010) states that High Frequency ventilation

required less vasopressor support, had shorter mechanical ventilation days, shorter stay in the

hospital and lessens the incidence of chronic lung disease.

Surfactant is composed of phospholipids, proteins and neutralipids. It is a substance produced

and secreted by the type 2 alveolar cells in the lungs (Donn et al, 2009). Meconium interferes

9
with surfactant in many ways, displaces and inactivates surfactant from alveolar surface and

decrease protein levels, inactivate its function, resulting toxicity type 2 pneumocytes (Raju et

al, 2010). Therefore, exposure to MSAF may increase the intensity of the damage into the

lungs (Okazaki et al, 2008). Surfactant is administered as bolus over one minute via

endotracheal tube (ETT) to ensure maximal dispersion, manual ventilation is applied (Lacaze

et al, 2006). Due to interruption of ventilation, transient Bradycardia and desaturation may be

observed (Nicolls, 2012). Chest X-ray should be performed prior to surfactant administration

to confirm proper placement of ETT and to rule out pneumothorax (Clark et al, 2010). In

addition, aspiration of meconium has been associated to non-inflammatory cell deaths in

damage lungs (Kaapa, 2009). Administration of surfactant in infants with MAS showed

improvement in oxygenation, decrease intensity of respiratory distress and lessen the needs of

extracorporeal membrane oxygenation (ECMO) (Dargaville et al, 2007). Surfactant dose is

from 100-200 milligrams per kilogram, and administration can be repeated every six to eight

hours till oxygenation improves (Stevens et al, 2007). Combined therapy of surfactant

administration and with inhaled nitric oxide in the treatment of meconium aspiration

syndrome, with complication of pulmonary hypertension shown effectiveness and

improvement in oxygenation and gradually reduction the mechanical ventilation parameters.

Inhaled Nitric Oxide (INO)

Zawadski & Furchgott, (1980) scientifically discovered nitric oxide as a regulator of vascular

muscle tone. The approval of inhaled oxide (INO) as a selective pulmonary vasodilator was

on December 1999. It is used for hypoxic respiratory failure (HRF) of term and near term

infants. When Nitric Oxide is administered as an inhaled drug, ventilation perfusion ratio

mismatch decreases and improves oxygenation in infants with Persistent Pulmonary

Hypertension (PPHN). Monitoring of pre-ductal and post-ductal saturation is important

(Nicolls, 2012). INO study (2000) and (Williams et al, 2004) expounded the effectiveness
10
and safety of its use. Meconium aspiration syndrome is mostly together with PPHN with

right-to-left shunting due to increase pulmonary vascular resistance. It improves oxygenation

by directly acting on the vascular smooth muscle (Walsh et al, 2007). PPHN is a deficiency

of the foetal circulation and respiratory transition to adjust to extra uterine life, represented by

a high pulmonary vascular resistance (PVR), which remain elevated leading to increase

pulmonary blood flow which causes right-to-left shunting of deoxygenated blood through the

foramen ovale ductus arteriosus into systemic circulation echocardiography is considered the

most reliable non-invasive test to establish the diagnosis of PPHN (Kamat et al¸2009). If

infant’s oxygen requirement is increasing and showing severe pulmonary disorder, when the

oxygen is greater than 25 or partial pressure of oxygen is less than 100 millimetres of

mercury and receiving 100% oxygen INO therapy will be initiated to term infants,

recommended dosage is 20 parts per million. To achieve the good effects of INO, effective

ventilation is needed, preferably in MAS, manifesting parenchymal disease of the lungs

(Dargaville, 2012). Konduri et al (2007), stated that if nitric oxide is mixed with

haemoglobin, a chemical in activation occurs leading in the formation of methaemoglobin,

which prevents oxygen from binding with the haemoglobin and therefore reduces oxygen

transporting ability of the blood. Methaemoglobin must be monitored every four to twelve

hours. The weaning of 5 parts per million is suggested if infant’s ventilation and oxygenation

is improving. Once the INO Dose gradually wean to 5ppm, the further weaning is suggested

to 1ppm parts per million to avoid rebound PPHN (Dhillon, 2011). INO should not be

exceeded to five days’ treatment (Askin et al, 2010). Neonatal nurse role is vital on the

success of INO therapy, close observation and proper referral on time must be obtained.

Blood gas should be checked thirty to sixty minutes’ post starting of INO due to rapid effect.

Extracorporeal membrane oxygenation (ECMO) is the last source of treatment for severe

respiratory disorders (Mugford et al, 2008) On the other hand ECMO therapy is seldom

11
indicated for infants with MAS due to alternative and successful treatment of surfactant

therapy, HFV and INO. (Karimova, 2009).

Infant normal thermal environment should be maintained. It is a vital role of a neonatal nurse

and health care professional to maintain thermoregulatory needs of infants preserving and

minimizing their metabolic rate, oxygen, and glucose consumption (Monce, 2008). Minimal

handling should be observed and important to prevent agitation of infants, causing

hypoxemia and resulting to severe acidosis (Raju, 2010). Quiet environment and dim lighting

is effective on minimizing agitation for infants. Infant is kept nothing per oral. Intravenous

therapy must be started without delay to prevent hypoglycaemia blood glucose is the

monitored closely, umbilical venous catheter and umbilical arterial catheter must be inserted

for easy access of blood letting for laboratory tests, blood gases and invasive blood pressure

monitoring, without disturbing infant and preventing agitation. Monitoring invasive blood

pressure and systemic blood volume expanders such as normal saline is needed if infants

blood pressure is low, transfusion of packed red blood cells is indicated if haematocrit is

lower than 40%. Strict intake and output monitoring is needed due to risk of renal failure

(Bresford et al, 2006). The total fluid intake is mildly restricted at 60 to 70 millimetres per

kilogram. Due to risk of oedema, eyes, oral and skin care must not be neglected to avoid skin

breakdown due to oedema. Inotropic and Vasopressor agents are used to improve myocardial

function, such as epinephrine, dopamine, norepinephrine, dobutamine and milrinone.

Vasoactive drugs are commonly administered to increase systemic blood pressure (Vain et al,

2009). The use of phosphodiesterase (PDE) inhibitor was introduced to promote relaxation of

vascular smooth muscle. These are Milrinone and Sildenafil, it helps improve oxygenation in

term infants with PPHN on INO therapy when the infants has been settled and stabilized

brain imaging is done in the form of cranial ultrasound, computed tomography (CT) scan and

magnetic resonance imaging (MRI) to assess neurological status of infants (Clark, 2010).

12
Cerebral function monitoring (CFM) is needed when seizure is suspected. Laboratory test is

vital, full blood count (FBC) is monitored due to platelet aggregation inhibited by INO, and

to determine underlying sepsis or pneumonia. Serum electrolytes is checked after 24 hours

due to the syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) renal

failure (Clark et al, 2010).

Sedation

Sedatives are given to alleviate in discomfort and pain. Term infant easily get agitated and

manifest sudden desaturation and deterioration. This can be prevented with the use of

sedatives. (Bhat, 2009). A stat dose of morphine 100 micrograms per kilogram can be given,

followed by 10 to 20 micrograms per kilograms per hour of continuous infusion, midazolam

10 to 60 micrograms per kilogram per hour can be administered. Muscle relaxant such as

pancuronium. On the other hand (Walls et al, 2000) stated that prolonged use of muscle

relaxant can lead to higher risk of hypoxemia, hypotonia atelectasis, and generalized oedema.

High dose of sedative and lead to hypotension respiratory depression, prolonged ventilatory

support feeding intolerance and drug abuse (Walls et al, 2000). The national pain agitation

scale (N-pass) is used in the writer’s clinical area where she works to assess pain. Nurse is

responsible to assess and document pain scale based on N-pass criteria, and the need for

continuing pain management.

The use of steroids showed favourable outcomes in MAS management however there is

inadequate evidence to support the use of steroids n MAS management (Tripathi et al, 2007).

Prophylactic use of antibiotics is not recommended in MAS management, without known

perinatal risk factor. (Bhat, 2009). In the writer’s clinical area, antibiotics are given to infant

with MAS. Benzyl penicillin and Gentamycin is the drug of choice. In case of foul smelling

liquor, if antibiotics are given for suspected infection due to perinatal risk factors, once blood

13
culture reveals negative for forty-eight hours consider discontinuing of antibiotics. Nurses

should be aware of the actions and adverse effect of the drugs, that a right dose is

administered, a double checking of two nurses should always be implemented. Nurses must

ensure that proper documentation of labour delivery and management decision action taken

and appropriate investigation should be replaced in medical and nurse’s record.

Family Support

Parents of sick infants admitted to NICU are experiencing anxiety and depression, the nurse

must ensure to give good moral support to the infant’s family members who seem to be afraid

of what will be the progress of their sick baby, considering the environmental surrounding of

Neonatal Intensive Care Unit which will give more fright to parents. Nurse and the health

care team should explain the management and the equipment being used in a way that the

parents would easily understand (Nicolls, 2012), facilitate visiting, keep parents up to date

with the infant’s management and condition. Early bonding of parents to their babies may

lessen their stress and anxiety. Parents were often afraid to touch their infants with fear of

causing harm and discomfort to their baby, nurses must always encourage parents to get

involved in the care of their baby. By letting them do the oral care and nappy changing. Make

them feel confident in giving comfort to their baby. Encourage mom to express breast milk,

breast feeding is very important to mothers.

Conclusion and Recommendation

Meconium Aspiration Delivery (MAS) can be prevented, possible reduction of MAS has

been credited to preventing post-maturity delivery where foetal distress is distinguished

(Dargaville et al, 2011). Excellent care of a new born through Meconium Stain Amniotic

Fluid involves good communication, teamwork between healthcare professionals and each

with different roles. Preparation and anticipation of possible problems should be initiated.

14
The nurse’s role is vital for the better outcome of infants with MAS. Nurses must continually

update their knowledge and skills to become more competent practitioner, proper

documentation of labour delivery and management decisions, action taken and appropriate

investigation should be reflected in medical nurse’s record. Lastly Nurses must encourage

parents to get involved in the care of their babies.

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