Elsevier

The Lancet

Volume 364, Issue 9434, 14–20 August 2004, Pages 597-602
The Lancet

Articles
Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial

https://doi.org/10.1016/S0140-6736(04)16852-9Get rights and content

Summary

Background

Meconium aspiration syndrome (MAS) is a life-threatening respiratory disorder in infants born through meconium-stained amniotic fluid (MSAF). Although anecdotal data concerning the efficacy of intrapartum oropharyngeal and nasopharyngeal suctioning of MSAF are conflicting, the procedure is widely used. We aimed to assess the effectiveness of intrapartum suctioning for the prevention of MAS.

Methods

We designed a randomised controlled trial in 11 hospitals in Argentina and one in the USA. 2514 patients with MSAF of any consistency, gestational age at least 37 weeks, and cephalic presentation were randomly assigned to suctioning of the oropharynx and nasopharynx (including the hypopharynx) before delivery of the shoulders (n=1263), or no suctioning before delivery (n=1251). Postnatal delivery-room management followed Neonatal Resuscitation Program guidelines. The primary outcome was incidence of MAS. Clinicians diagnosing the syndrome and designating other study outcomes were masked to group assignment. An informed consent waiver was used. Analysis was by intention to treat.

Findings

18 infants in the suction group and 15 in the no suction group did not meet entry criteria after random assignment. 87 in the suction group were not suctioned, and 26 in the no suction group were suctioned. No significant difference between treatment groups was seen in the incidence of MAS (52 [4%] suction vs 47 [4%] no suction; relative risk 0·9, 95% CI 0·6–1·3), need for mechanical ventilation for MAS (24 [2%] vs 18 [1%]; 0·8, 0·4–1·4), mortality (9 [1%] vs 4 [0·3%]; 0·4, 0·1–1·5), or in the duration of ventilation, oxygen treatment, and hospital care.

Interpretation

Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF does not prevent MAS. Consideration should be given to revision of present recommendations.

Introduction

An important complication in newborn infants born through meconium-stained amniotic fluid (MSAF) is the development of meconium aspiration syndrome (MAS).1, 2 Limited anecdotal data have led to the widespread practice of intrapartum oropharyngeal and nasopharyngeal suctioning of meconium-stained infants in the presence of MSAF.3 However, other data do not support this approach.4, 5 Nonetheless, this procedure is practised worldwide for millions of deliveries complicated by MSAF every year.6, 7

Additionally, prominent organisations such as the International Liaision Committee on Resuscitation, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists have recommended the procedure.6, 8, 9 Although it is no longer advocated in the UK Newborn Life Support Guidelines (Resuscitation Council),10 prenatal suction of meconium-stained infants is still frequently undertaken.

However, no randomised controlled trial so far has specifically assessed the effectiveness of intrapartum oropharyngeal and nasopharyngeal suctioning in the prevention of MAS in deliveries complicated by MSAF. Since intrapartum suctioning has potential risks, the need for assessment of this widely practised procedure should not be ignored.1, 4, 5

We aimed to assess the effectiveness of intrapartum oropharyngeal and nasopharyngeal suctioning compared with no suctioning in the prevention of MAS and its complications.

Section snippets

Patients

12 centres participated in our multicentre, randomised controlled trial: 11 in Argentina, and one in the USA. Trial sites included six public hospitals caring for patients from underserved populations who often failed to seek prenatal care, and six private hospitals that care for women of middle and upper socioeconomic classes who received high-quality health care. Patients were enrolled between March 13, 2000, and Oct 1, 2001. Enrolment did not start on the same day in all centres during this

Results

During the study, 3249 patients met inclusion criteria (figure). Of these, 735 were not enrolled because of: (1) insufficient time for a randomisation envelope to be opened (n=539) due to factors such as delayed notification of MSAF, or MSAF only being noted at the time of uterine incision during a caesarean section; (2) refusal by the obstetrician to allow his or her patient to participate (n=126); and (3) other reasons (n=70), mostly due to technical difficulties in the suction system that

Discussion

In our randomised controlled trial of term-gestation infants born through MSAF, intrapartum suctioning did not decrease the incidence of MAS. Other important outcomes, including mortality, air leaks, duration of mechanical ventilation, oxygen treatment, or length of hospital stay, were similarly unaffected by this procedure. In our trial, infants at highest risk for MAS (ie, those born through the thickest-consistency MSAF, with fetal distress, delivered via caesarean section, and needing

References (27)

  • V Katz et al.

    Meconium aspiration syndrome: reflections on a murky subject

    Am J Obstet Gynecol

    (1992)
  • BA Yoder et al.

    Changing obstetric practices associated with decreasing incidence of meconium aspiration syndrome

    Obstet Gynecol

    (2002)
  • TE Wiswell et al.

    Meconium staining and the meconium aspiration syndrome—unresolved issues

    Pediatr Clin North Am

    (1993)
  • Cited by (295)

    • Meconium-stained amniotic fluid

      2023, American Journal of Obstetrics and Gynecology
    • Acute Neonatal Respiratory Disorders

      2023, Avery's Diseases of the Newborn
    • Mechanical ventilation: Disease-specific strategies

      2022, Goldsmith's Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care, Seventh Edition
    • Delivery room stabilization and respiratory support

      2022, Goldsmith's Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care, Seventh Edition
    View all citing articles on Scopus
    1

    Members are listed at end of report

    View full text