INFORMATION FOR CANDIDATE:

A 26 year old Mia Stuckey presents to your

emergency department in a country hospital
who is 10 days post term and she noticed a sudden
gush of greenish vaginal discharge and is worried
about her baby. All antenatal investigations have been
normal except that she was GBS positive at 34 weeks.
You are the locum GP and the hospital is fully
equipped for caesarean sections.
YOUR TASK IS TO:
take a further history
examine the patient
arrange for appropriate investigations
discuss the diagnosis and management with
patient

HOPC: A 26 year old Mia Stuckey presents to your emergency department in a country
hospital. She is 10 days post term and 30 minutes ago she noticed a sudden gush of
greenish vaginal discharge and is worried about her baby. No contractions.
This is her first pregnancy and all antenatal investigations have been normal except that
she was GBS positive at 34 weeks. Because she is 10 days post term date she had a CTG a
few days ago which was totally normal.
You are the locum GP and the hospital is fully equipped for caesarean sections.
PHx. + FHx.: unremarkable
SHx: married shop assistant, non smoker, non drinker, NKA, no medication.
EXAMINATION: Well looking lady with normal vital signs (especially BP).
Fundal height c/w 36 weeks which is normal also for her gestational age, considering the
engagement of the fetus has engaged in the pelvis. On palpation cephalic presentation
with longitudinal, left lateral lie, the head fetal heart rate 140/min. No tenderness. On
speculum presentation you find greenish discharge. PV: cervix dilated 3 cms and effaced,
no cord prolapsed (which could be responsible for meconium staining!).
INVESTIGATIONS:
U/S for (fetal abdominal circumference, length of femur and the longest column of
amniotic fluid compared with nomogram)
CTG
DIAGNOSIS: Meconium stained liquor
Meconium is a thick, black-green, odorless material first demonstrable in the fetal
intestine during the third month of gestation, resulting from the accumulation of debris,
including desquamated cells from the intestine and skin, gastrointestinal mucin, lanugo
hair, fatty material from the vernix caseosa, amniotic fluid, and intestinal secretions. It
contains blood group-specific glycoproteins and a small amount of lipid and protein that
decreases during gestation. The black-green color results from bile pigments.
Passage of meconium occurs early in the first trimester of pregnancy. Fetal defecation
slows after 16 weeks gestation and becomes infrequent by 20 weeks, concurrent with
innervation of the anal sphincter. From approximately 20 to 34 weeks, fetal passage of
meconium remains infrequent. Almost all fetuses and newborn infants who pass
meconium are at term or postterm gestation.
In post term pregnancies meconium staining is common and usually the baby is quite
well, but if CTG shows abnormalities, further steps need to be taken like induction of
labour of caesarean section.
Past term, the placenta involutes, and multiple infarcts and villous degeneration produce
placental insufficiency syndrome. In this syndrome, the fetus receives inadequate
nutrients from the mother, resulting in soft-tissue wasting. During labor, postmature
infants are prone to develop asphyxia; meconium aspiration syndrome, which may be
unusually severe because post-term amniotic fluid volume is decreased and the aspirated
meconium is less diluted; and neonatal hypoglycemia caused by insufficient glycogen
stores at birth. Because anaerobic metabolism rapidly uses the remaining glycogen stores,
hypoglycemia is exaggerated if perinatal asphyxia has occurred.
GBS: seeing that she was GBS positive at 34 weeks, she will require antibiotics now to
prevent the babys infection which could be quite severe if not treated.

1. If CTG and vaginal examination are normal:

In consultation with the specialist, labour can be induced with the aim of a normal
vaginal delivery and the appropriate help of paediatrician for the newborn baby
with immediate suction to clear and maintain the airway (mouth, pharynx and
nasal passages) to avoid meconium aspiration!
2. If CTG is abnormal, fetal scalp monitoring should be instituted: pH <7.2 and
lactate >4.2mmol/L indicates significant fetal acidosis and need for immediate
delivery by vaginal or caesarean route!
3. The baby might need admission to neonatal ICU.
4. The baby should receive antibiotics because of the mothers positive GBS status.