Journal of Perinatology (2008) 28, S14–S18

r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30

www.nature.com/jp

REVIEW
Obstetric approaches to the prevention of meconium aspiration
syndrome
H Xu, S Wei and WD Fraser
Department of Obstetrics and Gynecology, Hoˆpital Sainte-Justine, Universite´ de Montre´al, Montreal, QC, Canada

Definition of meconium aspiration syndrome

Meconium aspiration syndrome (MAS) is associated with increased
risk for perinatal mortality and morbidities. To provide an overview of the
advances in our knowledge concerning the obstetric approaches to the
prevention of MAS. The evidence of the effectiveness of intrapartum
surveillance, amnioinfusion, and delivery room management in the
prevention of MAS are reviewed in the present paper. Meconium aspiration
syndrome remains one of the most common but challenging conditions
for obstetricians and pediatricians. The available evidence did not
demonstrate a beneficial effect of either of obstetric strategies in the
prevention of MAS.
Journal of Perinatology (2008) 28, S14–S18; doi:10.1038/jp.2008.145
Introduction
Meconium staining of the amniotic fluid (MSAF) occurs in <5% of
preterm, 7 to 22% of term deliveries, increasing to between 23 and
52% of births at >42 weeks.1–7 The mechanisms influencing
meconium passage are complex, involving hormonal and
neuroregulatory functions, chronic hypoxia or reflecting
maturation of the fetal gastrointestinal system.8–11 MSAF is
associated with an increased risk of neonatal morbidity and
mortality. Meconium aspiration syndrome (MAS) is the most
serious neonatal pathology associated with MSAF. It has been
reported to occur in 1.7 to 35.8% of cases complicated with MSAF,
and 1 to 3% of liveborn infants.1,12–14 The case fatality rate of MAS
has been reported to be high, ranging from 5 to 40%.1,13–17
Approximately one-third of babies with MAS require intubation and
mechanical ventilation, and other new therapies such as high
frequency ventilation, inhaled nitric oxide and surfactant
administration, although the effectiveness of certain of these
technologies remain controversial.2,17–19 Serious complications
resulting from MAS include pneumothorax, convulsion
and death.
Correspondence: Dr WD Fraser, Department of Obstetrics and Gynecology, Hôpital Sainte-
Justine, Université de Montréal, 3175 Chemin de la Côte Sainte-Catherine, Montreal, QC,
Canada H3T 1C5.
E-mail: william.fraser@umontreal.ca
Rossi et al.20 has defined MAS as respiratory distress in the first 4 h
after birth with oxygen requirement and chest roentgenogram
showing characteristic features of MAS. Recently, Cleary and
Wiswell have defined MAS as respiratory distress in an infant born
through MSAF, which cannot be otherwise explained. Mild MAS has
been defined as requiring <40% oxygen for <48 h, moderate MAS
as requiring >40% concentration of oxygen therapy for at least
48 h, and severe MAS if requiring assisted mechanical ventilation,
that is, often associated with persistent pulmonary hypertension.1,20
They further pointed out that the severity of MAS does not
necessarily correspond to the degree of chest radiographic
abnormality. MAS is associated with a range of radiographic
features including coarse, patchy infiltrates, consolidation,
atelectasis, pleural effusions, air leaks, hyperinflation, a wet-lung
picture and hypovascularity.1 In some cases, the chest film may be
interpreted as normal.1
Pathophysiology and risk factors
The pathophysiology of MAS is complex and remains controversial.
Many factors, such as airway obstruction, alveolar or parenchymal
inflammation, impaired surfactant production and function and
direct toxicity of meconium constituents could be involved in the
pathophysiology of the MAS.1,21,22 It has been suggested that the
extent of lung destruction is not closely correlated to the quantity of
meconium in lung tissue but rather to the degree of hypoxia and
acidosis present at delivery.23 Ghidini and Spong22 postulated that
the pathologic events leading to mild, moderate or severe cases of
MAS may be different. Severe MAS may not be in fact causally
related to the aspiration of meconium but rather may be caused by
other pathologic processes occurring in utero, such as chronic
asphyxia, infection or persistent pulmonary hypertension.22 The
hypothesis is in fact supported by the lack of evidence that the
severity of MAS directly correlates with the amount of meconium
aspirated, the consistency of meconium and the duration of
exposure to meconium.1,15,20,22,23 It is still unclear whether
obstruction of airways because of aspiration of meconium has a
pivotal role in the progress of MAS. MAS can occur before delivery,

even in the absence of labor, being reported in infants delivered by
elective cesarean section.24
Although the presence of meconium during labor is known to
be associated with an increased risk of perinatal morbidity and
mortality, most babies have favorable outcomes. Early recognition
of infants at the highest risk for the development of MAS could be
essential for optimizing the clinical preventive strategies. A vast
array of risk factors for the occurrence of MAS have been identified
either using unselected obstetrical populations or infants born
through MSAF. Those factors are heavy MSAF, nulliparity, postterm
delivery, fetal heart rate (FHR) abnormalities during labor,
presence of meconium below the vocal cords, cesarean delivery and
the low Apgar scores.13,14,20,25–30 It has been reported that there is
an apparent relationship between maternal ethnicity and risk of
MSAF, and the risk of MAS having been observed to be increased in
black Americans, Africans and Pacific Islanders.30–32
Intrapartum fetal monitoring
The goal of continuous electronic fetal heart rate monitoring
(EFM) is to detect fetal hypoxemia and therefore reduce the risk of
adverse neonatal outcomes. However, the effectiveness of this
approach to care has been questioned. Randomized trials of EFM,
with or without fetal blood gas and acid–base assessment, which
were conducted in the unselected obstetrical population, have
found no evidence that this approach to care reduces the risk of
fetal or neonatal mortality or morbidity.33–39
Intrapartum monitoring has been recommended to screen for
early signs of fetal hypoxia, a risk factor for MAS. Several authors
have noted an increase in the frequency of FHR abnormalities in
association with MSAF.15,20,40,41 It has been reported that, in the
presence of MSAF, fetal tachycardia, variable and late decelerations
and decreased long-term variability are risk factors for MAS.
Certain authors investigated the relationships among abnormal
cardiotocograms in labor, MSAF and adverse neonatal outcomes
such as low arterial cord blood pH, and low Apgar scores. The
authors did not find that the presence of abnormal FHR patterns
increased the overall correlation between MSAF and adverse
outcome.7,42 In contrast, Umstad et al.43 investigated the predictive
value of abnormal FHR patterns in early labor and found that the
presence of meconium in the amniotic fluid improved the
predictive properties of the test.
Amnioinfusion
Amnioinfusion (AI), or transcervical infusion of saline into the
amniotic cavity, was used first to relieve persistent variable FHR
decelerations during labor or to prevent the occurrence of
decelerations in presence of oligohydramnios.44 Results of
randomized controlled trials, including a meta-analysis indicate
that, in the presence of oligohydramnios, prophylactic intrapartum
Obstetric management of MAS
H Xu et al
S15
AI significantly reduces the risk of FHR decelerations and cesarean
section.45–52
AI has been also proposed as a method to reduce MAS. Potential
mechanisms through which AI could act include mechanical
cushioning of the umbilical cord, which could correct or prevent
recurrent umbilical compressions that lead to fetal acidemia, a
condition predisposing to MAS; and dilution of meconium that
could reduce its mechanical and inflammatory effects in the
pathogenesis of MAS.
To date, more than 15 randomized or quasi-randomized trials
of AI for MSAF have been reported, with conflicting results.53,54 The
methodological quality varied across studies. The largest trial (over
1998 participants) was an international trial performed in 56
centers where EFM and neonatal intubation and suctioning for
babies with respiratory difficulty were routinely available.55 Analysis
was by intention to treat. The primary outcome was a composite
indicator that included the occurrence of perinatal death and/or
moderate or severe MAS. The results indicated that AI showed no
effect on the primary outcome (relative risk; RR 1.26, 95%
confidence interval; CI 0.82 to 1.95). Furthermore, the frequencies
of oropharyngeal suctioning, laryngoscopy or intubation in the
delivery room were similar between groups, as were the proportion
of babies with meconium visualized below the vocal cords. There
were no differences between groups in the occurrence of the
combined outcome of perinatal mortality and/or serious morbidity
(RR 1.13, 95% CI 0.88 to 1.47). In addition, an analysis that
stratified for the presence or absence of variable FHR decelerations
before randomization found no effect on the primary outcome
either, although the study was underpowered to detect such effects
within strata.
We recently conducted a systematic review, integrating the
results of the largest trial.54 Studies were included if they were
randomized controlled trials that evaluated the effect of
prophylactic AI during labor with MSAF; treatment was randomly
allocated (AI versus controls). All included studies were further
subjected to a score-based quality assessment for randomized
studies that was adapted from the Jadad score. The main analysis
was based on the studies that were considered to be of high quality.
The meta-analysis included a total of 4030 women, 1999 allocated
to AI and 2031 allocated to control. Of these, 3178 women were
recruited in clinical settings with standard peripartum surveillance
and 852 women were randomized in centers with limited
peripartum surveillance, defined as the nonavailability of EFM
during labor. The methodological quality varied across studies.
Heterogeneity was noted across studies with respect to the AI
protocols and the end points evaluated. In the setting of standard
peripartum surveillance, the results failed to demonstrate a
reduction in the risk of MAS (RR 0.59, 95% CI 0.28 to 1.25),
Apgar-5 <7 (RR 0.90, 95% CI 0.58 to 1.41) or caesarean delivery
(RR 0.89, 95% CI 0.73 to 1.10). However, in clinical settings with
limited peripartum surveillance, AI appeared to reduce the risk of
Journal of Perinatology
 Obstetric management of MAS
H Xu et al
S16
MAS (RR 0.25, 95% CI 0.13 to 0.47). Several findings from this
meta-analysis are worthy of comment. Firstly, the observed
heterogeneity in the stratum of studies conducted in centers with
standard surveillance is largely attributable to our recent large
trial. The source of this heterogeneity remains largely unexplained.
The most significant finding of the meta-analysis is the apparent
discordance in the observed effect of AI on MAS between centers
with standard and limited peripartum surveillance. Continuous
EFM is a key component in the prevention of asphyxia in patients
with MSAF. Therefore, the application of this technology may
reduce the contribution of severe asphyxia to the risk of occurrence
of MAS. It would appear that in settings where this technology is
routinely used, AI confers no additional benefit over EFM in terms
of prevention of MAS. However, in settings where continuous EFM
is not routinely available, AI may be beneficial for the reduction of
MAS. Further studies in such settings are warranted to confirm this
hypothesis.
AI may not be without risk. The use of AI has been reported to
be associated with adverse events. Complications including uterine
overdistension and hypertonia, uterine rupture in association with
previous uterine scar, FHR abnormality, umbilical cord prolapse
and chorioamnionitis have been reported.56–59 Four cases of
maternal deaths have been reported associated with the AI.58,59
Several authors have reported the occurrence of excessive uterine
contractions or unusually rapid labor progress related to AI. In the
AI group of Fraser et al.’s55 trial, 10 women (1.1%) experienced
bleeding, and in 63 (6.9%) women, hypertonicity, hydramnios or
uterine overdistension was diagnosed during the procedure whereas
the incidence of other maternal complications were comparable
between AI and control groups.
American College of Obstetricians and Gynecologists has
recently published a Committee Opinion that concludes that
routine prophylactic AI for the dilution of MSAF should be carried
out only in the setting of additional clinical trials. However, they
state that AI remains a reasonable approach to the treatment of
repetitive variable decelerations, regardless of amniotic fluid
meconium status.60
Delivery room management
Routine oropharyngeal suctioning before delivery of the infants’
shoulders has long been involved in preventing MAS. The findings
of observational studies remain conflicting.20,26,61 –63 Falciglia
et al.26 compared infants with meconium-stained fluid who
underwent ‘early’ oronasopharyngeal DeLee suctioning with a
similar group of infants whose airways were suctioned ‘late’ (after
chest delivery). They found no evidence of benefit of oropharyngeal
suctioning in the prevention of MAS. Rossi et al.20 also reported the
similar rates of meconium visualized in the vocal cords despite
early oropharyngeal suctioning. In contrast, several authors
reported that intrapartum pharyngeal suctioning reduced the
Journal of Perinatology
severity of MAS and the risk of respiratory distress.61–63 They
suggested that combined approach of intrapartum oropharyngeal
suctioning and endotracheal suctioning was effective in the
reduction of MAS.
Vain et al. conducted a multicenter international trial to assess
the effectiveness of oropharyngeal and nasopharyngeal suctioning
before delivery of the shoulders for the prevention of MAS. They
found that the incidence of MAS, need for mechanical ventilation,
and neonatal mortality was similar between groups (suction versus
no suction). In addition, they found no evidence of a benefit of
intrapartum suctioning on the occurrence of MAS, MAS requiring
mechanical ventilation, or mortality.64
Regarding the postdelivery management such as routine
endotracheal suctioning and intubation, reports from observational
studies suggested that intratracheal suctioning could prevent the
occurrence of MAS for meconium-stained neonates and significantly
decreased the mortality subsequent to that disorder.65–67 Intubation
is not without risk and has been associated with hypoxia,
bradycardia and laryngeal stridor.67–70 Should endotracheal
suctioning and intubation be applied universally in infants born
through MSAF or selectively reserved for those who are depressed
after birth is another topic of controversy. Some investigators
suggested that a selective approach may be useful and
justified,6,8,71–73 whereas other suggested that universal intubation
and suctioning was the best strategy to prevent potential morbidity
and mortality related to meconium staining.67
Linder et al.68 suggested that nondepressed meconium-stained
infants did not benefit from immediate intratracheal suctioning
and such intervention could be harmful. Liu and Harrington
conducted a randomized trial to assess if intubation of the low-risk
newborn with thin meconium affects the incidence of respiratory
symptoms. They were unable to demonstrate the beneficial effect of
intubation and intratracheal suctioning in the infant with thin
meconium and an otherwise low-risk pregnancy.74 To address this
question, Wiswell et al.69 conducted a multicenter randomized
trial, involving a total of 2094 neonates, to investigate
whether intubation and suctioning of apparently vigorous,
meconium-stained neonates would reduce the risk of MAS. There
were no significant differences between intubation and expectant
management groups in the rates of MAS or other respiratory
disorders. Moreover, intratracheal suctioning showed no benefit
over expectant management even for infants born through the
thickest consistency MSAF. They further identified the independent
risk factors for the development of MAS using stepwise logistic
regression. The results indicated that the use of oropharyngeal
suctioning lead to a decreased risk of MAS (8.5% in infants who did
not have intrapartum suction versus 2.7% in infants with
intrapartum suctioning). The authors concluded that endotracheal
intubation and suctioning still be performed in infants born
through MSAF, if they are not vigorous, if they need positive
pressure ventilation or they develop symptoms of respiratory

distress. Furthermore, a recently published meta-analysis of four
randomized trials demonstrated no significant benefit of routine
endotracheal intubation and suctioning at birth over routine
resuscitation including oropharyngeal suction of vigorous,
meconium-stained infants born at term.75 The authors
recommended that intubation and suctioning be restricted to
depressed newborns, that is, those with a heart rate of <100 beats
per min, poor respiratory effort and poor tone.
Conclusion
MAS remains a challenging condition for obstetricians and
neonatologists. Despite the decreased risk of MAS and related
mortality and morbidity, the available evidence did not
demonstrate a beneficial effect of either of obstetric strategies in the
prevention of MAS. The suggested apparent disparity in the effect of
AI on MAS between centers with standard and limited peripartum
surveillance is worthy of attentions for clinicians. Additional
well-designed randomized controlled trials in settings of limited
peripartum surveillance are required to elucidate the optimal
management of MAS in this context.
Disclosure
WD Fraser has received grant support from Utah Medical Corporation. The
remaining authors have declared no financial interests.
References
1 Cleary GM, Wiswell TE. Meconium-stained amniotic fluid and the meconium
aspiration syndrome: an update. Pediatr Clin North Am 1998; 45: 511–529.
2 Wiswell TE, Tuggle JM, Turner BS. Meconium aspiration syndrome: have we made a
difference? Pediatrics 1990; 85: 715–721.
3 Scott H, Walker M, Gruslin A. Significance of meconium-stained amniotic fluid in the
preterm population. J Perinatol 2001; 21: 174–177.
4 Usher RH, Boyd ME, McLean FH, Kramer MS. Assessment of fetal risk in postdate
pregnancies. Am J Obstet Gynecol 1988; 158: 259–264.
5 Ostrea EM, Naqvi M. The influence of gestational age on the ability of the fetus to pass
meconium in utero. Acta Obstet Gynecol Scand 1982; 61: 275–277.
6 Eden RD, Seifert LS, Winegar A, Spellacy W. Perinatal characteristics of uncomplicated
postdate pregnancies. Obstet Gynecol 1987; 69: 296–299.
7 Steer PJ, Eigbe F, Lissauer TJ, Beard RW. Interrelationships among abnormal
cardiotocograms in labor, meconium staining of the amniotic fluid, arterial cord blood
pH, and Apgar scores. Obstet Gynecol 1989; 74: 715–721.
8 Lucas A, Adrian TE, Christofides N, Bloom SR, Aynsley-Green A. Plasma motilin,
gastrin and enteroglucagon and feeding in the human newborn. Arch Dis Child 1980;
55: 673–677.
9 Miller FC, Sacks DA, Yeh SY, Paul RH, Schifrin BS, Martin Jr CB et al. Significance of
meconium during labor. Am J Obstet Gynecol 1975; 122: 573–580.
10 Bochner CJ, Medearis AL, Ross MG, Oakes GK, Jones P, Hobel CJ et al. The role of
antepartum testing in the management of postterm pregnancies with heavy meconium
in early labor. Obstet Gynecol 1987; 69: 903–907.
11 Ahanya SN, Lakshmanan J, Morgan BL, Ross MG. Meconium passage in utero:
mechanisms, consequences, and management. Obstet Gynecol Surv 2005; 60: 45–56.
12 Brown BL, Gleicher N. Intrauterine meconium aspiration. Obstet Gynecol 1981; 57:
26–29.
Obstetric management of MAS
H Xu et al
S17
13 Davis RO, Phillips III JB, Harris Jr BA, Wilson ER, Huddleston JF. Fatal meconium
aspiration syndrome occurring despite airway management considered appropriate.
Am J Obstet Gynecol 1985; 151: 731–736.
14 Urbaniak KJ, McCowan LM, Townend KM. Risk factors for meconium aspiration
syndrome. Aust N Z J Obstet Gynaecol 1996; 36: 401–406.
15 Hernandez C, Little BB, Dax JS, Gilstrap III LC, Rosenfeld CR. Prediction of the severity
of meconium aspiration syndrome. Am J Obstet Gynecol 1993; 169: 61–70.
16 Falciglia HS. Failure to prevent meconium aspiration syndrome. Obstet Gynecol 1988;
71: 349–353.
17 Coltart TM, Byrne DL, Bates SA. Meconium aspiration syndrome: a 6-year retrospective
study. Br J Obstet Gynaecol 1989; 96: 411–414.
18 Bhutani VK, Chima R, Sivieri EM. Innovative neonatal ventilation and meconium
aspiration syndrome. Indian J Pediatr 2003; 70: 421–427.
19 Wiswell TE. Advances in the treatment of the meconium aspiration syndrome. Acta
Paediatr Suppl 2001; 90: 28–30.
20 Rossi EM, Philipson EH, Williams TG, Kalhan SC. Meconium aspiration
syndrome: intrapartum and neonatal attributes. Am J Obstet Gynecol 1989; 161:
1106–1110.
21 Katz VL, Bowes WA. Meconium aspiration syndrome: reflections on a murky subject.
Am J Obstet Gynecol 1992; 166: 171–183.
22 Ghidini A, Spong CY. Severe meconium aspiration syndrome is not caused by
aspiration of meconium. Am J Obsted Gynecol 2001; 185: 931–938.
23 Jovanovic R, Nguyen HT. Experimental meconium aspiration in guinea pigs. Obstet
Gynecol 1989; 73: 652–656.
24 Greenough A. Meconium aspiration syndromeFprevention and treatment. Early
Hum Dev 1995; 41: 183–192.
25 Meis PJ, Hall III M, Marshall JR, Hobel CJ. Meconium passage: a new classification for
risk assessment during labor. Am J Obstet Gynecol 1987; 131: 509–513.
26 Falciglia HS, Henderschott C, Potter P, Helmchen R. Does DeLee suction at the
perineum prevent meconium aspiration syndrome? Am J Obstet Gynecol 1992; 167:
1243–1249.
27 Alexander GR, Hulsey TC, Robillard PY, De Caunes F, Papiernik E. Determinants of
meconium stained amniotic fluid in term pregnancies. J Perinatol 1994; 14: 259–263.
28 Meydanli MM, Dilbaz B, Caliskan E, Dilbaz S, Haberal A. Risk factors for meconium
aspiration syndrome in infants born through thick meconium. Int J Gynaecol Obstet
2001; 72: 9–15.
29 Paz Y, Solt I, Zimmer EZ. Variables associated with meconium aspiration syndrome in
labours with thick meconium. Eur J Obstet Gynecol Reprod Biol 2001; 94:
27–30.
30 Dargaville PA, Copnell B, Australian and New Zealand Neonatal Network. The
epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and
outcome. Pediatrics 2006; 117: 1712–1721.
31 Sriram S, Wall SN, Khoshnood B, Singh JK, Hsieh HL, Lee KS. Racial disparity in
meconium stained amniotic fluid and meconium aspiration syndrome in the United
States, 1989 to 2000. Obstet Gynecol 2003; 102: 1262–1268.
32 Sedaghatian MR, Othman L, Hossain MM, Vidyasagar D. Risk of meconium stained
amniotic fluid in different ethnic groups. J Perinatol 2000; 20: 257–261.
33 Shy KK, Larson EB, Luthy DA. Evaluating a new technology: the effectiveness of
electronic fetal heart rate monitoring. Annu Rev Public Health 1987; 8: 165–190.
34 Lumley J. Does continuous intrapartum fetal monitoring predict long-term
neurological disorders? Paediatr Perinat Epidemiol 1988; 2: 299–307.
35 Paneth N, Bommarito M, Stricker J. Electronic fetal monitoring and later outcome.
Clin Invest Med 1993; 16: 159–165.
36 Neilson JP. Electronic fetal heart rate monitoring during labor: information from
randomized trials. Birth 1994; 21: 101–104.
37 Graham EM, Petersen SM, Christo DK, Fox HE. Intrapartum electronic fetal heart rate
monitoring and the prevention of perinatal brain injury. Obstet Gynecol 2006; 108:
656–666.
38 Thacker SB, Stroup DF, Peterson HB. Efficacy and safety of intrapartum electronic fetal
monitoring: an update. Obstet Gynecol 1995; 86: 613–620.
Journal of Perinatology
 Obstetric management of MAS
H Xu et al
S18
39 Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of
electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane
Database Syst Rev 2006; 3: CD006066.
40 Starks GC. Correlation of meconium-stained amniotic fluid, early intrapartum pH,
and Apgar scores as predictors of perinatal outcome. Obstet Gynecol 1980; 56:
604–609.
41 Hageman JR. Meconium staining of the amniotic fluid: the need for reassessment of
management by obstetricians and pediatricians. Curr Probl Pediatr 1993; 23:
396–401.
42 Krebs HB, Petres RE, Dunn LT, Jordaan HVF, Segreti A. Intrapartum Fetal Heart Rate
Monitoring. III. Association of meconium with abnormal fetal heart rate patterns. Am J
Obstet Gynecol 1980; 137: 936–943.
43 Umstad MP. The predictive value of abnormal fetal heart rate patterns in early labour.
Aust NZJ Obstet Gynaecol 1993; 33: 145–149.
44 Miyazaki FS, Nevarez F. Saline amnioinfusion for relief of repetitive variable
decelerations. A prospective randomized study. Am J Obstet Gynecol 1985; 153:
301–306.
45 Wang CC, Rogers MS. Lipid peroxidation in cord blood: a randomised sequential airs
study of prophylactic saline amnioinfusion for intrapartum oligohydramnios. Br J
Obstet Gynaecol 1997; 104: 1145–1151.
46 Nageotte MP, Freeman RK, Garite TJ, Dorchester W. Prophylactic intrapartum
amnioinfusion in patients with premature rupture of membranes. Am J Obstet Gynecol
1985; 153: 557–562.
47 Nageotte MP, Bertucci L, Towers CV, Lagrew DL, Modaniou H. Prophylactic
amnioinfusion in pregnancies complicated by oligohydramnios: a prospective study.
Obstet Gynecol 1991; 77: 677–680.
48 Owen J, Henson BV, Hauth JC. A prospective randomized study of saline solution
amnioinfusion. Am J Obstet Gynecol 1990; 162: 1146–1149.
49 MacGregor SM, Banzhaf WC, Silver RK, Depp R. A prospective randomized evaluation
of intrapartum amnioinfusion. Fetal acid–base status and cesarean delivery. J Reprod
Med 1991; 36: 69–73.
50 Schrimmer DB, Macri CJ, Paul RH. Prophylactic amnioinfusion as a treatment for
oligohydramnios in laboring patients: a prospective, randomized trial. Am J Obstet
Gynecol 1991; 165: 972–975.
51 Chauhan SP, Rutherford SE, Hess LW, Morrison JC. Prophylactic intrapartum
amnioinfusion for patients with oligohydramnios. J Reprod Med 1992; 37:
817–820.
52 Pitt C, Sanchez-Ramos L, Kaunitz AM, Gaudier F. Prophylactic amnioinfusion for
intrapartum oligohydramnios: a meta-analysis of randomized controlled trials. Obstet
Gynecol 2000; 96: 861–866.
53 Hofmeyr GJ. Amnioinfusion for meconium-stained liquor in labor. Cochrane Database
Syst Rev 2002; 1: CD000014.
54 Xu H, Hofmeyr J, Roy C, Fraser W. Intrapartum amnioinfusion for meconium stained
amniotic fluid: a systematic review of randomised controlled trials. BJOG 2007; 114:
383–390.
55 Fraser WD, Hofmeyr GJ, Lede R, Faron G, Alexander S, Goffinet F et al. Amnioinfusion
for the prevention of the meconium aspiration syndrome. N Engl J Med 2005; 353:
909–917.
56 Wenstrom K, Andrews WW, Maher JE. Amnioinfusion survey: prevalence, protocols, and
complications. Obstet Gynecol 1995; 86: 572–576.
Journal of Perinatology
57 Dragich DA, Ross AF, Chestnut DH, Wenstrom K. Respiratory failure associated with
amnioinfusion during labor. Anesth Analg 1991; 72: 549–551.
58 Maher JE, Wenstrom KD, Hauth JC, Meis PJ. Amniotic fluid embolism after saline
amnioinfusion: two cases and review of the literature. Obstet Gynecol 1994; 83:
851–854.
59 Dorairajan G, Soundararaghavan S. Maternal death after intrapartum
saline amnioinfusion-report of two cases. Br J Obstet Gynaecol 2005; 112:
1331–1333.
60 ACOG Committee Obstetric Practice. ACOG Committee Opinion Number 346, October
2006: amnioninfusion does not prevent meconium aspiration syndrome. Obstet
Gynecol 2006; 108: 1053.
61 Carson BS, Losey RW, Bowes Jr WA, Simmons MA. Combined obstetric and pediatric
approach to prevent meconium aspiration syndrome. Am J Obstet Gynecol 1976; 126:
712–715.
62 Yoder BA, Kirsch EA, Barth WH, Gordon MC. Changing obstetric practices associated
with decreasing incidence of meconium aspiration syndrome. Obstet Gynecol 2002;
99: 731–739.
63 Chishty AL, Alvi Y, Iftikhar M, Bhutta TI. Meconium aspiration in neonates: combined
obstetric and paediatric intervention improves outcome. J Pak Med Assoc 1996; 46:
104–108.
64 Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal
and nasopharyngeal suctioning of meconium-stained neonates before delivery
of their shoulders: multicentre, randomised controlled trial. Lancet 2004; 364:
597–602.
65 Gregory GA, Gooding CA, Phibbs RH, Tooley WH. Meconium aspiration in
infantsFa prospective study. J Pediatr 1974; 85: 848–852.
66 Ting P, Brady JP. Tracheal suction in meconium aspiration. Am J Obstet Gynecol
1975; 122: 767–771.
67 Wiswell T, Henley MA. Intratracheal suctioning, systematic infection, and the
meconium aspiration syndrome. Pediatrics 1992; 89: 203–206.
68 Linder N, Aranda JV, Tsur M, Matoth I, Yatsiv I, Mandelberg H et al. Need for
endotracheal intubation and suction in meconium-stained neonates. J Pediatr 1988;
112: 613–615.
69 Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K et al. Delivery room
management of the apparently vigorous meconium-stained neonate: results of the
multicenter, international collaborative trial. Pediatrics 2000; 105: 1–7.
70 Kresh MJ, Brion LP, Fleishman AR. Delivery room management of meconium stained
neonates. J Perinatol 1991; 11: 46–48.
71 Bent RC, Wiswell TE, Chang A. Removing meconium from infant tracheae. Am J Dis
Child 1992; 146: 1085–1089.
72 Peng TCC, Gutcher GR, Van Dorsten JP. A selective aggressive approach to the neonate
exposed to meconium-stained amniotic fluid. Am J Obstet Gynecol 1996; 175:
296–303.
73 Yoder BA. Meconium-stained amniotic fluid and respiratory complications: impact of
selective tracheal suction. Obstet Gynecol 1994; 83: 77–84.
74 Liu WF, Harrington T. The need for delivery room intubation of thin meconium in the
low-risk newborn: a clinical trial. Am J Perinatol 1998; 15: 675–682.
75 Halliday HL, Sweet D. Endotracheal intubation at birth for preventing morbidity and
mortality in vigorous, meconium-stained infants born at term. Cochrane Database
Syst Rev 2001; 1: CD000500.