Archives of Perinatal Medicine 15(2), 95-100, 2009 ORIGINAL PAPER

Intrapartum amnioinfusion for meconium-stained

amniotic fluid
MARIOLA KRZYŚCIN1, AGNIESZKA BANASZAK2, ANNA DERA1,
MARTA SZYMANKIEWICZ2, GRZEGORZ H. BRĘBOROWICZ1

Abstract
Aim: The purpose of this study was to assess whether the intrapartum amnioinfusion (AI) in the presence of
meconium-stained amniotic fluid (MSAF) influence the rate of cesarean section and perinatal outcome. Material
and methods: The investigated group consisted of 405 pregnant women in labor with meconium-stained amniotic
fluid: 163 had performed AI, and 242 constituted a control group (without AI). The way of delivery, the occurrence
of fetal distress symptoms in cardiotocography, fetal outcome based on Apgar scoring and umbilical artery aci-
demia, the presence of clinical and radiological symptoms of meconium aspiration syndrome and respiratory
disorders in neonates were analyzed. Results: The performance of AI influenced neither the occurrence of the
signs of fetal distress nor the rate of cesarean section indicated by fetal distress. There was no difference in the
incidence of low Apgar score (< 5) at 1 and at 5 min. and umbilical acidemia. The frequency of meconium aspira-
tion syndrome and neonate’s dyspnea were comparable. There were no major complications related to AI.
Conclusions: The prophylactic intrapartum AI for meconium stained amniotic fluid does not decrease the inci-
dence of fetal distress or the rate of cesarean section and it does not improve neonatal outcome.
Key words: amnioinfusion, meconium-stained amniotic fluid, meconium aspiration syndrome, fetal distress

Introduction
The functions of amniotic fluid can be categorized in
many areas. Physically it allows the fetus to move and
prevents it from injury as well as regulates its tempe-
rature. Functionally it enables fetal breathing mobility
that prevents pulmonary hypoplasia and exercises dige-
stive tract by swallowing amniotic fluid. It also plays
a role in homeostasis by maintaining amnion integrity,
protecting from umbilical compressing and fighting intra-
mniotic infections.
Meconium is detected in amniotic fluid in 7-22% of
term deliveries [1, 2], increasing up to 23-52% of births
over 42 weeks of gestation [3]. Its presence is associated
with an increased risk of perinatal morbidity and morta-
lity [6]. There is opinion that in the group of pregnancies
complicated by meconium stained amniotic fluid the rate
of cesarean section for fetal distress, low Apgar scores,
neonatal acidosis and frequency of meconium aspiration
syndrome (MAS) are higher. Excreting meconium into
amniotic fluid might be connected with chronic hypoxia
of the fetus and decreasing placenta perfusion [8, 9].
However, some researchers do not agree with such opi-
nion and claim that excretion of meconium to amniotic
cavity is a physiological phenomenon in term pregnan-
cy and is not connected with increased risk for the fetus
[7].
MAS is caused by obstruction of bronchioles and
chemical pneumonitis [4]. It is thought to be one of the
major complication in the full term neonates. MAS has
been reported to occur in 6.6-30% of cases complicated
with MSAF and in 1-3% of liveborn infants [16].
Transcervical intrapartum amnioinfusion (AI) has
been proposed as a useful procedure in the intrapartum
management to reduce the incidence of meconium aspi-
ration and to improve neonatal outcome. The procedure
of AI consists of infusion of a physiologic saline solution
through catheter that is inserted transcervicaly into the
uterine cavity. It is assumed that the potential, beneficial
mechanism of AI includes mechanical cushioning of um-
bilical cord which can reduce or prevent the recurrent
umbilical compressions which leads to fetal academia.
Moreover the infusion of saline dilutes the amniotic fluid
stained by meconium and therefore it reduces mecha-
nical and inflammatory effects of the meconium on the
neonate’s bronchioles.

1
Department of Perinatology and Gynecology, Poznań University of Medical Sciences
2
Department of Neonatology, Poznań University of Medical Sciences
96 M. Krzyścin, A. Banaszak, A. Dera, M. Szymankiewicz, G.H. Bręborowicz
AI was firstly described by Miyazaki and Taylor in
1983 [10]. The authors proved that in the case of MSAF,
AI significantly decreases the number of decelerations
in fetal hear rate and the rate of cesarean sections [10].
Subsequent studies found an overall reduction in the
incidence of MAS, operative and instrumental deliveries
and perinatal morbidity and mortality in the group of pa-
tients where AI was proceed [11]. However, the recent
multicenter trail couldn’t verify these benefits [12].
According to ACOG the intrapartum AI is only recom-
mended when variable decelerations in CTG are accom-
panied with presence of meconium in amniotic fluid [13].
The objective of the study was to determine whether
intrapartum amnioinfusion in pregnancies complicated
by meconium-stained amniotic fluid reduces the rate of
cesarean section for fetal distress as well as improves
perinatal outcome.
Material and methods
Between 1 May 2008 and 30 April 2009, 6388 preg-
nant women with singleton pregnancy delivered at Uni-
versity Women Hospital in Poznań. In this group we
identified 405 women, in whom we diagnosed meconium
stained amniotic fluid at the moment of amniotic sack
rupture. This group consisted of 163 women, in whom
we performed AI and 242 pregnant women (control
group), who received exclusively standard health care
during delivery. The medical documentation of these pa-
tients was collected and presented for statistical analy-
sis.
The inclusion criteria for this study were as follow:
singleton pregnancy, gestational age $36 weeks, the
diagnosis of meconium stained amniotic fluid during deli-
very and fetal weight > 2500 g. Pregnancies with fetal ab-
normalities were excluded.
In both groups we assessed the mode of delivery,
the rate of operational deliveries due to signs of fetal
distress in CTG or intrapartum gas blood analysis, the
Apgar score in the 1st and in the 5th minute, the occur-
rence of postpartum acidosis, the occurrence of respira-
tory insufficiency in neonate, which were not connected
with infection, as well as the symptoms of MAS in the
neonate. As acidosis we considered pH < 7.2 of the
blood in umbilical cord artery.
Table 1. Demographic data
Characteristics Amnioinfusion (n = 163)
Age (years)
Weeks of gestation
Primiparous – n (%)
The investigated groups were comparable in terms
of the maternal age, gestational age and parity.
Amnioinfussion was performed out in the latent pha-
se of labor (dilatation 4-6 cm) with a rubber Folley cathe-
ter that was inserted through the cervix into the uterine
cavity just above the fetal head. 1000 ml of saline at
36EC was infused through catheter by means of intra-
venous line between the bottle and catheter over 30-60
minutes at the rate of 15-25 ml per minute. We carried
out continuous CTG monitoring for each patient during
the procedure and untill delivery.
The data were analyzed with the GraphPad software
package. Student’s t test was used to compare continu-
ous normally distributed variables, and the chi-squared
test with Yates’s correction, Fisher’s exact test or Fis-
her-Freeman-Halton test were used for qualitative or dis-
crete variables. The results were presented as relative
risk (RR) with 95% confidence intervals. The difference
was considered to be statistically significant when p <
0.05.
Results
The socio-demographic and clinical profiles of the
women in amnioinfusion and control groups were compa-
rable (Table 1).
The characteristics related to the labor and delivery
that could influence the results of the study are shown
in table 2. The interval between detection of MSAF after
rupture of membranes or amniotomy and delivery was
longer in amnioinfusion group (5.2 ± 5.6 vs. 3.1 ± 6.7
hours; p = 0.002).
Table 3 presents the information concerning the
mode of delivery. The incidence of vaginal delivery was
higher in amnioinfusion group (76.7% vs 47.9%; p <
0.001). The rate of the cesarean section in control group
was significantly higher than in study group (14.1% vs.
46.7%; p < 0.001). Such a great difference can be ex-
plained by the fact that in the control group there were
patients, who had an elective cesarean section and in
whom the presence of MSAF was diagnosed only during
the operation. Therefore in those women the aminoinfu-
sion had not been taken into consideration.
Control (n = 242) p
28.5 ± 5.1 28.6 ± 5.6 0.826
39.4 ± 1.2 39.6 ± 1.4 0.361
93 (57.1%) 110 (45.5%) 0.221
 Intrapartum amnioinfusion for meconium-stained amniotic fluid ongenital diaphragmatic hernia 97

Table 2. Characteristics of labor

Amnioinfusion Control
Characteristics p
(n = 163) (n = 242)
First phase (min) 234,5 ± 156,3 228,4 ± 148,6 0.845
Second phase (min) 28,4 ± 32,5 29,2 ± 39,3 0.808
Induction 14 (9%) 25 (10%) 0.681
Interval between rupture of membranes and delivery 5,2 ± 5,6 3,1 ± 6,7 0,002 (hours)

Table 3. Mode of delivery

Amnioinfusion Control
Mode p RR (95% CI)
(n = 163) (n = 242)
Vaginal 125 (76.7%) 116 (47.9%) < 0.001 1.60 (1.37-1.87)
Instrumental 15 (9.2%) 13 (5.4%) 0.162 1.71 (0.84-3.50)
Cesarean section 23 (14.1%) 113 (46.7%) < 0.001 0.30 (0.20-0.45)
Operative delivery for fetal distress
Instrumental 12 (48.0%) 9 (23.1%) 0.115 1,98 (0.85-4.60)
Cesarean section 13 (52.0%) 30 (76.9%) 0.189 0,64 (0.35-1.28)
Total 25 (15.3%) 39 (16.1%) 0.890 0,95 (0.60-1.51)

However, concerning only the frequency of operative
delivery for fetal distress the difference was not signi-
ficant (15.3% vs. 16.1%; p = 0.890).
The analysis of the presence of fetal distress signs
(decelerations) in CTG during labor is presented in tab-
le 4. According to this analysis it appears that amnio-
infusion was connected with increased frequency of fetal
distress symptoms in CTG in all patients. The difference
was not statistically significant. However, the difference
concerned mainly the women, in whom we performed ce-
sarean section (p < 0.001). It was influenced by a great
number of elective cesarean sections in the control
group. Regardless of the performance of the amnioinfu-
sion, in case of vaginal or instrumental delivery, the dif-
ferences were not significant (45% vs. 43%).

Table 4. Signs of fetal distress in CTG in relation to the mode of delivery

Amnioinfusion Control
Characteristics p
(n = 163) (n = 242)
Signs of fetal distress in CTG 66 (40.5%) 79 (32.6%) 0.114
Mode of delivery
Vaginal 39 (31.2%) 35 (30.1%) 0.889
Instrumental 13 (86.7%) 10 (76.9%) 0.639
Cesarean section 14 (60.1%) 34 (30.1%) 0.008

Table 5. Neonatal outcome

Amnioinfusion Control
Characteristics p
(n = 163) (n = 242)
Birth weight (g) 3495.5 ± 517.9 3527.4 ± 581.4 0.739
Apgar score at1 min ( < 5) 18 (11.0%) 24 (9.9%) 0.741
Apgar score at 5 min ( < 5) 1 (0.6%) 6 (2.5%) 0.250
Umbilical artery pH (< 7.2) 32 (19.6%) 52 (21.%) 0.536
Umbilical cord complications 25 (15.3%) 45 (18.6%) 0.424
98 M. Krzyścin, A. Banaszak, A. Dera, M. Szymankiewicz, G.H. Bręborowicz

Table 6. Frequency of neonatal respiratory disorders

Amnioinfusion Control
Characteristics p
(n = 163) (n = 242)
Dyspnea 23 (14.1%) 28 (11.5%) 0.450
Mode of delivery
Vaginal 19 (82.6%) 10 (35.7%) 0.164
Instrumental 1 (4.3%) 0 (0%) 0.381
Cesarean section 3 (13.1%) 18 (64.3%) 1.000
Congenital pneumonia 3 (1.8%) 5 (2.1%)

The mean birth weights were similar in both groups
(3495.5 ± 517.9 g. vs. 3527.4 ± 581.4 g; p = 0,739). The-
re were no differences in the incidence of Apgar score
values lower than 5 at 1st min (11% vs. 9,9%; p = 0.741)
and at 5th min (0.6% vs. 2.5%; p = 0.250). The analysis
revealed that the frequency of pH values less than 7.2 in
fetal umbilical artery measured after delivery, is com-
parable in amnioinfusion and control group. Also umbili-
cal cord complications were observed in both groups
with the same frequency (Table 5).
Respiratory disorders in neonates were diagnosed
in 59 neonates (26 in the aminoinfusion group and 33 in
the control group). In 8 of them we diagnosed congenital
pneumonia therefore they were excluded from further
analysis. We assume that the respiratory disturbances,
which were not accompanied by pneumonia, could be
the consequences of meconium stained amniotic fluid.
Table 6 shows neonatal outcome which was divided ac-
cording to mode of delivery. Meconium aspiration syn-
drome (MAS) was diagnosed in 8 (2.0%) neonates; 3 in
amnioinfusion group and 5 in the control group.
In this study no major maternal complications were
diagnosed in relation to amnioinfusion.
Discussion
As the amnioinfusion was described as a prophy-
lactic procedure protecting fetuses from MAS it seemed
to be a great way to avoid the impact of meconium on
the neonate respiratory system [1]. The initial rando-
mized trails suggested that women receiving this proce-
dure had fewer operative deliveries and better outcomes
of the fetus and neonates. Based on those trails there
were two published meta-analyses that proved the effe-
ctiveness of this method [18, 23]. Parallel, there were
other randomized trails which evaluated the effect of
such prevention and it was reported out that AI neither
decreased occurrence of MAS nor improved neonatal
outcome [12, 13, 24]. Fraser et al. [12] compared the
outcomes of 1998 women in the 36th or later weeks of
pregnancy. Those women were randomized for amnioin-
fusion or preventive treatment according to the occur-
rence or nonoccurrence of deceleration in CTG. They
did not find any differences neither in neonatal survival
rate and MAS morbidity, nor in the frequency of surgical
deliveries in the women, in whom preventive amnio-
infusion was performed. In this retrospective study the
prophylactic AI was associated neither with a significant
decrease in the incidence of low Apgar scores (<7) at 1st
and 5th min. nor with low umbilical artery pH values (hy-
poxia).
Currently, it is thought that in case of pregnancy
complicated by MSAF a large proportion of infants have
aspirated meconium into respiratory tract before meco-
nium passage is diagnosed and AI is possible to be
performed. The alleged benefit of AI is the dilution of
thick fluid, in which the bearing child stays, as well as
the washing away of meconium specks the fetus respira-
tory tract. However, it should be taken into the conside-
ration that the dilution itself might cause that the small
particles can get to the terminal parts of fetus respirato-
ry tract.
In the etiology of MAS it is assumed, that this com-
plication can develop intra uterine just after meconium
is excreted [14]. Such a theory would impair the reasons
for AI performance. The recent studies show that other
procedures invented to remove specks from the airway
of the newborn, including routine tracheal intubations
combined with aspiration, oropharyngeal and nasopha-
ryngeal suctioning just after the neonate's head is deli-
vered, do not reduce the risk of MAS [5, 15]. It is not
clear whether the presence of meconium is the only
major cause of respiratory distress, asphyxia and intra-
uterine infection or it is the trigger for respiratory com-
promise in the presence of meconium [16]. Although the
frequency of MAS confirmed by radiological examination
was too low in our group to draw efficient statistical con-
 Intrapartum amnioinfusion for meconium-stained amniotic fluid ongenital diaphragmatic hernia
clusions. The frequency of the diagnosis of the respira-
tory disorders, which can be related with the aspiration
of meconium, was similar in both groups.
The effect of AI on operative delivery rates varies
between studies. Rathore et al. [17] showed statistically
more frequent necessity for applying cesarean section in
patients in which intrapartum amnioinfusion, in the case
of meconium stained amniotic fluid, is applied. Similar
observations were presented by Pierce et al. [18] in his
meta-analysis as well as in the observations of other
authors [11, 19]. Other studies show less optimistic data
[12, 20]. Presently, the frequency of the cesarean section
in our hospital is now around 33%. In the collected data
of 405 cases with meconium stained amniotic fluid the
cesarean section rate was of similar frequency (33.5% vs.
33.1%). In the investigated group the general frequency
was greater in women, in whom the AI was not applied,
however the frequency of cesarean sections due to of
fetal distress was comparable in both groups.
AI is considered to be rather a safe medical proce-
dure. Reports of adverse effects occurring in relation to
this procedure include uterine hypertonia, uterine rup-
ture in the uterine scar, placental abruption, chorioam-
nionitis, fetal heart-rate abnormalities, umbilical cord
prolapse, maternal pulmonary embolism and maternal
deaths [12, 21, 22]. In our study we did not observe such
complications.
The attitudes to perform amnioinfusion in the case
of the presence of MSAF are not coherent. According to
the last ACOG recommendations it is not advisable to
apply so called preventive aminoinfusion, that means in
each patient, in whom we diagnosed the meconium stain-
ed amniotic fluid. However, it should be applied, if
MSAF is connected with variable deceleration in fetal
heart rate [13].
In summary, our study suggests that in pregnancy
complicated by MSAF, the incidence of fetal distress,
the rate of cesarean section performed because of fetal
distress as well as the frequency of MAS is not reduced
by amnioinfusion. This implies that there is no indication
to recommend a prophylactic AI for the prevention of
MAS.
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J Mariola Krzyścin
Department of Perinatology and Gynecology
Poznań University School of Medical Sciences
60-535 Poznań, Polna 33, Poland