Intrapartum transcervical amnioinfusion formeconium-stained amniotic fluidAbstrakTujuan Penelitian: untuk menilai tingkat kelahiran dengan seksio sesarea dan hasil keluaran perinatal setelah amioinfusion intrapartum transervikal pada ibu dengan cairan amnion yang diwarnai oleh mekonium (MSAF) pada latar belakang tanpa monitoring elektrik dari fetus atau perawatan neonatal spesialistik.Bahan dan Metode Penelitian: Pada penelitian prospektif komparatif ini, dengan 150 ibu yang dalam proses melahirkan, dan terkena MSAF, 50 ibu menerima amnioinfusion transervikal dan sisa 100 ibu menjalani perawatan standar. Kriteria inklusi adalah kehamilan paling tidak 37 minggu, janin hidup tunggal dengan presentasi kepala, tidak ada komplikasi mayor medis atau obstetrik, dan tidak ada malformasi fetus. Amnioinfussion dilakukan dengan 1000 mL NS, melalui kateter karet merah. Hasil Penelitian: Amnioinfusion dikaitkan dengan penurunan signifikan dengan insidensi skor Apgar yang rendah (b7) pada menit pertama (12% berbanding 47%; resiko relatif [RR], 0.26; 95%, interval kepercayaan [CI], 0.12–0.56); skor Apgar yang rendah pada menit kelima (4% berbanding 23%; RR, 0.17; 95% CI,0.04–0.71); dan sindroma aspirasi mekonium (4% berbanding 18%; RR, 0.22; 95% CI, 0.05–0.92). Kami juga menemukan kecenderungan adanya penurunan insidensi kelahiran dengan seksio sesarea yang menurun (18% berbanding 30%; RR, 0.6; 95% CI, 0.31–1.16) dan kematian perinatal (4% berbanding 13%; RR, 0.31; 95% CI, 0.07–1.31). Insidensi dirawat lebih dari 3 hari secara signifikan akan lebih rendah dalam kelompok amnioinfusion dibandingkan dengan kelompok kontrol (24% berbanding 48%; RR, 0.5; 95% CI, 0.29–0.85). Tidak ada komplikasi mayor yang berhubungan dengan amnioinfusion.Kesimpulan: Amnioinfusion intrapartum untuk MSAF termasuk simpel, aman, efektif dan tidak mahal yang masuk akal untuk dilakukan pada latar belakang monitoring intrapartum sulit dilakukan. Hal ini diasosiasikan dengan hasil keluaran perinatal yang lebih baik dan bisa menurunkan tingkat kelahiran melalui seksio sesarea pada negara yang belum berkembang.Kata Kunci: amnioinfusion, distress fetal, cairan amnion terkontaminasi mekonium, sindroma aspirasi mekonium

1. IntroductionMeconium staining of amniotic fluid is frequently encounteredin obstetric practice, with incidences between 7%and 22% of all live births [1–3]. The presence of moderate to

thick meconium in the amniotic fluid is associated withan increased incidence of meconium aspiration syndrome(MAS), a potentially fatal hypoxic condition due to mechanicalobstruction of the bronchioles and chemical pneumonitis[1–3]. Routine prophylactic intrapartum oropharyngeal andnasopharyngeal suctioning have not been shown to reducethe risk of MAS [3–5].Transcervical intrapartum amnioinfusion has been proposedas a method for reducing the risk of MAS in widelyvarying obstetric and neonatal settings [2,6–13]. By increasingamniotic fluid volume, amnioinfusion cushions theumbilical cord and dilutes the meconium, thereby probablyimproving variable deceleration [13,14] and reducing the riskof mechanical obstruction of the bronchioles and chemicalpneumonitis [2,13]. Although a systematic review of randomizedcontrolled trials has suggested a lower frequencyof MAS, cesarean deliveries, and perinatal death followingamnioinfusion [15], a recent multicenter trial could not verifythese benefits [16]. In any case, most of these controlledtrials were carried out in developed countries, in facilitieswhere electronic fetal monitoring and neonatal intensivecare were available, and information coming from underresourcedcenters without such facilities is scant [2,10].Therefore, a prospective comparative study was designed to

evaluate maternal and perinatal outcomes following transcervicalintrapartum amnioinfusion in women with moderateto thick meconium-stained amniotic fluid (MSAF) in a ruralsetting with limited facilities for peripartum monitoring andneonatal care.2. Materials and methodsThe study was carried out between May 2001 and July 2002 atB.S. Medical College, Bankura, India, a busy teaching hospitalin rural eastern India. More than 14,000 deliveries are performedeach year at this hospital, which offers free service toan economically deprived population. The inclusion criteriawere being at least 37 weeks pregnant, having a single livefetus in cephalic presentation, and being in labor with moderateto thick MSAF. Women were excluded if they had majormedical complications, a scarred uterus, chorioamnionitis, orantepartum hemorrhage, or if there were known fetal malformationsor indications for immediate delivery such as severefetal bradycardia or cord prolapse. Women with mild anemia(hemoglobin concentration between 9 and 10.9 g/dL) or hypertension(blood pressure between 140/90 and 150/100 mm Hg)were not excluded.Of the 150 women who were included, 50 received anamnioinfusion (the study group), and 100 received standard care(the control group). In the study group, the amnioinfusion wascarried out with a size-8 red rubber catheter 2.5 mm in outerdiameter. The catheter was inserted through the cervix into theuterine cavity just above the fetal head. Initially, 500 mL ofnormal saline solution at room temperature was infused throughthe catheter over 30 min by means of an intravenous linebetween the bottle and the catheter. Then, another 500 mL wasinfused at the rate of 2 mL per minute by gravity drainage [2].The control group received only conventional treatment,which included cesarean delivery if immediate vaginal deliverywas not anticipated (in cases of early labor with unfavorablecervix) or if there was fetal bradycardia (heart rateb110 beats/min). Women in both groups were managed in the left lateralposition, and they received intravenous fluids and moist oxygen.Fetal heart rate was monitored by intermittent auscultationwith a stethoscope (every 20 to 30 min, and between and at theend of contractions). Uterine tone and the frequency of uterinecontractions were assessed by palpation. In both groups,decisions regarding assisted vaginal delivery or cesarean sectionwere taken if there were fetal rate abnormalities (bradycardiaor irregularity for 10–20 min) or slow progress of labor. Informedconsent was taken as per hospital practice. The residents andmidwives performed suctioning of the oropharynx and nasopharynxupon delivery of the fetal head, before delivery of theshoulders [3]. A pediatrician was usually not present at the timeof delivery, but was called upon when there were any neonatalproblems.The outcomes studied were the rates of cesarean delivery,low Apgar score (b7 at 1 and 5 min), MAS, perinatal death, andmaternal hospital stay longer than 3 days. Maternal febrilemorbidity (N38 °C) 24 h after delivery was also noted. Meconiumaspiration syndrome was defined as respiratory distress (tachypnea,retractions, or grunting) in a neonate born through MSAF,with a need for oxygen within 2 h of delivery in the absence ofcongenital malformations of the airways, lungs, or heart.Perinatal deaths included all stillbirths and deaths within7 days of birth. The 2 groups were compared using the t or χ2

test, as appropriate. Relative risks (RRs) with 95% confidenceintervals (CIs) were calculated using the Epi Info 2000 statisticalpackage (distributed by the Centers for Disease Control andPrevention, Atlanta, GA, USA).

3. Results3.1. Socio-demographic and clinical profiles of theparticipantsThe socio-demographic and clinical profiles of the women inthe amnioinfusion and control groups were similar. Most ofthe women were young (mean age, 22 years), in their firstpregnancy (76%), and with a mean pregnancy duration ofabout 39 weeks. Most belonged to a poor socio-economic

class and their literacy rate was low (58%). The incidence ofmild anemia and gestational hypertension was similar in the2 groups.3.2. Labor, delivery, and maternal outcomeThe incidence of spontaneous labor was high in the amnioinfusionand control groups (88% vs. 76%; PN0.05) (Table 1).Meconium staining of the amniotic fluid was first detected at amean cervical dilatation of approximately 5 cmin both groups.The interval between MSAF detection and delivery was alsosimilar in the 2 groups (3.8 h vs. 4.1 h; PN0.05). The rates ofmaternal febrile episodes (N38 °C) 24 h after delivery weresimilar for the 2 groups. However, cesarean delivery wasperformed less frequently in the amnioinfusion group than inthe control group (18% vs. 30%; RR, 0.6; 95% CI, 0.31–1.16).Moreover, the rate of maternal hospital stay longer than 3 dayswas also significantly less in the amnioinfusion group (24% vs.48%; RR, 0.5; 95% CI, 0.29–0.85). There were no majorcomplications or maternal deaths related to amnioinfusion.3.3. Perinatal outcomeThe mean birth weights were similar in the amnioinfusionand control groups (2662 g vs. 2711 g; P=0.51), and wereappropriate for gestations of 39 to 40 weeks (Table 2).Amnioinfusion was associated with a significant decrease inthe incidence of low Apgar score (b7) at 1 min (12% vs. 47%;RR, 0.26; 95% CI, 0.12–0.56) and 5 min (4% vs. 23%; RR, 0.17;95% CI, 0.04–0.71), and in the incidence of MAS (4% vs. 18%;RR, 0.22; 95% CI, 0.05–0.92). There were 2 neonatal deathsin the amnioinfusion group, and there were 1 intrapartumstillbirth and 12 neonatal deaths in the control group.Amnioinfusion was associated with a two-thirds reduction inperinatal deaths (4% vs. 13%; RR, 0.31; 95% CI, 0.07–1.31).4. DiscussionAlthough intrapartum amnioinfusion was introduced morethan 2 decades ago [14] and is practiced widely in the UnitedStates [17], reports of its regular use in developing countriesare scarce. This is probably caused by undue apprehension ofrare complications associated with the procedure [15], bythe prohibitive cost of a specially designed intrauterinecatheter [18] and a lack of equipment for electronic fetalmonitoring, which were often used in earlier studies fromdeveloped countries [6,7,9,15]. The present study's findings–that amnioinfusion is a safe, technically feasible, andeasily affordable procedure in a setting without electronicfetal monitoring or specialized neonatal care facilities–concur with the finding of others [2,11].As the participants were from same area and had similarbackgrounds, the study and control groups were balancedwith respect to socio-demographic variables. Furthermore,baseline obstetric characteristics such as parity, gestationalage, antenatal complications, cervical dilation at which thepresence of meconium was detected, interval between

detection of meconium and delivery, and mean birth weightwere similar, suggesting similar maternal and fetal profiles inthe 2 groups.

In this study no major maternal or fetal complicationsrelated to amnioinfusion were encountered, which is consistentwith earlier reports [6–12]. The procedure is easy toperform even with minimal training, and can be carried outin all labor wards without additional resources. A red rubbercatheter can be used more successfully than a pediatricfeeding tube [18].The threshold for a cesarean section is different in differentcenters, and the effect of amnioinfusion on cesareandelivery rates varies with the level intrapartum fetal surveillanceas well [15]. In the present study, there was a trendtowards a lower cesarean delivery rate in the amnioinfusiongroup (RR, 0.6; 95% CI, 0.31–1.16), which is in agreementwith some previous studies [10–12,19–21] but at variancewith others [2,8,16]. Further, among women for whomspontaneous vaginal delivery was not an option, the cesareansection rate was significantly reduced in the amnioinfusiongroup as the procedure was replaced by forceps-assisteddelivery. The probable explanation for the lower cesareansection rate in the study group is that by increasing theamniotic fluid volume around the fetus, amnioinfusionreduces the risk of fetal distress caused by umbilical cordcompression [10,15]. Whether amnioinfusion has any effectindependent of relieving fetal distress on reducing the rateof cesarean deliveries is not clear.In this study amnioinfusion was associated with asignificant decrease in the incidence of low Apgar scores(b7) at 1 and 5 min, suggesting a lesser need for immediateneonatal intervention, for which equipment and trainedpersonnel are often lacking in developing countries [22].Amnioinfusion was also associated with a reduction in theincidence of MAS, a finding concurring with previous reportsfrom centers with similar peripartum care [2,10–12,20].Fewer cases of MAS would reduce the burden of complicationsin developing countries where neonatal intensive careis scarce and often not affordable [22].Compared with the control group, there was a two-thirdsreduction of perinatal mortality in the amnioinfusion group(4% vs. 13%; RR, 0.31; 95% CI, 0.07–1.31), which is consistentwith earlier reports [2,10–12,20]. Although individualstudies are often under-powered to identify significantdifferences, the pooled data from 6 studies (including thepresent one) from centers where electronic fetal monitoringis not used (Table 3) show a substantial decrease in risks ofperinatal deaths in the offspring of women who received anamnioinfusion (12 of 792 vs. 62 of 1003; RR, 0.25; 95% CI,0.13–0.45). However, in a recent multicenter study, therewas no reduction in perinatal deaths, and the authorsexplained that the relative benefit of amnioinfusion coulddepend on cointerventions such as electronic fetal monitoring,operative delivery in selected cases, and specializedneonatal care [16]. It was also suggested that the results oftrials performed in developed countries should not beextrapolated to under-resourced settings [16].Although an accurate cost-benefit analysis of amnioinfusionis difficult, the possible cost savings are enormous [19].Amnioinfusion is an inexpensive intervention, with an

average cost of 75 Indian rupees (US $1.5) per procedure.In contrast, cost of a cesarean section is about 50- to 100-foldthat of an amnioinfusion in a similar setting. In addition, ashorter hospital stay also reduces the cost of childbirthwhere health resources are overstretched. Furthermore,emergency cesarean section can have serious consequenceson maternal health, especially if the operation is performedin a suboptimal condition in an under-resourcedfacility [18,19].In summary, intrapartum amnioinfusion for MSAF is asimple, safe, and inexpensive intervention. It is effective inreducing the rates of cesarean delivery, MAS, and perinataldeath in hospitals not equipped for electronic fetal monitoringand specialized neonatal care. This implies that a lack ofmodern facilities for peripartum care should not deter onefrom using amnioinfusion in the presence of MSAF. Thepresent study, along with other studies, suggests thatsubstantial benefits can arise from performing amnioinfusionsin most district hospitals in developing countries. Thereis a need for multicenter, randomized control trials ofamnioinfusion in women with MSAF who delivered in underresourcedsettings.