Background: Meconium stained amniotic fluid (MSAF) is frequently encountered in obstetric practice. Literature on the subject is still poorly documented in the African setting. Objective : The aim of this study was to determine the maternal and fetal outcomes in case of meconium stained amniotic fluid observed during term labour. Materials and Methods: We conducted a prospective cohort study enrolling all consenting pregnant women with term singleton fetus in cephalic presentation admitted for labour with ruptured fetal membranes in the maternity units of the Yaoundé Central Hospital (YCH) and the Yaoundé Gynaeco-Obstetric and Pediatric Hospital (YGOPH) of Cameroon between December 2014 and April 2015. The exposed grouped was considered as participants having MSAF, while the non-exposed group comprised those with clear amniotic fluid (CAF). The two groups were monitored during labor using the WHO partograph, and then followed up till 72 hours after delivery. Variables studied included the colour and texture of amniotic fluid as well as maternal and fetal complications. Data was analyzed using Epi-info version 3.5.4. The chi-square and Fischer’s exact tests were appropriate ly used to compare the two groups. A p-value less than 5% was considered statistically significant. Results: 2376 vaginal deliveries were recorded during the study period among which MSAF was observed in 265 cases, hence a prevalence rate of MSAF of 11.15%. Among these cases of MSAF, 52.1% was thick meconium and 47.9% was light meconium. Maternal morbidity was high in the group with MSAF ; these included : Higher proportions of caesarean delivery (RR = 2.35 p < 10-4) and prolonged labor (RR = 3 p < 10-4). In this same group, the incidences of chorioamnionitis and puerperal sepsis were low (0.94% and 0.70% respectively), although there was a three-fold higher risk that was not statistically significant (RR = 3, P = 0.31). Fetal and neonatal outcomes were poorer in the MSAF group compared to the CAF group. The complications included fetal heart rate abnormalities, low Apgar score at the 5th minute, need for neonatal resuscitation, neonatal asphyxia and neonatal infection which were significantly higher in the MSAF group (all p < 0.05). Meconium aspiration syndrome (MAS) was found in 2.34% of MSAF cases. Perinatal mortality was 2.34% and all cases of death occurred in the thick MSAF group. Conclusion: MSAF observed during labour is associated with increased perinatal morbidity and mortality. Its detection during labor should strongly indicate very rigorous intra partum and postpartum monitoring. This will ensure optimal management and reduction in the risks of complications.
Amniotic fluid is a clear and transparent liquid in which the fetus lives. It is principally made up of water (96.4%), mineral salts and organic substances [
Although the exact cause of this MSAF is unclear, fetal distress, cord accidents and maternal hypertension have been identified as potential risk factors [
This was a prospective cohort study which targeted pregnant women admitted in the labor wards of the maternity units of two university teaching hospitals of Cameroon; the Yaounde Central Hospital (YCH) and the Yaounde Gynaeco-Obstetric and Pediatric Hospital of Yaoundé (YGOPH). The study was conducted over a 5 months period from December 2014 to April 2015. Uniform and standard operating protocols for the management of labour were in use in both study settings.
We included all consecutive and consenting pregnant women presenting with singleton pregnancies at term, fetuses in cephalic presentation and ruptured fetal membranes and who gave their informed consent. We excluded women with pre-term or post term pregnancies, breech and other mal-presentations, multiple gestations, those admitted for elective caesarean, women with unknown last menstrual period and those with intra-uterine fetal death on admission. Cases of MSAF were considered as exposed while those with clear amniotic fluid (CAF) were considered as non-exposed. Women were matched based on parity. Participants were followed up during labor (using the WHO partograph), and 72 hours following delivery, checking for maternal, fetal and neonatal complications. Using a ratio of unexposed group to exposed group of 1, a 95% confidence interval, minimum risk ratio of 2 for differences to be detected, the formula for difference in proportions [
Data was collected using a pretested questionnaire and analyzed using Epi-info version 3.5.4. The Chi-square and Fischer’s exact tests were used to compare the two groups. A p-value of less than 5% was considered statistically significant.
Ethical considerations: Ethical clearance was obtained from the Institutional Review Board of the Faculty of Medicine and Biomedical Sciences of the University of Yaounde I, Cameroon.
A total of 2376 deliveries were registered during the study period. Among these there were 265 cases of MSAF, hence, a prevalence of 11.15% for MSAF. Of the 265 cases of MSAF, 52 cases (19.6%) were excluded because of post term gestation, prematurity, breech presentation and multiple gestations. Two-hundred and thirteen (213) labour cases with CAF were matched to the remaining 213 cases of MSAF. The average age of the pregnant women was 27.72 ± 5.34 years with extremes of 15 and 40 years. There was no significant difference in ages between the two study groups (
There was a significantly higher risk of prolonged labour and caesarean delivery
Variables | Total N (%) [95% CI] | Sub-groups | ||||
---|---|---|---|---|---|---|
MSAF n(%) | CAF n(%) | P-value | ||||
Age (years): | ||||||
<20 | 33 (7.7) [5.5 - 10.8] | 18 (8.45) | 15 (7.04) | 0.5862 | ||
[20 - 25[ | 79 (18.5) [15.0 - 22.6] | 43 (20.19) | 36 (16.90) | 0.3824 | ||
[25 - 30] | 191 (44.8) [40.1 - 49.7] | 88 (41.31) | 103 (48.36) | 0.1435 | ||
>30 | 123 (28.9) [24.7 ? 33.5] | 64 (30.05) | 59 (27.70) | 0.5926 | ||
Marital status | ||||||
Married | 167 (39.2) [34.6 - 44] | 88 (41.31) | 79 (37.09) | |||
Spinster | 257 (60.3) [55.5 - 65.0] | 125 (58.69) | 132 (61.97) | |||
Divorced | 1 (0.2) [0.0 - 1.5] | 0 (00) | 1 (0.47) | |||
Widow | 1 (0.2) [0.0 - 1.5] | 0 (00) | 1 (0.47) | |||
Level of Education | ||||||
None | 1 (0.2) [0.0 - 1.5] | 0 (00) | 1 (0.47) | |||
Primary | 27 (6.3) [4.3 - 9.2] | 15 (07.04) | 12 (5.63) | |||
Secondary | 209 (49.1) [44.2 - 53.9] | 110 (51.64) | 99 (46.48) | |||
University | 189 (44.4) [39.6 - 49.2] | 88 (41.31) | 101 (47.42) | |||
Occupation | ||||||
Housewife | 93 (21.8) [18.1 - 26.1] | 48 (22.54) | 45 (21.13) | |||
Trader | 81 (19) [15.5 - 23.1] | 45 (21.13) | 36 (16.90) | |||
Pupil/student | 138 (32.4) [28.0 - 37.1] | 70 (32.86) | 68 (31.92) | |||
Public employee | 77 (18.1) [14.6 - 22.1] | 32 (15.02) | 45 (21.13) | |||
Private employee | 37 (8.7) [6.3 - 11.9] | 18 (8.45) | 19 (8.92) | |||
MSAF = meconium stained amniotic fluid; CAF = clear amniotic fluid.
in cases of MSAF and especially when the stain was thick; 30.5% and 44.6% respectively (p < 0.001). Common indications of caesarean delivery were cephalo-pelvic disproportion and acute fetal distress. Chorioamnionitis, instrumental delivery and puerperal sepsis were also higher in cases of MSAF although the differences were not statistically significant (P > 0.05) (
The meconium inhalation syndrome (MIS) was found in 5 (2.34%) cases of MSAF. The risks of low Apgar scores at the first and fifth minutes were multiplied by 8 times (RR = 8.16, p < 0.001) and 3 times (RR = 3.42, P = 0.0023) respectively, in cases of MSAF. Fetal heart rate abnormalities, neonatal infection and neonatal asphyxia were significantly higher in cases with MSAF. All ten cases (4.7%) of perinatal deaths were in the group with MSAF (
Variables | Total n(%) [95% CI] | Sub-groups | ||
---|---|---|---|---|
MSAF n(%) | CAF n(%) | P-value | ||
Parity | ||||
Primiparous | 182 (45.1) [40.3 - 49.9] | 96 (45.07) | 96 (45.07) | 1 |
Multiparous | 234 (54.9) [50.1 - 59.7] | 117 (54.93) | 117 (54.93) | 1 |
Number of ANC | ||||
<4 | 71 (16.7) [13.3 - 20.6] | 39 (18.31) | 32 (15.02) | 0.3623 |
≥4 | 355 (83.3) [79.4 - 86.7] | 174 (81.69) | 181 (84.98) | 0.3623 |
Gestational age at delivery (weeks) | ||||
[37 - 38] | 60 (14.1) [11.0 - 17.8] | 19 (8.92) | 41 (19.25) | 0.0022 |
]38 - 40] | 220 (51.6) [46.8 - 56.5] | 105 (49.30) | 115 (53.99) | 0.3328 |
]40 - 42] | 146 (34.3) [29.8 - 39.0] | 89 (41.78) | 57 (26.76) | 0.0011 |
Pathologies in pregnancy | ||||
Anaemia | 32 (21.6) [15.3 - 9.1] | 14 (6.57) | 18 (8.85) | 0.4616 |
Malaria | 70 (16.4) [13.1 - 0.4] | 42 (19.72) | 28 (13.15) | 0.0673 |
HIV infection | 13 (3.1) [1.7 - 5.3] | 7 (3.29) | 6 (2.82) | 0.7781 |
Other STIs | 32 (7.5) [5.3 - 10.5] | 22 (10.33) | 10 (4.69) | 0.0272 |
Hypertension | 27 (6.3) [4.3 - 9.2] | 9 (4.23) | 18 (8.45) | 0.0739 |
History of C/S | 49 (11.5) [8.7 - 15.0] | 24 (11.27) | 25 (11.74) | 0.8792 |
Mode of membrane rupture | ||||
Spontaneous | 193 (45.3) [40.5 - 50.2] | 105 (49.30) | 88 (41.31) | 0.0976 |
Artificial | 233 (54.7) [49.8 - 59.5] | 108 (50.70) | 125 (58.69) | 0.0976 |
Delay of membrane rupture | ||||
Premature rupture | 60 (14.1) [11.0 - 7.8] | 28 (13.15) | 32 (15.02) | 0.5791 |
Prolonged rupture | 58 (13.6) [10.6 - 7.3] | 39 (18.31) | 19 (8.92) | 0.0047 |
ANC = Antenatal care; C/S = Cesarean section; MSAF = meconium stained amniotic fluid; CAF = clear amniotic fluid; STIs = sexually transmitted infections.
Characteristics | Number | Percentage |
---|---|---|
Colour | ||
Green | 111 | 52.1 |
Yellow | 58 | 27.2 |
Pure meconium | 44 | 20.7 |
Consistency | ||
Light | 102 | 47.9 |
Thick | 111 | 52.1 |
Odour | ||
---|---|---|
Fetid | 11 | 5.2 |
Non fetid | 202 | 94.8 |
Chronology | ||
AF initially clear | 50 | 23.5 |
AF stained at start | 163 | 76.5 |
Moment of detection | ||
Before labour | 4 | 1.9 |
Latent phase | 17 | 8 |
Active phase | 136 | 63.8 |
Expulsion phase | 9 | 4.2 |
Per operative | 47 | 22.1 |
AF = amniotic fluid.
Variable | MSAF n (%) | CAF n (%) | RR [95% CI] | P-value |
---|---|---|---|---|
Clinical chorioamniotitis | 3 (1.4) | 1 (0.5) | 3 [0.50 - 17.95] | 0.3120 |
Prolonged labour | 65 (30.5) | 19 (8.9) | 3.42 [2.13 - 5.49] | <0.001 |
Instrumental delivery | 6 (2.82) | 1 (0.47) | 6 [0.73 - 49.41] | 0.1219 |
Caesarean delivery | 95 (44.6) | 48 (22.5) | 1.97 [1.48 - 2.64] | <0.001 |
Puerperal infection | 3 (1.4) | 0 (00) | N?A |
N-A: not applicable (The relative risk could not be calculated because all the cases were in the exposed group).
MSAF(n = 213) n (%) | CAF (n = 213) n (%) | RR [95% CI] | P-value | |
---|---|---|---|---|
Fetal heart beat anomaly | 71 (33.3) | 29 (13.6) | 2.90 [1.79 - 4.72] | <0.001 |
Apgar < 7 at 1 minute | 51 (23.9) | 8 (3.8) | 8.16 [3.81 - 17.47] | <0.001 |
Apgar < 7 at 5 minutes | 26 (12.2) | 9 (4.2) | 3.42 [1.73 - 6.76] | 0.0023 |
Neonatal resuscitation | 35 (16.4) | 15 (7.0) | 2.66 [1.59 - 4.46] | 0.0026 |
NNI | 28 (13.1) | 5 (2.3) | 5.6 [2.46 - 12.71] | 0.0001 |
NNA | 19 (8.9) | 7 (3.3) | 2.71 [1.38 - 5.33] | 0.0186 |
Admission in neonatology | 42 (19.7) | 13 (6.1) | 3.41 [2.03 - 5.73] | <0.001 |
Deaths | 10 (4.7) | 0 (00) | N/A |
N-A: not applicable (The relative risk could not be calculated because all the cases were in the exposed group); NNI: Neonatal infection, NNA: Neonatal asphyxia.
The aim of this study was to determine the maternal and fetal outcomes in case of meconium stained amniotic fluid observed during labour of term singleton pregnancy in cephalic presentation. We found that the prevalence of MSAF was 11.15%. MSAF was associated with a significant risk of caesarean delivery and prolonged labor. Also, MSAF was associated with the following fetal and neonatal complications; fetal heart rate abnormalities, low Apgar score at the 5th minute, need for neonatal resuscitation, neonatal asphyxia and neonatal infection. Meconium aspiration syndrome (MAS) was found in 2.34% of MSAF cases. Perinatal mortality was 2.34% and all cases of death occurred in the thick MSAF group.
We found a prevalence of MSAF of 11.15%. This finding is within the 5% to 24.6% interval stated in the literature [
The mean gestational age was greater in the group with MSAF compared to the CAF group (39.7 vs 39.2 weeks: p = 0.0001). Moreover, the incidence of MSAF was 60.9% in cases with gestational age greater than 40 weeks. This positive correlation between advanced gestational age and the prevalence of MSAF concurs with previous observations made by Meis et al. [
Similar to studies done by by Erum et al. [
After stratifying maternal morbidities according to the consistency of the MSAF, it was noted that thick MSAF compared to light MSAF and clear amniotic fluid (CAF) respectively increased the risk of caesarean delivery by 1.67 and 2.48. Similar results were found by Aparna et al. [
Fetal morbidities were significantly higher in case of MSAF. These included non-reassuring fetal heart rhythm (p < 10−4), low Apgar scores at first and fifth minutes (p < 10−4 and p < 10−2 respectively), neonatal infection (NNI) and neonatal asphyxia (NNA) (p < 10−3 and p < 10−1 respectively). Similar results were obtained in India [
Our results should be interpreted within the study’s limitations. These include the sole use of fetal heart rhythm to diagnose acute fetal distress and the short term postpartum follow up period of 72 hours (coinciding with the hospital discharge of participants). As such, some complications could be missed because of this early exit from the hospital. However, based on well followed-up patients, we have used a cohort design to provide a contribution of level II scientific evidence to the scarcity on the outcomes of maternal and fetal outcomes in case of meconium stained amniotic fluid observed during labour of term singleton pregnancy in the sub-Saharan African region. These findings may guide obstetricians and midwives in making informed clinical decisions in their therapeutic strategies MSAF observed during labour in these resource-constrained environments.
MSAF observed during labour of term singleton pregnancies in cephalic presentations was associated with maternal and fetal complications. Its detection during labor warrants rigorous intra partum and postpartum monitoring for a timely diagnosis and management of these complications.
The authors report no declaration of interest.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Dohbit, J.S., Mah, E.M., Essiben, F., Nzene, E.M., Meka, E.U.N., Foumane, P., Tochie, J.N., Kadia, B.M., Elong, F.A. and Nana, P.N. (2018) Maternal and Fetal Outcomes Following Labour at Term in Singleton Pregnancies with Meconium-Stained Amniotic Fluid: A Prospective Cohort Study. Open Journal of Obstetrics and Gynecology, 8, 790-802. https://doi.org/10.4236/ojog.2018.89082
Patient identification:
File N˚: _________ Date: ____ /____/____
Contact adresss: ___________________ Age (years): _______
Marital Status: maried □; single □; divorced ,; widow ,
Level of education: not formal,; primary ,; secondary ,; higher ,
Occupation: housewife , student , civil servant , private worker , independant ,
Monthly revenu (Fcfa):
<25,000 , [25,000 - 50,000[ , [50,000 - 100,000[ , ≥ 100,000 ,
Last mentrual period:__/__/__ Expected day of confinment: _/_/_ Gestational age (weeks-days) ____________________
Presenting complaint: labour pains □; vaginal bleeding,; lost of liquoir□; others____________________
History of pregnancy:
No of antenatal care visits: ___; VIH serology: negative , positive ,
Level of haemoglobin: <10 g/dl ,; ≥ 10g/dl ,
Pathologies in pregnanacy: anaemia□; malaria □; urinary infection ,; diabetes ,; Hypertension , others ___________________________________
Gravida ___ Para__________________; No of past cesarean sections: ____
Medical History: None □; Hypertension: Yes ,/No ,; diabetes: Yes ,/No ,
Cardiopathy: Yes □/No □ others ____________________
Monitoring of labour (partograph)
Mode of rupture of membranes: Spontanous , Artificial ,
Delay of rupture of membranes: Premature Rupture: Yes ,/No ,
Prolonged Rupture: Yes ,/No ,
Nature of liquoir: Clear ,/Meconial , If meconial, colour: green ,; yellow ,; purulent ,
Consistency of liquoir: light , thick ,; Odour of liquoir: foul smelling , not foul smelling ,
Moment of detection of MSAF: before onset of labour ,; latent phase ,; active phase ,; expulsion phase ,; intra operative ,
MSAF noticed immediately at membrane rupture ,/Initial clear liquoir followed by MSAF ,
Fetal heart rate anomaly during labour: Yes ,/No ,
If Yes: Tachycardia , Bradycardia , Deceleration ,
If deceleration: type I , type II , type III ,
Maternal fever (temp > 37.8): Yes ,/No ,; Maternal tachycardia (>100): Yes ,/No ,
Uterine pain on palpation: Yes ,/No , Clinical chorioamnionitis: Yes ,/No ,
Mode of delivery:
Normal vaginal delivery □;
Instrumental □ (Indication: fetal distress , cephalopelvic disproportion ,; fatigue , others___________)
Cesaerian section □ (Indication: fetal distress □; cephalopelvic disproportion □; others ____________________________)
Duration of labour: Normal , Prolonged ,
If prolonged: 1st stage , duration____ 2nd stage , duration____ 3rd stage , duration____
Placenta: weight(g) __________; meconial stained: Yes □ /No □
Calcifications: Yes ,/No ,; other anomalies________________________
Umbilical Cord: meconial stained: Yes □ /No □; cord knot: Yes □ /No □
Cord round neck: Yes ,/No ,; cord prolapse: Yes ,/No , other anomalies _________________________
State of newborn:
Gender: Male , Female ,; Weight(g) _______________
APGAR: 1st min____/10; 5th min____/10
Resuscitation: Yes ,/No ,; if yes: Duration____________________ min, Method_________________
Respiratory distress: Yes ,/No ,; Neonatal Asphyxia: Yes ,/No ,
Meconium inhalation syndrome: Yes □,/No ,; Neonatal Infection: Yes ,/No,
Neonatal unit admission: Yes ,/No ,;
Neonatal death: Yes ,/No ,
Follow-up of the mother and newborn
NNI: Neonatal infection, NNA: Neonatal asphyxia, RD: Respiratory distress, MIS: Meconium inhalation syndrome.