Outcomes of Neonates Born Through Meconium-stained Amniotic Fluid Pre and Post 2015 NRP Guideline Implementation

Background: Meconium-stained amniotic fluid (MSAF), which occurs in 8-20% of all deliveries, remains a major perinatal clinical concern due to its association with meconium aspiration. Approximately 25-30% of infants who are born through MSAF require resuscitation in the delivery room, and often require admission to a neonatal intensive care unit. Therefore, many strategies have been applied to reduce complications in infants born through MSAF, including routine intubation and intratracheal suctioning. However, guidelines have evolved to address how to best manage this potentially life-threatening condition leading to the meconium debate: to suction or not to suction. A shift in the Neonatal Resuscitation Program (NRP) guidelines occurred in 2015 from routine intubation and intratracheal suctioning of all meconium-stained non-vigorous infants towards less aggressive interventions, namely expectant management and initiation of positive pressure ventilation (PPV) based on response to initial resuscitation. This study will contribute towards filling in gaps in the literature by examining the impact of this change on outcomes of non-vigorous infants born through MSAF at a level III academic NICU encompassing years before and after the change in guideline.

Methods: In this retrospective cohort study, we compare 117 non-vigorous newborns born during the time period pre-implementation of the guideline (January 1, 2014-December 30, 2015) to 106 non-vigorous newborns born during the time period post-implementation of the guideline (January 1, 2017-December 30, 2018). The data analysis plan includes logistic regression to account for the independent variables and t test analysis will be used to compare the continuous variables, controlling for maternal and neonatal demographics.

Results: Results indicated that nearly two thirds of infants in the pre-guideline change cohort received endotracheal suctioning with recovery of meconium compared to less than a third of infants in the post-guideline change cohort, demonstrating a statistically significant change in practice. In addition, though a higher proportion of the pre-guideline cohort were admitted to the NICU for respiratory issues compared to the post-guideline group (64.1% vs 59.4%), this difference was not statistically significant with an odds ratio (OR) of 1.33 (95% CI: 0.69-2.57). Furthermore, the two groups did not differ significantly with regard to incidence of respiratory outcomes, including RDS, TTN, need for supplemental oxygen/ventilatory support, or exposure to x-rays, or with regard to duration of antibiotics, breastfeeding, or length of stay.

Conclusion: Our results suggest there is no difference in outcomes between pre-guideline implementation vs post-guideline implementation in non-vigorous meconium-stained infants. Our institution embraced the recommendations suggested by the NRP’s seventh edition and markedly reduced rates of intubation and suctioning in the delivery room without any associated increase in morbidity. These findings support the recent NRP guideline change and highlight the benefit of expectant management.