Journal of Perinatology

https://doi.org/10.1038/s41372-019-0436-4

ARTICLE

Amniotic fluid transitioning from clear to meconium stained during

labor—prevalence and association with adverse maternal and
neonatal outcomes
Daniel Tairy1 Ohad Gluck
●
1 ●
Ori Tal1 Jacob Bar1 Neri Katz2 Zvia Hiaev1 Michal Kovo1 Eran Weiner1
● ● ● ● ●

Received: 15 March 2019 / Revised: 11 May 2019 / Accepted: 28 May 2019

© The Author(s), under exclusive licence to Springer Nature America, Inc. 2019

Abstract
Objective The objective of this study is to compare pregnancy outcomes in deliveries complicated by primary meconium-
stained amniotic fluid (MSAF, present at membrane rupture) and secondary MSAF (transitioned from clear to MSAF during
labor).
Methods The medical records and neonatal charts of all deliveries ≥ 370/7 weeks between October 2008 and July 2018 were
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reviewed. The primary outcome was composite adverse neonatal outcome that included early neonatal complications.
Results Of 30,215 deliveries during the study period, 4302 (14.2 %) were included: 3845 (89.4%) in the primary MSAF
group and 457 (10.6%) in the secondary MSAF group. The rate of the primary outcome was higher in the secondary MSAF
group (p = 0.006). This association remained significant after controlling for background confounders. The secondary
MSAF group had higher rate of cesarean deliveries (CDs) and assisted vaginal deliveries. There was a higher rate of
composite adverse neonatal outcome when secondary MSAF was diagnosed < 3 vs. >3 h before delivery (p = 0.004).
Conclusion Secondary MSAF was associated with higher rates of adverse neonatal outcome, CDs, and assisted vaginal
deliveries, compared with primary MSAF.

Introduction mortality [5–7]. The association has been shown to correlate

Meconium-stained amniotic fluid (MSAF) has been repor-
ted to occur in ~9.2–20.4% of deliveries [1, 2]. The fre-
quency of MSAF increases with gestational age from
31 weeks to term gestation and the independent predictors
for MSAF include advanced gestation, advanced maternal
age, preeclampsia, prolonged labor, labor induction, black
or South Asian ethnicity, and vaginal breech delivery [3, 4].
MSAF is associated with adverse maternal and neonatal
outcomes including higher incidence of cesarean deliveries
(CDs), severe fetal acidemia, low Apgar scores at 1 and
5 min, meconium aspiration syndrome, and perinatal
* Eran Weiner
masolbarak@gmail.com
1
Department of Obstetrics and Gynecology, the Edith Wolfson
Medical Center, Holon, Israel affiliated with Sackler Faculty of
Medicine, Tel Aviv University, Tel Aviv, Israel
2 mary and secondary MSAF in correlation with various
Department of Neonatal Intensive Care, the Edith Wolfson
Medical Center, Holon, Israel affiliated with Sackler Faculty of
Medicine, Tel Aviv University, Tel Aviv, Israel
with the thickness of the meconium [6].
Presence of MSAF at the time of membrane rupture
(primary MSAF) is a finding that is familiar to every
obstetrician and has traditionally been thought to be a sign
of fetal distress. However, large studies portraying the
association between amniotic fluid transitioning from clear
to MSAF during labor (secondary MSAF) and maternal and
neonatal outcomes are lacking.
Starting October 2008, we have implemented an insti-
tutional protocol that mandates obstetricians and midwives
to report their subjective impression of the color of amniotic
fluid (clear, meconium stained, bloody) during every
delivery (both vaginal and CDs) and to specifically report
transition from clear to MSAF during labor. Prior to
October 2008, the color of amniotic fluid was described
occasionally (not routinely), according to the medical
team’s judgment.
Therefore, 10 years after the implementation of the
protocol, we aimed to study the differences between pri-
adverse pregnancy and neonatal outcomes in a very large
cohort from a single university hospital.

Methods
Study population
The medical records, delivery charts, and neonatal charts
of all singleton vertex deliveries ≥ 37 gestational weeks
between October 2008 (the time at which we began man-
dating the documentation of amniotic fluid characteristics in
all delivery reports) and July 2018 from a single university
hospital were reviewed. We excluded all deliveries <
37 weeks, multiple pregnancies, non-vertex presentation,
terminations of pregnancy, intra-uterine fetal deaths
(IUFDs), pregnancies with a known major fetal malforma-
tion, cases with missing data, and cases with clear/ bloody
amniotic fluid. According to our departmental protocol,
early amniotomy is preferred in every labor (if membranes
are intact), as part of active management of labor.
The study was approved by our institutional ethical
review board (decision number 0232-16-WOMC dated 28
November 2017).
Exposure
Maternal demographics, neonatal outcomes, and pregnancy
complications were compared between deliveries in which
MSAF was present from the time of membrane rupture
(primary MSAF) and deliveries in which amniotic fluid
transited from clear to MSAF during labor (secondary
MSAF). In addition, a comparison of the neonatal outcomes
was performed for the cases of secondary MSAF between
those in which the transition to meconium occurred < 3 h vs.
>3 h from delivery.
Data collection
The following characteristics were collected from the
medical chart of each patient: maternal age, gravidity, par-
ity, pre-pregnancy weight, and height (from which the body
mass index was calculated), gestational diabetes mellitus
(GDM), pre-GDM, chronic hypertension, preeclampsia,
smoking, gestational age at delivery, pre-pregnancy diag-
nosis of thrombophilia (defined as any thrombophilia,
inherited or acquired, which necessitated thrombo-prophy-
laxis) [8, 9], drug abuse, oligohydramnios, polyhydramnios,
epidural, and trials of labor after a previous CD.
Gestational age was calculated based on the woman’s
first ultrasound examination in the pregnancy and last
menstrual period [10]. A woman was considered to have
diabetes mellitus if she had a diagnosis of type 1/type 2 in
the medical record or GDM based on the National Diabetes
Group criteria [11]. Chronic hypertension and preeclampsia
were diagnosed according to the current American College
D. Tairy et al.
of Obstetricians and Gynecologists criteria [12], which were
fully adopted by our institution for hypertensive disorders
diagnosis and management.
Oligohydramnios was defined as amniotic fluid index
≤ 5 cm and polyhydramnios as amniotic fluid index
≥ 24 cm [13].
Immediately after birth, all neonates were examined by
pediatricians. Birthweight percentiles for gestational age were
assigned using the updated local growth charts [14]. Small for
gestational age (SGA) was defined as actual birthweight ≤
10th percentile for gestational age. The following data were
collected from the neonatal discharge records: cord blood pH,
sepsis (positive blood or cerebrospinal fluid culture), need
for blood transfusion, need for phototherapy, respiratory
distress syndrome, meconium aspiration syndrome, need for
mechanical ventilation or support, necrotizing enterocolitis,
intraventricular hemorrhage (all grades), hypoxic-ischemic
encephalopathy, seizures (diagnosed clinically and confirmed
electrographically by a pediatric neurologist), hypoglycemia
(Blood glucose < 40 mg/dL), hypothermia,and periventricular
leukomalacia.
Our NICU protocol mandates routine cranial ultrasound
for every neonate born ≤ 34 weeks. Cranial ultrasound is
performed in neonates > 34 weeks based on clinical
suspicion. Further imaging (such as magnetic resonance
imaging) is performed as needed. All cases with findings
suspicious for periventricular leukomalacia are routinely
confirmed on repeat ultrasound at age 6–7 weeks.
The following data regarding pregnancy outcome were
collected from the chart of each patient: induction of labor,
placental abruption, mode of delivery (vaginal, assisted
vaginal, or cesarean including the indication for CDs),
intrapartum fever, chorioamnionitis, revision of the uterine
cavity, manual removal of the placenta, postpartum
hemorrhage (that necessitated medical and/or surgical
treatment), and postpartum blood transfusion.
Intrapartum fever was defined as elevated temperature
38.0 °C or greater during labor with no other signs
of chorioamnionitis. Clinical chorioamnionitis was
diagnosed in the presence of maternal fever (temperature
38.0 °C or greater) with no evidence of an extra uterine
cause accompanied by at least two of the following: fetal
tachycardia, maternal tachycardia, leukocytosis, uterine
tenderness, or new onset of foul-smelling vaginal dis-
charge [15].
Primary outcome
The primary outcome was a composite variable of neonatal
morbidity, defined as any of the following: umbilical pH ≤ 7.1,
seizures, hypoxic-ischemic encephalopathy, intraventricular
hemorrhage, periventricular leukomalacia, hypoglycemia,
Amniotic fluid transitioning from clear to meconium stained during labor—prevalence and association. . .
hypothermia, mechanical ventilation, meconium aspiration
syndrome, respiratory distress syndrome, necrotizing enter-
ocolitis, phototherapy, sepsis, or transfusion.
Secondary outcomes
Secondary outcomes were pregnancy outcomes including
the following: induction of labor, placental abruption,
mode of delivery (vaginal, assisted vaginal, or cesarean
including the indication for CDs), intrapartum fever, chor-
ioamnionitis, revision of the uterine cavity, manual removal
of the placenta, postpartum hemorrhage (that necessitated
medical and/or surgical treatment), and postpartum blood
transfusion.
Data analysis
Data were analyzed using Epi info 7 (Centers for Disease
Control and Prevention, Atlanta, GA). Data were presented
as follows: continuous variables are presented either as
mean ± SD or as median and range, as appropriate. Cate-
gorical variables are presented as n (%). Continuous para-
meters were compared by the Student’s t-test and
categorical variables by the χ2- with Yates’ correction test or
the Fisher’s exact test, as appropriate. A statistically sig-
nificant p-value of < 0.05 was defined.
Multivariate regression analysis models were used to
identify the independent association of secondary MSAF
and the following outcomes: composite adverse neonatal
outcome, CD, CD due to non-reassuring fetal heart rate
monitoring (NRFHRM), and assisted vaginal deliveries
(which separately serves as the dependent variables),
whereas the group (primary/secondary meconium), mater-
nal age, gestational age at delivery, nulliparity, neonatal
birthweight, and induction of labor served as independent
variables.
Fig. 1 Study design
30,215 deliveries during the study period
3,845 (89.4%)
Primary meconium group
Results
Characteristics of the study population
A total of 30,215 deliveries occurred at our institution
during the study period. After excluding cases of preterm
deliveries, multiple pregnancies, non-vertex presentation,
IUFD, terminations of pregnancy, known malformations,
clear/bloody amniotic fluid, and cases with missing data—
4302 (14.2%) deliveries—were analyzed: 3845 (89.4%) in
the primary MSAF group and 457 (10.6%) in the secondary
MSAF group. Among the secondary MSAF group, 308
(67.4%) transitioned to MSAF >3 h before delivery and 149
(32.6%) transitioned to MSAF <3 h before delivery (Fig. 1).
Maternal demographics of the two groups are presented
and compared in Table 1. Patients in the secondary MSAF
group were more likely to be older than 35 compared with
patients in the primary MSAF group (17.1% vs. 13.7%, p =
0.05). Patients in the secondary MSAF group were more
likely to be nulliparous and had lower rate of poly-
hydramnios, compared with patients in the primary MSAF
group (41.4% vs. 31.9%, p < 0.001 and 0% vs. 2.4%, p <
0.001, respectively). The two groups did not differ in other
background demographics.
Neonatal outcomes
Neonatal outcomes are presented in Table 2. There was a
significant difference in the rate of the primary outcome
(composite adverse neonatal outcome) between the sec-
ondary MSAF group, compared with the primary MSAF
(5.5% vs. 2.9%, p = 0.006), as well as the rate of neonatal
hypoglycemia (1.5% vs. 0.6%, p = 0.04). There were no
between-group differences in neonatal birthweight or the
rate of SGA neonates. Table 3 presents neonatal outcomes
for the cases of secondary MSAF, comparing those cases in
Excluded (n=4741):
2,897 preterm deliveries
1,125 mulple pregnancies
265 IUFDs/terminaons
169 known malformaons
25,474 273 missing data
Deliveries assessed 12 non-vertex presentaon
20,855 Clear amnioc fluid
317 Bloody amnioc fluid
4,302
Deliveries included in the study
457(10.6%)
Secondary meconium group
308(67.4%) 149(32.6%)
Transion >3 hr before delivery Transion <3 hr before delivery
 D. Tairy et al.

Table 1 Maternal demographics of the study groups Table 2 Neonatal outcomes of the study groups
Secondary Primary MSAF p-value Secondary Primary p-value
MSAF n = 457 n = 3845 MSAF n = 457 MSAF n = 3845

Composite adverse neonatal 25 (5.5) 111 (2.9) 0.006

Maternal age (years) 29.9 ± 5.5 29.5 ± 5.3 0.1 outcome (primary outcome)
Maternal age 78 (17.1) 527 (13.7) 0.05 Birthweight (gr) 3336 ± 397 3345 ± 422 0.6
> 35 years SGA 43 (9.4) 348 (9.1) 0.79
GA at delivery 39.3 ± 0.9 39.3 ± 1.1 1.0 Umbilical pH ≤ 7.1 2 (0.4) 9 (0.2) 0.32
(weeks) Seizures 0 (0) 4 (0.1) 1.0
Gravidity 2.6 ± 1.6 2.7 ± 1.7 0.1 Hypoxic-ischemic 0 (0) 6 (2) 1.0
encephalopathy
Parity 1.1 ± 1.2 1.3 ± 1.3 0.01
Intraventricular hemorrhage 0 (0) 1 (0.03) 1.0
Nulliparity 188 (41.4) 1225 (31.9) <0.001 Periventricular leukomalacia 1 (0.2) 0 (0) 0.10
BMI (kg/m2) 23.5 ± 3.3 23.7 ± 3.5 0.3 Hypoglycemia 7 (1.5) 24 (0.6) 0.04
GDM/PGDM 34 (7.4) 284 (7.4) 0.9 Hypothermia 0 (0) 2 (0.05) 1.0
Chronic hypertension 24 (5.2) 263 (6.8) 0.07 Mechanical ventilation 5 (1.1) 31 (0.8) 0.6
Meconium aspiration 5 (1.1) 39 (1.0) 0.8
Preeclampsia 24 (5.2) 263 (6.8) 0.2 syndrome
Smoking 70 (15.3) 499 (13.0) 0.2 Respiratory distress syndrome 0 (0) 2 (0.05) 1.0
Thrombophilia 9 (2.0) 74 (1.9) 0.9 Necrotizing enterocolitis 0 (0) 0 (0) 1.0
Drug abuse 3 (0.7) 28 (0.7) 1.0 Phototherapy 5 (1.1) 35 (0.9) 0.6
Sepsis 1 (0.2) 0 (0) 0.10
Oligohydramnios 20 (4.4) 143 (3.7) 0.5
Transfusion 2 (0.4) 13 (0.3) 0.7
Polyhydramnios 0 (0) 91 (2.4) <0.001
Epidural 379 (82.69) 3111 (80.9) 0.31 Continuous variables are presented as mean ± SD and categorical
variables as n (%) p-values in bold are statistically significant
TOLAC 31 (6.8) 253 (6.6) 0.8
SGA small for gestational age
Continuous variables are presented as mean ± SD and categorical
variables as n (%) p-values in bold are statistically significant
BMI body mass index, GDM gestational diabetes mellitus, PGDM pre- controlling for maternal age, gestational age at delivery,
gestational diabetes mellitus, TOLAC trial of labor after a previous
nulliparity, neonatal birthweight, and induction of labor.
cesarean
These included composite adverse neonatal outcome
(adjusted odds ratio (aOR) = 1.63, 95% confidence interval
which the transition to MSAF occurred <3 h vs. >3 h before (CI) 1.26–5.63), CD (aOR = 1.2, 95% CI 1.05–3.14), CD
delivery. There was a higher rate of composite adverse due to NRFHRM (aOR = 1.57, 95% CI 1.22–6.23), and
neonatal outcome when the diagnosis of secondary MSAF assisted vaginal deliveries (aOR = 1.12, 95% CI
occurred <3 h from delivery (10.1% vs. 3.2%, p = 0.004) 1.02–5.12).
and mean birthweight was significantly lower (3299 ± 336
vs. 3389 ± 345, p = 0.008).
Discussion
Pregnancy outcomes
Main findings
Table 4 presents pregnancy outcomes of the study groups.
Compared with the primary MSAF group, there were higher The aim of this study was to study the correlation between
rates of both assisted vaginal deliveries (10.1% vs. 6.0%, secondary MSAF and adverse pregnancy outcomes
p = 0.002) and CDs (22.3% vs. 16.6, p = 0.003) in the including maternal and neonatal morbidities, compared with
secondary MSAF group. Moreover, the rate of CDs due to primary MSAF. Our main findings were as follows: (1)
NRFHRM was higher in the secondary MSAF group secondary MSAF was subjectively described in about 1.8%
compared with the primary MSAF group (8.9% vs. 4.0%, of the term singleton deliveries studied; (2) secondary
p < 0.001). There was also a higher rate of inductions of MSAF was associated with our primary outcome of com-
labor in the secondary MSAF group (26.5% vs. 19.8%, p < posite adverse neonatal outcome; (3) within the secondary
0.001) compared with the primary MSAF group. Other MSAF, a transition to MSAF <3 h before delivery was
pregnancy outcomes including placental abruption, intra- associated with higher rate of composite of adverse neonatal
partum fever, chorioamnionitis, and maternal blood trans- outcomes; (4) compared with primary MSAF, secondary
fusions did not differ between the groups. MSAF was associated with higher rates of assisted vaginal
Table 5 presents the independent associations of deliveries and CDs (including CDs for NRFHRM), and
secondary MSAF and adverse pregnancy outcomes after higher rate of induction of labor.
Amniotic fluid transitioning from clear to meconium stained during labor—prevalence and association. . .

Table 3 Neonatal outcome in

Transition to MSAF <3 h Transition to MSAF >3 h p-value
the secondary MSAF group
before delivery n = 149 before delivery n = 308
stratified according to the time
of transition from clear to MSAF Composite adverse neonatal 15 (10.1) 10 (3.2) 0.004
outcome (primary outcome)
Birthweight (gr) 3299 ± 336 3389 ± 345 0.008
SGA 14 (9.3) 29 (9.4) 1.0
Umbilical pH ≤ 7.1 1 (0.6) 1 (0.3) 0.6
Seizures 0 (0) 0 (0) 1.0
Hypoxic-ischemic encephalopathy 0 (0) 0 (0) 1.0
Intraventricular hemorrhage 0 (0) 0 (0) 1.0
Periventricular leukomalacia 1 (0.6) 0 (0) 0.3
Hypoglycemia 4 (2.6) 3 (0.9) 0.16
Hypothermia 0 (0) 0 (0) 1.0
Mechanical ventilation 2 (1.3) 3 (0.9) 0.7
Meconium aspiration syndrome 3 (2.0) 2 (0.6) 0.18
Respiratory distress syndrome 0 (0) 0 (0) 1.0
Necrotizing enterocolitis 0 (0) 0 (0) 1.0
Phototherapy 3 (2.0) 2 (0.6) 0.18
Sepsis 1 (0.6) 0 (0) 0.32
Transfusion 1 (0.6) 1 (0.3) 0.6
Continuous variables are presented as mean ± SD and categorical variables as n (%) p-values in bold are
statistically significant
SGA small for gestational age

Table 4 Selected pregnancy outcomes in the study groups Table 5 Multivariable regression analysis for independent associations
with secondary MSAF
Secondary Primary MSAF p-value
MSAF n = 457 n = 3845 aOR* 95% CI

Induction of labor 121 (26.5) 760 (19.8) <0.001 Composite adverse neonatal outcome (primary 1.63 1.26–5.63
Placental abruption 6 (1.3) 73 (1.9) 0.5 outcome)
Cesarean delivery 102 (22.3) 639 (16.6) 0.003 Cesarean delivery 1.20 1.05–3.14
Cesarean delivery due 41 (8.9) 154 (4.0) <0.001 Cesarean delivery due to NRFHRM 1.57 1.22–6.23
to NRFHRM Assisted vaginal delivery 1.12 1.02–5.12
Assisted vaginal 46 (10.1) 231 (6.0) 0.002 *
Adjusted for: maternal age, gestational age at delivery, nulliparity,
delivery neonatal birthweight, and induction of labor
Intrapartum fever 5 (1.1) 22 (0.6) 0.2
Chorioamnionitis 2 (0.4) 20 (0.5) 1.0
9.2–20.4% of all deliveries [1, 2]. Previous studies have
Revision of the 19 (4.2) 153 (4.0) 0.8
uterine cavity suggested that the presence of MSAF may reflect fetal
Manual removal of the 7 (1.5) 100 (2.6) 0.2 maturity and not necessarily be a marker for fetal distress
placenta [2, 3, 16], although distinction between primary and sec-
Postpartum hemorrhage 28 (6.1) 302 (7.8) 0.2 ondary MSAF was not made in most previous studies.
Maternal blood 27 (5.9) 301 (7.8) 0.2 A few studies have investigated the difference between
transfusion primary and secondary MSAF. Meis et al. [17] in a land-
Continuous variables are presented as mean ± SD and categorical mark paper from 1978 described that “early heavy MSAF”
variables as n (%) p-values in bold are statistically significant was associated with increased fetal and neonatal morbidity
NRFHRM non-reassuring fetal heart rate monitoring and death, whereas “late passage of MSAF” encountered no
perinatal losses, but was associated with increased neonatal
Interpretation of the results in the context of morbidity occurring late in labor. They also described that
previous observations “early light MSAF (constituting over half of all meconium
cases) was not associated with any increased intrapartum or
The presence of MSAF during labor is a finding that is neonatal morbidity or death. Hiersch et al. [18] found that
familiar to every obstetrician, with a prevalence of the latter is associated with higher rate of both adverse

neonatal outcome and assisted vaginal delivery; Locatelli
et al. [19] found that secondary MSAF was associated with
poorer neonatal outcomes including NICU admission,
increased risk for low 5 min Apgar score and umbilical
artery pH < 7.1 compared with controls with clear AF; Meis
et al. [20] found, in another paper, that the combination of
late passage of meconium in labor with NRFHRM may
indicate a fetus at risk for asphyxia.
However, all of these were of relatively small sample.
Our study included a substantially larger cohort of women,
as well as a wider and more detailed spectrum of maternal
and neonatal outcomes. In addition, the very large cohort
allowed us to control for various confounders to validate
our results. These aspects provided the current study the
power to discover further correlations between secondary
MSAF and adverse maternal and neonatal outcomes. In
addition, the large cohort allowed us to specifically study
the correlation between secondary MSAF and adverse
neonatal outcomes in relation to the transition time to
meconium during labor.
In the current study we have found an association
between secondary MSAF and the primary outcome of
composite adverse neonatal outcome (which was defined a
priori). This result may not be surprising, as changing of AF
from clear to MSAF during labor (secondary MSAF) may
indicate a new insult of fetal distress during labor. Further
support of this hypothesis is the finding that neonates with
poorer outcome were those in which transition to MSAF
occurred <3 h before delivery. The direct correlation
between secondary MSAF during labor and adverse neo-
natal outcomes emphasizes the concept of MSAF (and
specifically a transition to MSAF during labor) as a strong
marker for inadequate fetal wellbeing. Moreover, secondary
MSAF was associated with a higher rate of both assisted
vaginal deliveries and CDs compared with primary MSAF.
Specifically, the rate of CDs due to NRFHRM was higher in
the secondary MSAF, which strengthens the hypothesis of
secondary MSAF as an indicator of fetal distress.
Strengths and limitations
There are a few strengths of the current study: first, as
far as we know, this is the largest study to be performed,
in this topic, of over 30,000 deliveries from a single
center. Second, we were able to study both neonatal
and maternal outcomes. Third, we specifically studied
the correlation between secondary MSAF and adverse
neonatal outcomes in relation to the transition time to
meconium during labor.
Our study is not without limitations. First, we are aware
that the diagnosis of primary and secondary MSAF was a
subjective impression of the obstetrician or midwife during
labor, which was not defined or standardized prior to the
D. Tairy et al.
study. Second, we are aware of the possibility of mis-
diagnosis of secondary MSAF as primary and vise versa
(fe.g., late amniotomy/“posterior” MSAF, which may not be
visible due to fetal position). Third, we have only collected
short-term neonatal outcomes. Lastly, we are aware that the
use of a composite outcome may be viewed as a limitation of
this study. However, we believe its utilization was neces-
sary, because the individual components of the composite
are rare complications. We have described and validated the
same composite neonatal outcomes in our previous pub-
lications with other pregnancy complications [21–23].
Conclusion
In conclusion, secondary MSAF observed in labor was
associated with composite adverse neonatal outcome,
especially when diagnosed within the last 3 h of labor.
Secondary MSAF was also associated with higher rates of
assisted vaginal deliveries and CDs, particularly in the
setting of NRFHRM. These findings highlight the impor-
tance of reporting intrapartum transition of amniotic fluid
from clear to MSAF, which should raise the alert of
obstetricians and neonatologists during labor.
Acknowledgements We thank Meir Azran, Computing and Informa-
tion Systems, E. Wolfson Medical Center, Holon, Israel, and Ela
Smirin, archive, E. Wolfson Medical Center, Holon, Israel.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Publisher’s note: Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
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