Suctioning of clear amniotic fluid at birth: A systematic review

Joe Fawke; Jonathan Wyllie; Enrique Udaeta; Mario Rüdiger; Hege Ersdal; Mary-Doug Wright; Myra H Wyckoff; Helen G Liley; Yacob Rabi; Gary M Weiner; International Liaison Committee On Resuscitation Neonatal Life Support Task Force

doi:10.1016/j.resplu.2022.100298

Suctioning of clear amniotic fluid at birth: A systematic review

Resusc Plus. 2022 Sep 17:12:100298. doi: 10.1016/j.resplu.2022.100298. eCollection 2022 Dec.

Affiliations

¹ Department of Neonatology, University Hospitals Leicester NHS Trust, Leicester, UK.
² Department of Neonatology, James Cook University Hospital NHS Trust, Middlesbrough, UK.
³ Committe of Neonatology, Mexican Association of Pediatrics, Mexico.
⁴ Saxony Center for Feto-Neonatal Health, Medizinische Fakultät, TU Dresden, Dresden, Germany.
⁵ Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway.
⁶ Faculty of Health Sciences, University of Stavanger, Norway.
⁷ Apex Information, Vancouver, Canada.
⁸ Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, United States.
⁹ Mater Research Institute and Mater Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
¹⁰ Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
¹¹ Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States.

Abstract

Context: Upper airway suctioning at birth was considered standard procedure and is still commonly practiced. Negative effects could exceed benefits of suction.

Question: In infants born through clear amniotic fluid (P) does suctioning of the mouth and nose (I) vs no suctioning (C) improve outcomes (O).

Data sources: Information specialist conducted literature search (12th September 2021, re-run 17th June 2022) using Medline, Embase, Cochrane Databases, Database of Abstracts of Reviews of Effects, and CINAHL. RCTs, non-RCTs and observational studies with a defined selection strategy were included. Unpublished studies, reviews, editorials, animal and manikin studies were excluded.

Data extraction: Two authors independently extracted data, risk of bias was assessed using the Cochrane ROB2 and ROBINS-I tools. Certainty of evidence was assed using the GRADE framework. Review Manager was used to analyse data and GRADEPro to develop summary of evidence tables. Meta-analyses were performed if ≥2 RCTs were available.

Outcomes: Primary: assisted ventilation. Secondary: advanced resuscitation, oxygen supplementation, adverse effects of suctioning, unanticipated NICU admission.

Results: Nine RCTs (n = 1096) and 2 observational studies (n = 418) were identified. Two RCTs (n = 280) with data concerns were excluded post-hoc. Meta-analysis of 3 RCTs, (n = 702) showed no difference in primary outcome. Two RCTs (n = 200) and 2 prospective observational studies (n = 418) found lower oxygen saturations in first 10 minutes of life with suctioning. Two RCTs (n = 200) showed suctioned newborns took longer to achieve target saturations.

Limitations: Certainty of evidence was low or very low for all outcomes. Most studies selected healthy newborns limiting generalisability and insufficient data was available for planned subgroup analyses.

Conclusions: Despite low certainty evidence, this review suggests no clinical benefit from suctioning clear amniotic fluid from infants following birth, with some evidence suggesting a resulting desaturation. These finding support current guideline recommendations that this practice is not used as a routine step in birth.

Funding: The International Liaison Committee on Resuscitation provided access to software platforms, an information specialist and teleconferencing.

Clinical trial registration: This systematic review was registered with the Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/prospero/) (identifier: CRD42021286258).

Keywords: Airway; Basic life support; Bpm, beats per minute; CI, confidence interval; CoE, certainty of evidence; DR, delivery room; GRADE, Grading of Recommendations, Assessment, Development and Evaluation; ILCOR, International Liaison Committee on Resuscitation; IQR, interquartile range; MD, mean difference; NICU, neonatal intensive care unit; NLS, Neonatal Life Support; NNT, number needed to treat; Neonatal resuscitation; PICO, population, intervention, comparison, outcome; PPV, positive pressure ventilation; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses; Quasi-RCT, quasi-randomized controlled trial; RCT, randomized controlled trial; RD, risk difference; RR, risk ratio; RoB, risk of bias; SGA, supraglottic airway device; SR, systematic review; Suctioning.

Publication types

Review