PURPOSE: To assess the delivery complications in neonates with meconium stained amniotic fluid (MSAF) and small for gestational age (SGA) birthweight. METHODS: The medical records of all term, singleton deliveries during 2014-2021 were reviewed. Obstetric characteristics and neonatal outcomes were evaluated among the following groups: SGA neonates with MSAF (SGA-MSAF group), SGA neonates without MSAF (SGA group), appropriate for gestational age (AGA) neonates with MSAF (AGA-MSAF group) and AGA without MSAF (AGA group). RESULTS: A total of 44,911 deliveries were included in the study, with 673 in the SGA-MSAF group, 2,762 in the SGA group, 6,958 in the AGA-MSAF group, and 34,518 in the AGA group. The SGA-MSAF group exhibited higher rates of nulliparity and hypertensive disorders compared to the SGA, AGA-MSAF, and AGA groups (p ≤ 0.001). Oligohydramnios, labor induction, vacuum extractions (VE), and intrapartum cesarean deliveries (CD) were significantly more frequent in the SGA-MSAF group compared to the SGA, AGA-MSAF, and AGA groups (p ≤ 0.003). The SGA-MSAF group had the highest rates of adverse composite neonatal outcomes compared to the SGA, AGA-MSAF, and AGA groups (p <
0.001). Multivariable logistic regression, adjusted for confounders, revealed increased ORs for the adverse neonatal composite outcome, VE, VE due to NRFHR, intrapartum CD, and CD due to NRFHR, in the presence of MSAF or SGA, and mostly when both risk factors were present (p ≤ 0.002). CONCLUSION: Deliveries complicated with MSAF and SGA were associated with increased obstetric complications compared to each alone. Clinicians should be aware of this and manage labor accordingly.