Objective Meconium aspiration syndrome (MAS) is one of the most important causes of neonatal intensive care unit admission for full-term newborn infants. We aimed to compare between meconium-stained infants who were intubated at birth and full-term infants who were subjected to oropharyngeal suction of meconium at birth in terms of mortality, MAS, respiratory symptoms, and other clinical outcome measures. We also aimed to evaluate plasma thrombin activatable fibrinolysis inhibitor activity (TAFIa) levels, which may be used as a sign of hypoxia or inflammation in neonates with meconium-stained amniotic fluid (MASF). Patients and methods Seventy five newborn infants delivered through MASF with green-stained vocal cord were studied. The neonates studied were classified into two groups. The first group included 40 neonates with MASF who received endotracheal intubation and airway aspiration at birth. The second group included 35 neonates with MASF who were subjected to oropharyngeal suction at birth. Venous blood sample was drawn from all neonates 6 h after birth to measure plasma TAFIa. Results There was a statistically significant difference in the severity of MAS and respiratory oxygen support, more in the oropharyngeal suction group than in the ETT suction group. There was a highly statistically significant difference in days of oxygen treatment, days of mechanical ventilation, and duration of hospital stay. It was prolonged in the oropharyngeal suction group. Also, there was a highly significant association between poor fetal heart rate tracing pattern and severity of MAS in both groups. Meconium thickness had a significant effect on the severity of MAS in the oropharyngeal suction group than the ETT group. A significant difference was found between plasma TAFIa levels and the severity of MAS, proving that MAS was associated with more acidosis, hypoxia, and depressed fibrinolysis. Conclusion There was a higher incidence and severity of MAS in the oropharyngeal group than the ETT group. Risk factors associated with the development of MAS among infants with MASF include thick meconium, fetal acidosis, nonreassuring fetal heart tracing, and low Apgar score. Also, there was an increase in TAFIa levels in neonates with MASF and this may indicate depressed fibrinolysis.