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276Psychiatric disorders and the puerperium

demonstrates multifactorial inheritance and the offspring of affected parents are at increased risk of developing the condition themselves.

Post-natally, the woman and her baby may benefit from an inpatient stay in a specialized mother and baby unit under the review and encouragement of a perinatal mental health team. Breastfeeding is to be encouraged to promote bonding with the newborn, and neuroleptic drugs in moderate doses are not a contraindication to this.

Bipolar affective disorder

This condition, also known as ‘manic depression’, is usually controlled with a combination of mood-stabilizing drugs (lithium, carbamazepine and sodium valproate), antidepressants and neuroleptics. Lithium carries a risk of causing cardiac defects if used in the first trimester and may cause fetal hypothyroidism, polyhydramnios and diabetes insipidus if used in the third trimester. Carbamazepine and valproate are also recognized teratogens. Stopping these medications abruptly before or just after conception carries a risk of causing a relapse. If the illness is stable, the mood stabilizers may be reduced and replaced by antidepressants with or without antipsychotics. Ideally, this is done following pre-pregnancy counselling. Ultimately, the fetal risks of continuing

C A S E 2

certain preparations may have to be accepted if the maternal risks of stopping treatment are thought to be too great.

Postpartum relapse occurs in approximately 50 per cent of women with bipolar illness and it is important that preventive therapy is commenced immediately after delivery. Lithium is contraindicated in breastfeeding, and the woman may be advised to bottle-feed so that it can be used in the postpartum period. Alternatively, a neuroleptic or antidepressant can be used for prophylaxis.

Anxiety disorders

Pregnancy, the anticipation of labour and the arrival of a new baby may all exacerbate an existing anxiety disorder. Cognitive–behavioural therapy may limit the need for drug treatment. Benzodiazepine use during the first trimester may be associated with an increased risk of cleft lip and/or palate, although the evidence is somewhat contradictory. Neonatal withdrawal effects are evident in the babies born to women who have used regular higher doses during pregnancy, and their use should be limited where possible. Breastfeeding may help to reduce the severity of the neonatal withdrawal (neonatal abstinence syndrome), as small amounts do reach breast milk.

A recent Eastern European immigrant to the United Kingdom, with minimal English, was seen by her GP at 12 weeks gestation. The only history of note was that her father had suffered a longstanding psychiatric illness which the woman believed to be ‘schizophrenia’. He had died when she was young in a road traffic accident. Her pregnancy proceeded without complication, and she went home on the second post-natal day following a normal delivery at term.

Within a couple of weeks, her partner reported to the community midwife that he had concerns about her mood. She seemed agitated, fearful, and unduly concerned about the wellbeing of the baby and refused any help offered by him. The GP saw her, without an interpreter, and diagnosed ‘post-natal depression’. He commenced tricyclic antidepressants, however, a week later

she became frankly delusional and believed that her partner was trying to kill the baby. She was hardly sleeping and eating very little. Admission to a mother-and-baby unit was organized where puerperal psychosis was diagnosed. She was treated initially with antipsychotics (trifluoperazine) and with appropriate help from the specialist nursing and midwifery staff was able to re-establish breastfeeding and was not separated from the baby. Later information from her family in Poland suggested that her father had suffered with a bipolar illness. This information should have prompted review by a specialist in perinatal mental health,

had it been known at booking. A post-natal plan, including regular review by a community psychiatric nurse, might have led to earlier intervention and may have prevented her deterioration to such a severe state.



New-onset psychiatric disease in pregnancy


Psychotropic medications during pregnancy and breastfeeding


The mood stabilizers carry particular concern. Lithium increases the risks of fetal cardiac defects, while valproate is strongly implicated in the causation of neural tube defects. Both valproate and carbamazepine can cause the ‘fetal anticonvulsant syndrome’.

The antidepressant paroxetine (an SSRI) is linked with an increase in fetal cardiac defects, and use of benzodiazepines may increase facial clefting.

Amitriptyline, imipramine (both tricyclic antidepressants) and fluoxetine (an SSRI) do not seem to be overtly teratogenic.

Other antenatal side effects

Monoamine oxidase inhibitors (rarely used now) are contraindicated in pregnancy because of their vasoconstrictive properties, which may impair placental function. Chronic use of antipsychotic drugs may cause glucose intolerance and diabetes during pregnancy.

Neonatal effects

Lithium may cause fetal and neonatal hypothyroidism and SSRIs have been linked with persistent pulmonary hypertension. Benzodiazepine use later in pregnancy may cause depressed

respiratory effort at birth, hypotonicity and poor feeding (the ‘floppy baby syndrome’). Anticholinergic, extrapyramidal and serotonergic side effects may be evident in the newborns of women taking these drugs in higher doses during the third trimester. A neonatal abstinence syndrome is also seen with maternal use of TCAs and SSRIs. The neonate may be irritable, jittery, slow to feed, restless and show poor sleep with occasional convulsions.


TCAs and older ‘typical’ antipsychotics are present in only small amounts in breast milk and do not contraindicate breastfeeding. SSRIs are found in higher quantities and those with shorter half-lives, e.g. sertraline, may be preferable. Women needing lithium should not breastfeed, for fear of neonatal toxicity, but carbamazepine and valproate are safe.

C A S E 3

A 36-year-old woman, with a previous history of moderately severe depressive illness treated with fluoxetine, booked at

8 weeks gestation with her midwife. Her only other pregnancy had been complicated by pre-eclampsia and preterm birth of the baby at 30 weeks by Caesarean section. He had done well, but she had subsequently suffered with a post-natal depressive disorder. She had fully recovered and declined referral in this next pregnancy to her psychiatrist, or the perinatal mental health team.

She later approached her GP at 24 weeks gestation with symptoms suggestive of a mild depressive disorder and a

series of counselling appointments, with brief psychotherapy, was accepted. Despite these measures, she continued to be very tearful and anxious about the outcome of this pregnancy. Amitriptyline was commenced and continued into the post-natal period. With her consent, the perinatal health team became involved and a community psychiatric nurse visited on a regular basis after the birth of the baby. She was encouraged to attend a local post-natal group, and baby massage sessions, where she found further support and new friendships. By six months, she was coping well with two small children and was able to stop the antidepressants.

New-onset psychiatric disease in


Women with no personal history of psychiatric disease are nevertheless at risk of mental illness during pregnancy. The ‘common’ symptoms of pregnancy (e.g. hyperemesis, poor sleep, backache), and ambivalence toward the pregnancy, may combine with social factors and relationship difficulties to cause depressive illness where there has been none

previously. Indeed, one-third of women with major depression during pregnancy have no preceding history. ‘Biological’ factors are of far greater significance in the aetiology of severe depression in the postpartum period. This is the highest risk time for new-onset disease and the umbrella term of ‘postnatal depression’ should be abandoned and replaced by more specific and descriptive terms which can differentiate between affective disorders of differing aetiologies and severities.

278 Psychiatric disorders and the puerperium


The normal emotional changes occurring during pregnancy (see under Normal emotional and psychological changes during pregnancy, p. 273) may become exaggerated and potentially harmful. Anxiety associated with panic attacks and specific phobias relating to labour (tokophobia) or needles may require treatment with cognitive or behavioural therapy, benzodiazepines or SSRIs. Depression may have its onset during the pregnancy and is a strong risk factor for postpartum depression. Both pharmacological and non-drug treatment may be necessary.

Symptoms of puerperal psychosis

Restless agitation





Failure to eat and drink

Thoughts of self-harm

Depressive symptoms (guilt, self-worthlessness, hopelessness)

Loss of insight


The greater part of new-onset psychiatric illness presents in the puerperium. Affective (mood) disorders account for the majority and these vary in severity from the mildest (minor depression) to moderate and severe depressive illness and, in the extreme, puerperal psychosis (a variant of manic depression or bipolar disorder). As discussed in the overview, the post-natal period represents perhaps the highest risk period in a woman’s life for the development of a psychiatric disorder. Although a previous history of moderate to severe depression or bipolar disorder is a significant risk factor, for many women this represents their first episode of mental illness.

Puerperal psychosis

This very severe disorder affects between 1:500 and 1:1000 women after delivery. It rarely presents before the 3rd postpartum day (most commonly the 5th), but usually does so before 4 weeks. The onset is characteristically abrupt, with a rapidly changing clinical picture.

Risk factors for postpartum psychosis

Previous history of puerperal psychosis

Previous history of severe non-postpartum depressive illness

Family history (first/second-degree relative) of bipolar disorder/affective psychosis


The patient should be referred urgently to a psychiatrist and will usually require admission to a psychiatric unit. If possible, this should be a mother and baby unit under the supervision of a specialist perinatal mental healthcare team. These units prevent separation of the baby from its mother and this may help with bonding and the future relationship.

Treatments include:

acute pharmacotherapy with neuroleptics, such as chlorpromazine or haloperidol;

treatment of mania with lithium carbonate;

electroconvulsive therapy (ECT) – particularly for severe depressive psychoses;

antidepressants (which will take 10–14 days to be effective) as a second-line treatment.

Recovery usually occurs over 4–6 weeks, although treatment with antidepressants will be needed for at least six months. These women remain at high risk of pregnancy-related and non-pregnancy-related recurrences. The risk of recurrence in a future pregnancy is approximately 1 in 2, particularly if the next pregnancy occurs within two years of the one complicated by puerperal psychosis. Women with a previous history of puerperal psychosis should be considered for prophylactic lithium, started on the first postpartum day.

Postpartum (non-psychotic) depressive illness

Depression can be classified as ‘minor’ or ‘major’.

Major depression can be divided into ‘mild’, ‘moderate’

and ‘severe’ categories. It is important to distinguish postpartum depression of any degree from the postpartum ‘blues’.

Between 10 and 15 per cent of women will suffer with some form of depression in the first year after the delivery of their baby. At least 7 per cent will satisfy the criteria for mild major depressive illness (see Symptom box) and many more could be described as having minor depression; 3–5 per cent will suffer a severe major post-natal depressive episode. Without treatment, most women will recover spontaneously within 3–6 months; however, 1 in 10 will remain depressed at one year.

Clinical features

In contrast to puerperal psychosis, non-psychotic postpartum depression usually presents later in the post-natal period, most commonly around 6 weeks, with a more gradual onset. The 6-week post-natal check is an ideal opportunity to detect early postpartum non-psychotic depression, but the signs are often missed. The Edinburgh Postnatal Depression Scale is an example of a screening technique, but there are others. NICE recommends that all women are asked about their mood at least twice in the postpartum period by midwives, obstetricians, health visitors or GPs, ideally at 6 weeks and 3–4 months after the birth. Particular attention should be paid to the assessment of women with risk factors for post-natal depressive illness. Indeed, women deemed at highest risk should be under close surveillance by a specialist community psychiatric nurse, with early admission to the local mother and baby unit if there are signs of concern.

Severe post-natal affective disorders usually present earlier than milder forms, and in this group, biological risk factors may be more important than psychosocial factors.

Treatment options include:

remedy of social factors;

non-directive counselling;

interpersonal psychotherapy;

cognitive–behavioural therapy;

drug therapy.

The earlier the onset of the depression and the more severe it becomes, the more likely it is that

New-onset psychiatric disease in pregnancy


formal psychiatric intervention will be needed. However, randomized trials have demonstrated the benefits of non-directive counselling from specially trained midwives and health visitors in the management of milder disorders. Even simple encouragement to join a local post-natal group may prevent social isolation and limit depression.

If pharmacotherapy is deemed necessary, tricyclic antidepressants or SSRIs are appropriate. There is good evidence to support the safety of the former in breastfeeding, less so for the latter. However, SSRIs in usual doses are probably safe.

There has been a vogue in the past for treating post-natal depression with progestogens in the erroneous belief that the fall in progesterone levels postpartum is the cause of post-natal depression. There is no good evidence to support this, and it may even be harmful if the use of other effective treatments is delayed because of it. This practice should therefore be avoided. High-dose oestrogen regimens have been tried in research trials, but these are not used routinely.

Women with a past history of severe post-natal depressive illness may be candidates for some form of prophylactic treatment, and the help of a specialist in perinatal mental health care should be sought before delivery.

Symptoms of severe post-natal

depressive disorder

Early-morning wakening

Poor appetite

Diurnal mood variation (worse in the mornings)

Low energy and libido

Loss of enjoyment

Lack of interest

Impaired concentration


Feelings of guilt and failure


Thoughts of self-harm/suicide

Thoughts of harm to the baby

280 Psychiatric disorders and the puerperium

Adverse sequelae of post-natal depressive



Physical morbidity


Prolonged psychiatric morbidity

Damaged social attachments to infant

Disrupted emotional development of infant


Social/cognitive effects on the child

Psychiatric morbidity in the child

Marital breakdown

Future mental health problems

Risk factors for post-natal depressive illness

Past history of psychiatric illness

Depression during pregnancy

Obstetric factors (e.g. Caesarean section/fetal or neonatal loss)

Social isolation and deprivation

Poor relationships

Recent adverse life events (bereavement/illness)

Severe post-natal ‘blues’

Understanding the pathophysiology of

postpartum affective disorders

The importance of psychosocial factors in the aetiology of non-psychotic mild and moderate postpartum depressive illness is in contrast to the biological factors (e.g. family history) predisposing to puerperal psychosis and severe postpartum depressive illness.

The constancy of incidence across cultures and the temporal relationship with childbirth would tend to suggest a neuroendocrine basis for the more severe conditions. Changes in cortisol, oxytocin, endorphins, thyroxine, progesterone and oestrogen have all been implicated in the causation. Comparable dramatic changes in steroidal hormones outside the

postpartum period have a well-known association with affective psychoses and mood disorders. A plausible recent theory is that the sudden fall in oestrogen postpartum triggers a hypersensitivity of certain dopamine receptors in a predisposed group of women and may be responsible for the severe mood disturbance which follows. The occurrence and the severity of the ‘post-natal blues’ are thought to be related to both the absolute level of progesterone and the relative drop from a prepartum level. However, there is no clear association between the ‘postpartum blues’ and affective psychoses, and no evidence as yet to implicate progesterone in the aetiology of puerperal psychosis or severe post-natal depression.

Depression is a characteristic feature of hypothyroidism, which may occur as a consequence of postpartum thyroiditis. The other features of hypothyroidism may be missed, and checking thyroid function is important in women with milder depressive symptoms in the first year following childbirth as correction with thyroid supplements may elevate the mood.

Key points

All women should be asked at booking about personal or family history of psychiatric illness.

Close collaboration is recommended between obstetrician and psychiatrist for women with mental illness, a previous history of severe mental ill health, or a strong family history of bipolar affective disorder.

Women with previous serious mental illness should be appropriately counselled regarding the recurrence risks associated with pregnancy.

All women should be screened for depression, at least twice, in the postpartum period.

Specialist perinatal psychiatric services should be available to all women.

The prescribing of psychoactive drugs in pregnancy and breastfeeding should be done with care under the guidance of a psychiatrist with particular interest in pregnancy-related mental illness.

Breastfeeding rarely needs to be avoided in women using psychotropic medications.

There is an adequate range of drugs available to safely treat the pregnant or lactating woman who is mentally ill.

C H A P T E R 1 9


Janet M Rennie

.........................................................The challenge of neonatology


.............................................................................................Infant feeding


Organization and provision of neonatal care.........................


Care of the ill term newborn baby................................................


Delivery room care .................................................................................


Management of the preterm infant .............................................


Care of the normal term newborn baby ...................................


Additional reading and website resources .............................


Prophylaxis and prevention of disease in the




well newborn....................................................................................









More than half a million babies are born every year in the United Kingdom, 4 million in the United States, 25 million in India and over 130 million worldwide. In the industrialized countries of the world, less than 1 per cent of these babies will die, and at least half the deaths are among premature babies with a birth weight of 1.5 kg. The picture is very different in the least developed countries, where the death rate is between 2 and 8 per cent. The countries of sub-Saharan Africa suffer the highest perinatal mortality rates in the world, around 80 per 1000 live births. Throughout the world, babies are still dying from prematurity, infections, congenital malformations, and hypoxia or trauma acquired intrapartum.

The challenge of neonatology

Neonatology is a relatively new subspecialty which has achieved some spectacular successes, most notably that of halving the mortality for very premature babies. Complex surgery can be performed safely, artificial nutrition maintained for weeks, and even the tiniest babies can be intubated and ventilated. Challenges remain; while therapeutic hypothermia holds promise for the treatment of some babies with perinatal hypoxic ischaemia, not all can benefit. Infectious diseases are still a problem. Advances in fetal medicine facilitate the antenatal diagnosis of a whole range of disorders, including cystic adenomatoid malformation of the lung, arachnoid cysts and other malformations of the brain, and dilatation of the renal pelvis. For many of these conditions, there is very little information about the natural history of the disorder if left untreated, and this makes counselling and management difficult. Early discharge and choice about the place of delivery have fragmented the provision of ‘well baby’ care. This means that all those who come into contact with newborns need to be informed about issues such as prophylaxis against vitamin K deficiency bleeding, the promotion of breastfeeding, the management of

jaundice, the prevention of hypoglycaemia and the implementation of child health screening policies. The occasional baby with a rare medical condition needs identification and a fast track to highly specialized and appropriate services.

Organization and provision of

neonatal care

About 10 per cent of all babies are admitted to UK neonatal units, with figures for different hospitals ranging from 4 to 35 per cent. Most of these admissions are for ‘special care’, for example jaundice requiring phototherapy or blood glucose monitoring. About 2 per cent of babies need full intensive care, mainly because they are born very prematurely and need artificial ventilation for respiratory distress syndrome (RDS). Table 19.1 gives examples taken from the current UK definitions of special care, high dependency care and intensive care. The UK Department of Health reviewed the neonatal service in 2003, and recommended the development of managed care networks. The Department of Health has also expressed government policy in the Maternity

282 Neonatology

Table 19.1 Categories of babies requiring neonatal care

Level 1 intensive care (maximal intensive care)

Care given in an intensive care nursery that provides continuous supervision by a suitably trained nurse, ideally 1:1, with immediate medical aid available.

Examples of babies who need intensive care are those:

1.receiving any respiratory support via a tracheal tube,

2.who are 29 weeks gestation and, 48 hours old.

Level 2 intensive care (high-dependency intensive care)

Care given in an intensive care nursery that provides care by specially trained nursing staff, who may care for two babies at a time.

Examples of babies who need level 2 intensive care are those:

1.requiring parenteral nutrition,

2.having convulsions,

3.having frequent apnoeic attacks,

4.requiring oxygen treatment and weighing 1500 g.

Special care

Care given in a special care nursery that provides care and treatment exceeding normal routine care. Nurses may care for four babies at a time. Some aspects of special care may be undertaken by a mother supervised by qualified nursing staff

Examples of babies who need special care are those:

1.being tube fed,

2.undergoing phototherapy,

3.receiving special monitoring (for example, frequent glucose or bilirubin estimations).

Normal care

Provided for babies who themselves have no medical reason to be in hospital.

Examples include:

1.maternal psychiatric illness requiring close observation of mother and baby,

2.social problems, such as homelessness.

Source: British Association of Perinatal Medicine.

Services National Service Framework (2004). The current model of neonatal services consists of three levels of care. A level 1 service provides neonatal intensive high dependency care only in an emergency; a level 2 service provides high dependency care and some intensive care, but not for the most extremely preterm babies, and a level 3 service provides all levels of care and is staffed by individuals with no

other commitments. Gradually, cooperative perinatal networks are becoming established in the UK, with the goal of equality of access and shared clinical guidelines. Transport services have evolved and most regions now have dedicated specialist teams, a vast improvement on the situation a decade ago. A national neonatal audit programme has been established and the first report was published in 2008.

Delivery room care

The transition from intrauterine to extrauterine life

The vast majority of babies achieve a remarkably smooth transition from intrauterine to extrauterine life, making their first respiratory efforts within 10 seconds of birth. Fetal lungs are filled with ‘lung liquid’, a fluid that is important for normal lung development and growth. During labour, the production of lung liquid ceases and reabsorption begins. Lung liquid is squeezed out of the thorax during vaginal delivery. Finally, the baby takes his first gasp, establishing an air–liquid interface which moves rapidly down through the lungs. The last vestiges of lung liquid are then absorbed by the lymphatics and the pulmonary capillaries. At the same time as the lungs are filled with air, the blood supply to them increases dramatically. Pulmonary blood flow is low in fetal life because a high resistance is actively maintained in the pulmonary capillaries. Immediately after birth, the pulmonary vascular resistance starts to fall. The fall is driven by the release of vasoactive substances, including prostaglandins and nitric oxide, and by the presence of oxygenated blood in the pulmonary capillaries themselves.

Infants who fail to breathe after birth may do so as a result of a deprivation of oxygen and blood supply to the brain before birth (hypoxia–ischaemia or asphyxia), or because they have a central nervous system or muscle disease, or because they are systemically ill with infection. The possible placental and other mechanisms of hypoxia–ischaemia are discussed in Chapter 10, Pre-eclampsia and other disorders of placentation. Our understanding of the newborn’s response to asphyxia is based on the classic primate experiments of Dawes. The changes in respiration and heart rate following asphyxia are illustrated in Figure 19.1. At birth, the asphyxiated infant may have taken his last gasp (terminal apnoea) or be in the phase of primary apnoea. A baby in terminal apnoea is unlikely to recover without intubation and positive-pressure ventilation, whereas a baby in primary apnoea can auto-resuscitate by gasping, and responds quickly to simple resuscitation.

All professionals who attend deliveries must be able to recognize when a baby is not establishing normal respiration and circulation, and be trained to initiate resuscitation. Certain situations are clearly

Delivery room care

















Resps apnoea





























































































































































PO2 in kPa



PCO2 in kPa


Excess acid



Heart rate in bpm



BP in mmHg




Figure 19.1 The response to asphyxia. (IPPV, intermittent positive-pressure ventilation; CM, cardiac massage.) (Reproduced with permission from the Northern Region handbook.)

high risk, and a person with intubation skills should be present at the delivery. Examples of such situations are given in Table 19.2, but about 20–30 per cent of babies who require resuscitation do not fall into highrisk categories. Our inability to predict which babies will fail to make a successful transition to extrauterine life is the reason why all those who attend deliveries have a responsibility to maintain their neonatal resuscitation skills. In the UK, the Resuscitation Council has developed a Newborn Life Support

Table 19.2 Deliveries at which a trained neonatal resuscitator should be present

Preterm deliveries

Vaginal breech deliveries

Thick meconium staining of the amniotic fluid

Significant fetal distress

Significant antepartum haemorrhage

Serious fetal abnormality (e.g. hydrops, diaphragmatic hernia)

Rotational forceps or vacuum deliveries

Caesarean section – unless elective and under regional anaesthesia

Multiple deliveries

284 Neonatology

Course, and there are similar such courses in the United States and Europe.

The Apgar score

The Apgar score is a tool which assists in the recognition of an infant who is failing to make a successful transition to extrauterine life. This is exactly what the score was designed to do, and in this respect it performs admirably. The reason for a low Apgar score may not be asphyxia, but the baby certainly has a problem, and the sooner it is recognized and treated the better. The original Apgar score (Table 19.3) includes an item (grimace) that reports the infant’s response to a suction catheter. Frequent deep suction of the oropharynx can cause bradycardia, and although regular recording of the Apgar score is to be encouraged, this item carries less weight than the heart rate, colour or breathing pattern. The Apgar score is usually recorded at 1 and 5 minutes. If the Apgar score is still low at 5 minutes, further observations should be made at intervals. The Apgar score cannot replace a detailed narrative describing the baby’s condition, the resuscitative efforts and the response to resuscitation. Recording the Apgar score is helpful because it has become an internationally recognized shorthand way of summarizing the condition of babies at birth and their response to resuscitation.


Babies fall into one of three categories within a minute of birth:

1.A healthy baby; born blue but who cries within seconds, with good tone and activity with a heart

Table 19.3

The Apgar score






Appearance: central

White or blue all


trunk colour



Pulse ratea



Grimace (response to






Activity (muscle tone)



Respiratory effort


rate of more than 100 beats per minute (bpm) and who rapidly turns pink. Leave this baby alone, preferably with his mother. If the baby has been given to you at the resuscitaire, dry him, wrap him in a warm towel and give him back

to his mother. Do not suck him out; this risks producing a vagal bradycardia and cools him.

2.Not breathing regularly, but with a heart rate of more than 100 bpm and remaining centrally cyanosed. Dry the baby and place him under

a radiant heat source wrapped in a warm, dry towel. Drying often provides enough stimulation to induce breathing, but gentle

rubbing can also be used. If there is no response, begin active resuscitation using five ‘inflation breaths’ via a bag and mask (see below under Lung inflation through a facemask, p. 285), continue with regular breaths, and call for help.

3.Not breathing or has a heart rate of less than 100 bpm or is pale. These babies are usually completely floppy. This baby is in need of prompt resuscitation and will not recover without it. Dry him quickly, place him on the resuscitation surface in a warm, dry towel and call for help. Initiate basic resuscitation with mask ventilation. If the heart rate remains less than 60 bpm, commence chest compressions. If there is not a rapid response, proceed

to intubation as soon as a person with the necessary skill arrives. Stay to help; a full-blown resuscitation is a job for at least two people.

Remember that, while time is of the essence in neonatal resuscitation, this is no excuse for rough



Pink with blue

Pink all over



100 bpm

100 bpm


Cry or cough

Some flexion

Well flexed, active



Gasping or irregular

Regular or strong cry

aBest to record the actual rate.

handling or sloppy thermal care. Remember, too, that the parents will be extremely anxious; watch what you say to other team members in their hearing and always spare some time to talk to them as soon as possible. Throwing the laryngoscope down, tipping the flat batteries on the floor and stamping on them may seem appropriate at the time, but will create an image that will never fade from the parents’ minds. Even if you intubate the baby within seconds with the reserve laryngoscope, if he does badly, the episode will be replayed time and time again, and if you are unlucky, you may be faced with an unpleasant hour or two facing a cross-examination on your actions.

Further information and a useful algorithm are available from the UK Resuscitation Council (www. resus.org.uk).

Lung inflation through a facemask

Position the baby face upwards on a resuscitation surface; a head-down slope is not necessary. The head should be supported in a neutral position to keep the tongue from obstructing the back of the pharynx: use a small folded towel under the shoulders if it helps. Gently suction the mouth and nostrils to

Delivery room care


remove debris. Choose a facemask that covers the baby’s mouth and nose, but does not press on the eyes or overhang the chin (Figure 19.2a). Hold the mask over the baby’s face with one hand, using some of the fingers of the same hand to lift the chin and support the jaw (jaw thrust; Figure 19.2b). Begin to ventilate the lungs with air using the source provided, but never connect a baby directly to the hospital gas supply without a suitable pressure-limiting device in the circuit. Medical gases are supplied at far too high a pressure for babies, who only need a pressure of about 30 cmH2O to expand their lungs. Make sure the chest is moving with the ventilator breaths and start with about five ‘inflation breaths’ of 30–35 cmH2O lasting for 1–2 seconds. Then reduce the pressure to that which is just sufficient to move the chest, usually about 20 cmH2O, and continue to give about 30 breaths per minute.

Chest compression

Babies whose heart rate fails to rise above 60 bpm after a minute or two of effective ventilation should be given chest compression. Seize the baby’s thorax with both hands, and place both thumbs over the lower







Figure 19.2 Correct use of the facemask. (From Resuscitation of newborn babies, 1998. RCPCH and RCOG, BMJ Publications, with permission.)

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