Clinical Review Lesson of the week

Perinatal asphyxia and inadvertent neonatal intoxication from local anaesthetics given to the mother during labour

BMJ 2004; 330 doi: (Published 30 December 2004) Cite this as: BMJ 2004;330:34

This article has a correction. Please see:

  1. Maria Serenella Pignotti, neonatologist (,
  2. Giuseppe Indolfi, neonatologist1,
  3. Riccardo Ciuti, toxicologist2,
  4. Gianpaolo Donzelli, neonatologist1
  1. 1Department of Paediatrics, Anna Meyer Children's Hospital, Via L Giordano 13, 50132 Florence, Italy,
  2. 2Laboratory of Toxicology, Careggi Hospital, Via Pieraccini 17, Florence, Italy
  1. Correspondence to: Maria Serenella Pignotti


In 1998, Edwards and Nelson discussed whether asphyxia at birth really is an important cause of neonatal encephalopathy and wondered how often neurological impairment in children is due to perinatal hypoxia-ischaemia and how often to entirely different causes.1 We describe two cases of neonatal intoxication resulting from the administration of local anaesthetic to the mother during labour but which we initially diagnosed as perinatal asphyxia. We analyse here the major manifestations of acute poisoning in newborns and the clinical picture that could be misdiagnosed as perinatal asphyxia. Early and correct diagnosis is recommended for allowing adequate treatment and a positive outcome and for ruling out the medicolegal aspect of perinatal asphyxias (law courts often have to decide whether a child's neurological impairment is the result of mismanagement of labour, leading to asphyxia).

Case reports

Within minutes of birth, two full term neonates delivered vaginally presented sudden neurological and cardiac signs such as apnoea, bradycardia, seizures, and hypotonia. In both cases no evidence of fetal distress was noted, and the fetal monitoring was normal. They were transferred to our neonatal intensive care unit with a presumptive diagnosis of perinatal asphyxia.

Case 1

A 3550 g male infant was born after an uneventful pregnancy; episiotomy was performed after application of combined lidocaine (2.5%) and prilocaine (2.5%) cream. The Apgar score was high (9 at one minute, 9 at five minutes). Thirty minutes after birth, while still in the delivery room, the neonate suddenly developed apnoea, bradycardia, and hypotonia. He was intubated and mechanically ventilated.

His cardiorespiratory function gradually improved, and he was extubated 30 minutes later. However, at this stage he began to show the first signs of neurological involvement, characterised by generalised hypertonia, which required transfer to our neonatal intensive care unit. During transport (at age one and a half hours) he had tonic …

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