Infants without signs of life (no heart beat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality or severe neurodevelopmental disability (LOE 5).106,107After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (Class IIb).That suggestion wasn't included in the original protocols. Children like Edie are the reason that suggestion was added to the protocol.
Her mom had a normal pregnancy and most of her labor was uneventful. Unfortunately, she delivered in a small hospital which did not, at the time, have in-house anesthesia coverage for emergency C-sections. Something went terribly wrong and he had no heart rate at delivery.
By 1 minute, his APGAR score was still zero - no heart rate, no respiratory effort, no reflex response, poor muscle tone, blue or pale. By 5 minutes, still no heartbeat. At 10 minutes, the pediatrician was still desperately trying to save the baby -- but still no signs of life. Finally, sometime between 10 and 15 minutes, Edie had a heartbeat -- and nothing else.
Edie was a beautiful baby, but she never moved spontaneously. A month later, she might gasp when disconnected briefly the ventilator for suctioning, but generally she didn't even do that. Her parents visited every day. They held her, talked to her, took pictures for their memory book. They hid their pain from most of the staff -- to the point that many believed they were in denial. Those of us who had quit trying to 'orient' them were privileged to share their pain, though. They knew it was just a matter of time and were determined not to waste their precious moments with this child crying at her bedside.
A few months later, Edie got septic and her parents agreed that resuscitating her if her heart stopped would not be in her best interest. She died, more or less peacefully, a few days later.
The other babies I've seen with 0 APGAR scores at 10 minutes survived only a few hours or days. I don't remember another who survived even a week.
It's very difficult to make the decision to stop resuscitating a full term, or near term baby, especially if the mom was in the hospital being monitored so we know the time that the heartbeat stopped prior to that emergency C-section . I've seen many babies respond to the Neonatal Resuscitation Protocol and go on to do very well. Those babies virtually all have had APGAR scores increasing by 5 minutes, and the rest definitely had signs of life by 10 minutes.
That suggestion to consider discontinuing resuscitation if it has been unsuccessful after 10 minutes makes a lot of sense to me as I sit here typing. In the adrenaline-laced atmosphere of a neonatal resuscitation, it's hard to put it into practice. I'm always grateful that the final decision is not mine.