Is a normal outcome impossible?

One reason for limiting resuscitation at birth to 10 min may be a belief that further resuscitation is futile because it is inevitable that the infant will either die or be profoundly impaired.8 However, the recent papers indicate clearly that in the current era the outcome is not universally poor. Focusing just on the 66 infants in published series who have received therapeutic hypothermia, discontinuing resuscitation at 10 min would have led to the death of 18 infants who do not have severe disability, many of whom are developmentally normal.

Is a ‘poor’ outcome highly likely?

An alternative justification for discontinuing resuscitation at 10 min is because the chance of a poor outcome is thought to be so high that resuscitation is not warranted. Here we need to be clear about the reason why it is considered too high. This should not be influenced by a high-mortality risk because in the absence of further resuscitation mortality will be universal. The reason here would therefore be a fear of generating additional survivors with severe disability.9 From the point of view of parents, the outcomes of death or severe disability may have quite different significance. Some parents may fear the possibility of their child surviving in a state of severe impairment, while others may be much more afraid of their child dying even if there is a likelihood of survival with disability. There may be an unwelcome trade-off with increasing duration of resuscitation between avoiding death in a child who could survive with a favourable outcome and avoiding survival in a child who will have profound neuro-disability. Even if the risk of disability can be estimated, identifying a level of disability that is so severe that it is contrary to the child's best interests to provide treatment is extremely challenging.10

Providing treatment in the best interests of the child

As with all medical treatment for newborn infants, clinicians should be guided by the best interests of the child.11 It is ethical to withhold life-sustaining treatment where a child's life would be limited in quantity or quality, and treatment would therefore do more harm than good.11 The evidence summarised above shows that it is far from clear that continued resuscitation beyond 10 min would be harmful. It is, therefore, highly questionable whether medical professionals should make a unilateral decision to cease resuscitation at 10 min in the absence of additional information.

Erring on the side of providing treatment

Faced with uncertainty, it is usually preferable to err on the side of providing life-saving treatment.11 The recently revised Royal College of Paediatrics and Child Health guidelines around limitation of treatment note that ‘Neonates should almost always be resuscitated in the labour ward, unless there is a clear decision to do otherwise made with the consent of parents’.11 Given the uncertainty about outcome and a likely inability to determine the parents’ wishes in a meaningfully informed manner, the default approach at 10 min should be to continue resuscitation, take the infant to intensive care if they have a return of circulation and at that stage to involve parents in decision-making about ongoing treatment.

The statistics summarised above, with an estimated chance of survival of 50% and a risk of severe disability in survivors of around 50%, are similar to the outcome figures for infants born alive at 23–24 weeks gestation.12 In that setting, there is widespread acceptance that parents' views are crucial to decisions.13 It would not be regarded as acceptable for clinicians to make decisions to limit treatment without knowing the parents’ views. Of course, the distinctive feature of decisions about the duration of resuscitation at birth for term infants is that it is extremely difficult to involve parents fully in decision-making. The acuity of the situation, its unpredictability, the intense time-pressure and the involvement of the clinical team in the ongoing resuscitation efforts combine to make it extremely challenging to counsel parents and gauge their views.

A risk of longer resuscitation and of taking infants to intensive care is that this potentially leaves some families facing a more difficult decision that they would have preferred not to have faced about whether or not to withdraw treatment. Some families may be unwilling to acquiesce to a decision to stop life support. This is a particular challenge for religious or cultural groups that traditionally do not accept withdrawal of treatment.14 However, there is no ethical difference between withholding and withdrawing life-sustaining treatment.15 Clinicians must be guided primarily by the best interests of the infant. As the paper by Shah indicates, in intensive care units with access to prognostic tests such as MRI and EEG, and for communities and cultures that accept withdrawal of treatment, such a policy is associated with a low rate of survival with severe impairment.1

If not 10 min, when?

On the basis of current evidence, the outcome for infants with an Apgar score of 0 at 10 min is not universally poor. In circumstances where neonatal intensive care (including therapeutic hypothermia) is available, resuscitation at birth should usually continue beyond 10 min. Infants should be supported with intensive care if their circulation is restored. Guidelines on resuscitation should be modified. The question then becomes how long resuscitation should continue beyond 10 min in the absence of a heartbeat. This a much harder question because there are (to our knowledge) little published data on longer durations of resuscitation at birth and outcome. Kasdorf et al2 have called for a registry of all infants with an Apgar score of 0 at 10 min, including infants for whom resuscitation is not successful. However, long-term outcome from any such registry is not likely to be available soon.

Although the series is small, the paper by Shah et al provides some pointers. Their five surviving infants all had their first heartbeat documented by 20 min. Of these five, four subsequently had a good outcome. No infant in their report who had their first heartbeat after 20 min of resuscitation survived.1 It may be possible to obtain information about the timing of the first detectable heartbeat and the final outcome for infants from the other reports. In individual cases, other factors may already be known at the time of birth that should influence decision-making.