when does one stop resuscitation in delivery room?, what exactly the establishment of circulation means while resuscitating the newborn?

You will find lot of clear guidelines in the AAP NRP book regarding this matter.

But each hospital should have a clear written policy on this topic based on international guidelines, your country's laws, respecting your local religious and cultural practices/beliefs and in accordance with your local laws.

Ultimately your local hospital guidelines have to be formulated in such a way that they will withstand scrutiny and challenge in a court of law in your country.

The Swedish guidelines are to stop resuscitation

- if the infant is still in asystole after 15 min

- if the infant is still without any breathing after 30 min

No heart rate after 10 minutes of complete and adequate resuscitation

No evidence of other causes of compromise

Confirmed gestational age of less than 23 weeks or birth weight less than 400 gm

Anencephaly

Confirmed trisomy 13 or 18

thanks for all the reply, i do appreciate fully the opinions expressed, but in reality what happens is that you resuscitate a baby with few heart beats and sustain the circulation by aggressive support and put him on ventilator. He has HIE stage 3, comes out of the ventilator, goes home, of course with a severely damaged brain. he develops quadriplegia, severe developmental delay. Now if the child asks for justification for what we have done, can we defend ourselves?

hello all..

I think we are doctors and not prophits we do all our best to help babies, but we must work gramatic as written in all protocoles and for this reason we must not continue resuscitation for more 15 minutes.

You may want to consider looking into the use of cerebral oximetry to track the effectiveness of compressions. I have done a large number of piglet LPS induced shock experiments, monitoring the cerebral rSO2 and it is quite sensitive to compressions in this model. If compressions don't effectively provide O2 to the brain it could contribute to neurocognitive morbidity. Hou has demonstrated the impact of various levels of rSO2 on hippocampal neuronal damage both by H&E staining and EM.

Hou X et al. 2007 Research on the relationship between brain anoxia at different regional oxygen saturations and brain damage using NIRS. Physiol Measures 28; 1251-1265.pdf

Thank you for open this important point,as although clear guidelines of AAP when to stop ,still some doctors during practice feel that they need to continue , especially after try to give IC adrenaline which make ineffective heart beats for more prolonged time ????

Thank you for open this important point,as although clear guidelines of AAP when to stop ,still some doctors during practice feel that they need to continue , especially after try to give IC adrenaline which make ineffective heart beats for more prolonged time ????

No body should give intracardaic epinephrine any more as per the most recent AAP -NRP guidelines, , few heart beats will continue for 15-30 minutes even after the pupils are fixed dilated. So if heart rate is less than 60/ min after 10 min of resuscitation in the abscence of pneumothorax or malpositioned ETT i usually stop resuscitation because i dont wish the heart to come back after the brain gone

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No body should give intracardaic epinephrine any more as per the most recent AAP -NRP guidelines, , few heart beats will continue for 15-30 minutes even after the pupils are fixed dilated. So if heart rate is less than 60/ min after 10 min of resuscitation in the abscence of pneumothorax or malpositioned ETT i usually stop resuscitation because i dont wish the heart to come back after the brain gone

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I wonder if it is correct (ethically and legally) to stop resuscitation when heart rate is more than zero ?

Yes Jack, legally you are correct, we may not be able defend ourselves if the heart rate is more than zero; but how much ethical for us to prolong the resuscitation which results in severe neurological handicap, putting the families in long emotional and financial suffering, and not forgetting the inflicted suffering on the child, can we defend ourselves?

when does one stop resuscitation in delivery room?, what exactly the establishment of circulation means while resuscitating the newborn?

in our hospital , It used to be too long to do Positive Pressure Ventilation to the newborn with Respiratory Failure, if Mechanical Ventilator was not available, but now we implement new policy : If there is an asystole during 10 minutes, we stop resuscitation. If there is still heart sound was heard, continue untill 30 minutes. Do the same until 3 times 30 minutes. If there is no spontaneous breathing, stop resuscitation

let us remember that the guidelines that are proposed are after proper research where they have weighed the facts of morbidity at each steps.

and about the question of are we creating major disabilites, i think eithically we are bound to resuscitate according to the protocols and situations could be individualised and decided with parental consent.

Well, what if HR < 60 and you tried chest compression and epinephrine 3 times and you were sure ETT is in and PPV is being given.. When do u stop ?? It may take long time for the HR to stop.. Do you keep trying for 30 min? One hour?