Ethics
National Neonatal Resuscitation Guidelines
Non initiation of resuscitation
A full ethical discussion regarding resuscitation, provision of NICU care, resource issues and the like is beyond the scope of this manual. South Africa experiences severe limits on the availability of health care compared to developed countries. In an attempt to address this issue, NICU is often rationed e.g. babies <1000 grams are not routinely ventilated. This must not be confused with resuscitation.
Infants <1000 grams should be resuscitated when needed. Resuscitation of neonates >600 grams is generally considered appropriate in the South African public sector environment. In some units, babies who have survived a severe asphyxial insult are denied ventilation as these babies have a high chance of neurological handicap and death.
The ethical standpoint is one that tries to provide the greatest benefit to most patients, rather than to only one, and it considers issues of social justice.
Non initiation of resuscitation
In some circumstances where almost certain death or an unacceptably high rate of morbidity in rare survivors is anticipated (e.g. anencephaly, Trisomy 18, gestation <23 weeks) it may be acceptable not to start resuscitation. Not starting resuscitation is ethically the same as withdrawing life support at a later stage. Resuscitating a baby and later withdrawing support allows time to confirm the diagnosis and to counsel the parents. Some people, however, may feel that “switching off” is more aggressive (and less acceptable) than not starting resuscitation. In South Africa, with limited health resources, many units have a birth weight cut off for ventilation. This varies from unit to unit. In principle, resuscitation should be initiated in extremely low birth weight babies and a decision regarding ventilation made once the baby has been weighed and assessed.
Important: the gestational age and birth weight of the baby are often not known in the first few minutes after birth.
If in doubt, resuscitate the baby and discuss further management with a more senior colleague.
Do not “half resuscitate” or delay resuscitation as this will worsen the overall prognosis.
If there is no resource issue, resuscitation is almost always indicated in babies above 25 weeks gestation. In circumstances with borderline survival and a relatively high anticipated morbidity, parental wishes regarding resuscitation can be considered.
Discontinuing resuscitation
The decision to stop efforts at resuscitating a baby is complex and emotionally difficult. The following serve as guidelines for a problematic situation. Where possible, discuss the individual case with a more senior colleague.
Always ensure that resuscitation efforts are effective before considering withdrawal of support. It is appropriate to consider discontinuing resuscitation after 10 minutes of asystole (no heart rate), as this baby is extremely unlikely to survive. Do not rely on a single feedback device, e.g. pulse oximeter, to diagnose asystole.
The decision to continue resuscitation beyond 10 minutes of no heart beat is complex and may be influenced by many factors such as the presumed cause of the arrest, the gestation of the baby and the presence or absence of complications.
Prolonged resuscitation of an infant with a heartbeat but no spontaneous respiratory effort, or an Apgar score of 1 to 3 at 20 minutes, is not indicated. In circumstances of limited resources, these infants would generally not be ventilated in NICU and resuscitation should be discontinued.
(Note: The use of magnesium sulphate and benzodiazepines in the mother and hypothermia should be excluded, as these may delay the onset of respiration in the neonate.)
Again, these decisions should be discussed with a more senior colleague. If there are unlimited resources, the baby may be ventilated in NICU for a period of 24 hours and then reassessed.