Twenty‐One Minutes Without a Heartbeat: A Case Report

The patient was a 24‐year‐old primigravida at 33 weeks gestation whose prenatal course was complicated by fetal growth restriction (FGR). She presented from the outpatient antenatal testing unit (ATU) for inpatient observation due to a nonreactive nonstress test (NST) with fetal heart rate (FHR) decelerations. A bedside biophysical profile (BPP) was performed on the antepartum floor, where prolonged fetal bradycardia was noted, prompting a plan to proceed with an emergency cesarean section. This plan of action was further supported after finding absent fetal cardiac activity on bedside ultrasound in the operating room (OR). Delivery revealed the presence of a true umbilical cord knot that was not observed on prenatal ultrasonography. APGAR scores were 0 at 1, 5, and 10 min. Cardiac activity returned 12 min after delivery following resuscitative efforts, for a total of 21 min without detectable cardiac activity. Considering the circumstances of fetal prematurity, FGR, and the complex antepartum course, the infant had an uncomplicated neonatal intensive care unit (NICU) stay and, at 4 years of age, demonstrates normal neurodevelopment without evidence of cerebral injury. This case reinforces the 2020 American Heart Association (AHA) guidelines recommending resuscitation efforts beyond 10 min in the case of no fetal heartbeat.