RSS

Giving Birth in the Cordillera Mountains

It has been two years since I started attending the Regional Neonatal and Maternal Death Review in our region, the Cordilleras. I had been invited to be a panelist and as such, it is my duty to critique why such happened, and what should have been the intervention, and what could have been the possible problem that really transpired for such a death. But this forum is not only me and my fellow panelists giving our “expert opinions.” Rather, I in particular had so much learnings and realizations that makes the scenario surrounding each death very painful to accept and embrace as a health care provider. These are some of the few things I came to realize…

GEOGRAPHY

One of the problems identified in our region is the geography. Because of the mountainous terrain of Cordilleras, one pregnant woman would need to hike 45 minutes, some 1 or 2 hours from their house just to reach the road or access a vehicle that will bring them to the nearest barangay health station (BHS), or rural health unit (RHU). Imagine a pregnant woman in labor, walking this distance in between contractions, you would expect a longer time to access the road. Likewise, because of this terrain, some areas are infested with the rebels (New People’s Army) that deters them to go the the nearest health facility, no matter what stage or phase of health emergency they are already in. So if the mother is having post-partum bleeding, they will wait till sunrise before the go to the nearest BHS. And if the midwife at the RHU or BHS would not be able to address the problem, they will have to transfer the patient to the nearest district hospital, which might again take them a while to look for a vehicle that will transport them there.

Another problem that the geography poses is the lack of telecommunication network’s signal. While the nurses, barangay health workers may have mobile phones that would facilitate referral to their superiors for proper advise while patients are being transported to higher centers, the lack of communication signal deters such and thus are only addressed when the midwives or the receiving doctor in the district hospital sees the patient

LACK OF HEALTH CARE PROVIDERS

Another deterrence to full delivery of health care to every household in the rural is the lack of midwives. While there may be barangay health workers (lay people who are not necessarily midwives who can be first line to check on ailing residents), it is the midwives who supervise them and who will ultimately decide whether she can manage the scenario or refer the patient to higher institution. In one municipality alone in Ifugao with 18 barangays, they only have 5 midwives. ONLY 5 midwives. Again, consider the distances of each house, their distance from the BHS or RHU or district hospital. And they usually access these houses on foot. Midwives need to track women who are pregnant, follow them up at the RHU, refer them to higher centers if the pregnancy is high-risk, deliver their babies if unable to reach a birthing facility, follow them up to make sure the mother-baby dyad is in perfect condition, submit monthly report to their municipal health officers.

During the past administration, nurses (nurse deployment program, NDP) and doctors (doctors to the barrios, DTTB) were hired to augment this vacuum of labor force. The nurses were deployed to each barangay or two, to help and facilitate the work of the midwives. Definitely being novice in the community and public health, there are flaws and misgivings, that given more time and experience, these will eventually be addressed. Nevertheless, there was a noted decrease in the number of maternal and neonatal deaths because they were monitored.

Unfortunately, starting next year, these contractual employees will no longer have their contracts renewed, making again the workload of our midwives double, maybe triple or quadruple when the NDPs are gone. Thus a rise again in the number of maternal and neonatal deaths will not be a surprise.

LACK OF SKILLS

We the panelists are specialists and subspecialists. We talk of interventions appropriate to our settings, which is way far up compared to the birthing facilities that the NDPs, midwives and MHOs work at. For one our NDPs, who are mostly first time on the job, still lack clinical acumen to detect subtle signs of disorder in the newborn, or signs of high risk pregnancy. Thus they only become alerted when the severe complications have set in, and thus intervention would be late already. Recognition of these subtle signs and early referral would definitely make a significant difference in these conditions.

Not all midwives are skilled in performing episiotomy. Not a single midwife in the region is even skilled in performing full course of neonatal resuscitation. Even doctors at district hospitals are not specialists to correctly treat these problematic parturients and/or their babies.

CULTURE

One thing that I commonly noticed is the influence of the matriarch of the family or clan. Usually, especially in a place where the house of the parturient is far from the nearest birthing facility, a birth plan is laid out. They assign which (of the limited vehicle) will be used to transport in case she goes on labor. And after birth, how soon they will be visited by the midwive or NDP. In other instances however, the matriarch interferes and alter already the planned contingency. A first-time mother ought not to contradict what their “experienced” seniors dictate upon them. While our health workers are campaigning and encouraging health facility deliveries, some “experienced” matrons insists that their daughters deliver at home, with them helping out. Only then will they call for help when they encounter a major problem. One classic example was when a woman on her third pregnancy delivered at home, assisted by the family members. It took them several minutes attempting to deliver the placenta. And because the placenta was adherent to the uterine wall, as they were tagging the former, the uterus inverted. Only then was the midwife called. And because there was no “birth plan” it took them several hours before the parturient was brought to the hospital. There was massive hemorrhage, with the source not identified, that eventually lead to hemorrhagic shock and her death. Such useless loss of lives would have been prevented had it not been for the “usual practice” that these elder people enforced.

 

Many of these problems presented are often preventable but it takes interplay of so many factors to prevent one maternal or newborn death. Our region as a long long way to go…

 
Leave a comment

Posted by on November 29, 2016 in Deliveries, neonates, Pregnancy

 

Tags: , , , , , , , , , , , , ,

My Cat Tale – 1

By profession, I am a pediatrician, subspecialist in Neonatology. As part of my job, I attend to deliveries of babies whether term or premature ones, at whatever time of the day!

Outside my job, I am a cat owner, now a self-proclaimed (persian) cat breeder. When I took care of a patient sometime last year, the parents gave me a female kitten (10 months old by human age) as a token of appreciation. At the time she arrived, she was manifesting an odd behavior, rolling over at the floor. It was my first time to learn about their estrus. I thought it should be addressed immediately. 



Strange to when is the optimum age when the cat should mate, I immediately searched for a male cat. In short, my kitten at 10 months old got impregnated. And few weeks into pregnancy did I learn that they should be at least 18 months before their first pregnancy. Too late! She was so attention seeking while she was pregnant. We sleep together on my bed. But on the day she was to give birth, she only slept beside me for about an hour and had been roaming around my pad. 


I noticed a greenish like fluid trail till it got to where my kitty was… I just learned that she was about to give birth. I called off my morning appointments because it seems she wanted me to stay beside her. During the active labor, she was heaving, and she wanted me to pet her in between contractions. Then my first kitten was born. 

https://instagram.com/p/7J0pnHDooh/ (Blanca in labor).

 
Leave a comment

Posted by on November 7, 2016 in Uncategorized

 

The Curious Case of Miriam

Few months ago, Sen Miriam Santiago announced she has stage 4 lung cancer. Some went sad because they, myself included, saw in her someone who could be their leader for a better governance.

Then afterwards a few months, in a press conference she announced that she has been cured, “I licked cancer.” She was cured! And now she is ready to accept the challenge to lead the country to a better future. Many, especially those from the medical field got baffled how easily would she be cured, in barely three months. Between her announcement of having a cancer and getting cured, you see her occasionally attending functions and delivering speeches. You never saw her wear a wig, get bald. She said her doctor had been giving her a new kind of treatment modality. Alright, fine. Perhaps that is someone I am not familiar too as oncology is not my field of specialty.

Then she declared her candidacy. People are used to her giving several pick-up lines of one liner jokes before her main speech to the amazement and entertainment of her audience. Even in her sorties that I have attended, she always commanded and drew attention to her with those jokes she never failed to deliver. But during this time, there were no pick-up lines, one liners. The speech was only a short 5-min run. And then she sat down and allowed photo ops with her followers. A very very unusual thing to happen.

People became skeptic. Did she really beat cancer in mere three months? Why the sudden change of her speaking style? Did she not really get cured and now cancer is taking its toll?

A doctor challenged her to present her case, whether it be a medical certificate or medical abstract to prove her claim of cure in barely three months. She is running for a sensitive position and as a voter we ought to know her health status, she claimed. But Miriam was so adamant that she invoked her right to privacy. Okay, so we respect that, but that leaves us hanging as to how she really is… cured? in remission? or worse, did she just make up stories to gain sympathy? I hope not.

We know that lung cancer, stage 4 at that has a very low survival rate. In fact, a 5-year survival rate of if the lung cancer at the time of diagnosis is already stage 4 is nil, barely 1%. Many of them would not even last six months from the time of diagnosis. We usually use the terms survival rate, in remission, but we rarely use the term “CURED.” I know of one patient (a relative of one of my patients) who had full remission, but being workaholic, he wanted to resume his stint in the government service. His doctor however advised him not to because the stress might just trigger relapse, causing expression of genes for replication of cancer genes.

If indeed her claim is true, personally I wanted to congratulate her for beating a stage 4 lung cancer. Such is not an easy feat.

The doctor wanted to know the state of health of MDS as campaigning and sorties would be energy-draining and stressful. But without really her medical abstract or certificate of full remission one in the know would cast doubt as to the authenticity of her claim. Her case is a curious one, I would say it is worth discussing in a medical conference. Her case is a statement that a stage 4 lung cancer is curable, inspire others not to lose hope.

Then recently, she changed her story… she is currently on chemotherapy, but her cancer is “stable.” Wait, whaaaat? So what happened now to “she licked cancer?” Was she really cured at all?

And what were the implications of her presumptive “cured” statement? She actually demoralized patients or relatives of patients who died for receiving a different treatment regimen. The indigent people would despair “pwede pala tayo mabuhay sa stage 4 lung cancer kung may pera lang tayo kagaya ni Miriam.” Chain or heavy smokers can say “why quit from smoking when stage 4 lung cancer is curable?”

She was just so hasty to let her audience know that she still can run for presidency. Wrong move though I must say…

 

 

 

 
Leave a comment

Posted by on December 4, 2015 in Uncategorized

 

My First Case of Congenital Cytomegalovirus Infection

I have this opportunity to demystify an infant’s case of long standing jaundice…

The mother’s prenatal course was apparently unremarkable, save for gestational diabetes that was controlled. The mother cannot remember any other symptoms such as flu-like illness, skin rashes, nor was she hypertensive during the prenatal period. Baby was delivered via repeat cesarean section, small for gestational age. He stayed quite long in the hospital because of infection. He was purely breastfeeding. His newborn metabolic screening result was normal. I was not the attending then.

At home, baby was quite fuzzy and irritable. Baby has been being attended to by the original neonatologist. He was jaundiced. In cases of purely breastfed babies, sometimes jaundice can be expected to last for about 3 months but the intensity is not that much compared to that during the first week of life. His stool color was still yellow. He developed umbilical hernia. The skin texture was fine; tongue was normal in size; hair was not coarse; there was no hypotonia; nor was there any constipation (something that is a remarkable findings among babies with hypothyroidism). Baby was worked up for possible hypothyroidism. Thyroid function test was normal. They were advised to go to a pediatric endocrinologist for evaluation.

Mother brought baby to my clinic for second opinion. I saw the laboratory result, it was normal. But what is puzzling is the jaundice that was quite intense. I could not evaluate baby well, especially the abdomen, because he is irritable. I advised mother that baby needs further test and treatment thus they agreed to be confined in the hospital.

I repeated the thyroid function test, it was normal. That reassured me baby has no congenital hypothyroidism which is one dreaded condition a baby can have because of life dependency on thyroid hormones for better quality of life and to attenuate whatever cognitive impairment it has already caused. I still called up an endocrinologist friend to confirm my understanding of baby’s thyroid function test result and she agreed baby is not a case of metabolic disorder.

I treated the baby as a case of sepsis pending work up results. Ultrasound of the abdomen showed the liver is enlarged, the biliary tree is intact. I am not afraid that this baby has biliary atresia which is another “lethal” condition that usually leads to baby’s death in a slow fashion.

Liver enzyme, alkaline phosphate and bilirubin were all elevated (it was a direct hyperbilirubinemia). I started the baby on ursodeoxycholic acid to help eliminate the bilirubin that could also cause inflammation of the liver cells.

After a week in the hospital, baby’s jaundice has significantly decreased and yet the direct hyperbilirubinemia (50%) was still persistent, and alkaline phosphatase level was still significantly elevated. I have discharged baby with instruction to undergo karyotyping and TORCH screening as I haven’t ascertained yet what was causing the baby’s jaundice.

A week later, mother brought back the results of baby’s tests. Karyotyping was NORMAL (thank God). On the other hand, TORCH panel revealed (+) IgM and IgG for cytomegalovirus. I referred the baby immediately to an ophthalmologist for chorioretinitis screening, and to a pediatric infectious disease specialist for further management. CT Scan of the head showed that there were periventricular calcifications near the parietal areas of the brain.

Baby is still jaundiced although the intensity is no longer that dark. He is on supportive treatment.

He will undergo repeat head CT scan as well as chorioretinitis screening one month after the first.

 
 

Tags: , , , , , ,

My Struggle Continues…

I was the happiest person last August of this year (2014) when I finally had a normal cholesterol level. This was accomplished through several means. First: I went hard on my diet. I literally had been eating veggies more often than not, and only taking meat 2 days in a week, in the form of chicken or fish. Second: the dose of my ruosovastatin was increased from 20 mg to 40 mg daily. My exercises were still zumba once to twice daily for 5-7 days.

My doctor as well was very elated with the result. So on that day, she decided to a) decrease my ruosovastatin back to 20 mg daily, b) decrease my ezetimibe to one tab every M-W-F, c) asked me to come back with repeat lab test after six months. On a personal basis, I tried now to enjoy eating some chicken more frequently, but not on a daily basis. I happily complied with decreasing the ruosovastatin (as it is very expensive) but I was on doubt of decreasing my ezetimibe to thrice weekly, so I secretly kept it daily. In my mind, I think six months is a long wait for my repeat lab tests, so I decided to have a repeat test after two months.

The repeat tests shocked me. My LDL went above the acceptable value for a post-bypass surgery patients like me. My total cholesterol went up from 120s to 180s, although it is still within the normal value. I got sad. I felt guilty for having a go with my meat intake just because I was getting bored with merely veggies daily.

I informed my physician that I will be increasing back my ruosovastatin to 40 mg daily and go back to mostly veggies diet (no matter how lifeless it seems).

I havent done yet my thyroid hormones as of posting but I plan to do it in the next few days to see if I might again need thyroid hormone supplementation.

On the other hand, I noticed that I got thinner again compare to two months ago. So I am guessing that my thyroid hormones are still within normal limits. Otherwise, I should have gained weight again. So if I am still losing weight, and yet my cholesterol is increasing, then I am guessing that I really had a very very bad gene for this disorder that I really need a strong dose of my anti-cholesterol. Because if I am gaining weight at the same time my cholesterol is rising, then it would mean that my cholesterol elevation is related to hypothyroidism, which causes a decrease in metabolism.

 
1 Comment

Posted by on October 18, 2014 in Uncategorized

 

Those Painful Teenage Years

In my work, I accidentally encounter problematic teens when they get admitted under my service as the consultant on duty. I would like to share these two stories that I have come across with. Let us not judge them too quickly until we have finally come to the bottom of their stories.

Teen Y was a 15 year old female who was brought to the hospital for attempted suicide; she drank a silver cleaner. We were glad she did not have any caustic injuries down her alimentary tract or else I would have been so stressed. I kept her for observation but while in the ward, I was not able to talk to her in depth. She always covered herself in blanket. She was always with a friend; the mother or parents never took watch.

I asked the mother to pay me a visit at the clinic as she is always busy with their retail store and I could not meet her by chance when I do my rounds. She revealed that her daughter was born out of wedlock during her younger years. She is now married to another man who accepted the elder daughter like his own. However due to conflicts with her, the daughter gets to live with the grandmother sometimes. Just before the suicide attempt, she was trying to call her daughter. Apparently her daughter was not taking her call, which made her mad. When her daughter arrived, she reprimanded her. While the daughter was trying to explain why she wasn’t able to get the call, the mother refused to listen. She raised her voice instead and had told the daughter that she is disrespectful and has no sense of indebtedness.

I discharged the patient after more than 24 hours observation and told her to follow-up at the clinic after a week. I was glad she came over with the mother. So I asked the mother that I needed to talk to the daughter alone, while she waits outside. I asked her what made her mother get mad at her to the point she had thought of committing suicide.

She said she was at home but on the next door building, manning the store. Then her phone’s battery got drained. She left the phone at the first floor and went upstairs. That was when the mother was calling. She had no way of knowing her mother calling. So when she saw her mother later, she was surprised why she was being reprimanded. She tried to explain that her phone died, but her mother kept on ranting. She got so desperate because deep inside her she knew she did nothing and yet here she is being wrongfully accused. She went back to the next door store, saw the silver cleaner and drank it.

I called the mother and talked to them both. I had to explain things, let the mother know that sometimes she also needs to listen to her daughter and if she thinks the daughter becomes disrespectful as she talks to her, then she can point it out in a non-authoritative manner. Meanwhile, I also told the daughter to listen to her mother as I was sure the mother only want good things to happen to her, and that she might not repeat whatever mistakes her mother had done during her younger years.

— 0 —

A 17-year old female came to the labor room with cervix fully dilated. History reveals she is 28 weeks pregnant. She came to the hospital with an 18 year old cousin. There was no time to transfer the mother to the delivery room as when the baby was at the treatment room, the head was already crowning. Baby was born vaginally and had to be brought immediately to the neonatal ICU. Baby was stabilized and initial x-ray didn’t show respiratory distress syndrome. But knowing that the mother was not given antenatal steroids, I was anticipating that eventually the baby will deteriorate respiratory wise in the next hours. I was not present at the labor room during the delivery but my resident was so I had been giving my instructions via phone call. He did a great job.

Baby had vomited repeatedly even if we only give minimal enteral feeding once. I had requested for x-ray to be repeated. On evaluation of the film, true enough, respiratory distress progressed. We needed surfactant to be administered so I asked what was the financial status of the patient (we don’t have surfactant in the hospital but it can be bought from a nearby pharmacy). I was told that the teen mom is unsupported, apparently she was disowned, and the boyfriend does not support her either.

I went to interview the teen mom after I did my rounds. She was from the south who was sent to the metropolis to stay with a male cousin, first-cousin, the reason why, I failed to ask. While being in Manila, the cousin would make her drink until she passes out. The next day, the girl would notice that her vulva feels sore. This had happened several times according to her, until she got pregnant. She never reported it, but she let her cousin know that she got pregnant. She then came over to the highlands. Her granny, who has end-stage renal disease came to learn about her condition. (But she could not support also this hospitalization as she is just dependent on her son for her dialysis expenses.) Teen mom only had one prenatal visit before the delivery. While I was interviewing her, my voice broke and said, “so, this is rape.”

I got to do something. I told the OB in-charge to notify the Women and Child Protection Unit, even if the crime was not committed locally. Meanwhile I wanted the baby to be transferred to another hospital where they can give surfactant for free. But we cannot make major decisions as the mom is a minor, and the cousin cannot sign for the consents. As I was about to leave the hospital I was glad I met a relative of legal age who took the role as the guardian of both the teen mom and the baby. Baby was transferred within few hours.

 
Leave a comment

Posted by on August 28, 2014 in Adolescents

 

Tags: , , ,

The Prize of My Sacrifices

My life has been an open book, especially after that dreaded meet and greet with Death and his scythe. I have allowed it to be, so people would be aware of their lifestyles; and make them learn from my example on how they are going to live their lives towards health.

Few months after that emergency bypass operation, I was never able to control the main culprit that made me this “known” to my colleagues. I was already in quadruple drug therapy for my lipids (ruosovastatin, ezetimibe, fenofibrate, EPA+DHA). I got back to working out two months after my surgery. I had been watching my food intake, avoiding red meat and only preferring vegetable and white meat. Aside from that, I also have problem with my heart beat rhythm hence I was maintained on amiodarone. Eleven months after the surgery, finally I saw light. Total cholesterol and triglycerides went to normal levels, although LDL (bad cholesterol) was still high for a patient who underwent a bypass operation. I was then advised to have another follow-up visit after the holidays to check the effect of christmas celebrations.

Not only did my laboratory result became abnormal and back to pre-operation level, I gained weight. The light I saw few months ago was just a glimmer. On investigation, my thyroid hormones suggested hypothyroidism leading to hypometabolism, which now explains my weight gain and abnormal lipid levels. These were the result of my anti-arrhythmic amiodarone. We had to drastically revise my medications. I had to take thyroid hormone supplementation, change amiodarone to beta-blocker bisoprolol, increase the dose of ruosovastatin and increased my workout. At first I was still having palpitations and skip beats with bisoprolol and thus dose was increased. I was supposed to undergo holter monitoring in case my arrhythmia would persist.

At 18 months after the surgery, getting depressed with all the elevations of my lipids, weight gain, I decided to make a drastic change in my diet. I dropped meat and went quasi-vegetarian (having chicken or fish once a week). It was a very difficult lifestyle change as I easily get hungry, forcing me to have a lot of snacks, sometimes taking pastries (which I should also be avoiding; not that I have high blood sugar, but then simple sugars have been identified as one culprit in causing chronic inflammation of the blood vessels trapping cholesterols and forming a plaque, even if your cholesterol level is not necessarily high). Being a residency training officer of the department of Pediatrics at SLU-HSH, I decided to quit the post while maintaining the post as head of breastfeeding committee and neonatal services unit of the same hospital.

Then having been a Zumba enthusiast, I went on training and earned my license to be an instructor. Having kept this diet, exercise and religious medication, I had my follow-up on my 20th month after the surgery. Sacrifice and effort finally paid off. My total cholesterol was now down to 156.96mg/dL (from a previous of 423 the first time I found out I had elevated levels to 212 prior to my cardiac arrest). Low density lipoprotein (LDL) was now down to 92 mg/dL, and my triglyceride was still maintained below 200mg/dL at 105.32. My liver enzyme was very slightly elevated and thyroid hormone was within acceptable normal limits, bordering hypothyroid. I lost two kilograms, I can now wear my old pants and I feel a little more confident than the previous months. Because of these, my cardiologist decided to discontinue my thyroid hormone supplementation, decrease my dose of ezetimibe and lower my ruosovastatin from 40 mg to 20 mg.

Whether these changes were due to my more frequent exercise or diet restriction, or lesser stress from work, it doesn’t matter; it also means that I will have to maintain these statuses so as to keep my lipids in check. I thought I could already have the clearance to eat lechon, sigh… Well, better this than have another heart attack soon. The sacrifices paid off.

Next goal: a sculpted body? I dare myself.

 
Leave a comment

Posted by on August 17, 2014 in Personal

 

Tags: , , , , ,