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10 Jun

Scenario:

A pregnant woman comes to the emergency room. On interview and examination, she complains of having loose bowel movement and abdominal pain. You also find out that she is in active labor, in fact, her labia is already gaping wide, and the head of the baby is already visible. The spice to that is, she is only 25 weeks pregnant. (As she is already in labor, it is impossible already to get a very DETAILED history from her before the baby comes out.)

Pediatrician is called. With the available data, pediatrician/neonatologist resuscitates the baby accordingly — full resuscitation provided aggressively. Baby being severely premature, no surfactant available, unable to breath spontaneously, gets intubated and bag-ventilation provided. Baby is brought to the NICU for further care. Mechanical ventilator is provided to assist baby’s respiration; saran wrap helps to improve and regulate his temperature; umbilical venous catheter inserted for central access; x-ray done to assess baby’s lung status and document the placement of endotracheal tube and umbilical catheter.

Obstetrician, who has established rapport with the mother also wondering why she went suddenly into labor when she has good and unremarkable prenatal status. She elicits that… (brace yourselves)… this is a case of INDUCED preterm labor after intake of some drugs. BOOM!

Question… 

Now suddenly, as the pediatrician, you try to go back from the start of everything and ask yourself: should you have been aggressive in providing care for the baby? And then you suddenly tell yourself, but the baby is not at fault, didn’t want to be expelled prematurely, and still deserve the best and optimum care as any other babies would… then the dilemma sets in… How far should you, as a physician, go and asserting the baby’s needs, over the lackluster of maternal affection.

To resolve matters, you call for the husband… Unfortunately, the mother was only accompanied by her live-in female employees. The husband is out of town, working. Not a single nearest of kin, who can stand as guardian, give consent, is available.

What would you do now as the pediatrician? The mother is sedated after the delivery procedure; you cannot get a consent from that kind of mind frame; the baby’s watchers are not legally suited to sign consent for him.

Resolution…

My resolve: I told the mother’s employees– I need you to inform the nearest of kin. I cannot make you sign for the baby’s welfare as it is not legally binding. Meanwhile, since the mother is still sedated and not at the best mind set to give any decisions yet, I will assume the responsibility for the baby, I will act as his parent until she has fully recovered from sedation. (I am not sure but I think these employees were not aware that the mother intentionally wanted to get rid of the baby). I gave them a prescription for surfactant as it is not available at the institution where she gave birth. (Some of you might disagree with me, but I had to think fast and consider the best option for the baby. And at that instant, that was the best I could come up to.)

Meanwhile, I waited from them. Baby’s condition was not good; he badly needed that surfactant. Do I expect the surfactant to be bought by the employees under the command of the mother (who wanted to get rid of the baby)? The father was apparently on the way home now. I waited still, and tried to give the baby a chance, but despite all I could do, he wasn’t faring well.

In my subspecialty, there are a lot of situations in which we are fazed with ethical quandary. The major template from which decisions will be based on is the current condition of the baby and its prognosis– what potential/s will be preserved to have a good quality of life. The other major factor is parents’ resources. It is a common knowledge that behind the intensive care of a sick baby, preterm at that, is a staggering hospital bill; cost of care of a baby requiring intensive care is NOT CHEAP. Other determinants include, among other else, the number of children in the family, age of parents, support of the community around them. The conflict sets in when: there is mismatch between either factors. This time, my dilemma is, should I go aggressive after knowing that the mother wanted to get rid of the baby? It would have been easier if the husband were here, at this very moment. I will pass on the decision to him, after full disclosure of course.

 

Dilemma…

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Posted by on June 10, 2012 in Abortion, neonates, Pregnancy

 

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