In The Nick Of Time

(photo: http://www.moondragon.org)

A first time mother was well into the third trimester of her pregnancy. She never got sick, currently with no pregnancy-induced illness like hypertension or diabetes. She was regular on her prenatal visits, compliant. Unremarkable.

During the wee hours in the morning, she began to feel some abdominal cramps. She thought it was hunger pangs, so she had something eaten. However, after few minutes, in contrast to the relief she was expecting, the abdominal cramps continued, intermittently.

She then went to consult her OB-Gyne and have the problem assessed. On internal exam, her cervix was already 1.5 cm dilated. Her abdominal contractions were intermittent. What was unusual was that she was screaming as if in in severe pain, which was incongruent to the degree of the abdominal contraction she was experiencing. She was thus advised admission.

Upon arrival at the emergency room, it was noted that the abdomen was a little harder than the usual premature contractions, with her screaming still as if in severe pain. A tracing taken from the abdomen to assess the contractions of the uterus and heart beat of the baby (cardiotocography, CTG) showed abnormal uterine contractions and variable fetal heart rate pattern. Quick thinking by the OB-Gyne lead to the consideration of impending abruptio placenta (premature detachment of placenta from the uterine wall).

Normally, the baby gets delivered first, before placenta separates from the uterus. When the placenta prematurely detaches from the uterine wall, ahead of the delivery of the baby, this can lead to exsanguination (massive hemorrhage). On the maternal part, she can have anemia, or worse, hypovolemic shock, due to the blood loss. On the fetal side, since the placenta (which serves as the baby’s siphon for blood from the mother, delivering nutrients and oxygen supply to the baby) prematurely detached, baby can also have hypovolemia, anemia and shock. And since baby gets deprived of oxygen, baby is in a similar situation to that who is drowning or strangulated, resulting to asphyxia, and worse, death. It is then crucial that this condition (abruptio placenta) be diagnosed and managed very early on to prevent the occurrence of such adverse effects on both the mother and the baby.

Mother had to undergo emergency cesarean section. While the obstetrician was doing her job, I went to peek on the complete blood count of the mother. It showed that the mother was already having anemia. This means that she was losing significant amount of blood. (This could then explain why the uterus was unusually hard, and her unusual screaming, characteristic of one in severe pain.) On opening up of the uterus, there was a huge blood clot between the uterine wall and placenta, with about 30-40% of the placenta detached from the uterus.

When baby came out one minute after opening of the uterus, baby had difficulty of initiating his first breaths. I had to stimulate and provide bag-mask ventilation until baby began to cry. We did uninterrupted skin-to-skin contact for that chance to acquire maternal bacterial flora that will eventually help protect baby from infections. As soon as baby began to grunt (which began at about 10 minutes after skin-to-skin), we took him to the NICU for care.

When the result of the complete blood count of the baby came in, it showed that per 100 of white blood cells (WBC), 45 of which were nucleated red blood cells (NRBC). RBCs are produced in the bone marrow. While still undergoing development, the immature forms are still nucleated. Once they mature and before they are released to the peripheral circulation, the nucleus is extruded. This now allows the RBC to be pliable in the peripheral circulation, with an increased carrying capacity for oxygen. If however, in cases where baby becomes deprived of oxygen such as in massive bleeding as was the case for this baby, immature RBCs, the nucleated ones, are then thrown out into the peripheral circulation, in an attempt to increase the oxygen-carrying capacity of the RBCs — to protect the brain, heart and adrenal glands from the devastating effect of hypoxemia and hypoxia.

The urgency of the cesarean delivery has just saved the mother from massive hemorrhage and the baby from being asphyxiated. A few minutes of delay perhaps would have resulted otherwise… In the nick of time.

IMAGINE this happening to a mother, who is living in a far-flung area, with no access to obstetrics care; where hospital is 2-days travel away; where there are no barangay health workers that can be called, or even if there are, but no nearby health care facilities… would we have saved the mother? the baby? How many perinatal deaths would have to occur before the reproductive law be enacted? Do we need to have a national dumping site of dead mothers and babies (similar to that of the “Killing Fields” of Cambodia), which our leaders will personally inspect, or perhaps do a skull count, before they believe there is a need for the immediate enactment of the reproductive law? Well, one senator wanted to have maternal death certificates as an evidence before he could believe high perinatal mortality is happening.

 

Ooops!

I was once called for a referral. A few days old preterm baby having seizures that occurred within the first few hours of life. Baby was having seizures despite the anti-convulsant that was already given. The baby was already referred to a neurologist before I stepped into the picture. Baby was worked up and his electrolytes showed low sodium (112). (The normal level is 135 – 145; if the value is lower than 135, that’s considered hyponatremia. If value is less than 125, baby can have seizure that will not be controlled by anticonvulsant until the problem is corrected). In this case, it seems the most likely cause of seizure was identified. Thus, the immediate thing for me to do was to correct this abnormality and hope that it will eventually stop the seizures.

So after 48 hours, the sodium level was already raised to near normal. The good thing was, seizure already stopped. So I guess the baby’s urgent problem was resolved.

The question that bothered us was, why did the baby have severe hyponatremia? It is a rule of thumb that the electrolyte picture of a baby within 48hrs from birth generally reflects that of the mother. Unless that baby also has a congenital abnormality such as in cases of congenital adrenal hyperplasia (CAH). The baby in this case did not have physical signs highly suggestive of CAH, and the newborn screening eventually was normal, so this as the cause was easily ruled out. So, this made me then thought of the mother’s electrolyte status.

I interviewed the mother when she visited her baby at the NICU. I asked her if she was on prolonged intravenous fluid administration, if she was taking medications. She revealed she was on prolonged furosemide “maintenance.” This was given by an internist she consulted. BINGO! Seems I nailed the culprit with mere few questions. So I went on further with my interview. I asked why was she on prolonged furosemide intake. She said, she consulted the internist because she had edema (swelling) of both her lower legs. I further asked, “at what months of pregnancy did she notice the onset of edema, of hypertension. She did not know she was pregnant then when she had that consultation. Then my next question was, “is your menstrual cycle irregular?” And she replied YES! I was then flabbergasted and felt sorry for the mother, most especially for the baby. Why?

Let me reconstruct the story for a clearer understanding. Here was a woman with irregular menstrual cycle. She became pregnant but was not able to realize it because of her irregular schedule. Then later in the pregnancy, she developed edema of both lower extremities. She consulted an internist because of the latter, who also incidentally discovered she was hypertensive. The internist did not know the patient was pregnant; he did not do pregnancy test nor abdominal ultrasound. Pregnancy was remote from his consideration, thus he did not do these tesst… even if the woman was already showing signs of PREECLAMPSIA. So he gave furosemide. But since the edema was unresolving, she kept on taking the drugs. Few days ago, she was having abdominal pain. She saw another doctor, an OB-Gyn, who requested for an ultrasound. HALLELUJAH of all hallelujahs, she was indeed PREGNANT. And since her blood pressure remained uncontrolled, she was scheduled for emergency CS delivery. Since she was on prolonged furosemide intake, aside from it removing water from the body, furosemide also eliminates electrolytes like sodium and potassium. Since she was already hyponatremic, so was also the baby whose blood supply comes from the mother via the placenta.

The rest of the baby’s course in the neonatal ICU was unremarkable thus I signed out from the service after making sure baby was ready for discharge.

 

When One of the Twins Die In Utero

Did you always think that when a mother conceives twins, triplets, quadruplets or more, all of the fetus will be born alive? As morbid as it maybe, some fetus/fetuses die prematurely even before being born. Some may die within the first, 2nd or 3rd trimester (3 months). And their death can bring about complication/s not only to the mother, but to the remaining twin as well.

The effect of the fetal death to the surviving twin may vary according to the timing of the death. In a data published 1994, loss of one twin at the first trimester does not impair the development of the surviving fetus. (Some are completely resorbed in a condition termed as “vanishing twin syndrome.”) In the second trimester however, this is associated with increased risk for the survivor as reflected by a high incidence of growth retardation, premature labor and perinatal mortality.

An observation of twin pregnancies where single fetal death occurred after 20 weeks of gestation, the mothers were known to have preeclampsia which may also prompt babies to be delivered prematurely. The surviving twin aside from being delivered prematurely, they are also observed to be with intrauterine growth restriction. This could be an effect of the death of the other twin, or that and the effect of preeclampsia wherein the blood flow to the fetus may become diminished. This in turn causes diminished delivery of oxygen and nutrients to the baby thus. Head MRI and ultrasound of these survivors revealed some neurologic injury. Fortunately, in these mothers, there was no detected abnormality on coagulation profile.

A similar observational study was also done among twin pregnancies where a single fetal death occurred after 20 weeks of gestation. The study showed that the main cause of the fetal death was twin-to-twin transfusion syndrome. The survivors were also delivered prematurely and later also died after birth because of the same cause. (TTTS is due to abnormal communication between the blood vessels supplying the placenta of both, leading to shunting of more blood to the other twin while deprivation of the other one. One may die immediately while still in utero, while the other may survive or end up hydropic; or both may survive with severe physical discrepancy — see my other blogs on hydrops fetalis). 

Another in depth observation was done among twin pregnancies complicated by single intrauterine fetal death after 26 weeks of gestation. Chorionicity of the twin pregnancies was noted (see illustration below on the types of twin pregnancy according to chorionicity).

(Image courtesy of  http://www.health.sa.gov.au/ppg/Default.aspx?PageContentMode=1&tabid=75)

Often times, the surviving twin was delivered prematurely, and that baby ended up with intrauterine growth restriction. The mother on the other hand had preeclampsia and gestational diabetes, both of which may also lead to the growth restriction of the surviving twin. In cases of monochorionic pregnancies, again twin-to-twin transfusion syndrome afflicted the babies. Some of the twin eventually died as well in utero (before being delivered), while others after birth. Also, ultrasound of the baby’s head should cerebral anomalies in some.

Even if one of the twins survive after the death of the other, and gets delivered, it is not reassuring that he will live and be discharged as well baby as his outcome may be compromised by the complications of premature birth, or presence of neurologic injury.

References:

1. Prömpeler HJ, Madjar H, Klosa W, du Bois A, Zahradnik HP, Schillinger H, Breckwoldt M. Twin pregnancies with single fetal death. Acta Obstet Gynecol Scand. 1994 Mar;73(3):205-8.

2. Axt R, Mink D, Hendrik J, Ertan K, von Blohn M, Schmidt W. Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.J Perinat Med. 1999;27(3):221-7.

3. Aslan H, Gul A, Cebeci A, Polat I, Ceylan Y. The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation. Twin Res. 2004 Feb;7(1):1-4.

4. Chelli D, Methni A, Boudaya F, Marzouki Y, Zouaoui B, Jabnoun S, Sfar E, Chennoufi MB, Chelli H. Twin pregnancy with single fetal death: etiology, management and outcome. J Gynecol Obstet Biol Reprod (Paris). 2009 Nov;38(7):580-7. Epub 2009 Oct 14.

 

LUCKY: Superstitions on Baby’s Birth Date

LUCKY: Superstitions on Baby’s Birth Date.

 

LUCKY: Superstitions on Baby’s Birth Date

Why do Filipinos still believe in superstitions, despite being a largely Catholic country? In every aspect, in every field, in every occasion, there’s always superstitious beliefs. Even if people just came from worship or Sunday mass, they still go to a Chinese person for some feng shui advice. When I was young, the first one I heard was that those “palaspas” are for driving away evil spirit. Now that I am older, there are so many silly (I consider them silly) things. During new year, people resort to silly practices just to be “lucky” for the next year. They must have 12 different round fruits on the table on new year’s eve, they must put some paper bills/coins in their wallet so that they will have money all year round, they should be wearing polka dots, again to attract money and good luck. Is that Chinese in our blood, or are we just money-driven?

In medical field, even during giving birth, again superstitions abound. Many consider giving birth at a date with the number 8 LUCKY. It’s not a strange thing anymore when parents tell you they had a cesarean delivery scheduled on the 8th, 18th or 28th of the month, at exactly 8:00am. Some even go to the extreme of informing the obstetricians that the baby should come out at exactly 8:08 or 8:18 am. If not the number 8, others want to deliver during the 9th of September, 2009; 10th of October, 2010; 11th of November, 2011; and I will not be surprised to hear someone schedule their delivery date this coming 12th of December, 2012.

Cesarean delivery has it’s own risk. As far as the baby is concerned, when the mother delivers via this method, without prior labor, the baby has not been subjected to the “stress” the mother undergoes during labor. Because of this, there is no surge in epinephrine (otherwise known as adrenaline). Low levels of circulating epinephrine in the baby’s blood leads to a low oncotic pressure (important to absorb fluids from the lung alveoli into the bloodstream; remember, the baby’s lungs are filled with fluid, NOT air, inside the uterus). After delivery, because of low oncotic pressure, there is less/slow absorption rate of the fluids from the alveoli of the infants lungs into the bloodstream. The infant then breaths fast until the fluid in his lungs is completely resorbed (condition known as transient tachypnea of the newborn), usually in 6 hours, but may last until 72 hours in some patients.

Another lifelong implication of cesarean delivery to the baby is INCREASED RISK for baby to develop allergic disorder, even if both parents deny family history of it. Vagina of adult women, just like our skin, is normally populated by bacteria; the bacterial population differs from one body part to the other. During vaginal birth, the baby tends to aspirate and swallow some of those bacteria along the maternal vaginal tract. These bacteria populate the intestines of the baby leading to, but not limited to: (1) closure of the gaps between intestinal cells, thus inhibiting proteinaceous substances to permeate the intestinal wall and incite infection or allergic reaction, (2) stimulate the intestinal immune system to secrete secretory immunoglobulin A (sIgA) that acts as a first line defense against invading pathogenic/infectious bacteria/virus/fungi in the intestines, therefore protecting baby from infection – this is how our immune system act for the first time after birth.

Now, when the baby is delivered via cesarean section, this BENEFIT of vaginal delivery is abolished. Why? The mother’s abdomen is prepared with iodine, to prevent infection of the cesarean wound. Because of this, majority if not all of the bacterial flora of the mother’s abdomen has been wiped out/eliminated. As the head of the baby is delivered, there’s nothing to aspirate/swallow that will give the above benefits of vaginal birth. Now, even if baby is latched onto the mother’s chest during that skin-to-skin contact to allow baby aspirating the chest bacterial flora, the quality of bacterial flora on the mothers’ skin is different compared to that of the vaginal flora and may act differently thus as far as infant’s immune system stimulation is concerned.

Third, just a recently published study found out that cesarean delivery led to lower expression of a protein UCP2 at the neurons found at the hippocampal region. This protein fosters short-term and long-term memories. Among mice, knocking out the UCP2 gene or chemically inhibiting this protein interfered with differentiation of the neurons and circuits at the hippocampal region and impaired adult behavior related to hippocampal functions. (See http://www.dailymail.co.uk/health/article-2185597/Babies-born-naturally-higher-IQs-delivered-caesarean-section.html?ITO=socialnet-twitter-mailonline).

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A woman who had this strange belief of giving birth during a “lucky date” REQUESTED for a cesarean delivery on the 10th of October, 2010, consciously knowing that her baby is premature at 36 weeks. (Not my patient though, but I took over the case during the weekend when baby was already deteriorating). Alright, so the baby was born with a very nice birthdate of 10-10-10. Lucky, yey! NOT…

Normally babies who are 36 weeks, considered near-term, have good transition from intrauterine to extrauterine life. We USUALLY do not expect complications, breathing becomes normal in most cases. However, this particular baby developed complications, his breathing wasn’t normal as expected and eventually required mechanical ventilatory support. Still, baby deteriorated, developed persistent pulmonary hypertension of the newborn, and expired within few days. So if babies who are 36 weeks normally have good transition, how come this baby did not do any good? Honestly I don’t know what went wrong too. Or maybe nature is telling us not to interfere, let nature take its toll.

Is there really a lucky number for a birth date? Do we really have to alter the expected date of delivery just to be born at a “lucky date?” Many of you reading this may just shrug your shoulders and go on… Just consider your child’s future, consider some of the disadvantage of cesarean section, especially if it is not indicated at your birth circumstances.

 

Post-Hemorrhagic Hydrocephalus

Post-Hemorrhagic Hydrocephalus.

 

When All Else Were Done…

When All Else Were Done….

 

When All Else Were Done…

She could have been my smallest survivor…

Mother was hypertensive, first baby to have been successfully conceived after 8 years of waiting. Unfortunately, the hypertension was causing distress to the baby, so she has to be born prematurely, or the mother will seize… or die.

She was pretty 515 grams, 25 weeks, brave baby girl. As most prematures would, she was immediately in distress thus intubated, and breathing was assisted by mechanical ventilator. She was given surfactant again thus after 5 days from birth, she was already off from the ventilator and was merely on low-flow oxygen support. She was also being fed already and was tolerating the gradual progression of feeding. But the drastic event happened on the 6th day of life: she all of a sudden vomited blood.

I was called when the resident was already attempting to rescue baby. As soon as I arrived, baby was already in a very compromised state. I had to bring back the mechanical ventilator to aid her breath. She was bleeding from all over, including her lungs; good thing her brain was spared. But alas, complications upon complications set in. Respiratory failure, kidney failure, patent ductus arteriosus. Considering the long wait of the parents to have a baby, that motivated me more to try to tug baby away from the grips of death.

One week from birth, as they were that excited to successfully have a child whatever the gender is, the father went overseas to work and help finance the expenses the baby will incur no matter how much it would take.

Baby was able to pull through from those complications, but with one grave sequela, she had bronchopulmonary dysplasia. Her lungs weren’t able to resist this complication such that on x-ray, it literally looked like a sponge. As a consequence, I couldn’t take her off from the mechanical ventilator.

She later on was also having regurgitation, and the milk that regurgitated were being aspirated, thus aggravating further her respiratory condition. I tried the textbook managements to no avail. Then out of frustration as her hospital bill was already mounting up I resorted to nonconventional remedies just for her to be able to be weaned off; mechanical ventilator is the real burden on one’s financial resources. I even already tried using those asthma inhaler puffs attached to make-shift gadgets; yes, my creativity had been challenged for real by this baby. Despite her dependence on oxygen and the respirator, she was gaining weight. Though her weight is far from what was expected for her age in weeks, still it was an upward climb.

All of a sudden, the respirator got accidentally removed from her system. I was so afraid because it happened when I was out of the hospital. But… she tolerated it, she was able to tolerate just breathing low-flow oxygen delivered by a nasal cannula. Finally, the mother can cuddle baby!!!

I was already planning how to discharge baby. Mother was already trying to find oxygen tanks and gauge that they can use if ever baby goes home. From 515 grams, baby was now 1.5kgs, after 3 months on respirator! The excitement was so pent up… until one early morning.

She strained hard while defecating… until her heart beat stopped. An anethesiologist colleague was at the adjacent operating room at that time and she intubated her and initiated resuscitation. I was awakened by the distress call. Upon learning that the residents started reviving the baby, I began giving instructions through the phone. (This was then the time when I had no car, I had to commute! But at that time that the call came in, it was busy hour. No cab could be hailed and all the jeeps were full from the place where I live). I was walking to almost running hurriedly towards the main highway, phone on ears as I don’t use bluetooth headset then. Then I successfully rode a jeepney and transferred to a cab en route to the hospital. Upon arrival (it took me about 30 minutes), I took over the resuscitation command. We were able to pull baby back but with a heavy prize. The period that her heartbeat stopped and blood was not circulated to her heart and brain really was significant that baby already began to seize, she was in coma.

I immediately notified the mother with a breaking heart. How do I tell her? The day before, she had been cuddling baby on her chest, doing her motherly “job” changing her diapers, feeding her, and assisting the nurse to bathe her. And now, I am going to tell her that her daughter almost died defecating, but is now in a vegetative state? How could I do that?

She arrived, and I explained how things happened. She was sad, tough, but breaking inside. I was teary-eyed because the baby was endeared to me. I was in pain. Then I asked to be excused as I realized I looked disheveled. I went home, took a shower and prepped for work. As I was doing that, the residents still kept calling me on the updates and I giving my instructions in return.

When I arrived again later, the mother, surrounded by her relatives, gave me the blow. She decided to bring baby home, while she still has heartbeat. I was crying in front of her when I heard her say that, but it was the wisest decision a person could muster on a painful moment such as that. I hugged her tightly, and then gave instructions to the nurses to prepare baby. As she was a very dear tyanak to me, I made sure that I was with the baby when she left the hospital. When everything else was settled, it was now time. I was bag-ventilating the baby while the nurses carried her until we entered their service car. Fighting back tears, I removed the endotracheal tube… Within few seconds… she was gone.

(Image courtesy of http://thesaltlist.wordpress.com/2011/04/15/the-great-euthanasia-debate/)

 

Unlucky (Post-Natal Asphyxia)

Unlucky (Post-Natal Asphyxia).

 

Unlucky (Post-Natal Asphyxia)

Disclaimer: This blog is not to solicit your sympathy, but read at your own will.

I had been taking care of this baby, who was born at 25 weeks gestational age. It seems that the mother had been having infection in her uterus that prompted the preterm labor. Studies have already shown the association that inflammatory process in the uterus at the time of pregnancy may also transmit the inflammatory factors to the brain of the fetus, thus the latter is at risk for cerebral palsy, even if he graduates from the neonatal intensive care unit. Another risk that this intra-uterine infection produces is development of bronchopulmonary dysplasia, BPD (otherwise called chronic lung disease of the newborn). BPD is usually considered when a child has a difficulty of tolerating room air (or the baby remains oxygen-dependent) after a certain period of time, when he is already expected to be off from oxygen support. BPD, aside from being a result of an infection, may also be precipitated by other inflammatory processes in the lungs (such as use of mechanical ventilators that induces trauma from volume of introduced air or employed pressure), or volume overload (such as patent ductus arteriosus).

My little baby, seemed to have contracted already BPD by two means: patent ductus arteriosus and inflammation from intrauterine infection prior to his delivery. He was already off from the mechanical ventilator on his seventh day of life, but still cannot tolerate being off completely from oxygen. He was given surfactant immediately within few hours from birth, and early x-ray studies showed clearing of the white ground glass picture that was initially seen after birth. After I extubated (removed the mechanical ventilator) on his seventh day of life, I did an x-ray revealing findings consistent with pneumonia or BPD. Considering the prenatal background of his birth, I was moved to treat his respiratory problem as BPD. Gladly, there were no crises arising from it. What was funny though was that every time he attempts to valsalva/defecate, he desaturates and his heart rate slows down. This makes the nurses panic. I reassured them to assist the baby’s breathing as this could be expected from someone with premature brain. So far, there had been no problem.

On his second week of life, something unexpected happen. During one of the episodes he was doing valsalva, his heart rate slowed down to the point he was unresponsive to the nurse’s maneuver. I was called to the rescue but in five minutes when I arrived, resuscitation was already ongoing, his heart rate was gone. We continued reviving, and after almost an hour, his heart beat came back. Unfortunately, a brain deprived of oxygen of at least five minutes duration is a poor sign.

Yes, baby was revived, but he was not breathing spontaneously already; his breathing depended on the mechanical ventilator. He was also already having seizures as an aftermath. In less than 12 hours from his near death hap, his brain activity already stopped; merely spinal cord reflexes were appreciated. I had the baby referred to a pediatric neurologist, who confirmed the brain’s inactivity. I then talked to the parents and explained the scenario, with full disclosure. After few hours, parents approached me at my office and said they will no longer be aggressive with baby’s care. After his currently medicines will be consumed we will not be refilling/replacing them. Bottomline, if baby’s heartbeat will stop, we will no longer do cardiac pump/massage. This is one of heart-wrenching moments we usually encounter, but it is one reality that we have to accept in our line of profession.

The parents and the relatives talked among themselves what to do with baby. Since baby no longer has a chance of recovering, and is solely dependent of medications and mechanical ventilator to keep him alive, this of course would entail exhaustive financial expenses on their part. Weighing financial resources vs benefit/outcome, it would be a loss-loss scenario on their side. They then decided to terminate aggressive treatment and bring home baby instead, considered in the hospital as HOME/DISCHARGE AGAINST MEDICAL ADVICE.

How does this work? Once parents are able to settle the hospital bill of the baby, the baby is then brought home by the parents. As much as possible, all contraptions are removed from the baby, except the (endotracheal tube) tube that is connected to the respirator. As the baby exits the nursery, the respirator is replaced by a bag-mask apparatus that is connected to a portable oxygen source. A personnel then does the bag-mask ventilation of the baby until he/she is inside the vehicle that will transport him/her home. Then that is the time now that the nurse/physician will remove the tape that secured the endotracheal tube to the patient’s mouth, and pulls it out. Then it will just be a matter of minutes when the heartbeat will stop. (Strictly speaking, it should be the parents who should pull out the endotracheal tube from the baby’s mouth. But to allay the pain their suffering, we [health care providers] instead do it for them.) This is the most painful part of the grieving I think, watching your baby’s last gasp of air until the heart completely stops. Is this considered euthanasia? I’d rather not classify it. Are the parents guilty of “pulling the plug?” No, they had full disclosure and they just had to appropriate and allocate their resources. Was it ethical? Yes, there was full disclosure of the outcome, they had to consider every aspects – their finances; the baby’s outcome– what would he become of if treatment had been aggressive; their custom and tradition, and their elderlies’ advices, before finalizing their decision.

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I saw patients at my office for their outpatient consultations and immunization. After my last patient’s vaccination, I heard a loud thud and screaming few seconds when the mother exited the door. It turned out she slipped on a fluid scattered by some irresponsible mammal on the floor. Gladly, the mother held tight onto her 2 months old infant thus was spared from getting hurt. The mother though had her head hit the floor, thus the thud we all heard. We immediately notified the hospital administration about the incident and we brought the mother to the emergency room for consultation and clearance. Meanwhile her baby was left to us. Unfortunately she was hungry. Gladly, the mother gave us milk for the baby to consume. I, my secretary stood as the baby’s nanny while the mother was being attended to at the ER. Baby seems a voracious feeder, I had to find milk while the mom is still being checked. It took almost three hours when the mother was cleared to go home.