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Aside

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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Prematurity and Post-Natal Malnutrition

(Photo courtesy: http://trendsupdates.com/global-malnutrition-one-sixth-of-humanity/)

Few days ago, a colleague of mine from a different region called and referred a preterm baby for transfer to my service. The case is that of a preterm baby who had blood infection but wasn’t apparently improving with anti-microbials. Baby already was given series of strong antibiotics and seemingly isn’t showing signs of improvement. After about 2 weeks being in the hospital, the first attending doctor talked to them and apparently told them that the baby has a nil chance of survival. They were asked to decide whether to keep baby in the hospital costing them unnecessary expenses or bring home the baby and wait till the baby expires at home. Distraught with the options, the parents brought the baby home. One week passed, and with the baby still alive, they brought him to another doctor, my friend. She honestly told them that it is not her expertise to take care of such case, thus she called me up if she could transfer the baby to my care. I gladly obliged. I really got puzzled why the first neonatologist told the parents the baby has no chance of survival when everything hasn’t been explored yet.

The baby arrived and weighed 1.0kg, he weighed 1.2kg at birth. Babies, whether term or preterm, normally lose weight few days after birth but are expected to regain their birthweight by the end of two weeks from birth. In this case, the baby was already 23 days old so he is expected to be 1.3 to 1.4 kgs. He thus have what we call postnatal malnutrition brought about by several factors – infection, inadequate feeding and gastroesophageal reflux disorder. Baby was immediately worked up and treatment started. During the first few days, baby was already showing signs of improvement; he was gaining weight daily. Unfortunately, he would still have occasional arrests in breathing (apnea). This became increasingly frequent until the day his abdomen distended causing prolonged apnea. Aside from anemia, prematurity as plausible causes of the repeated apnea, I considered infection already of the intestine (named as necrotizing enterocolitis). I had to withhold feedings and resume IVF nutrition, switch antibiotics and add antifungal coverage. I also had to correct the anemia as well as minimize or control the esophageal reflux. It took several days before the apnea could be controlled, and for the abdominal infection to resolve. At present, the baby is no longer on antibiotics, he is already feeding through bottle/dropper, but is still malnourished. Baby being stable and with continuous weight gain, I will be sending home on the next day and requested to follow him back quarterly for his developmental surveillance. His regular follow-ups will be done by my friend in their province. He is now 1.5 kgs, but still a far cry from 2.5 kgs which should be his minimum weight at present.

 
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Posted by on April 25, 2012 in Infection, neonates

 

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