Paperwork

The baby's great-grandmother, the guardian of the baby's teenage mother, had called me to ask if I would help them fill out some paperwork to get the baby some state sponsored insurance. It's kind of like Medicaid, but for children with special needs. She had received an application packet in the mail and seemed a bit overwhelmed by it.

When she brought it in, I had to sigh a little bit. None of us like to do more paper work. The forms, although written in the stilted formal language so typical of government applications, weren't that hard to figure out. With a little patience and persistence , she should have been able to complete them. It made me realize once again how great the gap is sometimes between me and my patients' families. I don't mean to sound arrogant, but I'm fortunate enough to be educated and intelligent. Many of my patients' family members are not, and the difference can make it hard to relate to them at times. Certainly it makes explaining NICU issues and diseases challenging, and sometimes it seems downright impossible to make parents understand.

On the other hand, I was a little miffed at the state for not making the applications easier. We know that many people in the inner city are functionally illiterate, and they should accommodate them when they design these forms. The state used to have the local health departments meet with families to complete the applications for this insurance program, but in a cost cutting move the state decided to skip that and just send the applications directly to the families. I suspect the state might have been hoping that some families would just give up on the applications, and then the state wouldn't have to pay as much for this program.

As we started going over the application, though, I noticed that this family had done a surprisingly good job with it. They had most of it completed correctly. I added some medical information to it, explained a couple of the more difficult points to them, and made sure they knew the right places to sign. I complimented them on the good job they had done.

I'm not sure why the family chose me to help them with it. Any nurse or another doctor could have done so. It was a little weird. A few minutes before I had been thinking somewhat derogatory thoughts about this family's ability or inability to complete the application; now, though, I was honored that they chose me to help them.

Greed

Those wild and crazy pharmaceutical companies are at it again, doing their best to prove that the big oil companies don't have a monopoly on corporate greed. One of their latest misadventures is told in a recent New England Journal of Medicine article.

Many of you may be aware that when a drug company develops a new drug, they have exclusive rights to produce that drug for 17 years. ( I'm pretty sure I've got that figure right.) After that time other companies can make generic versions of the drug that typically sell for much less than the original brand name drug. I'm guessing, though, that most of you don't know that it's legal for the original drug company to pay a generic drug company money to not produce a generic version of the drug.

An article in the September 28, 2006 edition of the NEJM tells the story of Plavix, made by Bristol Myers Squib. Forty eight million Americans use it at a cost of more than $4 per day. (I'll do the math for you: 48 million times $4 equals $192 million per day - per day!) It's patent was about to expire, so Bristol Myers agreed to pay the generic drug company Apotex $40 million - chump change for Bristol Myers - to not release the generic version of Plavix until 2011. The deal had to be approved by the FTC and Justice Department, and in this case the deal fell through.

This is only one example of what apparently is a common practive. Although the Federal government has been trying to block such agreements, judges have often approved them. As the article says, "In recent years, such settlements have generally stuck, despite federal authorities' efforts to undo them, and generics have been kept off the market" - at a cost to consumers of billions of dollars. The full story is more complicated - I've simplified it some to fit it into a few paragraphs - and I encourage you to read the whole thing (NEJM 2006; 355: 1297-1300.)

I'm not sure what surprised me more about the article, the fact that drug companies could actually do this, or the part about the federal government trying to stop them. (The feds are actually on the consumers' side?) What's not surprising, of course, is that the drug companies will do about anything for a buck. They may be called a type of health care company, but people's health is far from the first thing on their mind.

Afterlife

Healthy three month old babies shouldn't have to die, but they do, and I went to the funeral of one of them the other day. The infant son of a nurse I know, he was put to bed fine and normal but was dead when they went to awaken him in the morning.

At the funeral, which happened to be Catholic, I was struck by how much beliefs of an afterlife or opportunity to be together again sometime with the deceased are used to try to comfort the bereaved. We attempt to soften the blow of death by saying we'll see him again. I think that just about all religions, Christianity, Buddhism, Islam, Hinduism, and so on, have some belief of resurrection or reincarnation, some idea of persistence of the soul.

It makes me wonder what a funeral in a truly atheist family is like. Without any thought of reuniting with the loved one or any notion of living on in some other form, the finality of death must be stunning. I suspect that ideas like "His energy will persist," or "We'll see him in the wind and trees" or some such thing come out because we need some sort of defense mechanism against the awful thought of not seeing the person again.

I hadn't been able to go to the family visitation at the funeral home because I was working, and there were so many people at the funeral that I was a little concerned I wouldn't get to see the nurse to express my condolences. After the funeral, though, I was standing in the church lobby when she came up to me and touched my arm. As I turned to her, all I could do was say "I am so sorry," and give her a hug. In the face of such a tremendous loss, our words and gestures of sympathy seem so feeble, but they are all we mere mortals have.

Concerns II

The other day in my post entitled "Concerns" I wrote about some frustration I have at times because some mothers, when told of a serious problem in their child, only seem worried about not having the baby with them, or not being able to take the baby home. It struck a bit of a nerve; suffice it to say that I was roundly criticized in the comments for my attitude. In some way, I sort of expected that. It always looks bad when an educated doctor, familiar with medicine and a hospital, criticizes a relatively uneducated mother for saying something less than wise when she's in a difficult situation for the first time.

Consider the message received, but do let me try to explain my feelings one more time. I'm aware of the reasons why mothers will do this. I know that when people are stressed they don't always say the right thing. I also know that parents often don't understand what's going on, and even if they do, don't know what to ask. I know that medications can make mothers say some crazy things, although that wasn't the case in the example I gave. I know that delivery of a baby can be an overwhelming experience. Finally, I am well aware that it is not a trivial thing when a baby cannot go to mother's room or go home with her.

Try, though, for a moment to look at it from my side. Sure, it's very important for a baby to go to mother's room with her, but it's far more important that the baby live and not die. It's important to a mother to have her baby go home with her, but it's far more important that she take a live baby home rather than a dead baby. It's important for a mother to not be separated from her baby because of phototherapy, but the importance of that separation pales in comparison to the importance of not letting her baby get brain damage from jaundice. I'm not saying mother's concerns are trivial. It's just that compared to our concerns, the mother's are, well, less significant. And parents don't always get that. And we doctors (and nurses), imperfect beings that we are, can get frustrated by that - even when we understand why mother might be saying what she is.

Let me close by saying that when talking to parents I'm an insensitive boob maybe only about ten to twenty per cent of the time. The rest of the time, believe it or not, I usually have a good relationship with parents. It's a wonderful thing to not always say what you're thinking.

General

Flea's recent post about the things a general pediatrician can do without referring kids to a subspecialist put me in mind of the time I spent as a general pediatrician. I practiced it for about a year before I saw the light (realized it wasn't for me) and went into neonatology.

There are good and bad things about being a general pediatrician. The best thing is that you get to work with kids all day. They could really be pretty funny and just make your day. Some would be outgoing and glad to see you, while others would cry when you came near the door to their room. I also liked the variety of general pediatrics. You not only took care of all ages, you took care of all kinds of diseases, from infectious diseases like strep throat to the much more nebulous diseases like ADHD.

Eventually, though, the large amount of time spent on minor things, coupled with the huge amount of worry by parents about these minor things, got to me. You have to enjoy being a counselor, I think, to enjoy general pediatrics. Parents need lots of reassurance and instructions. And I don't mean this as a criticism of parents, because that's expected. When it's your own kid, even minor things seem major. Taking care of runny noses and ear infections, along with the seemingly endless stream of well child checks, just wasn't my thing.

One particular scenario bugged me the most. Mothers would often bring their, say, 8 to 15 month old child in to have the ears checked because the baby wouldn't sleep at night, and they were worried it might be an ear infection. More often than not, there was no ear infection and the baby was staying up at night because, well, that's what babies do sometimes. In such cases the parents would often be disappointed that their baby didn't have an ear infection, because then they would have had something to treat or at least to blame it on. Parents being disappointed because their kid wasn't sick: I understand it, but still, it bothered me.

I'm happy doing neonatology and at the same time am happy that there are docs who enjoy practicing general pediatrics. I have a great deal of respect for them. They work very hard, have to know a wide variety of things, and somehow have to pick out the one kid who has a serious disease like meningitis among the 100 or so kids with fevers and colds they see. My hat is off to them, but I'm glad I'm out of it.

Concerns

The baby was floppy and not crying when he was brought to the infant warmer table immediately after delivery. Because he had meconium staining - he'd had a bowel movement in utero into the fluid around him - we first suctioned his windpipe. After that he was still depressed and not breathing (no surprise there) so I began giving him artificial respirations by putting a mask on his face and squeezing a bag to blow air into his lungs. He began breathing by himself after that but not very well. I ended up intubating him - putting a breathing tube into his windpipe - so we could more effectively breathe for him. He perked up after that and we brought him to the NICU and connected him to a ventilator.

Before we left the delivery room we showed him to mom and I told her that we were helping him to breathe and so on. After I said this, Mom's only question was, "You mean he won't be able to come to my room with me?"

This happens quite frequently. We tell a parent about a serious health problem in their baby and they seem only concerned with a more minor thing, like being separated from the baby for a few hours or so. I really try to give the parents the benefit of the doubt on this; I know they don't always understand what's going on, and even if they do they don't always know what to say or ask. I know it's important for parents to have their baby with them. But still, the difference in gravity between a person not being able to breathe versus not coming to your room is so great you'd think they would understand it.

I try to put myself in their position, to try to understand it better, but if someone came and told me "Your daughter is having trouble breathing and is on a ventilator," I don't think my first response would be "You mean she can't go to the football game with me tomorrow?" Not all parents are like this, of course. Others are the opposite, getting extremely worried even if you tell them about a very minor problem. It's hard to predict a given parent's response.

Later the same day the baby improved, came off the ventilator, and looked like a normal, pink, breathing baby. When I went to the mother's room to give her the good news she had only one question: "Will he be able to come home with me in two days?" Sigh.

Denouement

A few posts ago I wrote about a baby with Trisomy 18. Perhaps you are wondering what happened to that baby.

At first the parents wanted everything done for the baby, including mechanical ventilation if necessary. When an echocardiogram showed the baby had serious heart defects that required major surgery, they wanted to go ahead with the surgery. The pediatric cardiologist and I each had long conversations with the parents, making sure they understood the poor prognosis of this child, even with surgery, and gently suggesting that maybe they didn't want to put the child through it.

They still wanted the surgery, so we transferred the baby to a center that does open heart surgery on newborns. After transfer and discussion with more physicians, they decided not to have the surgery. After hospice services were arranged, they took their baby home. Some people wondered who it was that finally talked them out of the surgery, but I don't think it's that. I think it just takes time for a family to come to the awful but appropriate decision to let their baby die.

I also have some follow up on a mostly unrelated matter, that of my traffic ticket. I went to court on the assigned day, and the officer said he would reduce the infraction from illegal lane usage to some lesser charge, so I wouldn't get any points on my record. The fine, though, remained the same, 130 big ones. I paid the fine and got out of there.

When baseball pitcher Cory Lidle died in a plane crash recently, I heard someone comment on TV that it put the Yankees' loss to the Tigers in the division playoffs in perspective. Similarly, the trisomy 18 baby puts my traffic ticket into perspective. The ticket is an irritation but just a small blip on the radar screen of life. Having a baby with trisomy 18, though, changes your entire view.

GBS

Group B strep is a type of bacteria that resides in the birth canal of some women. During delivery of a baby, the bacteria can infect the baby and cause nasty disease - sepsis, pneumonia, meningitis - that can be fatal in some cases, disabling in others. Fortunately, we know how to reduce the risk of a baby getting Group B strep (GBS) infections. During pregnancy we can screen women for the bacteria, and if they have it, treat them with antibiotics, usually penicillin, every four hours from the beginning of labor until delivery.

So I was surprised the other day when I went to the delivery of a mother with GBS in her birth canal to find that she had been treated the night before with two doses of penicillin but then, rather than continuing it until delivery, the obstetrician stopped it, for no good reason. When I found that out in the delivery room I wanted to say "Why would you do a stupid thing like that?" but decided that wouldn't be too professional.

A few minutes later I heard from another obstetrician that the obstetrician in the above case doesn't believe in treating GBS positive women until delivery with antibiotics, seeming to think that the whole thing is a little silly and that two doses are enough. This practice on her part is - how can I put this delicately - absolutely boneheaded. There are some areas in medicine where proper treatment is controversial and different options can be within the standard of care, but this isn't one of them. The Centers for Disease Control, the American College of Obstetrics and Gynecology, and the American Academy of Pediatrics all have official statements and guidelines saying the same thing, that these women should be treated with antibiotics until delivery. It's straight forward, uncomplicated, evidence based medicine. To ignore the guidelines is to invite malpractice suits; should one of the babies develop GBS infection, she might as well just write a blank check to the parents.

I'm not sure why this OB doesn't follow the guidelines. It's hard to believe she is ignorant of them, because it is such a common thing. Also, in other ways she is a consientious obstetrician. Now, though, I have to decide what to do about it. The easiest thing for me would be to refer the case to the OB Quality Assurance committee and let them handle it. That seems a bit heavy handed, though, and I wonder if I should just take the OB aside and talk to her, friend to friend, making sure she knows the guidelines and telling her she should follow them.

But I don't think it will make any difference. For one thing, I can't really say I'm friends with her; she's a bit prickly and doesn't seem to have many friends. Also, she's got a reputation for being a little stubborn. Official guidance from the QA committee might be more likely to change her practices - and keep a baby from getting infected.

Preventable

I practically begged the court referee to take the baby out of the home. Please, I said over the phone, this kid has been abused. The referee disagreed and sent the baby with the parents.

The baby had been admitted at about 6 weeks of age with a couple of rib fractures. It seems he might have had some other fracture but it was a long time ago and I don't remember for sure. Child abuse was number one, two, and three on our list of possible causes. I was a second year resident at the time and dutifully filed a report with Protective Services. The parents weren't too happy with me. I asked the P.S. folks if they wanted me to come to court to testify, but they said no, that wouldn't be necessary.

Later that day I heard the news that the court ordered the child released to his parents, which prompted my phone call to the referee who made the decision. I have to give him credit, at last he took my phone call - but he didn't change his mind.

I think that a big part of the reason this baby went home instead of to foster care was because it was a white, suburban, intact family. There were other kids in the home, I think, with no signs of abuse. If this had been a black baby with a single mom on Medicaid, I can't help but think that things would have been different.

If only they had been. About six weeks later this baby was found dead at home. The medical examiner ruled it a SIDS case, even though one of our hospital pathologists said the baby had a cut frenulum - the thing that holds your tongue to the floor of the mouth - that he said can indicate smothering. Like most pediatricians, I've seen a fair amount of child neglect and abuse, but this stands out as probably the most preventable death I've seen.

A couple of days ago Flea wrote about a family he reported to his state's protective services, and he criticized them for removing the children from the home. Maybe he's right in that case, but I don't know. We are all influenced by our past experiences; I think I'll always be one who's in favor of erring on the side of removing the kids if it's questionable.

Screamer

I could hear the woman's screams from far down the hallway. She was in labor, nearing delivery, and was really losing it. When I arrived at her room, she was writhing on her bed, laying partly crosswise on it, making it practically impossible to control the delivery of her baby. Any hope for rational response to instructions had been lost long ago.

In general, there is a fairly "normal distribution" of the amount of crying and moaning that occurs during labor and delivery. As you might expect, some women are fairly stoic, while others are more animated and show more pain. I find it hard to be judgemental of any of these women. I'll never know what it feels like to deliver a baby, but I imagine it as something akin to a bowling ball coming through a very tender part of your body, so I don't blame women for showing some pain. I really don't know how I would be if I were delivering a baby.

Every now and then, though, we get a woman like the one described above, whose response to pain is far beyond the norm, who totally loses control and goes absolutely bonkers. They move around on the bed, they close their legs, they don't push; they are very difficult to care for, and their lack of control just makes it worse for them. I like to think that I wouldn't be like that if having a baby, but who knows?

It didn't help that this woman's obstetrician, who happened to be a woman, was screaming right back at her. It was almost comical to see the two of them yelling and carrying on, although the situation was a little serious for anyone to be laughing. There aren't any easy ways to make a person who's "lost it" get it back, but I really think that calm explanations and instructions have got to be better than shouting at her.

Finally the woman delivered, in spite of herself, and things calmed down. Labor and delivery can be a crazy place, and the people even crazier.

Blood

Her baby had been born at 27 weeks gestation and was doing very well. She hadn't needed to be on a ventilator for long and now was cruising on nasal CPAP, which is when we blow air and oxygen into the nose and lungs with a little bit of pressure. The baby's hematocrit (the amount of red blood cells in the blood), though, had become quite low so we gave her a blood transfusion. The mother was a frequent visitor to the NICU and very knowledgeable about her baby's condition, but this day she was late and not there when we decided to transfuse. When she came in to find there had been a transfusion, she struggled to keep her composure but finally couldn't, her face cracking as she began sobbing.

This was a long time ago, at a different hospital where we didn't obtain consent before blood transfusions. Now we do and even if consent has been previously obtained I still try to contact the parents to let them know before a transfusion. Blood transfusions aren't that big of a deal to neonatologists. We do them frequently but not carelessly; they are simply part of our therapeutic armamentarium.

For parents, though, blood transfusions can stir an emotional reaction, even if they're not Jehovah's Witnesses. There's something about receiving another person's blood that really bothers some people. Part of it may be a fear of infections like HIV, but I think it's more than that. I think it's a very personal thing, taking another's blood into your own body. I don't understand it completely, but maybe it's sort of like chewing another person's already chewed gum, or licking their ice cream cone.

Over the past several years neonatologists have tended to be more and more conservative with transfusions, letting a baby's hematocrit drop lower and lower before transfusing them. I have done the same thing, although I have to admit that this practice wasn't always necessarily evidence based. In the past year approximately, two studies have examined the issue. One of them, from Iowa, suggests that this lower threshold for transfusing might not be good. The second study, from Canada and just published, suggests the opposite, that transfusing at lower levels is indeed safe.

Oh well, it's not like this is the first time we've had to deal with contradictory evidence in neonatal medicine. I'll keep transfusing when I think it's best, while all the while looking for better evidence to support my practices, and I'll definitely keep notifying parents before I do.

Generations

We have in our NICU now a set of twins with a 15 year old mother. Not only was she unfortunate enough to get pregnant at age 15, she became pregnant with twins. Not only was she unfortunate enough to have twins at age 15, she was unfortunate enough to have them at 27 weeks gestation. Both were on ventilators initially but now are just on some oxygen and growing well, although they still have weeks of hospitalization to go.

I have written more than once before of my combined feelings of sympathy and frustration for these moms, sympathy for their rough life and frustration with their choices that contribute to that rough life. In this situation, though, I have to say that my sympathy certainly outweighs my frustration. This 15 year old's own mother is apparently in and out of her life. Her grandmother, who is thin and wheelchair bound, has custody of the 15 year old. It seems like this 15 year old is sort of out there on her own, left to deal with 27 week twins as well as she can.

She's doing her best. Her twins have had some typical problems of prematurity, such as a patent ductus arteriosus (a blood vessel near the heart that is supposed to close remains open), and she has tried very hard to understand that. Her twins also have some unusual brain cysts (note to clinicians: not PVL), the significance of which is uncertain, but it might not be good. It's a lot for a 15 year old to take in.

I find myself being a little miffed at the 15 year old's mother, for not being there more for her, for not giving her guidance that might have prevented this teenage pregnancy, but I also realize that 15 or 20 years from now these twins might be mothers themselves, and then who am I to blame? The current 15 year old mother? When do we go from feeling sorry for someone because their inadequate upbringing leads to problems in their life, to being frustrated at them for not bringing up their own kids any better?

Is there anything we can do to prevent these twins from following in their mother's footsteps? I think there is. Personally, I think we need to have a big push for education about birth control and preventing teen pregnancies and that this education needs to be done in the schools and with public service advertising. I won't argue with people who say that this subject should best be covered in the home. Sure, it should be, but the fact is that it is not being covered in way too many homes, and way too many people are cutting their education and chances for a better life short because of it.

Amish

When I think of the Amish as a neonatologist, I think of the increased risk they run of having children with birth defects or things like dwarfism, because they are a small community and husbands and wives may be related, so their bad genes can get together and cause problems. I think of the fact that they probably don't have health insurance and that the whole community might chip in to pay a hospital bill.

Today, though, I think of the Amish in a different light. I think of the tremendous pain there is in the community that suffered the deaths of five schoolchildren at the hands of a madman. The thought of those small schoolgirls in their old fashioned long dresses and white bonnets lined up around the schoolroom, terrified by the gunman, is heartbreaking. Imagining their thoughts as they saw the gunman shoot the others and then turn the gun on them is too painful.

But I am struck by an Associated Press article I read about the Amish community's reaction to the slayings. At a time when many would be furious at the gunman and his family, the Amish are urging forgiveness. In fact, they are reaching out to the family of the murderer. One Amish neighbor comforted the gunman's family just hours after the shooting.

What a tremendous example they are for the world. Can you imagine a Palestinian offering forgiveness to a Jew after an Israeli army attack killed a Palestinian child? Or a Jew offering forgiveness to a Palestinian after the Palestinian's family member killed several Israelis in a suicide bombing? Or a Shiite forgiving a Sunni? A Hutu forgiving a Tutsi? A Northern Ireland Catholic forgiving a Protestant? Can you imagine how improved the situation in world hotspots like the Middle East would be if instead of a constant cycle of retribution, someone just offered forgiveness for a change?

I have never meant for this blog to be about religion, but I don't think forgiveness like this has to necessarily be a religious thing. It can simply be a progressive way to help to end conflicts. I'm not so naive to think that everyone will buy into it or that it will solve all the world's problems, but even if we can get people to try it a little bit it would be a good thing.

We sometimes think of the Amish as being backwards and old fashioned. We might laugh at them for not using electricity or automobiles; but in this aspect they are way ahead of the rest of the world.

Eighteen II

The baby had the typical features of trisomy 18: small mouth, clenched hands, narrow, tight hips, abnormal ears and feet, and so on. She would likely have the same natural course of babies with trisomy 18 if we did not intervene; 50% of them die within the first week of life, 90 to 95% die by age one year, with the survivors being severely mentally defective.

I had spoken to this mother prenatally about a month earlier, after her baby had been diagnosed by amniocentesis with trisomy 18. At that time she said she wanted everything done for the baby. Tonight, after the baby was born and they had a chance to hold the baby for a good while and see her, I talked to mother and father again. After congratulating them and telling them the baby was cute (because she was) and inquiring of the baby's name, I told them the baby unquestionably had trisomy 18. I told them the grim statistics about trisomy 18 and that many of these babies simply stop breathing and pass away. We discussed what they wanted done should that occur, and mother emphatically said she wanted everything done, including intubation and mechanical ventilation, including an IV if needed for hypoglycemia.

When she said that, I just felt very tired, and not only because it was 2 a.m. I was tired of having to discuss this with parents; I was tired of the parents trying to disbelieve the truth about their baby, tired of them not wanting to deal with the hard questions, tired of them not seeing my point of view, which is that we should allow nature to take its course in these situations. I've seen babies with trisomy 18 before, and I've seen many babies on mechanical ventilation, and I just don't think the two should go together. Why put an innocent child like this through needle sticks, IV starts, the trauma of having a tube rammed down their throat when it's not going to make much difference?

I know this probably sounds terrible, to complain of being tired at a time like this. I know it's not about me, it's about the baby and her family. I know the baby is a human being, and because of that we shouldn't take letting her die lightly. But I also know I've seen this picture before and have gone through the ethical and moral questions in my mind many times, while the parents are doing so - or maybe not doing so - for the first time.

The father said to me, "It's in your hands." Ah, if only that were true.

P.S. I wrote the above at about 3 a.m., right after talking with the parents. As I read it now in the light of day, I realize it might sound a little harsh. Don't worry, we did the right thing and are treating the family and child with dignity and respect. I also should say that I respect the opinions and rights of those parents who have done everything for their trisomy 18 kids, including heart surgery; their pictures and stories of the kids as they grow give me pause. But I guess I just want to share how it looks from our side sometimes.

Language

The mother labored, close to delivery, while the obstetrician and nurses called out instructions and encouragement. It was a big baby and they had to use a vacuum to get the baby's head out. Mother had been making the usual sounds, some cries and questions, but just before delivery she suddenly shouted "WHAT THE F---!?" She repeated the phrase a little louder, just in case anyone in the hospital had missed it the first time, and followed it up with some choice scatalogical terms.

It struck me as she said this just how rarely I hear that term in the delivery area. In an area filled with high emotion and people in pain, I practically never hear the F word, although I didn't realize that until I heard it at this delivery. I'm a little surprised by that. You would think we would hear it commonly as an exclamation - not only because it's a common expletive but also because the F word and pregnancies share a common origin.

I'm not sure why we don't hear it much. I mean, I'm sure our patients have it in their vocabulary. Yet, in the labor and delivery area, cries to an almighty being far outweigh the use of the F word. Don't get me wrong: I'm not asking to hear it more, just puzzling briefly over it's scarcity.

This mother had more unusual language, too. As mentioned before, this was a large baby, weighing more than 4 kilograms, more than 9 pounds. When told this the mother asked "Is that why it hurted so much?"

Yes, the nurse said, that's why it hurted so much.

Good grief - it's contagious.