Tuesday, December 12, 2006

Pawns

The note on the front of the chart read "If the father of Mary Doe's baby comes up here with any female, do not let him or her in to visit," and it was signed with the mother's name. I sighed. Once again, a mother was using her baby as a weapon in a fight with the father.

It's not that unusual and typically goes like this: The parents are unmarried and sometime before or around the birth of the baby have an argument. Maybe dad has taken up with another woman, or maybe it's something small, but being unmarried the mother has the right to control who visits the baby, and in her anger towards the father uses one of the only weapons at her disposal - visiting privileges for their child. Sometimes the parents fight and make up and visiting privileges change daily for the father, depending on the couple's status. If the parents are married or the father officially claims paternity, then the mother cannot keep the father from visiting, but those circumstances are fairly uncommon in our NICU.

Our social worker and I really don't like this, and even though it's legal for mother to do this we generally tell them they cannot do it. Let's face it; there are too many kids in urban America without a strong father or male influence in their life, and we hate to allow anything that might contribute to the father's absence from his child's life. Just because the parents don't get along doesn't mean the kid should be deprived of his or her father. Sometimes when we put it to the mother in those terms, she will let the father visit (although not necessarily the father's girlfriend, and who can blame her for that?)

It's not that we don't sympathize with the mother. Any father who impregnates a woman and then leaves her before the baby is born doesn't rate real high in my book. He's especially a rat if he shows up in the nursery with another woman as his girlfriend. But parents splitting up are a fact of life, and the children shouldn't be pawns in the disagreement between them, whether it's at birth or later in life.

Sure, the father should claim paternity, and we encourage them to do so if they want to visit, but that is not always done immediately. Also, the flip side of the father's bad behavior in showing up with another woman is the mother having multiple affairs so the father isn't sure if he's really the father. There's crap all around, but let's let the kids have two parents, even if they're not together.

12 Comments:

Anonymous amy said...

Our social worker and I really don't like this, and even though it's legal for mother to do this we generally tell them they cannot do it.

I pretty much agree with your post, doc, but is it legal for you and the social worker to lie to the mother about her legal rights? Something about this really doesn't sit right with me.

9:31 PM  
Anonymous Stacy said...

I have just spent quite a bit of time reading your past posts. I have a few comments. I hope you will bear with me and understand that we all should learn from each other.

Let me start by saying that I think neo docs and nurses are very special. The path you chose in life gives you the opportunity to change lives forever. Please do not forget this.

I read your post about how NICU parents can misunderstand your statements. I agree with you 100%. As a former NICU parent, I learned very early on, that my mind was not in a normal state. I wrote everything down.

My daughter was born at 25.5 weeks (805 grams at birth-635 at her lowest) after PROM occured at 23.0 weeks. During a meeting (that I requested) with a neo at the first hospital I was admitted to, hubby and I sat there while he told us that the best decision we could make was to let our daughter die if she was born before 26 weeks. He said that she would never be normal, MAY not walk or talk (he really did say this-I saw your post about this comment) and would be financially draining for us. Being my first pregnancy, I lost it. I yelled at this poor doctor (whose brutal honesty I now appreciate), had the head of hospital in my room within an hour, and was eventually trasferred to another hospital that had a level 3 NICU. There I stayed, being shot up with prenatal steroids to mature her lungs.

My daughter had a very easy NICU stay (compared to most 25 weekers). PDA was resolved with meds, stage 2 ROP self corrected, no bleeds, clean cranial ultrasounds, no infections, no bowel issues, less than 24 hours on the vent (she extubated herself), very few a's and b's, blah, blah, blah. She did receive massive amounts of steroids due to her lack of urinating, which was thought to be congetital adrenal hyperplasia. It cleared on its own also. Our only issue was with one nurse who was clearly overwhelmed (I don't blame her) but chose not to ask for help. Because of this, a blown vein with IV leaking for 3 hours (just like you mentioned in one of your previous posts) almost caused our daughter to loose her arm.

A few days before discharge our neo told us that our daughter was one of the best cases. She went on to tell us that there is no reason why our daughter would not lead a normal life. "A feeder and grower" She even went on to say that preemies born as early as my daughter are almost all turning out normal.

Hope you are still with me....

So, we have 2 neos, 2 different feelings on the outcomes of micropreemies.

Jump ahead 8 years. (boy I wish it only felt like a little jump) My daughter is intelligent. She does walk. Even though she had very mild CP, you can't tell. She does talk. She actually quite advanced in language and reading. She does not have any lung issues. Is she normal? NO She has chronic constipation, severe fine motor delay, an anxiety disorder, OCD, possible bi polar, epilepsy, eating disorder, severe sensory issues, blah, blah, blah.

My point to this mini novel... please, please, make it a part of your continuing education to understand that these preemies are NOT turning out normal. If you attend Hot Topics-ask to be educated on the outcomes of these babies you save. Inform parents that, although their preemie will most likely survive, they are at a great risk for a lifetime of medical, and more importantly, psychological issues. The research by Dr. Maureen Hack is a great place to start.

I know parents will not appreciate your honesty at the time, but I assure you they will appreciate the knowledge in the future. Fasle hope is very damaging and not accurate at all.

I cringe when I am introduced to a parent of a new or very young preemie. Their blind optamism (most of the time fed to them by the NICU staff due to their lack of knowledge on the outcomes-I'm not placing blame) is scary. I feel like screaming, "just wait until they reach school age".

I am a part of many preemie groups. My daughter is by far, not the only preemie with issues.

Since parents are not in a great state of mind when they are faced with the possiblity of having a preemie, they are not going to believe the statistics. It is our nature as parents to want our child saved. Once the preemie is born, there needs to be neos that are honest with parents and let them know that the chance that their preemie with be "normal" is actually quite low.

Like I stated in the beginning...

I think that neos are special. You are wonderful and work miracles on a daily basis. But, please, be honest with parents. They need it.

9:52 AM  
Anonymous Anonymous said...

Stacy....what did the poor neonatologist who WAS honest with you get? He had to deal with a raving lunatic parent and was for sure pulled up by the hospital administration as well. The bottomline is that you HAVE to be politically correct in this country. People like sugar-coated opinions and will quickly turn on you if you say something they dont want to hear. I am ALL for withdrawing support/not doing heroic measure to save micropreemies, because frankly, I havent seen any of them develop into 'normal' children.
I believe in using statistics when talking to patients parents. For eg, only 10% of babies born before 26 weeks gestation will have a normal/average IQ (hypothetical statement). This way, you have conveyed your message and it is for the parents to decide what they want to do.

3:29 PM  
Blogger Ex Utero said...

Stacy (Neo Doc - this is a HiJack)

I heard Maureen Hack speak at SPR last year and she's brilliant, but the populations she's been following was generated decades ago and outcomes have already changed substantially since then. One of the differences between then and now will be the amount of steroid use (more then verses much less now). Steroids stunt brain growth, so that will be something to look for. Still, I think it likely we will see some differences if we look hard enough and this is an area of great concern.

Here is a review she wrote that's pretty comprehensive: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7MFD-4HVF257-6&_coverDate=04%2F30%2F2006&_alid=507771289&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=23256&_sort=d&view=c&_acct=C000039638&_version=1&_urlVersion=0&_userid=709071&md5=fa0ee8e217c94379ec6256893f72166b

Neonatology is a rapidly changing discipline but the fact is, we are always going to have a population of infants who don't do well precisely because we don't rest on our laurels. It's tough to know how to counsel parents from one year to the next and even harder when we step up to the bed of a parent who is in the "circle the wagons" mode. It is especially difficult to tell them don't intervene because early research suggests that your child might have a higher risk of mental health issues. All we can do is mention it in the long litany of things that can go wrong and, honestly, I imagine that very few do. In the scheme of things it is awful, but it's just so far off/away at the time that most parents can't fathom it.

There's no magic bullet here in terms of parental counseling unless it is this: The public needs to become educated about the realities of extreme prematurity. Parents need to think ahead of time about what kind of decisions they would make if their growing fetus were to come out tomorrow (and in particular at 22-23 weeks gestation). Unfortunately, this is a very uncomfortable area for most people. It feels emotionally and ethically like the same sorts of issues surrounding planned parenthood, reproductive freedom, and (dare I say it) abortion -- because we are talking about how to value the life of an ex utero fetus...who also happens to be a child. It's not a discussion zone America has a good track record in. So instead, we have neonatal medicine on one end and the bible belt on the other pushing down a road that, following it to it's logical conclusion, will eventually have us doing everything at conception. In the mean time, people like Stacy are going to feel like they got blind sided by the system. The truth is, I'm not so sure that she didn't... and yes, it makes me angry.

4:34 PM  
Blogger Breath said...

Thank you, ex Utero. A remarkable, thought-provoking reply with lots more pointers to further reading.

It is more dramatic when it is neonates, but I've met too many people who are horribly disappointed when their loved ones fail to be resuscitated or or are altered following a dramatic brain insult. They report such conflicting stories from the staff that they tend to cling on to the more optimistic ones and are devastated when they don't have the outcome they felt entitled to.

Whether it is extreme prematurity or end of life issues for an older person, there seems to be a tremendous amount of unjustified optimism that leads to people feeling betrayed at one of the most vulnerable times in their lives.

Regards - Shinga

10:24 AM  
Anonymous Dianne said...

Let's face it; there are too many kids in urban America without a strong father or male influence in their life, and we hate to allow anything that might contribute to the father's absence from his child's life.

Ok, there might be times when this is a reasonable statement. But always? Is the lack of a father always and inevitably tragic?

Studies of children of lesbian couples demonstrate that children do fine with no "father" in the picture--in fact, children of lesbian couples are essentially indistinguishable from their straight-parent-raised peers in terms of adjustment, mental health, etc.

Of course, it is generally harder for a single person to raise a child than a couple. But a number of men (and women) seem to think of the father as a sort of extra child--he doesn't contribute to the care of the child and just creates more work for the mother by demanding that she take care of him as well.

And, really, what can a man who shows up to see his newborn baby with a woman who is not the mother contribute to the child's life? He's sure not a good role model. (Ok, that's an overgeneralization...The "female" in question could be his sister or mother whom he's bringing to see her niece/granddaughter. He and the mother could have split amicably months before. They could have a mutually agreed on non-exclusive relationship. But a guy showing up with a woman he picked up after he abandoned the woman pregnant with his child? The baby's probably better off not knowing him.)

11:29 AM  
Anonymous Leah said...

Neonatal Doc: I love your blog and am an avid reader - please keep up the great writing. I want to hear your thoughts.

I can't say I always agree with you but you always provide a good read. I admire your work and really enjoy the glimpse into your world.

I just had to chime in because of the flaming above - of course someone will take issue with your statements and not see the generalizations for what they are.

1:07 PM  
Blogger WendyLou said...

OT ?

Do preemies have a higher risk of having a fracture than full term babies?

I'm asking because my DD, an ex 34 weeker IUGR 2lbs 13 oz baby has a plastic fracture of her femur. She and my mom were sitting on a bench when the bench collapsed. My mom was holding DD by the leg and we thing she twisted in the fall as she gripped DD's leg to not drop her.

Thanks

2:07 PM  
Blogger neonataldoc said...

Thanks for all the great comments. Stacy, I hear you. Instead of replying at length here, let me write a post replying to you. (I always need ideas to write about, anyway.)Ex utero, I don't mind being hijacked and agree with you.

Amy, I don't really lie to parents. I guess I was exaggerating, but we do let parents know, if we have the chance, that we don't think it's a good idea to exclude the father.

Dianne, I see your point, but in the NICU I have no way of knowing whether the dad will be a good one or not. I think inner city kids often lack male role models, so I'll take my chances that having a dad in his life will be a good thing. Leah, thanks for the compliment.

Wendylou, extremely preterm babies often have osteopenia, poorly mineralized bones, that can increase the risk of fracture in the newborn period. A 34 weeker could possibly have a minor degree of that, but not much. Maybe IUGR could contribute to it, but I guess I'm not convinced the fracture is due to prematurity, especially if your child is quite distant from the newborn period, since a normal diet would make up for her mild potential osteopenia fairly quickly. What does OT stand for?

5:26 PM  
Blogger Surgeon in my dreams said...

exgroAren't some parents just terrific.

My son was used as a pawn when I left his daddy in 1999, Poisoned his mind and then feel apart and my son felt forced to help him not fall apart because of my leaving.

My son has not spoken to me since 1999. My son has two babies now. Two babies I am not alloed to see or to hold or to tell them how much I love them.

My son and I were always very close. He came to me when he was hurt or in troule or had banged up his dads truck. Me - not his daddy.

Now who did my ex-husband hurt the most by turning my son against me...?

12:17 AM  
Blogger WendyLou said...

OT in blog land usually means... Off Topic. Sorry, I meant to say this has nothing to do with the topic of your post. I tried to respond to the Pawns post but only came up with really nasty things to say about parents who do this. I've seen this happen all too often in the child welfare system.

Thanks for answering my question. I was trying to figure out if this is something which would happen to a full term baby, or if it is because she was preemie. This is just so not a question that comes to mind while sitting in the ER, again, when I was more worried about her getting RSV from the wheezing baby in the hall. She was 34 weeks by date, we are sure of that, but her neo felt she was developmentally and size wise about 29-30 weeks. He felt the IUGR contributed to that. I was just wondering if this is a one time accident, or if easily broken bones were something that I have to look forward to in her future.

Other than a splint which she hates she is doing wonderfully. It's the adults in her world who are having a hard time with this, ie her mom, dad, grandma, and day care provider.

1:07 PM  
Blogger purple_kangaroo said...

My first thought when a mother didn't want the baby's father to visit would be to wonder if the father was abusive. There are a few good reasons to take such a stand.

3:00 AM  

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