Maternity

Maternity is a 1st season episode of House which first aired on December 7, 2004. When a newborn has a seizure and another newborn becomes ill, House believes an epidemic is spreading through the hospital. Cuddy dismisses the suggestion until other babies show up with the same symptoms. House and his team race against time to diagnose the illness, but the choices they have to make may be lethal to some of the newborns if their diagnosis is incorrect.
This episode, the fourth in the series, is the first to break away from what has always seemed to be the standard format of "patient of the week". It is also the first episode of the series to involve the death of a primary patient, one of the infants.
It's also the first episode to bring up another issue that was later explored in All In, Kids, and Meaning - House seeing a medical mystery that no-one else sees and everyone else believing House has seen something that's not there. Later, we learn that House has a history of looking for zebras when all that's there is a horse and making the patient suffer for it.
As for the development of other characters, Cameron is put front and center here and House figures out that she has lost someone to illness. It's only revealed later in the series who that person is and how it further complicates her character.
==Recap==
The parents of a newborn are discussing what to call her when the baby starts spitting up, even though she hasn't eaten. They call the obstetrician to examine her, and he realizes the baby is having a seizure. She is taken to intensive care.
House is watching a medical drama in the obstetricians' lounge when Dr. Lim comes in. Dr. Lim and another doctor start talking about the fact their newborn patients both had a seizure although they were both healthy at birth. House leaves the room. He goes to intensive care and finds two babies with similar symptoms, although the first has been diagnosed with a bowel obstruction and the second with a high fever. He thinks it's a contagious infection. Wilson thinks they have unrelated diseases. House goes to Cuddy to ask the two patients be put in isolation. Cuddy thinks the other doctors are right but House is standing by his opinion and says they have an epidemic. However, Cuddy says two sick babies don't prove an epidemic.
House gets his team. They go to look at all the other babies in the maternity ward. All of the other babies are fine. However, House finds another sick baby on another floor with the same symptoms. Cuddy moves the babies with a fever to isolation and starts directing women in labor to Princeton General.
There are now four sick babies, and they are getting worse - rising fever and blood pressure dropping to the point where they are unlikely to last for a day if it keeps up. They can't find anything they have in common. Cuddy goes to build a team to swab surfaces for infections. House starts to think what the disease might be. House orders two powerful narrow spectrum antibiotics, Vancomycin and Aztreonam, for the two most likely resistant bacteria.
They do a MRI on the babies, but find nothing. They start them on the antibiotics. Cameron tells the mothers of Baby Boy Chen-Lupino that their baby's sick, but Foreman has to step in to tell them how bad it is. One of his moms says she had a cold while she was pregnant, but Cameron rules it out because the child was healthy at birth.
Foreman challenges Cameron about not being up front with the parents. Cameron tells Foreman it's easier to die than to watch someone die and defends her habit of not being completely honest with people about the conditions of their loved ones.
Cuddy is still looking for the infection by swabbing surfaces. She admonishes a student for letting his tie flop around over all the surfaces, spreading any possible infection.
The antibiotics are shutting down the babies' kidneys. However, they can't decide which antibiotic to discontinue because they both cause kidney damage and they still don't know what disease they have. House tells them to withdraw a different antibiotic from each of two patients. However, this will mean one of them is likely to die, but the one that lives will tell them how to treat the rest. His team challenges him, but House makes it clear he knows what he is doing.
Cuddy and the hospital's lawyer challenge House's decision. House can't get informed consent because the parents would have to know. The number of patients is now up to six. The lawyer doesn't want to do it, but Cuddy lets House go ahead.
Cameron and Foreman each tell one set of parents each that they have to discontinue one of the antibiotics. Foreman is straightforward, but Cameron is evasive.
Wilson asks Cameron if she told the parent how sick the child was. He upbraids her for not preparing the parent for the worst possibility. However, she snaps back at him that it won't matter what she said if the baby does die.
Cuddy is finding more contamination, but nothing related to the illness. She also sees the med student with the loose tie again and cuts it off, reminding him she warned him about it.
One of the parents finds Chase and tells him she's afraid her marriage might break up if the child dies. He tells her not to get ahead of herself. At that point, one of the babies goes into distress - it's Baby Boy Chen-Lupino. The baby goes into cardiac arrest. Chase and Foreman work hard, but can't get the heart beating again. House calls off the code blue and calls time of death. They realize that the other antibiotic, Vancomycin, is the one that will work. House tells Cameron to tell the parents. She resists, but he insists and tells Wilson to make sure she does her job.
Cameron goes to see the parents, but freezes up, leaving Wilson to tell them. They start crying. House is angry at Cameron and at Wilson for letting her get away with it. However, at that moment, Chase comes and tells them the Vancomycin isn't working either. They think it might be Vancomycin resistant staph, but it's very rare. House blames the medical profession for overprescribing antibiotics. However, then he wonders why the dead baby's blood pressure was so low before he died. The only explanation is heart damage. He sends his team home and starts an autopsy on the dead baby.
The next morning, House shows the team the autopsy results - it's a heart virus. Foreman notes that there are still thousands of possibilities. However, they can't draw enough blood to test for them all. They start eliminating possibilities and getting likely candidates. Wilson starts looking for antiviral agents that are effective against them. Even Cuddy is helping. They narrow it down to eight and get a sample from an uninfected baby as well.
All the infected children are antibody positive for three viruses, but the healthy baby also tested positive for two of them. However, House realizes the healthy babies got immunity from their mother's antibodies. Foreman goes to take blood from the mothers. They rule out everything but Echovirus 11, a disease that only causes diarrhea and a rash in adults, but can be deadly to infants. Foreman tells the parents that the only possible treatment is experimental.
Cameron lets the parents help when they change the baby's bed linen so they can be close to their newborn.
House wants to speak to Foreman about how Cameron is doing. Foreman thinks she is doing fine.
Foreman checks the patients - they are getting better. He and Chase give the parents the good news.
House goes to see Cameron. He thinks she's had personal experience with death. He asks her where she got the idea to let the parents help with the baby. She doesn't want to talk about it and tells House he can be a real bastard. As she's leaving, she sees one of the families getting ready to leave and brightens up.
Wilson finds House wondering where the virus came from. He also wonders why Cuddy didn't find the person who spread it as they must have been showing symptoms. He's also mystified by the fact that none of the babies had common personnel. However, he sees one of the volunteer women who hands out teddy bears coughing, and she also has a runny nose. He realizes all the sick babies had a teddy bear. He celebrates by watching Prescription Passion in the maternity doctor's lounge, courtesy of the fact that the clinic patient wants him to help with her pregnancy.
==Clinic Patient==
A patient is exercising but not losing weight. House tells her she's pregnant. She thinks it's impossible because she's on a birth control implant, but House tells her it didn't take. She tells House the baby might not be her husband's. House tells her to have the baby if the ex-boyfriend looks like the husband.
The woman comes back with her husband to get his blood tested for a paternity test on the pretext he might have mononucleosis. House schedules a paternity test. He realizes that she may want to have an abortion if the baby is her ex-boyfriend's.
The tests show that the baby is the husband's. The patient is grateful and wants House to deliver the baby, but House wants to be done with her until he realizes he can use her as an excuse to hang out in the comfortable lounge reserved for maternity ward doctors.
==Major Events==
*Cuddy states for the first time she would be happy to pay for a psychiatrist for House if he would agree to see one.
*Cameron is shown to display reluctance when it comes to telling patients bad news.
*House discovers that an elderly woman volunteer at the hospital had the virus that affected the newborn babies (it's unknown if he confronted her about it).
*This episode features the first death of a patient (who was a part of the primary storyline), Baby Boy Chen-Lupino.
==Title==
The title of the episode comes both from the fact that most of the case takes place in the maternity ward and from the case of the clinic patient.
==Zebra Factor 1/10==
Echovirus is a common infection, and just about everyone gets it at some point during their life. It's generally only dangerous to infants.
==Trivia & Cultural References==
*The antiviral drug used to treat the newborns is most likely Pleconaril, an experimental pharmaceutical for Picornaviruses (which include Enteroviruses like Echovirus 11).
*A lot of people thought that CMV, which is part of the herpes group of viruses, should have been ruled out when the patients did not respond to the most common drug to treat herpes - acyclovir. However, CMV is not affected by acyclovir so it should remain a possibility.
*The discussion about "Hunting Wabbits" [sic] is, of course, an allusion to Bugs Bunny's arch-nemesis Elmer Fudd.
*TiVo is an American brand of digital video recorder which works on a subscription service.
*The Magic 8-ball is a novelty device that consists of an icosohedron inside a liquid filled giant billiard ball with a viewing window. The user asks a yes or no question, and turns the viewing window to the top to see one of the 20 possible yes/no/maybe answers.
*A Hail Mary pass is a football play, made in desperation, where the quarterback throws the ball as far as possible into a group of his receivers hoping that either one will catch it or that the defence will interfere with the pass resulting in a penalty call.
*It's very clear to see that baby dolls replaced actual babies in most scenes. You can clearly see this as the dolls don't move. In the opening scene, only close-ups of the baby had an actor instead of a doll in the scene.
==Reviews==
*TV.com users rated the episode an 8.8. They picked Hugh Laurie as the Most Valuable Performer in the episode.
*IMDB users rated the episode an 8.5 with 28.8% of it rating it a "10" and "8" being the most common rating. It rated highest with females under the age of 18 who averaged it a 9.7, and worst with males over the age of 30 who rated it an 8.3.
==Medical Ethics==
===Diagnostic trials===
It's not inherently unethical to treat a patient without a definitive diagnosis. For example, in this case, patients with fevers were given antibiotics, an excellent first choice that could work without a diagnosis ever being reached. Generally, the safer the treatment, the more ethical it is to attempt the treatment during the diagnostic process.
However, no treatment is without risk. With newborn infants, an allergic reaction to an antibiotic is not a great risk, but as the team soon finds out, most antibiotics pose a risk of kidney damage in high doses and the problem is magnified in a newborn patient. The problem in this case wasn't the use of antibiotics, but the dose. Each infant had to be given a full dose of each antibiotic, essentially a double dose for the purpose of side effects. While the use of one dose posed no risk to the kidneys, both together would result in almost certain permanent kidney damage and death.
Although in this case neither treatment turned out to be effective, the ethical conundrum faced by the team was real, as were the legal risks of withdrawing what might be an effective treatment. In effect, the two sickest babies were guinea pigs for the less sick babies. Had one treatment actually worked, and the rest of the babies saved as a result, the hospital would almost certainly be facing a lawsuit for malpractice and failure to provide informed consent. In addition, both House and Cuddy may have been facing disciplinary charges for deceiving the parents.
===Keeping people informed===
House and Wilson were rightfully concerned about Cameron's failure to keep the parents informed about the seriousness of their child's condition. Although it is ethical to keep information from a patient when the doctor has concerns about the effect of the news on the patient, in almost every case the parents, the spouse, a medical proxy or a guardian ad litem have to be kept informed about the patient's true condition.
In this case, it was obvious that the parents were standing in the shoes of their newborns from a patient information standpoint. They were entitled to any information that would have been provided to a conscious adult patient. Wilson probably knows more than anyone else how difficult this could be, but whether the prognosis is a matter of hours or years, patients may want to use the time they have left to their best advantage, such as contacting family. Ms. Chen and Ms. Lupino, for example, may have reached out to their friends or parents for support. They may have wanted to see if it was possible to seek out a second opinion. They may even want to contact a lawyer to consider a malpractice suit or determine their legal rights. Their reaction showed that they also wanted to be as forthcoming as they could with the doctors. As House pointed out so well in Three Stories, letting someone know that they're dying may provide a diagnostic clue.
It cannot be stressed how difficult this can be for a physician. When faced with the same situation in House Training, Foreman put his fist through a wall after having to tell the patient she had less than 48 hours to live because of their mistake. Moreover, as Wilson has shown, a doctor can often provide needed emotional support to their patient at this moment which often makes it easier for the family to deal with the doctor after the patient's death. The reaction of the parents to the death of their child indicates first and foremost their alienation from Cameron and this lack of trust can also make it more common for family to bring a lawsuit.
===Prescribing antibiotics===
House's discussion of the responsibility of the medical profession for drug-resistant strains of bacteria is fairly accurate. For example, the spread of MRSA from hospitals to "the wild" is most likely the result of patients insisting on Vancomycin to treat common staph infections, even though most staph infections are not highly resistant and can easily be treated with penicillin or other common antibiotics. Another factor is the tendency of patients to stop taking antibiotics when they feel better, rather than finishing a complete course of treatment. Although the body is usually strong enough to fight off the infection, the surviving bacteria can spread to other patients and are more likely to be resistant to the very antibiotic used to treat the disease.
However, as House later discussed in Occam's Razor, in the American "pay for visits" health care system, a patient who is out of pocket perhaps over $100 for a doctor's visit is unlikely to be satisfied by mere reassurance that they require nothing more than rest and recuperation. A patient with a viral infection may be given antibiotics, which are generally safe, merely to mollify them. However, the use of antibiotics in this manner again can make the patient's other bacteria resistant to the drugs.
Ideally, when a patient actually needs antibiotics, they should be started on the most common type that would likely cure the infection, then should be closely monitored. In most cases, patients on antibiotics start improving in a matter of days and, if they continue to get worse, it's clearly obvious at that point they need another antibiotic.
===Patient confidentiality===
Although in this episode we see that an infant has no expectation of confidentiality, even children have some expectation of privacy when dealing with a doctor. In Kids, a pregnant 12-year-old about to have an abortion is fully entitled to withhold this information from her parents.
Sexually-transmitted diseases, from gonorrhea to AIDS, are a common exception to this general rule. As they can be deadly if untreated and often show no symptoms until they are untreatable, contacts have to be notified so they can be tested and treated. Doctors can lose their licenses for failure to report cases to local health departments, which follow up with all the necessary contacts if the patient is unwilling or unable to do so. However, even in this case, sharing such information with persons outside the contact group can lose someone their job.
Jill, of course, spontaneously shared confidential information (an affair) with House. The fact that this was irrelevant to the medical treatment does not relieve House of his duty to keep the information confidential. Moreover, there is no really good advice he can give Jill despite his offhand remark to have the child if the lover resembles the husband.
Jill, on the other hand, puts House in a bind when she brings Charlie around for a paternity test. Even though the test is harmless, it does require House to lie about the reason for the test in order to preserve Jill's confidentiality.
===Neckties===
Cuddy is right about neckties. Although many patients like to see doctors dress in a more business-like manner, all clothing collects pathogens and, unless the clothes are regularly laundered, those pathogens are a primary source of hospital acquired infections. The reason lab coats and scrubs are tolerated for hospital personnel is because they're usually laundered on a daily basis which along with regular hand washing can cut way down on secondary and opportunistic infections.
A tie clip is a great compromise and most of the characters who wear ties on the show, like Chase, Foreman, Taub and Wilson, wear them religiously. They make the tie part of the rest of the clothing and prevent it from touching contaminated surfaces accidentally. It also keeps it out of the way in an emergency where it could easily touch a patient or medical equipment.
==Goofs==
*Early in the episode, the team is discussing what kind of infection the epidemic must be and they rule out both parasites and viruses, figuring it must be a bacteria. However, they never considered fungi.
*A confused bit of chronology. House tells the obstetricians that he will be delivering a baby in five months and mentions March. However, the episode is clearly set on December 2 because that's the date of death given for Baby Chen-Lupino. March would only be three to four months away.
*As the Hartigs leave the hospital, Ethan the father is carrying flowers. However, in the cut to the slow motion shot, the person pushing the wheelchair is now holding the flowers.
*A blood pressure of 80/40 for a newborn is well within range, not dangerously low. A similar blood pressure in an adult would be dangerous.
*When the team starts naming viruses, Foreman mentions toxoplasmosis - which is not a virus, but a parasitic protozoan.
*Wilson mentions that ribavirin was ineffective. This should rule out respiratory syncytial virus (RSV), which responds well to it. Instead, Cuddy rules out herpes and later adds RSV to the list.
*Foreman says that the entire group of TORCH viruses can be ruled out. However, Chase later suggests CMV, which is the "C" in TORCH and it is added to the list.
*When Chase is treating Baby Chen-Lupino's cardiac arrest, he describes it as ventricular fibrillation even though when we look at the monitor the heart has completely stopped - asystole.
*It's unlikely a 36 hour old baby would not have been fed, but when House describes Baby Hartig's case, that's how old he says the baby is and the Hartigs tell Dr. Lim that the baby hasn't eaten.
==Quotes==
:House: Lift up your arms. You have a parasite.
:Jill: Like a tapeworm or something?
:House: Lie back and lift up your sweater. You can put your arms down.
:Jill: Can you do anything about it?
:House: Only for about a month or so. After that it becomes illegal to remove, except in a couple of states.
:Jill: Illegal?
:House: Don't worry. Many women learn to embrace this parasite. They name it, dress it up in tiny clothes, arrange playdates with other parasites.
:Jill: Playdates?
:House: [shows her the ultrasound] It has your eyes.
:Wilson: I'm amazed you're still in the same room as a patient.
:House: People don't bug me until they get teeth.
:House: Get up. We're going hunting.
:Foreman: For what?
:House: Wabbits.
:Cameron: It's easier to die than watch someone die.
:Cameron: Needle in the haystack.
:House: It's worse than that. We don't even know if it's a needle we're looking for.
:House: See, this is why I don't waste money on shrinks, 'cause you give me all these really great insights for free.
:Cuddy: Shrink! If you would consider going to a shrink, I would pay for it myself. The hospital would hold a bake sale, for God's sake.
:Jill: Thank you so much. I gotta get you a gift or something.
:House: Sometimes the best gift is the gift of never having to see you again.
:Jill: Okay. All right.
:House: We have an epidemic!
:Cuddy: Two sick babies is very sad, but it doesn't prove an epidemic.
:House: How many do?
:Chase: Good news: No epidemic.
:Foreman: [to House] Tragic, huh?
:Jill: Do you think you...
:House: No
:Jill: ...could do the prenatal...?
:House: No
:Jill: ...or deliver the baby?
:House: That would be "no".
:Jill: Okay...
:House: This is our fault. Doctors over-prescribing antibiotics. Got a cold? Take some penicillin. Sniffles? No problem. Have some azithromycin. Is that not working anymore? Oh, got your levaquin. Antibacterial soaps in every bathroom. We'll be adding Vancomycin to the water supply soon. We bred these superbugs. They're our babies. And they're all grown up and they've got body piercings and a lot of anger.
:House: How's Cameron?
:Foreman: Dr. Cameron?
:House: Sure, let's start with her and move on to all the other Camerons we know.
:Foreman: I'm sorry – I'm just not used to you asking about someone's well-being.
:House: I can understand how the question would surprise you. I don't quite get how it would confuse you.
:Foreman: Why do you want to know?
:House: Why do you want to know why I want to know?
:Foreman: Just curious.
:House: Me too.
:Foreman: You don't get curious.
:House: I'm the most curious man in the world.
:Foreman: Not about trivialities.
:House: Then this must not be trivial.
:House: I sometimes forget patients. I thought you were this idiot who didn't know how to use birth control.
:Charlie: C'mon, Jill - he obviously doesn't want to talk to us.
:House: Oh, I was trying to hide it...
:House: The most successful marriages are based on lies. You're off to a great start.
:House: If [Cuddy] doesn't solve this soon, her head's going to explode and I don't want to get any on me.
:Cuddy: Well, there's got to be something in common.
:House: Yeah – that would be the difference between an epidemic and a coincidence.
==Cast==
*Hugh Laurie as Gregory House
*Lisa Edelstein as Lisa Cuddy
*Omar Epps as Eric Foreman
*Robert Sean Leonard as James Wilson
*Jennifer Morrison as Allison Cameron
*Jesse Spencer as Robert Chase
*Ever Carradine as Karen Hartig
*Hedy Burress as Jill
*Cress Williams as Hospital Attorney
*Melissa Marsala as Judy Lupino
*Alexandra Bokyun Chun as Kim Chen
*Kenneth Choi as Lim
*Ben Parrillo as Kubisak
*Sam Trammell as Ethan Hartig
*Dwight Armstrong as Charlie
*Shawn Carter Peterson as Male Med Student
*Nate Torrence as Young Man
*Jocelyn Jackson as Young Woman
*Marc Menard as Soap Opera Doctor
*Madison Bauer as Soap Opera Patient
*Donna Stearns as Volunteer
*Amber Matthews as Nurse
*Baby Girl Hartig
*Baby Boy Chen-Lupino
*Baby Boy Hausen
==Release Dates==
*United States - December 7, 2004 on Fox
*Canada - December 7, 2004 on Global
*Estonia - January 6, 2006
*Hungary - April 12, 2006
*Germany - May 30, 2006
*Finland - October 12, 2006
*Mexico - January 31, 2007
*France - March 1, 2007
==In Other Languages==
A good example of a title that seems to be simple to translate into other languages, but isn't for several reasons. To an English speaker the title has an appropriate double meaning - "of or pertaining to motherhood" and "place in a hospital for women giving birth". However, Spanish places a lot more of a burden on the word depending on context, including, "state of being a mother or parent" and "in relation to a mother in hospital waiting to give birth". A "maternity ward" however is a "sala de partos" (roughly "delivery ward"). French similarly places a burden on "maternité" which although it has a formal meaning of "state of being a mother" can mean the same as "maternity", "motherhood", "childbearing" or "mother and child" as well as being the exact translation of "maternity ward". It is also commonly used in the phrase "Le congé de maternité" ("maternity leave").
As such, the Spanish is pretty much a direct translation, although it doesn't have the same nuance as the English title. The French need to see the word "maternité" in context to get any meaning out of it so it's used in a sentence that indicates it's a place (à la) and not a person or an abstract concept.
*Spanish – Maternidad (Eng. "Maternity" or "Motherhood")
*French – Panique à la maternité (Eng. "Panic at the maternity ward")
*German – Nichts hilft (Eng. "Nothing helps")
==Links==
*Episode page at IMDB
*Episode article at Wikipedia
*Episode page at House MD Guide
*Episode article at TV IV
*Transcript at Clinic Duty
*A review of the medicine at Polite Dissent
*Episode page at TV.com
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Category:Season 1
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Category:Episodes ending in the patient's death