As a certified nurse midwife, Emelia Udd is well acquainted with the complexities of labor and delivery. But as she faced the birth of her own second child last month in the midst of the coronavirus pandemic, she found herself weighing a number of troubling new scenarios.
Udd’s main worry was the possibility that she would be separated from her partner or her doula, “as policies evolved daily and everyone tried to adapt.” She was also afraid of being an asymptomatic carrier, “as many of those in the birth community have been exposed due to lack of screening, testing and [personal protective equipment].”
As a patient, it wasn’t always clear to her what to expect, but as a midwife, Udd knew this was because everything is in flux as health care workers deal with a rapidly evolving situation.
The outbreak of COVID-19, the illness caused by the new coronavirus, has changed almost all aspects of medicine in Seattle, even for people well-versed in it. But as medical centers take appointments online and postpone elective procedures, health care workers who specialize in women’s health care find themselves in a challenging position: delivering babies and providing care to new parents while on the front lines of a public health crisis.
Udd attributed the fluidity of the situation to “the lack of a coordinated nationwide response to the pandemic.”
As a result, local hospitals and health care workers have had to pick up the slack, enacting a variety of policies and precautions that include operating separate labor and delivery units for COVID-positive patients and limiting the number of people in the delivery room.
It’s all part of a delicate balancing act between staving off the virus and ensuring that patients giving birth can have as “normal” an experience as possible, at a time when, as Dr. Edith Cheng of the University of Washington puts it, “the only antidote to this virus is actually no exposure.”
How are hospitals protecting pregnant patients?
At UW Medicine, which weeks ago opened the area’s first drive-thru testing site, every patient admitted is screened for COVID-19, and this includes laboring patients or those arriving for inductions or planned caesarean deliveries, said Cheng, UW’s chief of service for obstetrics.
“Here at the University of Washington, this command system was set up as soon as we realized what was going on,” she said.
The turnaround time for the UW’s tests is two hours, so patients can be efficiently tracked through labor and delivery based on their COVID status. Health care workers wear personal protective equipment (PPE) around COVID-positive and symptomatic patients awaiting test results, said Cheng, but if an asymptomatic patient tests negative for the virus, “her labor and her delivery and postpartum and newborn care will be just a very normal, regular pathway.”
“Once you screen negative, you can basically enjoy your labor and delivery,” Cheng said.
Patients are screened for COVID-19 symptoms and risk factors upon admission to Swedish Medical Center, said Melissa Short, system executive director for women’s health and pediatrics, though the turnaround time for testing is 12-16 hours — longer than at the UW.
As at UW, patients without suspected or confirmed COVID-19 infections can essentially have a normal birth experience, albeit with social distancing measures in place while they’re in the hospital.
Other changes included the closure of Swedish’s Edmonds Family Birth Center on March 26; labor and delivery patients were referred for care to Providence Pavilion for Women and Children in Everett.
At Swedish’s First Hill campus, containment efforts extend to the hospital’s two different “geographically separate” labor and delivery units. One is now designated for COVID-positive and COVID-suspected patients, complete with its own operating room. Having two units makes it possible to keep exposed patients away from those who are COVID-negative and also prevents providers from “going back and forth between infected and uninfected patients,” Short said.
How are hospitals keeping newborns safe?
Perhaps the most controversial among new birth protocols is the Centers for Disease Control and Prevention’s (CDC) recommendation that women who test positive for COVID-19 be quarantined from their newborns. This is only a recommendation, though, health care providers said, and the patient gets to decide whether to separate.
The recommendation is backed by major health care organizations including the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), said Tanya Sorensen, executive medical director for women’s health at Swedish. (The World Health Organization has not made this recommendation.)
“The vast majority of spread of this virus is by contact and droplet,” Sorensen said, “So a baby is born uninfected, and that baby [is at risk] of getting the virus from the mother by droplets and contact.”
Sorensen said she’d seen emerging case reports of direct transmission from mother to child during pregnancy or delivery, but “nothing in my mind that’s super convincing.” So, if it is happening, it’s rare.
However, Sorensen cited a case series out of China which showed that “children can and do get COVID virus, and infants, when they get it, get much sicker than older children do,” and said this led the AAP to change its recommendation around quarantining parents from babies.
“We don’t know the absolute right thing to do for this virus in many respects,” she said. “But this is what we think is the most cautious. What we also think is that that is the mother’s decision.”
If a patient chooses not to separate from her infant, said Sorensen, “we have a very detailed protocol about how to best protect the baby in that circumstance.”
This includes masking, distancing the baby from the mother’s bed when the baby isn’t with the mother, washing breasts before breastfeeding, and hand hygiene. “We will do everything we can, regardless of what she decides, to help keep the baby healthy,” said Sorensen.
UW’s Cheng said COVID-positive patients who opt not to separate from their infants are trained in preventive guidelines set by WHO, and regardless of quarantine status, Cheng and her women’s and children’s health leadership colleagues at the UW recommended that patients continue to breastfeed their babies. “Breast milk is still the best for the baby,” she said. “And right now, there’s no indication that the virus is in breast milk.”
Separating parents from their infants can be “emotionally heavy … and extremely disruptive for all involved,” said Udd, the midwife. “There are risks and benefits to both separation and quarantine of parent and baby.”
Cheng acknowledges it could be especially frustrating for patients who are asymptomatic. But the data was clear to her: “These little babies of under 1 year of age are at risk,” Cheng said.
She hopes patients take protective measures that protect not just new babies and other children at home, but also everyone patients would come into contact with, including health care workers. “[I]f health care workers go down, then we’re even in worse shape,” she said.
Why the new limits on who can enter the delivery room?
In some cases, hospitals’ protective measures impact how many people are allowed into the delivery room or, in the case of a caesarean delivery, the operating room.
The limitations on OR access have to do with “infection control,” said Udd. “People similarly are asked to not leave the birth room for the entirety of the process — labor, birth, postpartum, to discharge — which, again, is in an effort to minimize the potential for viral spread.”
A routine C-section involves a team of 10-13 people, Cheng said, all of whom need PPE if they are treating a COVID-positive patient. The risk of infection is also different in an operating room. “In any C-section, there is a chance, although small, that we would have to convert into intubation,” she said. “And it is at the time of intubation when the virus is aerosolized into the room.”
Visitation to neonatal intensive care units (NICUs) is similarly limited for patients with confirmed or suspected cases of COVID-19.
At Swedish, COVID-positive patients have been asked to designate an asymptomatic person who’s had no contact with the family for 14 days to effectively care for a newborn who needs to stay in the NICU. (This is in addition to the support person a laboring patient is allowed to bring into the delivery room.) Short said there had been very few situations where this was necessary. Patients with COVID symptoms are limited to one supporter at Swedish; asymptomatic patients are allowed two — often a partner and a doula.
Overlake Medical Center in Bellevue has a policy similar to Swedish’s, but requires that doulas be certified. Mariah Falin, a certified doula and president of the certification and professional development organization PALS Doulas (formerly, the Pacific Association of Labor Support), said that fewer than a quarter of Washington’s 400 doulas are certified, and that certification, due to the costs involved, “can be a barrier to access.” To fill the gaps in credentialing amid new regulations caused by the pandemic, PALS has launched a provisional certification program with fees waived.
Should you change your birth plan?
What about pregnant people who, unnerved by the outbreak, are revisiting birth plans and considering changes, like moving a hospital birth to a home birth?
“I absolutely would not say that they shouldn’t do a home birth,” said Sorensen. “I think, though, that making a decision … at the last minute to have a home birth without fully informing yourself probably is more of a fear reaction than a reaction to what the reality is.”
Sorensen and the UW’s Cheng both said that a hospital setting, with its testing and precautions, was still likely safer than an outpatient birth center without the same capacity for screening.
Short, who is pregnant herself, said she plans to deliver at Swedish. “We have a really large population of patients that deliver their babies with us. We deliver almost 12,000 babies a year,” she said. She said Swedish’s labor and delivery staff are experienced in dealing with challenging birth scenarios and supporting their patients throughout the process regardless of what obstacles they face.
Udd, now home with newborn Wally, said that expectant families should seek out support and agency, and find health care providers who will give them a voice.
“Babies come during hard and easy times,” Udd said. “Their arrival is so important, as is their parent’s and family’s transmutation through the process. Identify people who will support you through this, come what may.
“Remember that the biggest asset in parenting is a willingness to embrace uncertainty and the unknown. Look for providers who will give you choices within the narrows. We will see you through, no matter what.”