Keywords
COVID-19 - labor and delivery - novel coronavirus - psychosocial challenges - universal
testing
A viral infection of novel coronavirus disease 2019 (COVID-19) emerged with initial
cases reported from Wuhan, China, in December, 2019.[1]
[2] As of March 11, 2020, COVID-19 had become a pandemic. By April 15, there were1,914,916
confirmed cases worldwide and 605,390 cases with 24,582 deaths in the United States.[3]
[4] New York State has the most cases, 201,834 (33.3% of the total reported cases in
United States).[4]
Several organizations have recently promulgated standards for the care of COVID-19-infected
pregnant women.[5]
[6]
[7]
[8]
[9] While these standards are evidence-based and reasonable, executing them can be challenging.
There have been some publications providing guidance for instituting COVID-19 care;
however, they covered only a few selected topics (e.g., operating room and second
stage of labor).[10]
[11] Having now cared for over 80 such women, we can share our experience, highlighting
the difficulties in translating policies into practice, and offering practical tips
for implementing the new standards into obstetric practice ([Table 1]).
Table 1
Summary of practical tips
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Summary of recommended changes
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Outpatient practices
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• Screen patients prior to presentation to outpatient offices
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• Revise protocols to decrease frequency of visits (office and perinatal unit)
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• Use video conferencing or phone visits
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• Combine ultrasound with office visit when possible
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• Ask patients to delay visit until symptom free for 8 days
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• Designate a high level provider to follow-up on COVID-19 patients
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Inpatient practices
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• Screen patients prior to presentation for scheduled procedures (inductions and
cesarean delivery)
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• Centralize visitors screening at hospital entrance
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• Screen unscheduled patients at presentation
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• Repurpose space: designate rooms for COVID-19-positive or PUI patients in Triage
and inpatient ward. Cohort patients when needed
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• Use video or phone to connect with patient
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• Set up rooms to minimize health worker exposure (long-IV tubing to place IV pumps
outside rooms)
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• Prioritize testing for pregnant patients
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• Early discharge for low-risk mothers and neonates
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Protocols and dissemination
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• Create clear protocols with use of algorithms and checklists
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• Designate one leader in charge of editing and dissemination
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• Use multiple media for dissemination: blast emails, online repository, online advisory
meetings, videos, simulation
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Provide psychosocial support to both patients and staff members
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• Work with your institution's human resources and designated institutional officer
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• Create back-up schedule to avoid fatigue
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• Say thank you often
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Abbreviations: COVID-19, novel coronavirus disease 2019; IV, intravenous; PUI, persons
under investigation.
Outpatient Practices
Two aspects of outpatient care needed to be considered: (1) how to change practice
to minimize viral exposure of healthy patients and providers, and (2) how to utilize
outpatient resources to off-load some of the inpatient burden of taking care of COVID-19
patients.
To address the first point, a system should be implemented to screen all patients
by phone for COVID-19-related symptoms and exposure prior to their presentation to
perinatal units or outpatient offices. In addition, perinatal unit protocols should
be revised to decrease the frequency of ultrasound testing and the visit frequency
for high-risk and low-risk patients in outpatient offices, using published guidelines.[8]
[9] Using those guidelines, we were able to decrease our ultrasound volume by over 50%.
We maintained approximately the normal frequency of contacts with high-risk patients
by converting office visits to phone visits.
Each institution should assign a designated COVID-19 provider. To address patients
who screen positive for COVID-19 symptoms, they are asked to stay home to isolate,
and set up a system of outpatient follow-up. The designated practitioner acts as a
referral provider for all pregnant COVID-19 patients. That provider maintains a list
of patients and performs regular phone visits, with the frequency of calls dependent
on patient acuity. Patients should also be given the provider's contact number, which
is essential for answering patient questions, and for decreasing the flow of low-acuity
patients into inpatient triage areas. If a patient, who was followed on an outpatient
basis, needs in-hospital evaluations, either for maternal indications (e.g., shortness
of breath) or for fetal monitoring, the designated provider coordinates visits between
the patient and the in-patient staff.
Inpatient Practice
Changes to the inpatient practice can be more challenging. All patients referred to
triage, or scheduled for cesarean delivery or induction, should be screened for COVID-19-related
symptoms prior to presentation. Hospitals should institute screening at the entrance
(with a questionnaire and temperatures) for visitors accompanying patients. Labor
and delivery registration staff and nursing must be taught to screen patients at presentation
(screening questions in [Fig. 1]). Among the 950 patients evaluated in triage, between March 15 and April 15, 2020,
81 (8.5%) screened positive by questionnaire. Of the patients who screened positive,
21 (25.9%) had no symptoms but did have exposure, 32 (39.5%) had a cough and no fever,
and 28 (34.6%) had moderate/severe symptoms (e.g., fever or shortness of breath).
Fifty-eight (71.6%) of the patients were confirmed COVID-19 positive by screening
through polymerase chain reaction (PCR) of nasopharyngeal swabs. Among the patients
who were COVID-19 positive (n = 58), 23 (39.7%) had mild symptoms and 23 (39.7%) had moderate-to-severe symptoms.
Among the patients who tested negative for COVID-19 (n = 23), nine (39.1%) had mild symptoms and five (21.7%) had moderate-to-severe symptoms.
Fig. 1 Sample screening and testing algorithm. COVID-19, novel coronavirus disease 2019;
ED, emergency department; L&D, labor and delivery; PPE, personal protective equipment;
PUI, persons under investigation; RRT, rapid response team.
The labor and delivery waiting room may need to be repurposed, removing most chairs
to prevent congregation of large groups, or reconfigured to create a closed off patient
intake space. Patients who screen positive should immediately be given a mask, have
their cell phone number recorded, and be escorted to a designated, isolated COVID-19
triage room. Nurses and providers should take a patient history over the patient's
cell phone prior to entering the room. The setup of the COVID-19 designated triage
room should be capable of streaming maternal and fetal monitoring information to screens
from outside the room. Personnel from Information and Technology should be involved
in planning for the organization of the unit.
If a patient needs admission, she should be transferred to a designated room, which
should be set up for phone or overhead communication with the patient, and have a
window installed in the door. Intravenous (IV) extension tubing should be utilized
to allow the IV pumps to be placed outside the rooms, decreasing nurses' exposure
to COVID-19 patients.
As our hospital began to see more and more COVID-19 patients, we became unable to
accommodate all of these patients in the designated rooms. If this happens, hospitals
should create rooms where COVID-19-positive patients can be cohorted. This can be
a labor room that can accommodate multiple patients. An unused gynecological operating
room (available because of the suspension of elective surgery) can be used as a recovery
room for up to three postpartum/postoperative COVID-19-positive patients. With adequate
resources and materials for testing, universal testing of all patients admitted to
labor and delivery should be performed with providers wearing personal protective
equipment for all patients until the result is available. However, the unavailability
of universal COVID-19 testing and/or a long-turnaround time for test results can significantly
limit the ability to cohort patients. Strong consideration should be given to prioritizing
pregnant patients when allocating testing resources within an institution. The benefits
of cohorting include increased safety to the labor floor staff and other patients
due to confined exposure, conservation of personal protective equipment (PPE), streamlined
care for COVID-19 patients, and the psychosocial benefits of decreased isolation for
COVID-19 patients. Cohorting of patients may be unnecessary if the prevalence of coronavirus
is low, but should be instituted if and when it increases.
Development of Clinical Protocols and Information Dissemination
Development of Clinical Protocols and Information Dissemination
One of the biggest challenges of the pandemic is the constantly evolving flow of clinical
information. When we saw our first few COVID19--infected patients, we managed them
on a case-by-case basis, with a multidisciplinary approach and extensive consultation
by other services such as emergency medicine, infectious disease, internal medicine,
and intensive care unit (ICU). If the number of COVID-19 cases remains low, that approach
can be maintained. However, the rapid increase in volume and the overwhelmed critical
care services made such a model impossible. Instead obstetricians should work with
colleagues in other disciplines to create a series of guidelines and protocols that
match their institution's needs. It is important to note that due to the decreased
respiratory reserve in pregnancy and fetal requirements for maternal oxygenation,
pregnant patients require different thresholds than the general population for oxygen
supplementation and ICU care. As resources become limited, specific allocation of
respiratory equipment and ICU care for pregnant patients will be needed. Discussions
about these resources should be held early in the course of preparation.
Due to the constantly changing information, protocols should be updated on a regular
basis. In our experience, designating one leader in each discipline (nursing, physician,
and resident staff) to distribute information can decrease misinformation and insure
clear communication among multiple providers.
Psychosocial Challenges
The COVID-19 pandemic poses unique psychosocial challenges for pregnant patients who
are too numerous to be addressed in detail in this paper. The difficulties span all
aspects of care including outpatient communication, patient screening, labor management,
breastfeeding, and postpartum bonding between the mother and her newborn. The ability
for frequent reciprocal communication with patients to mitigate stress is essential,
and creating systems for different modes of communication (e.g., phone, e-mail, and
text) are helpful.
An unexpected challenge was addressing the patients' and their visitors' reluctance
to answer screening questions truthfully due to fear of isolation during the hospitalization
and labor. This should prompt strict screening protocols, including mandatory temperature
measurement for all visitors, and allowing only one designated visitor for the entire
hospitalization. Despite such measures, we continue to experience inadvertent COVID-19
exposure due to lack of universal testing and misinformation obtained during the screening
process. Support systems during hospitalizations, such as virtual doulas and easily
accessible phone and video connections have the potential to relieve patient anxiety
and promote accurate screening.
Maternal and newborn bonding remains a significant challenge. Frequent communication
with the parents, providing video streaming from baby cameras in the NICU, educating
parents regarding risks of transmission and providing multiple options for newborn
nutrition are some useful strategies.
The psychological burdens on providers must also be considered. In addition to the
fear of infection, there is the fear of being a “transmitter” to family members. Directly
addressing this is a critical component of maintaining morale in the midst of the
pandemic. Psychological services should be available to all staff.
Conclusion
The standards promulgated by American College of Obstetricians and Gynecologists (ACOG)
and Society of Maternal-fetal Medicine (SMFM) are extremely helpful. Putting them
into practice can be challenging. The blueprint for implementation that is presented
in this article should help providers and hospitals to plan as the number of cases
of COVID-19 increase in the United States.
