Practical obstetrics in pandemic times: Teamwork, flexibility, and creativity promote safety for patients and the care team
How one institution adapted to provide safe obstetric care in the midst of the
COVID-19 pandemic
Staying flexible to the changing
COVID-19 environment
Postponed in-person visits. Whenever possible, deliveries that were not medically indicated and in-person outpatient care visits were postponed until isolation/quarantine precautions could be lifted to avoid the need for special pathogens precautions, separation of mother and infant, and visitor restrictions. We did not postpone any medically indicated deliveries or appropriate care due to COVID-19 alone. As the CDC guidelines changed regarding the timing of infectivity, we had to continually re-evaluate when a patient could return to regular outpatient care instead of the COVID-19 clinic and/or be delivered.
Mother-infant separation. As outlined in an article we wrote with our pediatric colleagues, originally all infants were immediately separated from their COVID-19–positive mothers, and delayed cord clamping was not performed.6 We adjusted our protocols as experience and data grew regarding the risk of transmission to the newborn from asymptomatic mothers and as updated recommendations were made by ACOG and the CDC. Currently, if desired, asymptomatic mothers are not separated from their well term infants. We practice our standard delayed cord clamping technique for all patients. Masking, hand hygiene, and physical distancing are used to reduce the risk of infection transmission. Breastfeeding is encouraged if the patient desires it, either directly using precautions or supported via pumping.
Reduced workplace exposure. Along with many others, we are even more cognizant of reducing the risk of workplace exposure; thus, we conduct our daily multidisciplinary huddle and physician transition of care sign-outs. We use multiple rooms for our larger group with secure video chats, and we limit huddles to a single representative from each specialty.
Medication protocols. Early in the pandemic in our area, we limited antenatal corticosteroids for fetal lung maturity to patients who were at less than 34 weeks’ gestation, per ACOG recommendations, carefully considering necessity in the critically ill. Now, we continue to administer antenatal steroids according to our usual protocols up to 36 6/7 weeks, per ACOG and SMFM recommendations, regardless of illness severity.7 Nonsteroidal anti-inflammatory drug use, once limited in COVID-19–positive patients, are now used again. Additionally, we had a comprehensive venous thromboembolism (VTE) prophylaxis protocol for our obstetric patients, and we have added special consideration for prophylaxis for patients with moderate to severe illness or other VTE risk factors. While we do not perform routine circumcisions on infants of COVID-19–positive mothers, we have a process in place to provide that service after discharge when isolation precautions are lifted.
Labor accommodations. As COVID-19 cases increased in our hospital during recent months, we made one more significant change in our care protocols. To open up space in the ICU, we moved our care for asymptomatic COVID-19–positive laboring patients to our new labor and delivery unit with implemented special pathogens precautions. This is not revolutionary; many other hospitals did not have the same capability we did with our existing collaboration with the ICU for critical obstetric care. However, this change again required communication and collaboration among multiple care teams, agreement on the qualifications for delivery on labor and delivery versus in the ICU, and physical alteration of our unit to accommodate additional isolation precautions.
Visitor policy. Another change is that we have opened up the visitor policy to welcome an asymptomatic support person for the COVID-19–positive labor patient, giving special attention to adherence to isolation precautions. Our staff members have embraced this change as they have everything else, with cautious optimism and focus on keeping both the patients and the health care team safe. Our moderate to severely ill patients continue to be cared for in the COVID-19 unit in close collaboration with our infectious disease and ICU colleagues.
It’s all about teamwork
I hope I have given a clear example of our approach to providing obstetric care in the ever-changing landscape of the COVID-19 pandemic. We embraced this period of necessary change as practically and safely as possible for both our patients and our health care workers. We learned multiple times along the way that what seemed to be a good idea was not feasible, or not the ideal option, or that COVID-19 had changed the rules of the game again. Our team met daily if not more frequently, as we found we had to constantly adapt and change to each new challenge or new clinical scenario. When we struggled, it generally related to a gap in communication.
I am privileged to work with a dedicated, selfless, multidisciplinary team that rose to the occasion. They had the focused goal to provide the highest quality and safety in obstetric care while offering compassion and empathy for the experience of having a baby during a pandemic. ●
The author would like to acknowledge Danielle Prentice, DO, and Jaimie Maines, MD, for their manuscript review.
- The requirement for reduced in-person contact due to the COVID-19 pandemic challenged our traditional obstetric care models. This led us to comprehensively incorporate technology for communication with patients and their families and to significantly alter how, where, and when we delivered prenatal care.
- Both patients and clinicians needed to adjust to the impact of these changes, especially concerning visitor policies.
- Early incorporation of universal COVID-19 testing for labor and antepartum patients was initially instituted to improve patient and staff safety and to preserve PPE. However, it quickly led to the need for various protocols for both anticipated and unanticipated clinical scenarios.
- As new data emerged and the number of cases fluctuated throughout the pandemic, our approach and protocols necessitated flexibility: Our strategy for maternal and neonatal care early in the pandemic was not the same as our current approach, and it will likely change several more times before we are done.
- One of the biggest challenges to our care team was maintaining standards of excellence and safety in obstetric care while also adhering to the physical barriers of isolation precautions and maintaining vigilance to reduce exposure risk during our routine workflow.
- The physical and operational specifics of our institution determined our approach to obstetric care during COVID-19, in part because halfway through the pandemic we moved our maternity unit from the adult hospital to a new center within our children’s hospital.
- The frequent changes in the knowledge of and recommendations for COVID-19 highlighted the importance of maintaining multidisciplinary communication on a daily, if not more frequent, basis.
