Practicing evidence-based medicine, as obstetricians know, is not always possible when one does not have evidence due to lack of data or long-term experience in pregnancy. During the COVID-19 pandemic, the evidence changed so rapidly that we were compelled to alter our strategy frequently as we learned more about the impact of this disease on our vulnerable patient population. The COVID-19 pandemic taught us that, in unprecedented times, centering the safety of the patient, her child, and the health care team requires quick thinking, flexibility, and above all effective communication between team members.
Here, I share our institutional experience in providing practical obstetric care through various stages of the still-evolving COVID-19 pandemic. We based our strategy on guidance from the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG),1,2 and the Society for Maternal-Fetal Medicine (SMFM).3-5 We were reminded yet again that the only constant is change and that timely but thoughtful adjustments were needed to keep up with the coronavirus.
Changes to prenatal care
Like many others, our institution has provided continued in-person outpatient prenatal care to both our low- and high-risk patients throughout each stage of the pandemic. While continuing to provide the necessary obstetric care, we made alterations to limit exposure and practice social distancing when possible.
Limiting patient support persons. One significant change was to restrict or limit support persons in the outpatient clinics based on guidelines reflecting community infection rates. Recognizing that this was not optimal for our patients’ emotional well-being, we needed to become more flexible in using technology to include family or support persons in prenatal visits and ultrasonography exams.
Altering test frequency. Using the guidance from SMFM,1 we changed the frequency of our antenatal testing and ultrasonography exams in the following ways: We increased the duration between indicated growth ultrasonography to every 4 weeks and decreased fetal antenatal testing to weekly, with twice-weekly testing continued for the highest-risk patients. Early first-trimester ultrasonography exams were limited and, when possible, delayed until after 10 to 12 weeks’ gestation or combined with other indications (nuchal translucency). Prenatal visits for low-risk patients were spaced out using existing models if the patient was amenable, especially in early pregnancy.
Adjusting staff assignments and using telehealth. In the early part of the pandemic, we divided into 2 groups to limit the number of clinicians at any one site: a dedicated group of outpatient clinicians who saw patients in the clinic only and a dedicated group of inpatient clinicians who staffed labor and delivery and the inpatient antepartum service. Additionally, our consultative maternal-fetal medicine service transitioned to a telehealth platform and performed the majority of consults remotely. Ultrasonography exams at various sites were read remotely and pertinent findings were communicated directly to patients via phone or the telehealth platform. Amniocentesis continued to be offered.
Responding to lower COVID-19 case numbers. When the number of COVID-19 cases decreased in the summer and fall of 2020, we returned to our prepandemic in-person practices, but we continued to offer telehealth visits as an option for patients who desired it. Patients were limited to one support person.
Shifting gears again. During the second surge of COVID-19 in our region, we used our experiences from the first to transition our practices to reduce in-person contact. Appointment frequency was decreased if appropriate, and we developed a tiered system of antenatal testing frequency based on risk factors. Visitors were again restricted, with exceptions made for extenuating circumstances. Consults were transitioned to telemedicine as appropriate and ultrasonography exams were read remotely when possible to limit exposures. Given the varied experiences with telemedicine and patient preferences, patients who desired in-person consult were (and are still) offered this option.
Some patients who were interested in telehealth but unable to access the technology were offered appointments via telehealth with the use of our clinic devices. Telemedicine increased our flexibility in offering consults as one provider could see patients at different office sites in one session. We continued our routine inpatient and outpatient coverage during this time as this kept our coverage options more flexible and expanded our obstetric backup plan in response to increased rates of community infection that affected both clinicians and patients.
Coordinating care for infected patients. One vital part of our prenatal care during the COVID-19 pandemic was to coordinate with our colleagues in medical specialties to provide outpatient care for patients with confirmed or suspected COVID-19 during their period of isolation or quarantine. Patients could be seen as outpatients in a dedicated space that used appropriate personal protective equipment (PPE) for not only prenatal care but also any needed in-person evaluation for COVID-19. Our obstetric clinicians and sonographers performed exams, antenatal testing (in the form of biophysical profiles), and indicated ultrasonography exams (such as umbilical artery Doppler studies and fetal growth assessments). This required a concerted effort and excellent communication between teams to provide the necessary care in the safest manner possible.
Continue to: Universal testing on labor and delivery...