Birthing in a Pandemic - Obstetrical Care During Covid -19
Updated: Mar 30, 2020
Birthing Through a Pandemic
Obstetrical Care During Covid -19
By Lisa Arshawsky, CNM, RN
March 28, 2020
Edited March 30
First off - I am sorry for all the soon to be mothers out there right now. This just sucks. By now you have heard about new guidelines that seem to be changing daily. This post is not a scholarly paper - it is prepared for YOU - the pregnant mama, the doula, the birth educator and the prenatal postnatal yoga teacher there to support mothers and expecting families. It is to help inform and prepare you This will take your dedication to accept whatever might be happening at the time you deliver. Hire a doula or birth educator now to prepare you through some form of interactive education. Practice meditation and visualizations.
This post will answer the questions I have been receiving these past 2 weeks. The information was crossed checked with source articles, Centers for Disease Control and Prevention (CDC) suggested guidelines, and the American College of Obstetrics and Gynecology (ACOG) compared with position statements with the UK’s, RCOG. This is where we stand currently with obstetrical care during the corona virus pandemic.
In the end, no one can take away from the love of having your child. The outer environment might be in chaos for the next several months at least but your internal environment can hold the beauty of your child's birth story.
Q n A
What are the risk factors in pregnancy during this pandemic?
As far as medical science knows, there are no known teratogenic risks if a mother contracts the virus in the first trimester during embryology. Unlike the Zika Virus, that started spreading in 2015, where the risk of birth defects from contraction of that virus is 5-10%, this virus is only a threat to mothers if they contract covid-19. Furthermore the risks and rates of illness and pneumonia are the same for the general population. To date, no pregnant mothers have died because of Covid-19 pneumonia or related illness.
As far as we now know, pregnant women are NOT MORE likely to contract Covid -19. However, the immune system in pregnancy is more susceptible to its symptoms if one does become positive after exposure, especially during the last trimester. This means that if you are pregnant, the advice would be to use extreme caution right now to protect yourself from exposure as your symptoms may be more severe. There are also risk factors once you have it which you can see further in this post. Have someone grocery shop for you. Heed the federal guidelines of social distancing. Wash your hands.
What do appointments with my provider look like?
You should ask your provider if Telehealth appointments are an option to avoid exposure during routine care. Obstetrical care involves blood pressure monitoring and urine dipsticks at each appointment so this may not be an option for all visits but there is no precedent for the current state of obstetrical care. Have a discussion about the possibility of monitoring through an online interactive appointment. If you are able to obtain a fetal doppler, blood pressure monitor, urine ph sticks and measuring tape sent from your OB’s office, this may be an option. Ask whether grouping your appointments around necessary testing is an option. The UK is already doing this. Perhaps your provider is not yet aware of this possibility. If your OB is not open to setting new standards for their own practice, ask what precautions are being taken at the office to prevent spread and transmission. Are they scattering patients to avoid sitting in a waiting room with other patients? Is it just an OB office or are there GYN or primary care patients there who pose a greater risk to you because of exposure? Are they wiping down equipment per CDC guidelines?
You should know that I have been at some clinics in the past few weeks that have not been using extra precautions such as spraying down exam tables or surfaces adequately, sanitizing their fetal dopplers with alcohol pads or using new measuring tapes for fetal growth with each patient. I am horrified by these actions. Please be an advocate for yourself and ask your clinicians about their safety practices.
Can I have my Doulas and Birth Partners in the Hospital Setting
The World Health Organization still supports the integrity of birth stating: "All pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth [which includes] having a companion of choice present during delivery" (WHO, 2020). At least in the US, hospitals have slightly different versions of how they are handling extra personnel during labor and delivery at this time. Administrative protocol from hospital to hospital depends on community spread in that area. The CDC put out a position statement that reads “if a restriction of all visitors is implemented, facilities can consider exceptions based on end-of-life situations or when a visitor is essential for the patient’s emotional well-being and care” (CDC, 2020). This means it is the hospitals choice to deem doulas or even partners as essential or non-essential. This is their right in implementing protocol and I foresee being exercised with extreme prejudice during this climate.
Please ask your provider about what is happening at the hospital you are delivering in. Until rapid global testing is invented for this particular virus that can confirm a negative status for both mother and partner at the point of care (same day, or an immediate test) families are at the mercy of a country trying to stem the spread. This is motivating some women to look into other avenues of where they might deliver. Partners and doula’s are an integral part of a birth team and without them, I fear the harm being caused to countless women when we deny them the vital support they need. Please ask you providers NOW and see if they can advocate for your rights at the hospital.
Can I Home Birth
Home birth and some birth centers are still able to deliver out of the hospital but there are a few cases which show fetal compromise during labor and delivery. I saw some recommendations for continuous fetal monitoring during labor which can’t happen in the home birth setting. Although ACOG has no position yet on out-of-hospital births during this pandemic, some OBGYNS are already discouraging home birth. ACOG in general still supports birth centers over home births. The newborns with fetal compromise however were born to mothers who were positive for the virus AND symptomatic. Out-of -hospital births should still be considered safe, especially with the one-on-one care that reduces a mothers risk for exposure over the longevity of her pregnancy. Unfortunately you many not have a choice or other available options. The unknown factor here is if you are exposed to this virus you may not show symptoms for a few weeks. Screening is important but the unknown factor is driving decision tree's right now.
Birth tubs and water births are being discouraged as well. I can only presume this is due to the secondary risks of ones inability to use universal precautions during a water birth. Birth is not a sterile procedure and water birthing may just complicate that. I will post any new position statements that comes out on this. The UK has already suspended home births and water births within their national healthcare system which may influence ACOG’s position on this as well.
Perhaps you have never considered midwifery care. Now is the time to start talking about it. Support your local midwives by calling them and having a conversation. Call the birth centers in your area.
What are the risks if I am or may be positive?
During pregnancy, there are a few cases now for preterm birth possibly due to the effects that infection and fevers can have in pregnancy. Illness, infection and fevers are a general risk for preterm rupture of membranes (PROM) and Preterm Birth which is found in the general pregnant population.
Risk at Delivery: One study from Wuhan, China looked at the clinical characteristics of Covid-19 in 38 positive pregnant mothers. They tested amniotic fluid, cord blood, neonatal throat swabs, breast milk and genital fluid and found no evidence for risk for transmission during pregnancy or through the delivery process.
A second cohort study out of Wuhan China looked at 33 babies born surgically to Covid-19 positive mothers who were symptomatic and found 3 neonates that tested positive, all on day 2 of life. Samples taken from nasopharyngeal and anal swabs were found to be maternal sources. After isolation and some intervention in NICU, all 3 newborns tested negative by day 6 and 7. The news media is mis-interpreting this publication stating that there may be direct transmission because they tested positive at birth but that is not exactly how this reads. We can't rule out vertical transmission from this publication and we can't rule out transmission through secretions during the surgical birth (as they tested positive on Day 2 of life). What we can still surmise is that transmission most likely occurred from contact with mother during breastfeeding or any other contact they may have had but more information is needed. See the study below in reference section.
Newborns in general are at risk from exposure as everyone else once they are born. This could happen during breastfeeding by a positive mother merely by close contact between mother and baby rather than in breast milk (which is not found to be the case). Breast feeding at this time is still recommended.
Cesarean versus Vaginal Delivery
Method of delivery does not reduce transmission. The studies in China of neonates with nasopharyngeal swabs were born to mothers who had C-sections. The other preliminary studies have found no evidence of the virus in vaginal or amniotic secretions. Although you might hear that a cesarean section is warranted if you are at risk or are SARS Covid-19 positive, this is not the case and mothers should be allowed to deliver vaginally.
What Happens at Delivery if I am positive?
Only if the mother is positive are recommendations now for separating mother and baby after birth for 14 days. The CDC has” advised hospitals to consider temporarily separating the mother with confirmed or suspected COVID-19 from her baby until the mother's transmission-based precautions are discontinued” (CDC, 2020). This is a shared decision between parents and health care providers. Additionally, infants born to mothers with confirmed COVID-19 should be considered a patient under investigation and appropriately isolated and evaluated”. My heart aches for this one but it should be noted that the CDC did state ‘this is a shared decision”. Unfortunately hospital protocols will always trump a physicians singular practice decisions.
There is some good news for those advocates of natural birthing. Delayed cord clamping is still recommended as is keeping the white biofilm covering of vernix caseosa (vernix) on baby for 24 hours as a protectant mechanism. Please ask your practitioners about this as part of your birth plan
We still don't know all there is to know and transmission at birth seems to be one of those question marks that can't fully be ruled out. This is a difficult place to be in but one of the positive action steps you do have control of right now is reducing your risk for exposure. If you aren't exposed, then through the process of pregnancy and delivery at least you can have some peace of mind. Stay tuned for up to date
What can go on my Birth Plan during this time?
PREGNANCY and BIRTH PLAN
Can I have Telehealth appointments? What is their precaution practice at the clinic?
I would like to delivery vaginally, as per the current studies which show no evidence for vertical transmission or transmission during the delivery process. I realize we still don't know all there is to know.
I would like my birth partner at the delivery (You should establish the plan of who can be there as of now. If your doula can’t be there, take as many tele-classes as you can with them now. Have them record some hypno-birthing tracts for you. Prepare through the pregnancy with meditation and prepare your mind body and soul with acceptance now)
I would like to delayed Cord Clamping as per the studies which show no risk for transmission
I would like to leave my baby's Vernix on for 24 hours
If I am positive for Covid, I would (or would not) like to breastfeed while wearing protective face gear. Will I be able to access that given the shortages of medical supples?