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The current Coronavirus pandemic is ever-evolving and we are learning more every day about SARS-CoV-2/COVID-19 and pregnancy. Click here to see the most recent episodes, articles, and resources on this topic.

Overview

A lot has happened over the last week since we first discussed the coronavirus on the podcast. This article covers the updates on how this pandemic affects you during pregnancy, whether or not you get exposed to this virus. You will see changes to your access to prenatal care and changes in your birth plan as a result of this pandemic. This is an ever-evolving situation and this article is the most recent info and data available as of March 22nd, 2020.

Helpful Links

Article and Resources

This episode we are talking more about the coronavirus with lots of updates. You know I have been following this very closely. If you are clicking links and reading these studies you may notice they look a little different than the format of the studies I usually link to. Many studies regarding COVID-19, are being released prior to going through peer-reviews and some of the other red tape required to publish a study. Time is critical and the data we do have needs to be available as quickly as possible.

In the previous article we covered all of the basics around the coronavirus and this week we are digging into more information that we did cover last week and updating you with more information that has come out this week. If you have not read that article I suggest you go back and read that before this one. Thankfully there are more conversations taking place about how this pandemic will impact people who are pregnant, especially as it relates to your access to prenatal care and how this could impact your labor and birth. This is something I will continue to update you on.

This is an ever-evolving situation and this article is the most recent info and data available as of March 22nd. I will be updating info as we learn more. Let me know how I can help you. Send me your questions. I am here to help you navigate this situation as much as I can.

An Email from a Listener in Italy

“I am currently 21 weeks pregnant and living in Italy and thought I would share what I have seen here so that people can maybe have an idea of what could happen in the states if it gets like it is here. I had my morfologica (anatomy scan) ultrasound a couple of days ago and the hospital where they did it called before to say no one could accompany me into the room (usually, of course, this is allowed).

I also have friends that are about to deliver and both them and their partners are required to be in quarantine with no outside contact for 14 days before the anticipated date (both are planning on c-sections for medical reasons). Not sure how that would work for natural (vaginal) births at this time. The situation is constantly changing so I am not worrying about it too much for now but thought I would share just so people may realize that they have to adjust. It was a hard call to get as this is our first child and I really wanted, plus my husband really wanted to be there, but we must remember these rules are being put in place to protect us and hopefully keep us and our babies safe which is what we want.”

What I want you to take away from this email is that changes are being made to prenatal care and births. While these policy changes are not ideal, the purpose of them is to keep you, your baby, and everyone else safe. The United States is predicted to be about 2 weeks behind Italy. As more cases of COVID-19 show up we will see more changes in hospitals and birth centers. We need to keep in mind that these rules are being put in place to protect everyone. 

An Update on Testing

We have seen a lot more testing in the United States but there are still a lot of barriers to getting a test and these are not widely available to everyone yet. ACOG and the Society for Maternal Fetal Medicine have an algorithm to aid practitioners in assessing and managing pregnant women with suspected or confirmed COVID-19. There have not been changes to this in the past week. If you do not have symptoms they will not test you. This seems to be pretty much across the board in the United States and I have heard a lot of anecdotal reports that even people with symptoms are not being tested if they are not at risk for being admitted to the hospital. The good news is that the World Health Organization recommends that pregnant women with symptoms of COVID-19 should be prioritized for testing.

How Pregnancy Affects Your Risk

According to ACOG pregnant women do not appear to be at a higher risk for severe disease. This has not changed in the past week, which is good news. We are not seeing evidence that being pregnant is an increased risk. However, ACOG does state that pregnant women are known to be at greater risk of severe morbidity and mortality from other respiratory infections such as influenza and SARS-CoV. As such, pregnant women should be considered an at-risk population for COVID-19. Remember, there are some changes during pregnancy that could affect you if you are exposed to SARS-CoV-2. First, your immune system is suppressed during pregnancy which can make it more difficult to fight off a virus. Second, as your pregnancy progresses and your baby and uterus grow you will have a decreased lung capacity. That is due to less space for your lungs, which is not ideal for a respiratory illness.

New Research on Whether You Pass SARS-CoV-2 to Your Baby

When something is transferred from you to your baby during pregnancy it is called vertical transmission. Last week we talked about a very small study from China that included 9 pregnant patients who all had a cesarean birth in the third trimester. This study showed the virus was not transmitted to the babies. Fortunately, more research has come out in the past week. There is another small study of three pregnant women who all tested positive for COVID-19. All 3 had vaginal births and all three babies tested negative. Yes, these are very limited studies but all very promising in showing that this virus, when contracted in the third trimester, is not showing transmission to babies. This study is particularly interesting because all babies were born vaginally. In the previous research, we discussed the births were all cesarean.

In one other study of four mothers who were positive for COVID-19, three of the babies also tested negative. The COVID-19 status of the fourth baby was not known because the parents did not consent to test. More good news supporting that the SARS-CoV-2 virus is not being passed to babies. This was in China and for all four births, the babies were separated from their mothers at birth and were not breastfeeding.

Social Distancing is Still Critical

I cannot emphasize enough how important social distancing is right now. Last week I mentioned that I thought that we would be seeing more rules in regards to social distancing and that has happened. The governors of California, New York, New Jersey, Connecticut and Illinois told their residents to stay indoors as much as possible. They have said that all nonessential workers must remain at home.

In cities like San Francisco, $400 tickets are being issued to people who are not practicing social distancing. In other countries not obeying these rules is punishable by fines of up to $100,000 or jail time. The United States has not taken it that far yet. It will be interesting to see how the local and national governments respond to people who are not taking these “shelter in place” orders seriously. Remember the big aim of social distancing is to slow down this virus to avoid overwhelming hospitals.

Image credit: New York Times.

Don’t Panic, Plan

I know there is so much we don’t know and there is a lot of fear around this current pandemic. You should not panic. You can plan. There is a lot you can be doing right now to plan and prepare for changes to your routines, your prenatal care, your birth, and your postpartum period. It is always a good idea to have a backup plan. Hopefully, you do not need it, but if you do you will be prepared.

Changes to Your Prenatal Care

Doctors and midwives may be spacing appointments out more so that multiple people are not sitting in a waiting room together. Allow for some flexibility with scheduling. More appointments are moving from in-person to virtual. If you have the opportunity to conduct your appointments virtually, take advantage of it. You want to limit your risk of exposure as much as possible. New guidelines are coming out in the American Journal of Obstetrics & Gynecology MFM recommending all appointments happen via telehealth. They advise that patients should obtain a blood pressure cuff to use at home. They also recommend that no support person should accompany the patient to outpatient visits. I have always advocated for your partner to attend prenatal appointments with you. If your care provider requests you do not have any additional people at your appointment get your partner on the phone during your appointment or pull them in via FaceTime. We need to be thinking creatively about how we can work with these new rules.

There are some appointments that are challenging to do remotely. One of those is the glucose challenge screening which is a gestational diabetes screening test. This screening test is performed between 24-28 weeks and is considered to be a standard routine test in the United States.

During this test, you drink a sweet liquid of glucose (sugar) and then have blood drawn one hour from having the drink, as blood glucose levels normally peak within one hour. To limit the time you are sitting in an office you could potentially wait the hour out in your car.

An alternative to this one hour test that does not require a visit to your doctor or midwife’s office is to monitor your blood sugar at home. This involves an at-home glucose monitor that requires a prick of your finger. For 1-2 weeks you take blood glucose readings at various times of the day and record those along with a journal of the food you eat. This is more involved on your end but more accurate than the one-hour test. If this is something you want to consider please bring it up with your doctor or midwife.

Why You Should Avoid SARS-CoV2

Other than the obvious of not wanting to get sick there is a big reason you want to avoid this virus and it comes from the guidelines set by the American College of Obstetricians and Gynecologists. The guidelines we reviewed from ACOG last week have not changed. According to ACOG infants born to mothers with confirmed COVID-19 should be considered patients under investigation. As such, these infants should be isolated according to the Infection Prevention and Control Guidance for PUIs. ACOG goes on to state that to reduce the risk of transmission of the virus from the mother to the newborn, facilities should consider temporarily separating (eg, separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.

I want to make sure that you understand exactly what ACOG is saying here. If you are positive for COVID-19 the recommendation is that you will be separated from your baby at birth. That alone should be enough information to tell you that you want to avoid this virus and that you should be taking every precaution to do that. ACOG releases these guidelines for all OBGYNs and it would be good to ask your doctor or midwife hypothetically, what would happen if you are positive for COVID-19 at birth.

The RCOG takes a little bit of a different approach. They state that literature from China has advised separate isolation of the infected mother and her baby for 14 days. However, routine precautionary separation of a mother and a healthy baby should not be undertaken lightly, given the potential detrimental effects on feeding and bonding. Given the currently limited evidence, we advise that women and healthy infants, not otherwise requiring neonatal care, are kept together in the immediate post-partum period. That has not changed from last week. They have updated this guideline to state that a risk/benefits discussion with neonatologists and families to individualize care in babies that may be more susceptible is recommended. They emphasize that this guidance may change as knowledge evolves. This is the big takeaway here. These guidelines will change as we learn more and as this situation evolves.

As for separating mothers and baby’s after birth the World Health Organization states: Yes you should be able to hold your baby after birth, even if you have COVID-19. Close contact and early, exclusive breastfeeding helps a baby to thrive. You should be supported to

  • Breastfeed safely, with good respiratory hygiene
  • Hold your newborn skin-to-skin, and
  • Share a room with your baby

You should wash your hands before and after touching your baby and keep all surfaces clean.

I imagine it is an impossible task for hospitals to balance supporting mothers and babies while limiting risks for everyone. I will be updating you as more information is available.

Updated Research on COVID-19 and Babies

In a study of 2,143 pediatric patients in China, they confirmed what we have been hearing, that this virus is not affecting children nearly as much as adults. This is good news. They also found that the proportion of severe and critical cases was much higher in infants under one year. 10.6% of infants had severe and critical symptoms, compared to 7.3% in 1-5-year-olds, and 4.2% for 5-10-year-olds. Groups in the United States, Canada, and elsewhere, are looking at data from other countries. Any information on how babies are responding to exposure will help determine policies in our hospitals. Infants being particularly vulnerable could support a policy of separating a baby and a mother who is positive for COVID-19 at birth. Hospitals are starting to implement widespread testing of mothers entering the hospital in labor. You could test positive even if you do not have any symptoms. I do not know how hospitals will be treating those scenarios. This week in London, a newborn tested positive for COVID-19 and was being treated at a separate hospital.

More Changes Coming to Your Birth Plan

In the last article, we reviewed the CDC guidelines for healthcare facilities and discussed how this could impact your labor and birth. These recommendations have not changed and more hospitals are adopting stricter rules. As we learn more about this virus and as hospitals are further impacted I expect we will see more policies and procedures put in place that will affect your birth. You should advocate for yourself and the birth experience you want and you may need to be flexible as hospitals, birth centers, and home birth midwives are working very hard to keep everyone safe.

Your Birth Support Team

The RCOG made a lot of updates to its guidelines last week. While this applies more to Britain than the United States, this gives us an idea of what other countries are doing, and what changes could be coming to the healthcare system in the United States.

The RCOG states that if a birth partner is symptomatic they should remain in self-isolation and not attend the unit. Women should be advised when making plans about birth to identify potential alternative birth partners, should the need arise. This is something that you may want to think about. What happens if your spouse or partner gets the virus? Is there someone else that could be with you during your labor?

The World Health Organization states that expecting mothers should have a companion of choice present during delivery. This is what we have been seeing in the United States. Doulas are providing support remotely over the phone or via Facetime when they are unable to attend a birth in person. I have heard several stories of expecting mothers being told that their ability to have a partner present could change.

Today, a hospital in New York came out with a statement that they are not allowing partners and that they are testing all women coming into the birthing unit for COVID-19 regardless of whether they are showing symptoms. I am sure this was an incredibly tough decision for the hospital to make. Hospitals have a lot of incentive to have a support person there for a birthing mother. This is especially true when hospitals and birthing centers have fewer staff members available. They want you to be supported and have your partner there. If your partner has any signs of COVID-19 you may need to be prepared to have someone else present. As is the case of the hospital in New York, I do not know whether this policy of not allowing a birthing partner will become more common. Unfortunately, with how this pandemic has been unfolding, we will likely see more of this. I will be updating you as we learn more.

Risks for Your Care Provider

Health care workers and first responders are at a higher risk for COVID-19. This could be due to a higher level of exposure. Plus, they are in very stressful environments and working long hours. This could impact our health care system as these people get sick and are taking these critical workers out of the workforce. This is a concern that has been mentioned by ACOG  and they state that Ob-gyns and other prenatal care practitioners should consider creating a plan to address the possibility of a decreased health care workforce, potential shortage of personal protective equipment, limited isolation rooms, and should maximize the use of telehealth across as many aspects of prenatal care as possible.

A great question to ask is what is your doctor or midwife’s plan if they become sick? While I am sure they are taking every precaution, if they get this virus they will not be available. Who is their backup? If you are in a practice that has multiple doctors or midwives this may be less of an issue than if you are seeing an independent practitioner.

Considering Home Birth

The changes happening in hospitals and growing concerns have prompted some expecting mothers to consider home birth as an option. If you are exploring this option I suggest you start reaching out to homebirth midwives in your area now. There are a few other things to keep in mind for home birth:

  • Homebirth is not for everyone, and it should be an option for anyone who has a low-risk pregnancy. What is considered low-risk varies by state.
  • You will not have access to pain medications for a home birth and you will need to rely on alternate methods of managing your contractions.
  • Health insurance typically does not cover as much (or any) of the costs of home birth.
  • There is always the possibility that you will need to transfer to a hospital.

I had a wonderful experience with homebirth and it was the right decision for me for my last birth. I know this is not the best fit for everyone. If this is something you want to explore, I encourage you to talk to some midwives in your area and learn more. Also, keep in mind that homebirths will not be exempt from changes due to this pandemic. If you do work with a midwife you will want to know what their plan is in the event they, or you, are positive for COVID-19. Do they have a backup if they get sick, or could they attend your birth if you were positive?

Pain Management Options

While homebirth does not involve medication for pain management you still have all the options for this in a hospital setting. ACOG did not publish any changes to the availability of pain management options. The RCOG recommends continuous electronic fetal monitoring in labor. They also state that the use of birthing pools in hospitals should be avoided in suspected or confirmed cases. This is due to the inability to use adequate protective equipment for healthcare staff during water birth and the risk of infection via feces. There is some evidence showing that SARS-CoV-2 can be transmitted through fecal matter. Yes, it is true you could poop during labor.

In the last article, we discussed that the use of nitrous may be limited. The good news is that the RCOG says there is no evidence that the use of nitrous is an aerosol-generating procedure, it should be used with a single-patient microbiological filter. Thankfully, this is standard issue throughout maternity units in the UK. Nitrous is more commonly used in the UK than the US but its use has been increasing here. It is good to know this would still be an option.

Shorter Hospital Stays & Restrictions on Visitors

It is likely we will see shorter hospital stays after birth. There is an incentive from hospitals, and for you, to return home quicker. If hospitals see more issues with infections you could be at a higher risk for infection in a hospital setting. We are seeing hospitals restrict visitors after birth by limiting numbers or banning them altogether.

Stay Informed & Talk to Your Doctor or Midwife

Continue to check in with local resources for your city, county, or state for instructions that will apply to you. Please discuss this topic with your doctor or midwife for their thoughts and recommendations. They are your trusted partner during your pregnancy and birth and can help you navigate this. Hopefully, they are communicating any changes in their practice, policies, or recommendations with you as this situation evolves.

The reality is that even when we stay home, few people have zero risks. You are exposed to some risk anytime a package is delivered, you go to a store, or have contact with anyone, etc. It is tough to find a balance between being careful and living your life. I will be coming out with more information very soon on what you can do to continue limiting your risk.

How Can I Help?

Please email me and let me know what resources I can help you find and how I can help you navigate this challenging time.

Helpful Links

 

Thank you to the amazing companies that have supported this episode.

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