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In early April, Maura Quinlan, MD, was working nights on the Labor and Delivery unit at Northwestern Medicine Prentice Women's Hospital in Chicago. At the time, hospital policy was to test only patients with known COVID-19 symptoms for the SARS-CoV-2 virus. Women in labor wore N95 masks, but only while pushing — and practitioners didn't always don proper protection in time.
Babies came and families rejoiced. But Quinlan looks back on those weeks with a degree of horror. "We were laboring a bunch of patients that probably had COVID," she says, and they were doing so without proper protection.
She's probably right. According to one study in the New England Journal of Medicine, 13.7% of 211 women who came into the labor and delivery unit at one New York City hospital between March 22 and April 2 were asymptomatic but infected, potentially putting staff and doctors at risk.
Quinlan already knew she and her fellow Ob/Gyns had been walking a thin line and, upon seeing that research, her heart sank. In the middle of a pandemic, they had been racing to keep up with the reality of delivering babies. But despite their efforts to protect both practitioners and patients, some aspects slipped through the cracks. Today, every laboring patient admitted to Northwestern is now tested for the novel coronavirus.
Across the country, hospital labor and delivery wards have been working to find a careful and informed balance among multiple competing interests: the safety of their healthcare workers, the health of tiny and vulnerable new humans, and the stability of a birthing mother. Each hospital has been making the best decisions it can based on available data. The result is a patchwork of policies, but all of them center around rapid testing and appropriate protection.
One case study of women in a New York City hospital during the height of the city's surge found that, of 7 confirmed COVID-19-positive patients, 2 were asymptomatic upon admission to the obstetrical service, and these same two patients ultimately required unplanned ICU admission. The women's care prior to their positive diagnosis had exposed multiple health care workers, all of whom lacked appropriate PPE, the study authors write. "Further, five of seven confirmed COVID-19-positive women were afebrile on initial screen, and four did not first report a cough," they note. "In some locations where testing availability remains limited, the minimal symptoms reported for some of these cases might have been insufficient to prompt COVID-19 testing."
As studies like this pour in, societies continue to update their recommendations accordingly. The latest guidance from the American College of Obstetricians and Gynecologists came July 1. The group suggests testing all labor and delivery patients, particularly in high-prevalence areas. If tests are in short supply, it recommends prioritizing testing pregnant women with suspected COVID-19 and those who develop symptoms during admission.
At Northwestern, the hospital requests patients stay home and quarantine for the weeks leading up to their delivery date. Then, they rapid-test every patient who comes in for delivery and aim to have results available within a few hours.
The hospital's 30-room labor and delivery wing remains reserved for patients who test negative. Those with positive COVID-19 results are sent to a 6-bed COVID L&D unit elsewhere in the hospital. "We were lucky we had the space to do that, because smaller, community hospitals wouldn't have a separate unused unit where they could put these women," Quinlan says.
In the COVID unit, women deliver without a support person — no partner, doula or family member can join. Doctors and nurses wear full PPE and work only in that ward. And because some research shows that pregnant women who are asymptomatic or presymptomatic may develop symptoms quickly after starting labor with no measurable illness, Quinlan must decide on a case-by-case basis what to do, if anything at all.
Delaying an induction could allow the infection to resolve, or it could result in her patient moving from presymptomatic disease to full-blown pneumonia. Accelerating labor could bring on symptoms, or it could allow a mother to deliver safely and get out of the hospital as quickly as possible. "There is an advantage to having the baby now if you feel okay — even if it's alone — and getting home," Quinlan says.
The hospital also tests the partners of women who are COVID-19 positive. Those with negative results can take the newborn home and try to maintain distance until the mother is no longer symptomatic.
In different parts of the country, hospitals have developed different approaches. Southern California is experiencing its own surge, but at the Ronald Reagan UCLA Medical Center in Los Angeles there still haven't been enough COVID-19 patients to warrant a separate labor and delivery unit.
At UCLA, staff swab patients when they enter the labor and delivery ward — those who test positive have specific room designations. For both COVID-positive patients and women who progress faster than test results can be returned, the goals are the same, says Rashmi Rao, MD, an Ob/Gyn at UCLA: Deliver in the safest way possible for both mother and baby.
All women, positive or negative, must wear masks during labor — as much as they can tolerate, at least. For patients who are only mildly ill or asymptomatic, the only difference is that everyone wears protective gear. But if a patient's oxygen levels dip, or her baby is in distress, the team moves more quickly to a cesarean delivery than they'd do with a healthy patient.
Just as hospital policies have been evolving, rules for visitors have been constantly changing too. Initially, UCLA allowed a support person to be present during delivery but had to leave immediately following. Now, each new mother is allowed one visitor for the duration of their stay. And the hospital suggests that patients who are COVID-19 positive recover in separate rooms from their babies and encourages them to maintain distance from their infants, except when breastfeeding.
"We respect and understand that this is a joyous occasion and we're trying to keep families together as much as possible," Rao says.
How hospitals protect their smallest charges keeps changing too. Reports have been circulating about newborns being taken away from COVID-19-positive mothers, especially in marginalized communities. The stories have led many to worry they'd be forcibly separated from their babies. Most hospitals, however, leave it up to the woman and her doctors to decide how much separation is needed. "After delivery, it depends on how someone is feeling," Rao says.
The American Academy of Pediatrics recommends that mothers who are COVID-19-positive pump breastmilk and have a healthy caregiver use that milk, or formula, to bottle-feed the baby, with the new mother remaining 6 feet away from the child as much as she can. If that's not possible, she should wear gloves and a mask while breastfeeding until she has been naturally afebrile for 72 hours and at least 1 week removed from the first appearance of her symptoms.
"It's tragically hard," says Northwestern's Quinlan, to keep a COVID-19 positive mother even 6 feet away from her newborn baby. "If a mother declines separation, we ask the acting pediatric team to discuss the theoretical risks and paucity of data."
Until recently, research indicated that the SARS-CoV-2 virus wasn't being transmitted through the uterus from mothers to their babies. And despite a recent case study reporting transplacental transmission between a mother and her fetus in France, researchers still say that the risk of transference is low. To ensure newborn risk remains as low as possible, UCLA's policy is to swab the baby when he/she is 24 hours old and keep watch for signs of infection: increased lethargy, difficulty waking, or gastrointestinal symptoms like vomiting.
Transmission via breastmilk has also, to date, proven relatively unlikely. One study in The Lancet detected the novel coronavirus in breastmilk, although it's not clear that the virus can be passed on in the fluid, says Christina Chambers, PhD, a professor of pediatrics at UC San Diego School of Medicine. Chambers is studying breastmilk to see if the virus or antibodies to it are present. She is also investigating how infection with SARS-CoV-2 impacts women at different times in pregnancy, something that's still an open question.
"[In] pregnant women with a deteriorating infection, the decisions are the same you would make with any delivery: Save the mom and save the baby," Chambers says. "Beyond that, I am encouraged to see that pregnant women are prioritized to being tested," she says, something that will help researchers understand prevalence of disease in order to better understand whether some symptoms are more dangerous than others.
The situation is evolving so quickly that hospitals and providers are simply trying to stay abreast of the flood of new research. In the absence of definitive answers, they are using the information available and adjusting on the fly. "We are cautiously waiting for more data," says Rao. "With the information we have we are doing the best we can to keep our patients safe. And we're just going to keep at it."
Katharine Gammon is a freelance science writer who lives in Santa Monica. She's written for The New York Times, The Atlantic and The Guardian and can be found on Twitter @kategammon.
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Cite this: OB-GYNs Struggle to Keep Pace With Changing COVID Knowledge - Medscape - Jul 20, 2020.