Whether facing a fast-approaching due date, or recently discovering two pink lines on a home pregnancy test, navigating pregnancy during a global pandemic is one complication today’s expecting parents certainly didn’t see coming.
As COVID-19 sweeps through the country, medical providers everywhere are eagerly answering the call. With businesses shut down, jobs lost and events cancelled, the gravity of the situation is sinking in for expecting parents all over the world. In Texas, maternal fetal medicine providers have proactively banded together to strategically care for these patients bringing new life into a brave new world.
An Unprecedented Threat
The enormity of COVID-19 is difficult to comprehend. With millions global cases, and over 30,000 reported in Texas alone, battling this infectious disease is top of mind for patients and providers alike. Although over 50% patients have recovered in the Lone Star State, the most vulnerable and at-risk populations remain concerned, particularly as the state begins to reopen for business.
Pregnant women are incredibly wary of the disease that has claimed the lives of hundreds of thousands of people. They are concerned about catching it themselves, passing it to their vulnerable unborn and newborn babies and fearful of the chance of clinical and hospital exposure in an uncertain medical climate.
Science does not yet know if pregnancy increases the chance of getting sick from COVID-19, nor whether they are more likely to have serious illness as a result. According to the Centers for Disease Control and Prevention, while a very small number of babies have tested positive for the virus shortly after birth, it is still unknown if these babies got the virus before or after birth. Despite the lack of evidence-based certainty at this early stage, Dr. Catherine Eppes, maternal fetal medicine physician and chief of obstetrics and gynecology at Baylor College of Medicine in Houston, says available research provides some much-needed reassurance so far. “We know from early case reports that pregnant women seem to do fairly well in terms of COVID-19,” said Dr. Eppes. “If they contract it, many just have mild illness.”
Nevertheless, providers are taking every possible precaution to protect both of their patients: mother and baby. Closely following modeled projections and adjusting contingency plans daily, providers are making significant modifications to outpatient and inpatient maternal health care, as well as relying on the CDC and TexasAIM for up-to-date information and ongoing guidance.
It Takes a Village
Dr. Eppes is faculty chair for TexasAIM, an initiative between the Texas Department of State Health Services, the Texas Hospital Association and the Alliance for Innovation on Maternal Health and Texas hospitals. For the last two years, TexasAIM has provided data, educational sessions to promote collaborative learning and best practices to vastly improve patient care and reduce preventable maternal mortality and morbidity. The initiative primarily focuses on best practices regarding obstetric hemorrhage, hypertension and treating opioid disorders. COVID-19 and obstetric care has now become a focus.
Although participation is completely voluntary, engagement rates are staggeringly high. “When we kicked off this project, we were hoping to have 75% of our birthing hospitals participate. Today, we have 97% voluntary participation in this project,” said Karen Kendrick, RN, MSN, THA’s vice president of clinical initiatives and quality.
Kendrick is pleased by the progress made in just a few years since the project’s inception. Strong member participation has yielded tremendous results. “Our members are very engaged, hardworking caregivers. Everyone is eager to do what’s best for their patients, and that alone tells me that we are doing a wonderful job across our state. I can’t say enough good things about the maternal health community in our hospitals,” said Kendrick.
Using the pre-existing TexasAIM framework for postpartum hemorrhage, Dr. Eppes’ team now hosts weekly webinars to connect state experts on the fight against COVID-19. Among these experts are specialists in infectious diseases, sharing insights as it relates to obstetrics patients. The forum provides an opportunity for physicians to swap tactics and insights, and to implement promising findings in real time in their hospitals. Specifically, the opportunity for rural providers to collaborate with their urban peers has proved especially rewarding. “Some of the most inventive and creative ideas have come from our smaller, rural hospitals because they’re great about adapting quickly and working with less,” said Dr. Eppes.
Coping in Suboptimal Conditions
In addition to the strain the pandemic places on pregnant patients, the shadow of COVID-19 takes its toll on providers as well. Physicians are committed to caring for their patients’ well-being while simultaneously fearing for their own health, and the health of their families at home.
Stress levels are high, especially as standard deliveries require a completely different approach when a COVID-19 positive pregnant mother is in labor. Maternity wards do not typically deal with infectious diseases, creating a substantial learning curve as health providers rethink processes and protocols to align with recommended precautions. “It is extremely difficult to transfer a patient in labor with a highly infectious, aerosolized virus. It requires a lot of pre-planning, knowing the right way, the right path and the right equipment needed,” said Dr. Eppes. Additionally, ongoing supply, personal protective equipment and blood shortages mean providers must use equipment sparingly and carefully cohort care.
Texas providers are working as hard as possible to conduct routine care during these unusual circumstances, but the adjustments are far from easy. “We know the standard of care with optimal settings and optimal resources, and this is definitely not that time,” said Dr. Eppes. “There is now a new way to do everything we’ve done before in order to protect patients and providers.”
Despite enormous challenges, Texas medical providers are rising above. “COVID-19 is a complicating factor, but hospitals have quickly gotten up to speed. They’re doing a really good job of protecting our moms and babies,” said Kendrick.
As researchers work with haste to develop a vaccine, maternal health providers continue to modify outpatient prenatal care. Providers are minimizing in-person exposure by assessing which patients are eligible for telemedicine appointments, spacing out in-person visits and delaying ultrasounds. Additionally, Dr. Eppes says some hospitals are rolling out drive-through options for regularly scheduled checkups. With this option, physicians can listen to fetal heart tones and check blood pressure, all within the comfort and safety of the patient’s own vehicle.
Inpatient care modifications are a bit more complex. Hospitals are implementing drastic staffing, process, diagnostic and policy changes to reduce risk. At a minimum, most hospitals now only permit laboring patients one support person in the room, and labor and delivery admissions require an extra precautionary step. “When someone comes in for labor evaluation, whether preterm or term, and they have respiratory symptoms like a cough or shortness of breath and fever, they are masked and placed in a negative pressure room if available in that hospital,” said Dr. Eppes.
Donned in appropriate PPE, providers then further evaluate the patient to determine oxygen levels and evidence of pneumonia and send the results off for testing which is done via nasal pharyngeal swabs.
For patients with confirmed or suspected COVID-19, the CDC recommends immediate separation of the mother and baby after delivery. This separation period may be as little as 48-72 hours until negative test results arrive, or as many as 14 days for confirmed cases. Although precautionary measures are in everyone’s best interest to protect against the virus, it introduces its own set of challenges and disappointments. “It goes without saying that these precautions are very impactful for pregnant women who may not be getting the pregnancy experience they envisioned,” said Dr. Eppes. In these scenarios, time-sensitive matters like skin-to-skin contact and feeding preferences are jeopardized, making any period of separation emotionally taxing.
While patient health and risk reduction are the utmost priorities, there certainly isn’t a shortage of compassion. “Childbirth is very much a family affair, so the idea of limiting guests is stressful on families and it changes the dynamic for that experience,” said Dr. Eppes. For that reason, hospitals are offering virtual engagement in the delivery room, permitting video calls to incorporate family, friends and coaches into the birthing experience.
The Best in Texas
It remains to be seen when the world will get back to normal, and what that will look like when that day arrives. However, as Texans continue to manage this time of deep uncertainty, Dr. Eppes is sure of one thing. “Knowing how much this group of folks cares about women's outcomes, there’s no other place I’d want to have a baby than in Texas. I know they will continue to rise to the challenge for COVID-19 just as they have for postpartum hemorrhage.”