Voices in Bioethics (Apr 2020)
COVID-19 Labor & Delivery
Abstract
Over the course of my training as an obstetrics and gynecology resident, I have performed numerous vaginal and cesarean deliveries. Every time, it feels like an immense privilege to share this important moment with expectant parents and, in many cases, their chosen support person or persons. I, like many of my colleagues, never imagined a time when hospitals would ban partners and other support persons from the labor and delivery unit. I also never imagined a time when I could feel unsafe while working in a hospital. The COVID-19 pandemic represents an unprecedented modern-day global health crisis. While the majority of fatalities are in elderly persons, COVID-related deaths have been reported among all demographics and have included doctors, nurses, and other essential healthcare professionals (HCPs). In fact, in some of the most affected countries, such as China and Italy, HCPs have accounted for a significant portion of cases.[1],[2] The infection of healthcare workers has been attributed to delays in testing, inadequate personal protective equipment (PPE), and asymptomatic exposures. Exposure of healthcare workers to initially asymptomatic patients prompted New York-Presbyterian Hospital in New York City to institute a network-wide restriction extending hospital visitor prohibitions to all support persons in the labor and delivery unit on March 23. Partners and birthing attendants, such as doulas, could no longer attend deliveries. Indeed, Breslin at al. from the Division of Maternal-Fetal Medicine at New York-Presbyterian reported on their initial experience with SARS-CoV-2-positive obstetrical patients.[3] Notably, two patients, who were initially asymptomatic on admission, developed symptoms post-partum. In both cases, 15-20 healthcare providers were exposed to the patient without adequate PPE. Following this experience, additional measures were taken to protect HCPs and obstetrical patients, including requiring all members of the obstetrics care team and patients presenting to the labor and delivery unit to wear a surgical mask at all times with additional protections for SARS-CoV-2-positive deliveries, universal testing of all patients presenting to the labor and delivery unit, and, the most drastic measure, prohibiting support persons, including partners, from entering the unit. The decision to ban partners from the delivery room was met with significant backlash from the public, most notably from expectant parents. Many other hospitals had also moved to restrict visitors, but had made exceptions for labor and delivery, permitting one designated support person to accompany the expectant mother. These policies were in line with the New York State Department of Health guidance published on March 21, which states, “For labor and delivery, the Department considers one support person essential to patient care throughout labor, delivery, and the immediate postpartum period.” A change.org petition was launched in order to “safeguard the right of all laboring people to have support during COVID-19 crisis” amassing over 600,00 signatures. In response, on March 28, New York State Governor Andrew M. Cuomo announced an executive order which would require all hospitals in New York to allow women to have one support person in the labor and delivery room. Those against the restrictive visitor policies have quoted the American College of Obstetricians and Gynecologists Committee Opinion, which states that emotional support is associated with improved outcomes for women in labor, such as better pain management and lower caesarean section rates.[4] Others, such as renowned maternal-fetal specialist Dr. Vincenzo Berghella, have argued, “I understand well both sides—I remember every minute of assisting emotionally during the birth of our two sons […] But saving lives now is more important,” an opinion that is shared by other HCPs.[5] In fact, in response to Governor Cuomo’s executive order, another change.org petition was created to “protect the lives of frontline medical staff during COVID-19.” While this petition amassed far fewer signatures, a number of valuable arguments were presented, including increased exposure of HCPs to COVID-19 via support persons and their increased use of scarce PPE. Indeed, according to New York-Presbyterian’s safety measures for labor and delivery, partners would require valuable resources, as they would need to be screened for signs and symptoms of COVID-19 prior to entering the labor and delivery unit and would need to wear a surgical mask at all times. Across the border, in my hometown of Montreal, Quebec, a similar debate has unfolded. On April 4, the Jewish General Hospital, one of Quebec’s designated COVID-19 centers, made the difficult decision to extend their restrictive visitor policies to ban all support persons from the labor and delivery unit. This decision was made in response to members of the obstetrics care team being exposed to a partner who concealed symptoms of COVID-19 to attend the birth of his child, and was later found to be infected.[6] Despite another petition, which amassed close to 100,000 signatures, this decision has not been overturned. Quebec Premier François Legault supported the Jewish General Hospital’s decision, stating, “at the Jewish General Hospital, there are many cases of COVID-19, so there are good reasons for this rule, but I want to be very clear, there is no intention of the government [to] extend these bans to other hospitals.”[7] The incident at the Jewish General Hospital reveals a further challenge to the one-person visitor policies: some people seem unable to put their personal interests aside for the safety of others. By lying about possible exposure and symptoms, patients and support persons not only put HCPs at increased risk, but also put other mothers and babies on the labor and delivery unit at risk. While COVID-19 does not appear to confer an increased risk to pregnant women compared to non-pregnant adults, a number of cases of severe illness requiring intensive care have been reported among previously healthy pregnant adults.[8] Furthermore, recent data also suggests that while disease manifestations are less severe in children than in adults, infants under the age of one may be more vulnerable to severe or critical disease.[9] There is no question that protecting mothers and babies should be the number one priority. However, protecting healthcare workers is crucial as well. While I see both sides of this issue, I believe the decision should belong to the individual hospitals responsible for providing the best, safest environment for their patients and employees. These decisions must consider abilities to screen support persons, provide them with face masks, and implement surveillance measures to ensure they are following the unit’s rules. The decisions will depend on the strain of the workforce at each institution and the availability of PPE for HCPs, which may be threatened as the outbreak progresses in certain areas like New York City. From following the COVID-19 situation in both the United States and Canada over the last few weeks, I observed that elected officials do not always have a clear sense of what is happening inside hospitals where resources may be scarce, elevating the dangers caused by a lack of PPE, limited testing capabilities, and extra staff to screen support persons. Decisions restricting visitors are not made lightly or unnecessarily. Such policies profoundly affect expectant parents who are already subjected to increased anxiety due to the pandemic. They also have implications for members of the obstetrical care team, as the absence of support persons also affects their roles and responsibilities. To all the expectant parents, I just want to say, I’m sorry you are going through this. I promise that no matter the hospital policy, you will not be alone. The obstetrics care team, which includes highly trained labor and delivery nurses and doctors, will be there for you. They know how important these precious moments are to you and your loved ones. They know this is not what you had planned and feel your disappointment. They are trying their best to advocate for your safety and that of your newborn. They are advocating for more and better PPE, not only to protect themselves so they can stay healthy for you and all the other expectant mothers, but also so that labor and delivery units can return to their previous state of normalcy as soon as possible, and so that women can soon have the birthing experiences they had planned. April 16,2020 photo credit: Jonathan Borba [1] Gawande, Atul. Keeping the Coronavirus from Infecting Health-Care Workers. The new Yorker. March 21, 2020. Accessible at: https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers. [2] Latza Nadeau, Barbie. Coronavirus Is Killing Italy’s Doctors. The U.S. Could Be Next. March 19, 2020. Accessible at: https://www.thedailybeast.com/covid-19-is-killing-italys-doctors-the-us-could-be-next?ref=scroll. [3] Breslin N, Baptiste C, Miller R, et al. COVID-19 in pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM. 2020. DOI: https://doi.org/10.1016/j.ajogmf.2020.100111. [4] American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Delivery. ACOG Committee Opinion No. 766. Obstet Gynecol. 2019;133: e164-73. DOI: 10.1097/AOG.0000000000003074. [5] Van Syckle, Katie & Caron, Cristina. ‘Women Will Not Be Forced to Be Alone When They Are Giving Birth.’ The New York Times. March 28, 2020. https://www.nytimes.com/2020/03/28/parenting/nyc-coronavirus-hospitals-visitors-labor.html. [6] Scott, Marian & Tomesco, Frédéric. Jewish General bars spouses after COVID-19-infected man attends birth. Montreal Gazette. April 4, 2020. Accessible at: https://montrealgazette.com/news/local-news/jewish-general-bans-spouses-from-maternity-after-covid-19-infected-husband-attends-birth/. [7] Canadian Press Staff. Midwives, patients push for clarity on companions at childbirth during COVID-19 crisis. CTV News. April 6, 2020. Accessible at: https://montreal.ctvnews.ca/midwives-patients-push-for-clarity-on-companions-at-childbirth-during-covid-19-crisis-1.4884994?cache=sazhusyrecmk%3FclipId%3D89926%3FautoPlay%3Dtrue%3FautoPlay%3Dtrue. [8] Yang H, Wang C, Poon LC. Novel coronavirus infection and pregnancy. Ultrasound Obstet Gynecol. 2020; 55: 435–437. DOI: 10.1002/uog.22006. [9] Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020. DOI: 10.1542/peds.2020-0702.
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