Birth in a Pandemic
Updated: Jun 4, 2020
How does one describe the past few months in this time of pandemic? It would probably depend how close to home COVID19 has come for you - directly as an illness or indirectly in terms of canceled plans, interrupted livelihoods, changes to family dynamics, loss of sense of security. We are admittedly fortunate that our patients and our families have been largely healthy thus far, but still some adjectives that come to mind for us include interesting, stressful, weird, exhausting, tragic, worrisome, chaotic. As working mothers running an essential midwifery practice, it's been hard to keep all the balls in the air. Among all the chaos we wanted to reflect on a birth that occurred at the beginning to give some perspective of where we were, where we really still are, but hopefully where we will come from.
It is mid-March 2020 and suddenly COVID19 is a real thing. Prior to this time we heard about it in the news but it seemed like something that was only a problem somewhere else - like Ebola, SARS and Zika had been. I attended a birth on March 14th that I would consider my last “pre COVID19” birth. I remember chatting with the laboring mom, who was comfortable with an epidural, and her partner about COVID19 the way you would talk about any other news or world events when passing time. It did not seem heavy or overly serious. Schools were only going to be closed for a week or two. Other than asking screening questions on admission, we were not really doing anything special. Care providers were just starting to wear surgical masks in the hospital. We had some discussion about assuming everyone or anyone could be positive. During the delivery, I remember my hair moving from the mom’s breath during pushing and thinking, “well hopefully she doesn’t have Coronavirus.”
By my next call everything had changed, and everything continues to change from PPE (personal protective equipment) guidelines to testing protocols, which are then again changed due to availability and new data. The week had gotten off to a busy start with two sleepless nights in a row welcoming babies. Dealing with all the COVID19 aspects for the practice was also exhausting. There had been so many changes in the office and hospital in regards to what we should and should not be doing at that time. The staff were overwhelmed with phones ringing off the hook and massive amounts of rescheduling appointments. Do we cancel annual exams and for how long? What appointments can we do with telehealth? Will we need to furlough staff? How do we keep our staff and our patients safe? There were many, many phone calls from scared mamas. The scarier piece was that we were in the dark as much as they were. We scrambled to stay up to date with accurate information regarding maternal morbidity, vertical transmission, and risks to newborns, however, we were left with very little definitive information, comfort was not something we could definitely pass on. We felt helpless.
On March 25th, I was home with my family but by late afternoon felt myself running out of steam. I told my husband that I HAD to get some good sleep as we still had several people “due” and I was going to be in bad shape if I got called in again. The phone rings that evening, waking me from a sound sleep. I hear an upset voice “Michelle, this is Danielle. I’m sorry to call but…(insert sob)....my husband Sam tested positive for COVID!” I’m not fully awake. Did she just say her husband has Coronavirus? Shit! What do I do with this information? My brain is trying to shift into alert triage mode….I call it playing 20 questions. How far along are you? What number baby is this for you? Is the baby active? How frequent are your contractions? Are you bleeding or leaking fluid? But this was a new problem, not one I was used to making a plan for. What were the questions I needed to ask?
My brain started to wake up. When did he test positive? Was he having symptoms? Was she having symptoms? She had even more questions than I did, questions that I did not have all the answers to. What if she has to come to the hospital now? Can he come to the hospital with her? Can her doula come? Should she be tested now? Will she be tested on admission? Will she have to be separated from her baby? I wanted to pass on my usual air of calm confidence, but it is difficult to be reassuring in this time of so many unknowns. I am always careful not to promise “everything will be fine” as I can never really make that guarantee, but felt even more unable to now.
Aside from the fear of Coronavirus and the sadness of potentially not having her husband with her in labor, Danielle explains to me that she has baseline medical anxiety and a fear of being in the hospital. Having to tackle this fear without the support of her husband is a nightmare for her. She is visualizing everyone in the room wearing hazmat suits and being scared to take care of her. She is scared she will be alone. She is worried she will be made to feel “dirty”. I reassure Danielle that some form of PPE is something we all should be wearing regardless of COVID19 and that the midwives and nursing staff were all elite, caring professionals. I could safely say that she did not need to worry about those things at least - she would be safe, she would be cared for, she would not be alone.
So through our series of triage questions, we concluded: It’s Danielle’s first baby. She is 39+4 weeks. She is feeling well. Her husband is feeling well now. Lots of times first babies come late, so hopefully her baby will stay in. We tried to ignore the fact that her cervical exam the day before was very favorable and she was already 4cm. Cease membrane sweeps, evening primrose oil, and red raspberry leaf tea. Danielle’s new plan would be anti-labor, just laying low hoping her baby would come when her husband could be present in the hospital. If she makes it to 41 weeks exactly, her husband will be two weeks out from his positive test date and he can be present for the labor and birth. Graciously, her doula, Lauren, plans to be present with her regardless. I promise Danielle that I will make some calls and as I find out more information I will call her back.
This would be our unit’s first “Person Under Investigation” or PUI in labor. I paid attention to all the emails that were sent regarding what to do for a PUI, how to test, who to call, what PPE to wear, but I couldn’t think at that moment and couldn’t fully trust any information I did remember. I called the unit manager that night - apologetic for bothering her in the evening because I knew she had been overwhelmed as the rest of us had been with all the news and change. We reviewed the logistics of being a PUI while in the Family Birthing Center and the current infection control protocols. We would notify the unit now that Danielle would be a PUI when she came in so they would be prepared. The unit was prepared for a PUI at any moment, but knowing ahead of time always seems to cut down on the emergent atmosphere on admission. We discussed if we should have Danielle get tested as soon as possible or if that should wait. We ultimately decided together that it wouldn’t be helpful - since at that time outpatient testing was taking more than 1 week to get results and her results could change over time since she was living with a COVID positive spouse.
I also discussed the situation with one of the neonatal providers the next morning. The hospital policy, based on guidance from the CDC (Centers for Disease Control), stated that COVID19 positive mothers or a PUI should be separated from her baby in the hospital and continue that separation for 14 days. Danielle and I had already discussed the night before that her preference was to follow the WHO (World Health Organization) guidelines, which do not suggest separation, versus the CDC guidelines. Separating asymptomatic moms and babies means we can’t take advantage of the health benefits of skin to skin, especially in the golden first hour. We also know the benefits of early and frequent breastfeeding are vast, and this would be difficult to establish without contact with the baby. In this situation, as in many like it, there were mental health implications for mom and potential bonding issues for the new parents. Danielle also took into consideration that the nurses taking care of the baby instead of her could very well be asymptomatic COVID19 positive themselves, Remember, this was the early stages of the pandemic in our region and news of asymptomatic carriers and long incubation periods was just coming to light. Furthermore, she had no one else to help care for the baby at home, so the baby would be going home to her care in 2 days regardless.
The recommendation to separate mom and baby and the position of the neonatal provider comes from the argument that these aforementioned benefits are not life or death matters, while if the baby ended up critically ill from COVID19 it could very well be fatal. There was a clear discussion of risks and benefits. Danielle had educated herself on the various factors. With a lack of clear data showing a risk to newborns and guidance from the WHO, Danielle and Sam made an educated decision to decline separation.
The hospital developed an informed refusal, basically stating that they can not be held liable for all the awful things that could come with a baby becoming ill with COVID19 - including death - and the admission process for Danielle would include a detailed discussion of these things, further adding to her anxiety surrounding the hospital setting. I give Danielle a lot of credit for educating herself on the various factors prior to admission and being consistent in her discussions with various neonatal providers. Danielle verbalized to me how much she appreciated our support and for “having her back” on this decision. I am not a cavalier provider, I would not recommend you ignore a medical recommendation if I thought you were putting you or your baby’s health in danger, but her rationale was reasonable and I do strongly believe in supporting a woman’s birth and parenting choices once all the risks and benefits have been discussed and educated on. This was just one more stressful aspect of birthing in a pandemic - Danielle was not only dealing with birthing without her husband but also having to make serious decisions about the care of her baby.
Of course, the baby had her own plans regarding arrival times (as babies do) and did not honor our request to stay inside until 41 weeks. Danielle calls THE VERY NEXT MORNING in early labor. Now I’m in a bit of midwife denial. “No way you’re actually in labor, you’re just stressed/ thinking about this too much.” I encouraged Danielle to rest and take a warm bath with hopes her contractions would stop. But labor does not go away and Danielle is dropped off at the hospital door late that afternoon with her doula. Danielle did a great job managing early labor at home and on arrival at the hospital she is already 7cms dilated and contracting regularly.
It’s a somber time donning the PPE for the first time. It feels surreal. The staff that are not involved in the patient’s care look at me with concern as I put on a N95 mask, a surgical mask, gown, gloves, hair cover, and face shield just to go in my patient’s room. Less than two weeks ago this problem seemed far away - not a problem we were going to be dealing with our healthy mamas at our small community hospital. I would brazenly walk into the patient’s room without fear and without any PPE. But here I am putting on my “hazmat suit.” Being a midwife of low risk, adequately screened patients, I don’t usually wear much of this. The full PPE is hot and cumbersome. It feels like a barrier to connecting with your patient. How will I support this woman “like this”? I do not mean to sound ungrateful, as I know healthcare workers in other settings have gone without such protection when they desperately needed it. It is just a vastly different feeling than my normal midwife vibe.
Once I get in the room and get busy working with Danielle, I am consumed with the business of being a midwife, being “with woman”. I feel myself able to give normal care, be present, and hold space despite the discomforts of the PPE. Danielle states she is surprised how “normal” everything feels once you get used to seeing everyone in PPE. Danielle’s doula is a constant, amazing presence, the nurses give amazing support despite their own new adjustments to care in a pandemic, and her husband surprisingly feels part of the process even though he is present only virtually. Danielle is so strong, so composed throughout. Despite the PPE, I can still do all the normal labor supports - give a hip squeeze, hold eye contact, murmur reassuring sentiments. My worries about lack of connection fade away and you can almost forget that the necessary PPE (and even the reason for it) is there. We were all present in the moment. In addition to Sam’s virtual presence, he lingered in the parking lot for quite some time, worried that he would be too far away if something went wrong and holding on to hope that someone would change their minds and let him inside. We could certainly write a whole other blog from the COVID positive father’s experience in this and it is a piece that is often ignored.
Even though at 6pm when Danielle was admitted she was already 7cms and contracting frequently, it ended up being a slower climb to fully and pushing. Five plus hours later Danielle is finally 9 cms, but contractions have spaced considerably, and she is growing tired. Now we aren’t on a clock, there is no rush to get to delivery per se, but I do believe there is a balancing act deciding the right time to intervene to avoid exhaustion in a mother who wants to avoid an epidural. I am discussing this slow progress, medically termed dystocia, with her labor nurse and doula. Is this an emotional dystocia? Has the fear, stress, mental exhaustion of birthing in a pandemic, bringing a baby into this world without her husband, finally caught up to her physical self? We leave her alone in the bathroom with her husband on Facetime, hoping that connection with him and privacy will do the trick. We also all know that the humane thing to do is to let this laboring mom get rid of the surgical mask covering her face. She complained about it only very little initially but you could tell it was bothering her in transition. I felt that I could not really allow mom to take off the surgical mask prior to this time since that was the only real protection the doula had. PPE is a hot commodity in the birthing center, I could not give her doula a hospital N95 mask when there were concerns that we would be running out for the nursing staff soon. Luckily our practice had obtained it’s own supply of N95s and I realize we could sacrifice one for the sake of this mother. I shared one with the doula. With everyone in the room now protected with a full set of PPE (N95 mask, hair cover, gloves, eye cover, and gown), Danielle could take her mask off and breathe freely. While addressing the emotional aspects, we also discuss the option of physical intervention. Danielle accepted having her water broken or AROM (artificial rupture of membranes), to try to get contractions going again. Following AROM and a few spinning babies maneuvers, Danielle progressed to fully and pushed for less than 2 hours before her beautiful, healthy baby girl, Eleanor, was earthside. Danielle successfully reached her
goal of having an unmedicated and safe labor experience.
The story of birth in a pandemic doesn’t stop at hospital discharge. Danielle’s COVID19 test was ultimately negative. Even so, she still had to go home and self isolate for several weeks as she and her baby continued to be PUI with a positive family member in the home and the possibility of false negative testing. After discharge, her husband was present and helping, but only while wearing a mask and gloves. Her mother was staying with them as well to be present for postpartum support but ultimately did not touch Eleanor for two weeks. Under normal circumstances, we have mom and baby come into the office soon after discharge and as frequently as needed for lactation support, but given the circumstances, most of her early lactation support after discharge was all done via telehealth. While we are thankful for this option and it seemed to work for Danielle and Eleanor, this lack of in person support could have easily led to the demise of the breastfeeding relationship for some others. The next several weeks were wrought with anxiety. Normal newborn questions, fussiness at the breast, sleep irregularities, reflux, were always prefaced by the question “Could this be COVID19?”
Finally at Danielle’s 6 week postpartum visit she was able to take a sigh of relief - knowing she and her baby are both on the outer limits of becoming ill from the initial exposure to her husband. Although lessened, the anxiety continues in other ways as she navigates this new normal that is social distancing - Is it safe for others to help with the baby? What about routine medical visits? What about childcare when you need to go back to work? I have so much empathy for new moms in this unprecedented time. Everything I know about making the postpartum period tolerable - “it takes a village” and “social supports” are suddenly not easily available without assuming some other risk. It is an isolating, scary time to be a new mom. I suggest women do, as Danielle did, to educate yourself as much as possible, advocate for yourself, and pick a support team that will be down for whatever the future holds. It was always important to be empowered - but even more so in this time of pandemic.
Women are amazingly strong and resilient and I know that women will continue to have the amazing capability to take care of business - to do what is necessary to protect, nurture, and grow their families. In giving this mother support and comfort, I was also the recipient of comfort that night. In what had become a stressful, exhausting time for me, there is something reassuring about being around the constant that is birth. Supporting women in labor distracts you from the extraneous noise in the world. As time continues to march on, it gives me immense hope to see babies burst into this world, oblivious to pandemic, into the arms of their strong mamas.
Special thanks to Danielle and Sam for allowing us to share the story of Eleanors birth and their photos. To hear Danielle's birth story in her own words, check out the Birth Hour Podcast! https://thebirthhour.com/giving-birth-when-your-husband-has-covid-19/
Lauren, her doula, selflessly went above and beyond, staying with Danielle for her entire hospital stay. For more information, check out her website. https://www.babyblissct.com/