Universal testing on labor and delivery
Not surprisingly, obstetric delivery volumes in our institution were not affected in the same way as elective surgery volumes. Our inpatient team continued to bring babies into the world at the same if not a higher rate than in prepandemic times. We continued elective inductions when space allowed. Our first COVID-19–positive patient was already at 40 weeks’ gestation when the result of her test, done due to exposure, was received. Creative effort among multiple specialties quickly developed her delivery plan, and she and her infant did well.
As data started coming out of the New York City obstetric experience, concern for preservation of the PPE supply and the potential for asymptomatic/presymptomatic patients led us, in consultation with our infectious disease colleagues, to institute universal testing for all antepartum and laboring patients. At first, all patients were tested on admission with our rapid in-house test. Eventually, we moved toward preoperative testing 3 to 5 days prior to scheduled cesarean deliveries in alignment with the surgical services when elective cases were reinstituted. Finally, we instituted preprocedure testing for all scheduled labor and delivery procedures, including inductions, cerclages, and fetal blood transfusions, while we still used rapid testing for patients who presented urgently or in labor.
We needed to address several considerations almost immediately after instituting universal testing, including:
- what to do in case of patient refusal to be tested
- which precautions to institute while awaiting test results
- potential postponement of elective delivery if a patient tested positive, and
- where best to deliver patients.
What we did at the beginning of the pandemic was not necessarily the same as we do in our current practice, and we expect that our procedures may need to change in the future. Derived from what we learned from others’ experience, we tailored our protocols to our own physical space, staffing capabilities, and testing limitations. We adjusted them often, with input from multiple services, based on updated policy, recommendation for isolation and quarantine durations, rates of community infection, and changes in the unit spaces. As with many things, one protocol did not fit every patient, necessitating case-by-case flexibility.
Delivery considerations
To answer some of the above questions, all patients who declined testing, were awaiting test results while in labor, or were in triage were placed in droplet and contact isolation on our unit, a practice we continue currently. Given the concern of potential aerosolization during the second stage of labor or during intubation, for any patients in those categories who required delivery, we limited the number of staff in their rooms as possible. Additional pediatric staff waited in close proximity of the room and were ready to come in if needed depending on fetal complications and gestational age. For delivery, all team members used full special pathogens precautions (N95 masks, face shields, gowns, and gloves).
Patients who were asymptomatic and tested negative for COVID-19 had and continue to have routine care from a PPE (standard gowns, gloves, face mask, and eye protection) and health care team perspective. We have allowed visitation of one support person per hospital stay for these patients throughout the pandemic.
For the majority of our experience during the pandemic, adult patients who tested positive for COVID-19 were cohorted within dedicated negative pressure units of varying levels of care. As these units included the same intensive care unit (ICU) we utilized in non-COVID times for critical obstetric patients, we had already operationalized their use and they were wired for our electronic fetal monitoring system. These rooms are adjacent to the main operating room (OR) complex, which allows for transition to a dedicated COVID-19 OR for cesarean delivery. We worked with the primary COVID-19 team, ICU team, anesthesia, and neonatal ICU team to develop a written protocol that detailed the care for our COVID-19–positive laboring and postpartum patients in this critical care COVID-19 unit.
For a time, admitted COVID-19–positive patients were not permitted to have support persons. The health care team therefore stepped in to be the patients’ support during the delivery of their child. Care of these patients required a great deal of coordination and communication between teams as well as the addition of a dedicated obstetric physician—separate from the regular labor and delivery team—assigned to care for these patients.
For pregnant patients in the emergency room or in the intermediate or floor COVID-19 units, portable fetal monitors and ultrasonography equipment were used for obstetric consults, fetal testing, and obstetrical ultrasonography as appropriate based on gestational age and medical conditions. Again, communication between teams was essential to provide seamless and timely patient care. Patients usually were admitted to the COVID-19 teams with maternal-fetal medicine or obstetric consult teams following daily; they were admitted and transferred to the ICU COVID-19 unit if delivery was necessary. To limit exposures whenever possible, coordinated care (such as exams and telephone evaluation) was performed outside of the room with the nursing and primary teams.
Continue to: Staying flexible to the changing COVID-19 environment...