Review: Modifications in Obstetric Care During Viral Pandemics
Key findings
- Evidence-based modifications to prenatal care during a pandemic include a telephone or telehealth intake appointment for risk stratification at <11 weeks of gestation and an initial in-person visit and ultrasound examination at 11 to 13 6/7 weeks
- In the labor and delivery unit, minimize elective induction of labor, and lower the thresholds for cesarean delivery to prevent emergent OR transfers
- Immediately postpartum, rooming-in of the newborn may decrease the risk of nosocomial infection; patients with active infection should participate in decision-making about temporary separation from the newborn
- Early discharge (30–48 hours after delivery) removes the mother–newborn pair from infectious exposure and frees hospital resources
- Before transitioning a patient to telehealth, confirm they have sufficient privacy to communicate openly, and confirm they are free of any disability that will interfere with communication or use of the technology
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Obstetrics is one of the most frequently used health care services in the U.S. and is a logical target when a viral pandemic is straining community medical systems. However, providers face medico-legal liability when deviating from standards of care, especially if no alternative access is provided.
Christina M. Duzyj, MD, MPH, maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, and colleagues have published an evidence-based review in Obstetrics & Gynecology that discusses pandemic-related modifications in obstetric care.
Early Pregnancy Care
Evidence-based modifications to the prenatal care schedule include a telephone or telehealth intake appointment for risk stratification at less than 11 weeks of gestation and an initial in-person visit and ultrasound examination at 11 to 13 6/7 weeks.
In case of early pregnancy loss, no-touch protocols should be considered, including expectant management or medical management. However, if preferred, dilation and curettage should be considered an essential procedure. Outpatient manual vacuum aspiration is a safe alternative.
The American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine consider surgical abortion an essential procedure that should not be delayed during pandemics. A telehealth consultation can be used for early medical abortion.
Other topics discussed with regard to pandemics are:
- Risk factors that suggest the first in-person visit should be earlier
- Adaptations to genetic counseling
- Management of ectopic pregnancy
- Modifications to medication regimens
Antepartum Care
Models of prenatal care may require pandemic adjusted schedules regarding antepartum surveillance and inpatient or outpatient management of routine obstetric complications including preeclampsia, fetal growth restriction, preterm labor and diabetes.
Intrapartum Care
The review makes the following recommendations for intrapartum care:
- When community transmission of a virus is high and rapid testing resources are available, consider universal infection testing in the labor and delivery unit
- Set staffing ratios that reflect patients' increased needs during visitor restrictions
- Minimize elective induction of labor (outpatient cervical ripening protocols are appropriate for selected patients)
- Lower the thresholds for cesarean delivery to prevent emergent transfers to the operating room, rushed donning of personal protective equipment and intubation
Postpartum Care
Immediately postpartum, rooming-in of the newborn may decrease the risk of nosocomial infection. Patients with active infections should participate in decision-making about temporary separation, factoring in the regional epidemiology of the pandemic, potential benefits and infectious risks to themselves and their newborns.
Early discharge removes the mother–newborn pair from infectious exposure and frees hospital resources. The evidence is best for discharge at 30 to 48 hours after delivery.
Health care systems may label postpartum tubal ligation as elective surgery. A temporary alternative is to provide injectable medroxyprogesterone acetate before discharge or by curbside administration after telehealth consultation.
Telehealth Caveats
Before transitioning a patient to telehealth, confirm they have sufficient privacy to communicate openly. Patients at risk include those experiencing abuse from a parent or intimate partner and LGBTQ+ individuals who are not "out" at home.
Telehealth may increase access to health care for some patients with disabilities, but clinicians should check that the disability is not a barrier to communication or use of the technology.
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