Latest / The SHEA Podcast / COVID-19: Changes in Obstetrics, 8/06

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COVID-19: Changes in Obstetrics, 8/06 · The SHEA Podcast

• 0:07
  SPEAKER_03: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:21
  SPEAKER_03: I am Dr.
• 0:22
  SPEAKER_03: David Bannock from the University of Connecticut School of Medicine Novel Service, today's podcast moderator.
• 0:27
  SPEAKER_03: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication with multiple perspectives and experiences as we go through this challenging time together.
• 0:35
  SPEAKER_03: Shay is excited to launch the 25th episode of this podcast, COVID-19 updates, What We Know Now.
• 0:40
  SPEAKER_03: Today's discussion will focus on COVID-19 and how it has affected the field of obstetrics and delivery.
• 0:47
  SPEAKER_03: Our speakers today are Dr.
• 0:48
  SPEAKER_03: Jennifer Hanahan, infectious disease specialist at the University of Toledo, Dr.
• 0:52
  SPEAKER_03: Christina Bryant, Pediatrics Infectious Disease Specialist at Norton Children's Hospital, and Dr.
• 0:57
  SPEAKER_03: Lynn Ramirez, Pediatric ID Specialist at the University of California, San Francisco.
• 1:02
  SPEAKER_03: So thank you all for joining us today.
• 1:04
  SPEAKER_03: I would like to turn it over to Dr.
• 1:05
  SPEAKER_03: Hannahan to get us started with a brief news and guidance update of the week.
• 1:09
  SPEAKER_02: Thank you, David.
• 1:10
  SPEAKER_02: In the news this week, there are 18,318,928 cases of COVID-19 in the world and 695,043 deaths.
• 1:22
  SPEAKER_02: Safe school reopening has been a topic of discussion for some time, and New England Journal of Medicine, the Journal of the American Medical Association, and Lancet all are featuring articles on safe school reopening.
• 1:34
  SPEAKER_02: In an interesting article titled Assessment of SARS-CoV-2 screening strategies to permit the safe reopening of college campuses in the United States, authors performed an analytic modeling study that included a hypothetical cohort of 4,990 students without SARS-CoV-2 infection and 10 with undetected asymptomatic SARS-CoV-2 infection at the start of the semester.
• 1:57
  SPEAKER_02: Decision and cost effectiveness analyses were conducted for screening and tests of varying frequency every 1, 2, 3, and 7 days, sensitivity between 70 and 99%, specificity 98 to 99.7%, and cost varying between$10 per test to$50 per test.
• 2:16
  SPEAKER_02: Model projections were for an 80-day abbreviated fall 2020 semester.
• 2:22
  SPEAKER_02: Screening every two days resulted in 243 cumulative infections and a mean daily isolation census of 76 people versus 1,840 infections if screening occurred every seven days.
• 2:36
  SPEAKER_02: The conclusion was that screening every two days using a rapid, inexpensive, and even poorly sensitive test coupled with strict behavioral interventions to keep the reproductive rate less than 2.5 was estimated to maintain a controllable number of COVID-19 infections and permit the safe return of students to campus.
• 2:56
  SPEAKER_02: An editorial in Newland Journal of Medicine points out that safe return to school should be a national priority.
• 3:02
  SPEAKER_02: The authors state that social injustices are exacerbated by not having children in school, and that school is important for emotional development and informative relationships with peers and adults, and schools also provide additional benefits.
• 3:16
  SPEAKER_02: More than 50% of all U.S.
• 3:18
  SPEAKER_02: school-age children rely on schools for free or reduced price meals.
• 3:22
  SPEAKER_02: Schools provide mental health services, therapeutic services, and social services to children.
• 3:28
  SPEAKER_02: The editorial calls for reopening schools by reducing community transmission in areas with high transmission rates, which includes closing non-essential indoor work and recreational spaces, universal masking, and increasing testing and surveillance.
• 3:42
  SPEAKER_02: The editorial states that communities that refuse to implement necessary measures to reduce transmission are putting children at risk.
• 3:50
  SPEAKER_02: The National Academies of Science, Engineering, and Medicine published a report titled Reopening K through 12 Schools During the COVID-19 pandemic, prioritizing health, equity, and communities 2020.
• 4:02
  SPEAKER_02: And the CDC updated a toolkit for K through 12 schools yesterday that includes posters that can be downloaded for classrooms to illustrate safe behaviors in schools.
• 4:13
  SPEAKER_02: CDC has also updated a QA about clinical questions about COVID-19 that includes information about transmission and updated information about underlying conditions that predispose to more severe illness.
• 4:25
  SPEAKER_02: And that's the news for this week.
• 4:28
  SPEAKER_03: Great.
• 4:28
  SPEAKER_03: Thank you, Dr.
• 4:29
  SPEAKER_03: Hannahan, for that news update.
• 4:31
  SPEAKER_03: So I want to turn the discussion over to Dr.
• 4:34
  SPEAKER_03: Brian and Dr.
• 4:34
  SPEAKER_03: Ramirez.
• 4:35
  SPEAKER_03: I know both of you have a wealth of experience in the area of obstetrics.
• 4:39
  SPEAKER_03: So first I'll turn to Dr.
• 4:40
  SPEAKER_03: Bryan.
• 4:41
  SPEAKER_03: Can you talk a little bit about some of the changes that have been implemented since the COVID-19 pandemic has been evolving specifically as it pertains to the labor and delivery metro hospital?
• 4:51
  SPEAKER_01: We have two birthing hospitals in our healthcare system.
• 4:55
  SPEAKER_01: And both of those hospitals have been screening women who present in labor for COVID-19 with a rapid test.
• 5:04
  SPEAKER_01: Now, early on, we followed AAP and CDC recommendations to recommend separation of a positive mother from her infant.
• 5:16
  SPEAKER_01: We used a shared decision-making model, but really communicated that this was likely the safest for the infant.
• 5:24
  SPEAKER_01: Since the AAP updated guidance regarding management of infants born to COVID-positive moms in late July, we have moved away from recommending separation of mother and infant.
• 5:37
  SPEAKER_01: For infants who are well enough to room in with mothers, we just reinforce mask wearing and hand hygiene and of course support breastfeeding.
• 5:47
  SPEAKER_03: All right, thanks.
• 5:47
  SPEAKER_03: I think what you're describing really reflects some of the evolution of obstetrics and labor and delivery through COVID-19.
• 5:55
  SPEAKER_03: So, Dr.
• 5:55
  SPEAKER_03: Ramirez, can you reflect on some of your experience?
• 5:58
  SPEAKER_00: Yeah, of course.
• 5:59
  SPEAKER_00: So as mentioned, I'm based at UC San Francisco, where we do have a relatively large birth population.
• 6:05
  SPEAKER_00: And I would say that there have been a number of changes that have overall affected the way that pregnant women come and seek care.
• 6:12
  SPEAKER_00: So it includes everything from women presenting in our lobby and being screened, the number of support people that can come with a woman, specifically only one, during the birth process, as well as a testing program that includes testing all women, including those who are asymptomatic.
• 6:29
  SPEAKER_00: I mean for the asymptomatic population, testing them within four days of their admission or at the time of admission.
• 6:34
  SPEAKER_00: And then also processes, as Dr.
• 6:37
  SPEAKER_00: Bryant was alluding to, if a woman does test positive, there is a shared decision model approach to counseling that mom if the baby is eligible, i.e., a term baby and would be eligible to room in.
• 6:49
  SPEAKER_00: Even actually before the update from the AEP, I would say for the majority of our term babies, they actually with a shared decision model that the families were opting for the babies to room in, especially for these 36 to 48 hour admissions for these older babies.
• 7:05
  SPEAKER_00: And we have now more officially moved to that on paper given the AEP updates that are more permissive around rooming in.
• 7:13
  SPEAKER_03: Okay, thanks.
• 7:13
  SPEAKER_03: It sounds like processes that are still evolving.
• 7:16
  SPEAKER_03: I think we're interested in hearing about how the screening, presumably you're referring to symptom screening as well as testing, has been.
• 7:23
  SPEAKER_03: So Dr.
• 7:24
  SPEAKER_03: Mary's, you know, you're out in California, we're hearing about rising cases on the West Coast.
• 7:29
  SPEAKER_03: Can you share a little bit as far as what your experience has been with uh positive symptom screening on labor and delivery as well as testing your labor and delivery patients?
• 7:38
  SPEAKER_00: Sure.
• 7:39
  SPEAKER_00: We have since the beginning of the pandemic developed clinical algorithms and the OB population um falls within the overall adult algorithm approach at our institution.
• 7:49
  SPEAKER_00: And that includes a pretty broad set of symptoms that we screen for, including you know the more common things that you would expect, like fevers, respiratory symptoms, um loss of smell, loss of taste.
• 8:00
  SPEAKER_00: But also, you know, if a woman happens to have any signs consistent with COVID, such as abnormal chest imaging or these types of things.
• 8:08
  SPEAKER_00: So using that comprehensive list of symptoms, if the women screen in, they are considered symptomatic, get put under appropriate transmission-based precautions, and are offered a COVID test.
• 8:20
  SPEAKER_00: For asymptomatic women, we have a program of testing all women either within four days of their admission or at the time of admission.
• 8:29
  SPEAKER_00: Um, I would say this is part of our standard procedures.
• 8:32
  SPEAKER_00: It's my sense that it's uncommon for women to opt out of that.
• 8:35
  SPEAKER_00: And if they do happen to, then from a healthcare worker standpoint, a higher level of PPE is followed very specifically for the asymptomatic populations with test pending.
• 8:45
  SPEAKER_00: We have a hybrid approach to our PPE, which is basically a surgical mask with eye protection.
• 8:52
  SPEAKER_00: So for those women who decide not to test, healthcare workers would follow the higher level of PPE until they're tested or discharged.
• 9:01
  SPEAKER_03: Yeah, we've we've been having a similar approach and it's been evolving in terms of the testing strategy as well as the PPE, both while the test is pending as well as you know throughout the entire process.
• 9:12
  SPEAKER_03: So can you comment a little bit as far as the rates of positivity you've been seeing?
• 9:17
  SPEAKER_03: Have the rates of positivity you've seen been aligned with what you've seen in other adult populations?
• 9:23
  SPEAKER_03: Have you seen higher rates or has it been variable throughout the last few months?
• 9:27
  SPEAKER_03: First, I'll turn to Dr.
• 9:29
  SPEAKER_03: Bryant.
• 9:31
  SPEAKER_01: We have been screening all women in labor with a rapid test since early April.
• 9:37
  SPEAKER_01: And currently our percent positivity rate is at 1.4%.
• 9:43
  SPEAKER_01: Interestingly, this is higher than the percent positivity rate in individuals who are being screened before elective surgery.
• 9:53
  SPEAKER_01: That's a mixed population of PEDs and adults, but our adult population is larger.
• 9:58
  SPEAKER_01: And percent positivity in that population currently is less than a half a percent in Louisville.
• 10:05
  SPEAKER_01: So we do identify a number of pregnant women with screening who have no symptoms, and that we would not have identified through symptom screening.
• 10:16
  SPEAKER_03: So it sounds like at your institution doing testing has been relatively high yield and impactful in terms of both the PPE implications during the labor delivery process as well as postpartum care.
• 10:28
  SPEAKER_03: So, Dr.
• 10:29
  SPEAKER_03: Ramirez, can you share some of your experience in terms of the rates of positivity that you've been seeing?
• 10:34
  SPEAKER_00: Yeah, of course.
• 10:34
  SPEAKER_00: So our process for testing has involved a COVID PCR, as I mentioned, asymptomatic and symptomatic OB patients.
• 10:42
  SPEAKER_00: The overall UCSF health test positivity rate for all comers, including peas and adults across the different populations, is 2.4%.
• 10:51
  SPEAKER_00: The OB test positivity rate is about 1.2%.
• 10:55
  SPEAKER_00: And it's been interesting that although our test positivity rate has definitely increased in the last four weeks in the setting of the surge that is happening in California, that trend has not been the case in the OB population.
• 11:08
  SPEAKER_00: In terms of our asymptomatic versus symptomatic, I would say that our asymptomatic testing program has also identified patients who are COVID positive.
• 11:17
  SPEAKER_00: So I would say that that program has been beneficial as well.
• 11:20
  SPEAKER_03: So it sounds like at your institution you're seeing some benefit in terms of the management of patients and labor and delivery.
• 11:27
  SPEAKER_03: So I want to also hear about some of your experiences with the patients that do test positive.
• 11:31
  SPEAKER_03: Both of you have alluded to an evolution of practices in terms of rooming in.
• 11:36
  SPEAKER_03: How has that been going at your respective institutions?
• 11:39
  SPEAKER_03: This has been evolving, and different hospitals have been having different experiences in terms of patient responses to these different types of practices.
• 11:46
  SPEAKER_03: So I'll turn to Dr.
• 11:47
  SPEAKER_03: Bryant.
• 11:48
  SPEAKER_03: Can you sort of describe how the implementation of this has been in terms of the intrapartum and postpartum care?
• 11:54
  SPEAKER_01: I will say that we have terrific OB and neonatal teams who have really tried to implement these strategies in a family-focused way.
• 12:07
  SPEAKER_01: But boy, recommending that a mother separate from her newborn infant causes a lot of heartache.
• 12:15
  SPEAKER_01: Now, as Dr.
• 12:16
  SPEAKER_01: Ramirez sort of alluded to, we allow the woman in labor one support person.
• 12:24
  SPEAKER_01: It can be the father or another support person.
• 12:28
  SPEAKER_01: If the baby needs to go to the NICU, we do not allow the same support person flipping back and forth between the infected mother and the baby, who we hope is uninfected.
• 12:41
  SPEAKER_01: And so that too has caused a lot of heartache.
• 12:46
  SPEAKER_01: We have noted that women who do not speak English as their first language are disproportionately represented in our number of COVID-positive tests.
• 12:59
  SPEAKER_01: And so trying to explain risk and benefits and support breastfeeding with some of these women has been a challenge, really just to confirm that we are doing that well.
• 13:13
  SPEAKER_01: And I have heard anecdotally from some pediatricians in the community that the separation we really recommended early on had consequences for breastfeeding and really maternal well-being.
• 13:30
  SPEAKER_03: Thanks for sharing that experience.
• 13:32
  SPEAKER_03: Dr.
• 13:33
  SPEAKER_03: Meares, anything to add from your experience at UCSF?
• 13:37
  SPEAKER_00: Yeah, I want to echo Dr.
• 13:38
  SPEAKER_00: Bryan's comment in the challenging time, trying to create workflows that are as patient and family-centered as possible has been a focus of ours, but it is quite challenging.
• 13:48
  SPEAKER_00: So from a support person's standpoint, we do ask that the support person coming with that COVID-positive mom be ideally not exposed and definitely not symptomatic.
• 13:58
  SPEAKER_00: So sometimes that's a challenge, especially in these settings where there are multiple household members that have symptoms or end up testing positive for COVID and are asymptomatic.
• 14:07
  SPEAKER_00: So that's, I would say, one challenge that we've seen.
• 14:11
  SPEAKER_00: In terms of the postpartum care, especially for these term babies, it's been, I would say, like an overall positive experience in that because there was a shared decision-making approach, and we actually haven't had a single family for these term babies opt for separation.
• 14:30
  SPEAKER_00: Although there are additional considerations for these women around wearing a surgical mask and keeping six feet apart as much as possible and the challenges of breastfeeding with those two things in hand.
• 14:42
  SPEAKER_00: I think it's been overall okay experience of those families, especially because their admissions in the hospital tend to be quite short on the order of 36 to 48 hours.
• 14:50
  SPEAKER_03: We've had a similar experience, I think, with regard to the postpartum care.
• 14:55
  SPEAKER_03: You know, most patients have elected to keep the baby in the room, and we've been doing everything that we can to support it.
• 15:01
  SPEAKER_03: I think that maintaining a very patient-centric approach and supportive care within the entire team has been really critical, and being open and communication has also been a huge piece.
• 15:12
  SPEAKER_03: So I do want to go a little bit back into the labor and delivery aspect of care.
• 15:16
  SPEAKER_03: One of the big areas that we've been discussing is the labor process itself.
• 15:21
  SPEAKER_03: You know, what is the extent in which healthcare providers need to use PPE to protect themselves?
• 15:28
  SPEAKER_03: What's the best environment of care?
• 15:30
  SPEAKER_03: Is active labor an activity that actually generates significant aerosol?
• 15:35
  SPEAKER_03: But I'm interested in hearing both of your experiences in terms of PPE during the actual laboring process.
• 15:42
  SPEAKER_03: So at first I'll turn to Dr.
• 15:43
  SPEAKER_03: Amirez, can you comment a little bit?
• 15:46
  SPEAKER_00: Sure.
• 15:46
  SPEAKER_00: So for COVID positive, COVID exposed patients with signs and symptoms concerning for COVID with a test pending, if they are proceeding to a labor process before the test is back for that population that's undergoing evaluation.
• 16:00
  SPEAKER_00: Our PPE approach would be, as of right now, actually pertinent for today, is that we actually are rolling out a change in our PPE approach.
• 16:09
  SPEAKER_00: So for patients irrespective of their AGP status, we actually are rolling out an expanded N95 program, where for those three categories of patients, we're recommending N95, face shield, gloves, and gowns.
• 16:24
  SPEAKER_00: And that's because our N95 supply has stabilized and allows for that change.
• 16:29
  SPEAKER_00: I would say up until now, though, our approach had been the following.
• 16:33
  SPEAKER_00: If the OB patient was not getting an aerosol generating procedure, then the PPE would have been a surgical mask, eye protection gloves and gowns.
• 16:42
  SPEAKER_00: And then in the second stage of labor, because of the recommendations from some of the professional bodies around second stage of labor being an AGP.
• 16:49
  SPEAKER_00: So I think that's an area of controversy.
• 16:51
  SPEAKER_00: The staff were transitioning to an N95 eye protection gloves and gowns.
• 16:56
  SPEAKER_00: And then postpartum, they would go back to using a surgical mask, eye protection gloves and gowns.
• 17:03
  SPEAKER_00: So in the OB population up until today, there had been a shift in the PPE approach during that second stage of labor.
• 17:10
  SPEAKER_00: As of today, that will no longer be an issue because we've standardized our PPE irrespective of a patient's aerosol-generating procedure status.
• 17:19
  SPEAKER_03: No, thanks.
• 17:20
  SPEAKER_03: That's actually been our approach throughout the pandemic.
• 17:22
  SPEAKER_03: Fortunately, we've been able to supply N95 respirators in addition to the eye protection gowns and gloves.
• 17:29
  SPEAKER_03: So, Declan, any comments on that particular area?
• 17:32
  SPEAKER_01: Nothing really to add there, except to say that we, despite a lot of discussion with our OB colleagues, have not considered the second stage of labor as an AGP.
• 17:47
  SPEAKER_01: It creates a lot of challenges when you know each professional society comes up with a list of procedures that are different than you know what the CDC recommends.
• 17:57
  SPEAKER_01: But I think practically our OBs have made the point that it's hard to predict when a woman in labor may need an AGP, may decompensate quickly, and need intubation.
• 18:12
  SPEAKER_01: So I will say there's been some flexibility and ongoing discussion there.
• 18:17
  SPEAKER_00: One thing I'd like to add is like a part of the considerations for RPP approach prior to today when we've made this change is that also the unknown factors for the baby at the time of birth.
• 18:26
  SPEAKER_00: Like, you know, will they need CPAP?
• 18:28
  SPEAKER_00: Will they need some positive pressure breaths?
• 18:30
  SPEAKER_00: So that was part of our consideration as well.
• 18:33
  SPEAKER_03: Okay, great.
• 18:33
  SPEAKER_03: Thanks for reflecting on that and sharing some of that experience.
• 18:36
  SPEAKER_03: You know, the last topic I wanted to cover is a bit of a controversial one when it comes to pregnancy, particularly management of pregnant healthcare workers.
• 18:46
  SPEAKER_03: So there's been guidance that's been issued from different organizations with different approaches, and we have been evolving that a bit at my institution, but I'm interested in hearing both of your experiences on managing the pregnant healthcare workers and any uh special measures that you've been implementing.
• 19:03
  SPEAKER_03: So, first I'll turn to uh Dr.
• 19:05
  SPEAKER_03: Bryant.
• 19:06
  SPEAKER_01: Sure.
• 19:07
  SPEAKER_01: Early on in the pandemic, I think we were operating under the assumption that pregnant women were not necessarily at increased risk from COVID.
• 19:18
  SPEAKER_01: But a recent MMWR did point out that pregnant women who were infected with COVID were more likely to be hospitalized and at increased risk for ICU admission.
• 19:29
  SPEAKER_01: So I think our knowledge is certainly evolving.
• 19:33
  SPEAKER_01: From early on, we tried to be sensitive to the concerns of the pregnant healthcare worker, to encourage all pregnant healthcare workers to discuss their concerns with their manager and with HR.
• 19:46
  SPEAKER_01: To the extent feasible, we encouraged flexibility in assignments.
• 19:52
  SPEAKER_01: So if there was an alternative on a particular unit, a non-pregnant healthcare worker could be assigned to care for a COVID-positive patient, recognizing that in some settings that would not always be possible.
• 20:08
  SPEAKER_01: The OBs who practice within our system have recently adopted recommendations of national organizations asking women to self-isolate at home for a couple of weeks prior to their anticipated delivery date.
• 20:24
  SPEAKER_01: And the system, of course, has been very supportive of that.
• 20:28
  SPEAKER_03: Okay, great.
• 20:28
  SPEAKER_03: Thanks for that insight.
• 20:30
  SPEAKER_03: Dr.
• 20:30
  SPEAKER_03: Mears, can you reflect a little bit on your experience with pregnant healthcare workers?
• 20:34
  SPEAKER_00: Sure.
• 20:34
  SPEAKER_00: And this has also been an evolving topic for us as we have learned more around outcomes of pregnant women with COVID and specifically the MMWR that Dr.
• 20:43
  SPEAKER_00: Bryant was alluding to.
• 20:45
  SPEAKER_00: As of right now, our recommendation as an institution is that we recommend direct care to patients with COVID after 36 weeks gestation, with the idea that you would want to reduce the chance of a pregnant healthcare worker having COVID at the time of delivery and all the downstream effects that we've been discussing.
• 21:02
  SPEAKER_00: There's also the ability for pregnant healthcare workers to have discussions with their leadership or managers if there are other concerns.
• 21:10
  SPEAKER_03: Thank you, Dr.
• 21:11
  SPEAKER_03: Ramirez and Dr.
• 21:12
  SPEAKER_03: Brian.
• 21:13
  SPEAKER_03: Really appreciate you joining the podcast and lending some of that insight and expertise within the realm of obstetrics and COVID-19.
• 21:21
  SPEAKER_03: Thank you again to our speakers for sharing their perspectives and experiences.
• 21:25
  SPEAKER_03: And a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID-19.
• 21:31
  SPEAKER_03: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 21:37
  SPEAKER_03: You'll also find additional resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHA COVID-19 town halls.
• 21:45
  SPEAKER_03: Additional resources available on Learning CE pertinent to this pandemic include the SHAY CDC Outbreak Response Training Program, ORTP, and the Prevention Course in HAI Knowledge and Control, Prevention Check.
• 21:58
  SPEAKER_03: This concludes this episode of the Rapid Response Podcast.
• 22:02
  SPEAKER_03: Thank you to our speakers and thank you all for tuning in.