Supporting obstetricians and midwives in COVID-19 times

It is 2 am at a busy public hospital in a metropolitan city in Australia. Sarah* presents in established labour to the birth unit. She is visibly distressed, her contractions are only a few minutes apart and lasting a minute each. Her high-pitched cry is audible through the corridor, as she gets wheeled to the birth room. Accompanying her is Simon*, her anxious partner. This is their first baby and he is not sure what happens next. A couple of midwives and doctors rush to the birth room to assess Sarah’s condition. They have prepared for Sarah’s arrival but were not prepared for her to be in advanced labour. After all, this is Sarah’s first labour and they expect it to be long and slow. They are taken by surprise but quickly get organised for an imminent birth.

*Not their real names

FOR anyone who works as an obstetrician or a midwife, the above scenario is a familiar one. It is a situation that probably occurs once every couple of shifts, if not more often. Women may present to the birth unit at short notice, after a somewhat hesitant phone call, or even unannounced. Often, medical and midwifery staff may have to attend to women promptly on arrival as they may be close to birthing or occasionally have a risk of developing sudden, unexpected complications.

Coronavirus disease 2019 (COVID-19) presents a unique challenge for midwifery and obstetric staff. On the surface, it may appear that we look after mostly healthy young women with no background illnesses. However, as obstetricians and midwives, we may not have the complete history of the woman when she presents. We may not be aware of background high risk factors, especially those that have developed recently. Questions of recent travel (personal or that of a family member), contact with either someone who is infected with, or is at high risk of being infected with the novel coronavirus are becoming part of the initial assessment of women presenting in labour.

Additionally, there exists a risk of asymptomatic spread, where the woman or her partner may not be aware of their infection risk. Chowell et al’s modeling study suggested that 18% of the 700 infected passengers on the Diamond Princess cruise ship continued to be asymptomatic. Recently, emerging evidence has shown that asymptomatic carriers may have a similar viral load as those with symptoms, and may hence potentially transmit COVID-19. This may pose a risk to midwives and obstetricians who look after seemingly well, healthy, young women, and similarly, other health care workers, who attend to patients with non-COVID related complaints.

Women may have heavy breathing or can often be screaming with agonising labour contractions for hours while being in the same room as the midwife. Exhaled air may contain aerosols that can transmit viruses responsible for causing respiratory tract infections. Although this has not yet been confirmed in the case of COVID-19, this risk was documented for the transmission of influenza virus in emergency health care practitioners. Midwives often spend most of their shift providing medical care and also comforting the woman and her partner. This puts them at risk of prolonged exposure merely by being in the same room and interacting with the woman and her partner at close quarters over an entire shift of 8–10 hours.

The second stage of labour may last for 2 hours or more with the labouring woman exerting herself to birth the baby. Intensified breathing coupled with loud straining and pushing efforts are often witnessed in birth rooms. Birth may be attended by two midwives and also by obstetric and paediatric staff, who may be assisting in birth or resuscitating the newborn. Usually, these encounters are in close range of the birthing woman, putting the health care professionals at risk and requiring attending staff to take special precautions. Frequently, there is faecal loss during active second stage of labour, which can potentially expose the accoucheur to risk of acquiring COVID-19. Faeco-oral route has been suggested as a mode of spread, although at this early stage, there is no evidence of this transmission through second stage of labour.

Similar to other emergency specialties, birth complicated by fetal distress or postpartum hemorrhage requires rapid team-based actions by the medical and midwifery staff to manage these complications. These may occur unexpectedly even in low risk pregnant women requiring multiple staff members to congregate around the birthing woman. An example can be of a significant postpartum haemorrhage, where life-threatening blood loss can occur within minutes, requiring all hands on deck. Medical and midwifery staff members, available at the time, would be called to help in these emergencies. Together, they will be required to insert two large bore intravenous cannulae, massage the uterus to encourage uterine contraction, check for vaginal tears and assess ongoing blood loss, insert urethral catheter and administer large bolus of fluid and medications, all occurring simultaneously. While health care workers immerse themselves in tasks that require their prompt attention to save the woman’s life, it puts them at risk of having close encounters with each other and with the woman and her partner, performing their duty of care, at a personal cost of being exposed.

Anyone who has travelled in an aircraft is familiar with the safety briefing: “Put your own mask on before you help others”. We are taught this in medicine as well but may forget this very important message when faced with time critical emergencies.

Although all protocols start with assessing danger, risk assessment of danger to health care workers is poorly documented. Very few studies have focused on occupational hazards to emergency response teams during resuscitation. If danger is perceived, we are taught to not proceed until we are out of harm’s way. But what do we do where the perceived danger is not visible? With the rapid spread of community-acquired COVID-19, how do we as health care providers, reassure ourselves that the patient we are caring for, or the accompanying staff member, is not infected with the novel coronavirus?

Does this mean that, in a pandemic, health care providers forgo their duty of care towards their patients in the interest of their own safety? Can we suddenly forget the oath that we have abided by all our lives, the ideology and principles that we share as health care professionals? Where stakes are high, it is likely that most health professionals would rather soldier on and continue treating their patients and fulfill their duty of care.

The COVID-19 pandemic calls for novel actions. We need our governing bodies, chief medical and health officers and hospital administrators to show genuine support for frontline health care staff.

On 31 March 2020, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists issued a statement on the protection of midwives and doctors on the birth unit, advising use of personal protective equipment (PPE), including the use of protective apparel, surgical masks and eyewear in the pushing stage for all obstetric patients (including those who are low risk for suspicion of COVID-19). If similar guidelines are adopted by colleges and licensing authorities for other specialties, frontline health care staff will be likely to feel more supported to continue their roles with confidence.

While physical PPE is non-negotiable, mental protective equipment should also be prioritised. Health care, now more than ever, needs a flattening of the traditional hierarchy, reaching out to each individual worker risking their life and wellbeing in the line of duty. There is an urgent need for the role of a “door bouncer” in health — someone who stops individual practitioners from putting themselves at risk without adequate protection, both physical and mental.

While we collectively wait with bated breath for a cure or a vaccine, health care leaders should put all their effort into supporting highly skilled staff to perform their job safely, with clear guidance and continued support. If we don’t rise to the occasion, we risk losing not just this generation of health care workers but also future generations who will not be willing to pay the ultimate price for their profession.

Dr Arunaz Kumar is a Fellow of the RANZCOG and is a consultant obstetrician and gynaecologist based in Melbourne. She has a special interest in interprofessional education and simulation, evaluating translational outcomes of educational programs.

Dr Nisha Khot is a Melbourne-based obstetrician and RANZCOG Councilor for Victoria.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.