Coronavirus-2019 (COVID-19), also referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first observed in Wuhan, China in December 2019. Following vast and rapid global spread, COVID-19 was characterised as a pandemic by the World Health Organization on 11 March 2020. COVID-19 has seen over one million fatalities globally, with pregnant women being identified as an at-risk cohort; antenatal physiological adaptations increase intolerance to hypoxia, alongside both pregnancy and SARS-CoV-2 being implicated by decreased lymphocytes, NKG2A inhibitory receptors and increased ACE2, IL-9, IL-10 and IP-10 (Phoswa and Khaliq, 2020). Low-to-middle income countries have noted particularly severe effects on maternity care, with Nepal documenting a 50% increase in stillbirth rate and reduction in hospital birth since the beginning of the virus (Ashish et al, 2020).
The COVID-19 pandemic has had a significant impact on maternity services in the UK. Multiple changes occurred regarding the structure of antenatal care and access to antenatal education to reduce risk and exposure, alongside regulations surrounding birthing partners and hospital visiting. While visiting and attendance to antenatal appointments and ultrasound scans are reinstated in most hospitals, some restrictions are still observed, including that of 24-hour visiting policies for birth partners. This has had an effect on both women and birthing people, and the staff delivering the service.
In this report, we explore the midwifery and obstetric perspectives of perinatal care in a case of SARS-CoV-2 in a South London District General hospital, part of a larger teaching NHS Trust. This case of interest occurred in late March 2020; at this time, there was limited knowledge about the disease regarding its effect on pregnancy, labour and delivery. Moreover, in this early stage of the pandemic, guidance was frequently changing surrounding personal protective equipment (PPE). All accounts of care were voluntarily provided for this sole purpose and have been published with the service user and the healthcare professional's consent. All clinical care, including examinations, investigations and procedures, were undertaken with informed consent from the birthing mother.
Case summary
A 36-year-old primigravida booked at 11 weeks for antenatal care. She was of East Asian ethnicity, with a BMI of 26. She had no significant past medical or surgical history, however, a first-degree relative family history of diabetes mellitus and hypertension. She was non-smoker and drank one unit of alcohol per week on average prior to conception. She experienced minor vaginal bleeding in very early pregnancy, following which an ultrasound showed viable intrauterine pregnancy. Her booking bloods, nuchal scan, anomaly scan, oral glucose tolerance test (undertaken in view of family history), 28 weeks full blood count and 36-week routine growth scan were all normal.
She attended face-to-face regular routine antenatal appointments till 38 weeks' gestation. However, at 39 weeks' gestation, COVID-19 affected antenatal care provision and her last antenatal consultation was undertaken virtually. At this appointment, she reported a raised temperature with no other respiratory symptoms. She self-isolated as per government guidance. Three days later, her husband updated the midwifery team about her ongoing pyrexia. She had been prescribed amoxicillin by her GP, commonly prescribed in cases of pyrexia to cover possible group A streptococcus infection but had no other accompanying symptoms. She reported good fetal movements and no other concerns. She was encouraged to remain at home with a low threshold for further advice or maternity unit attendance.
Several days later, she reported spontaneous rupture of membranes with clear liquor. She attended the maternity assessment unit, where she also reported reduced fetal movements. Observations revealed a pyrexia of 37.8 degrees Celsius, a maternal pulse of 97 beats per minute, a respiratory rate of 22 per minute and oxygen saturation of 97%. She appeared breathless while speaking and upon chest examination, there were bilateral crepitation. A full septic screen was undertaken, alongside SARS-CoV-2 PCR swabs, a chest X-ray, and the commencement of erythromycin. cardiotocography, which was commenced upon admission, was and remained reassuring throughout. Augmentation of labour was discussed and accepted with informed consent due to background of possible sepsis, reduced fetal movements, rupture of membranes at term and potential risk of further deterioration. Unfortunately, her husband was unable to attend as a birth partner as he also was symptomatic of SARS-CoV-2 and was isolating under government guidance.
In view of her symptoms and a strong suspicion of SARS-CoV-2, a multidisciplinary approach was used. Upon consultation with the medical team, anaesthetics, obstetrics, and neonatology, one-to-one midwifery care with donning of full PPE was commenced. A chest X-ray showed patchy, increased density noted in the right lower zone, likely in keeping with SARS-CoV-2 infection. Initial bloods of interest are displayed in Table 1. Intravenous paracetamol and co-amoxiclav were commenced.
Table 1. Initial blood results and normal ranges
| Test | Result | Normal range: general populationValues may differ in pregnancy (Strong, 2016) |
|---|---|---|
| Haemoglobin | 105 g/dl | 115−165 g/dl |
| Platelets | 165 109/L | 150−400 109/L |
| White blood cells | 4.9 K/uL | 4·0−11·0 K/uL |
| C-reactive protein | 42 mg/L | <5 mg/L |
| Serum Ferritin | 437 μg/L | 15−150 μg/L |
| Troponin | 7 ng/L | <14 ng/L |
| pH (arterial) | 7.417 | 7.35−7.45 |
| pCo2 (arterial) | 3.95 kPa | 4.7–6.0 kPa |
| Lactate | 0.7 mmol/L | 0.5–2.0 mmol/L |
After a drop in oxygen saturation to 90%–94%, high flow oxygen at 25 litres per minute was commenced. Epidural anaesthesia was administered with informed consent, which was not contraindicated following anaesthetic review. Continuous CTG fetal monitoring was used throughout the intrapartum period in view of maternal pyrexia and epidural anaesthesia as per National Institute for Health and Care Excellence ([NICE], 2014) guidance with regular obstetric reviews. Oxygen supplementation via nasal specs continued throughout intrapartum period and observations generally remained stable. Her labour progressed well following augmentation, and the second stage of labour commenced after 7 hours and 15 minutes of the intravenous oxytocin infusion which was titrated as per Trust guidance.
Following a period of active pushing, she gave birth to a male infant via ventouse delivery which was assisted by the consultant obstetrician on call. The neonate was born in very good condition with APGARS of 9, 10 and 10, and weighed 3 735 grams. She had active management of third stage, and experienced a minor postpartum haemorrhage of 850 ml which was managed with ergometrine and misoprostol.
Postnatally, her pyrexia continued, peaking at 39.0 degrees Celsius. She additionally experienced oxygen desaturation on room air, which saw oxygen at two litres via nasal specs continued. The ongoing pyrexia and oxygen requirements were discussed with physicians, however no alterations in plan or treatment were required at this stage. The baby was screened and treated for infection at 6 hours of age as per NICE (2021) guidelines for neonatal sepsis. Neonatal nurses attended the maternal bedside to administer these antibiotics to reduce infection risk on the neonatal unit.
The result of the initial SARS-CoV-2 PCR swab taken at admission was negative, however in view of her ongoing symptoms, was repeated the next day. This second PCR swab result was positive for SARS-CoV-2. She remained an inpatient for three days. During this time, her pyrexia resolved, along with her dyspnoea. She was discharged home to community care with low molecular weight heparin and oral antibiotics. Her postnatal recovery was unremarkable. Both mother and baby continue to do well under the support of the health visitor.
Discussion
This case was the first incidence of a symptomatic SARS-CoV-2-positive mother within the maternity department at this District General Hospital. At this time, SARS-CoV-2 was a new disease entity with minimal yet rapidly evolving guidance. Fortunately, this case was not medically complex and management of her symptoms were simple but effective. Staff were able to refer to the Royal College of Obstetricians and Gynaecologists guideline (2020) on SARS-CoV-2 management in pregnancy and labour. However, frequently evolving evidence has meant there have been 11 updates since its initial publication.
This scenario was understandably reported as anxiety inducing amongst staff, particularly with regards to appropriate PPE and ensuring safe practice. The support and guidance received from infection prevention and control colleagues was invaluable. Public Health England PPE guidance was rapidly changing, with evolving evidence surrounding labour care and aerosol generating procedures. Labour care was and continues to not be considered an aerosol generating procedure, however due to the nature of the infectivity and gravity of the disease, it remained hard for the staff to be reassured. The multidisciplinary team were anxious to provide the best available care to the woman and her family medically, emotionally and psychologically. However, ensuring the healthcare professionals safety remained a key focus.
Despite the clinical challenges, a particularly difficult aspect of this episode of care was that this woman did not have her birth partner present. Utilising technology to enable her partner to be as involved as possible improved communication, however we must never underestimate the distress that lack of familiar support may entail. These women in particular should be offered close continuity of midwifery and obstetric care. This case study is an example of when the multidisciplinary team should explore methods of facilitating bonding between partner and baby in non-conventional ways.
Personal accounts
As part of this case study, we spoke to the professionals involved in her intrapartum care. They kindly shared their thoughts and feelings regarding this individual birth experience.
Midwifery perspectives
‘The guidelines for COVID-19 care were unstable and changing frequently. During this time, I did not feel confident in both the advice I was giving to the patient and the PPE I was required to wear for different procedures. The matrons were keen to support me and obstetricians responded quickly and efficiently to my concerns upon her admission. The infection prevention and control nurse came and supported the team also, and were happy to help us with any PPE queries. I feel, overall, that the care I gave for the patient was not the best it could be due to the confusion. I feel our care currently is much improved from the case in question.’
—Midwife A
‘It (SARS-CoV-2) was suspected as soon as she walked through the door. It was picked up on time … I think we did well, thinking about the care. It was the beginning of the pandemic, so I think that the PPE was not enough … that was my fear; I thought I was not well protected. In future cases, I would want testing for the partner also. We did not know if he had it but they are living together. We are looking after a family and so her partner should be there. She was alone for a long time and we had to do a lot of video calling to her partner who was not present. We could have done better.’
—Midwife B
Obstetrician's perspective
‘It was early days in the COVID-19 pandemic, and doctors were frantically looking for guidelines or evidence for the care of pregnant women who were symptomatic of SARS-CoV-2. Obstetricians were very aware that with Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome, pregnant women suffered from much higher morbidity and mortality than background populations.
Moreover, there were anxieties regarding our own protection and the use of PPE at that stage. Labour itself, nor the use of entonox, were considered to not be aerosol-generating procedures, so theoretically speaking, it was not a very high-risk clinical scenario. However, having said that, there was limited evidence.
As the consultant obstetrician on call during this episode of care, I decided to provide the bedside care myself to not to expose junior staff unnecessarily. The midwives and I decided to utilise video calls for some reviews to reduce exposure; it was a new experience, but it worked very well. This also enabled me to show my face to the woman without a mask and, in my opinion, enabled us to create a better relationship and reduce her anxiety.
When the need for an assisted delivery was identified, I performed a ventouse delivery in the labour ward room. I asked for the postpartum haemorrhage emergency drugs and equipment box in advance to reduce risk of emergency theatre transfer, which I was grateful for as she bled slightly more than expected.
Due to her partner isolating at home with symptoms, we again had to utilise video call for the birth so that he would be involved in the experience in some capacity. Prior to COVID-19, I had never done this but, upon reflection, I think we should undertake this more frequently if partners cannot not attend the labour or birth due to whatever reason.
It was a unique experience caring for a labouring mother with full PPE. Our facial expression plays an important role in creation of rapport and relationships with our service users—an aspect of care I miss. Looking back, since this period we have learnt a lot about SARS-CoV-2 and pregnancy. Now we have significantly further developed protocols for their management and the use of PPE.’
Conclusion
The outcomes of this episode of care medically were good. To date, the family remain at home under the care of her health visitor and have made a full recovery from COVID-19. The multidisciplinary team of midwives, anaesthetists, obstetricians and support workers provided the best possible care at the time, with limited guidance on both the disease itself and PPE for their protection.
The reflections of the multidisciplinary team in this case study have enabled us as authors to reflect on what may be improved upon in future as the COVID-19 pandemic continues. The absence of a birth partner was undoubtedly a significantly challenging aspect of care for primarily the mother but also for those involved with her care. We cannot measure the impact that birthing alone may have had on this family. Maternity services should explore ways that we can better support families who are birthing without familiar support.
Key points
- COVID-19 has had a profound effect on maternity services in the UK, affecting antenatal, intrapartum and postnatal care provision particularly in cases of the disease
- Cases can be well-managed with a multidisciplinary team approach with quick escalation and frequent monitoring
- Midwifery and obstetric feedback show that communication between service user and healthcare professional has been affected by PPE. We can adapt our approaches, both with regards to communication skills and support, when service users are birthing alone
CPD reflective questions
- Thinking back to earlier in the COVID-19 pandemic, what could the maternity service have done differently to improve this episode of care?
- How best can you support a service user birthing alone, due to choice or circumstance?
- Reducing the number of healthcare professionals at the bedside during cases of SARS-CoV-2 can be challenging. How best can we work as a team to ensure that we continue to provide safe and thorough care in these circumstances?
- How can we still attempt to facilitate partner-newborn bonding in circumstances such as this case study?