The same nightmare awaits Rishma Pradhan most evenings after she enters the REM cycle. It starts with her going into labour. Her husband drops her off at the hospital and drives home. Medical staff in hazmat suits tell her she is not allowed to push; they are going to deliver the baby by C-section so they can get her out of the hospital as quickly as possible.
Ms. Pradhan, who is 28 weeks pregnant, is in a constant state of panic over what her labour and delivery will be like in the midst of a pandemic.
Available research suggests pregnant women do not have an elevated risk of contracting the novel coronavirus and that women who are infected cannot pass it on to their babies in utero.
But across Canada, women face daily changes and a world of certainty in how their deliveries and prenatal and postnatal care will be handled by a health-care system rocked by COVID-19. They are listening to their baby’s heartbeat for the first time without a partner present, being told to buy blood-pressure cuffs to monitor themselves at home, meeting with midwives and obstetricians virtually, making difficult decisions about who – if anyone – will accompany them in the delivery room and planning to have their babies at home or at a birth centre to avoid the hospital.
Ms. Pradhan’s most recently scheduled prenatal appointment was postponed because her obstetrician has been exposed to COVID-19 and is in self-quarantine. Michael Garron Hospital, where she plans to deliver her baby, is only allowing one support person to accompany Ms. Pradhan when she is in labour, which means she will have to choose between her husband and her doula, who was her biggest advocate during her last birth. The in-hospital breastfeeding clinic, which she visited daily in the weeks after her first child was born, was closed for a week in March, but is now open for telephone consultations and some in-person visits. And she worries about whether she will have access to the many postpartum depression support groups that were a lifeline to her the last time around.
“In the last few weeks it’s been getting really scary," Ms. Pradhan says. “I’ve been really worried because my first labour and delivery was horrific and if [my husband] wasn’t there, I don’t think I would have made it through.”
This week, Rachel Seelig, who is 33 weeks pregnant, dropped her obstetrician to switch to a neighbourhood midwifery practice so she can have a home birth instead of one at Toronto’s St. Michael’s Hospital as planned.
She was concerned about hospitals being overrun by her delivery date in mid-May. “Even though I know they’re taking every precaution to keep the labour and delivery ward separate and secure, it still made me nervous,” she said. Her elderly parents live with her, so she also thought switching to a midwife and a home birth would reduce the risk of her getting infected with COVID-19 and potentially transmitting it to her mother and father.
Roberta Pike, the executive director of the Toronto Birth Centre, says midwifery practices across the city have reported a jump in intake in the past week from women who want to avoid hospital deliveries. She anticipates that demand will trickle down to the number of births handled at her centre in the weeks and months ahead.
Only midwives provide medical care at the Toronto Birth Centre, which normally does not restrict the number of visitors a woman can have present. But as at most hospitals, it is now allowing only one support person from the client’s family to attend; all those who arrive, including women in labour, will first be screened at the door for symptoms of COVID-19 and denied entrance if they have a fever or cough.
In recent weeks, staff at the Midwives Collective in Victoria have seen 25 to 50 per cent of clients who had planned for a hospital birth inquire about a home birth, says Aly Jones, a midwife at the practice and vice-president of the Midwives Association of British Columbia. As long as the woman is healthy and the pregnancy is low-risk, a home birth can be a great option in these uncertain times, she said.
But even her practice has made dramatic changes to their operations. Because some evidence suggests COVID-19 can live in feces, Ms. Jones said they are no longer allowing tub births (only tub labouring) to reduce the risk of infection. And while it is routine to make many at-home visits in the first weeks after a birth to check the baby’s weight and assess the mother’s recovery, Ms. Jones says her practice has been limiting these calls, instead providing breastfeeding support through video chats and sending parents home with scales so they can weigh their babies themselves.
The one-support-person rule has already been difficult for many families to accept, but even stricter policies may be coming as health-care providers deal with limited access to COVID-19 testing and a dwindling supply of personal protective equipment, said Jennifer Blake, chief executive officer of the Society of Obstetricians and Gynaecologists of Canada in Ottawa.
Facilities across Canada have “very, very heartbreaking decisions they’re having to make as to whether they can keep women safe and have another person come in with them,” she said.
Every morning at 8 a.m., Wendy Whittle, medical director of labour and delivery at Toronto’s Mount Sinai Hospital, attends a daily leadership meeting on COVID-19 during which visitor policy is often discussed. She said the medical ethicist dedicated to mother and infant care is constantly weighing the ethics of having a support partner present against the ethics of the disease and potential transmission.
Continuing to allow support partners for labour, delivery and immediate postpartum care is a priority given the volume of patients with high-risk pregnancies they serve, Dr. Whittle says. “We think of labour, delivery and the birth of a child as a life-altering event."
While access to epidurals will not be affected by COVID-19 since Mount Sinai has a dedicated anesthetist in labour and delivery, one pain-management option that is no longer available to women in the delivery room is nitrous oxide, also known as laughing gas. COVID-19 can be spread through aerosolization and the use of nitrous oxide could potentially enable that.
Mount Sinai used to accommodate “social inductions,” which allowed a woman to schedule an induction around the availability of her particular obstetrician. In response to COVID-19, inductions will be allowed only when there is a clear “medical indication" for one.
Haligonian Amanda Guitard, who has gestational diabetes, is due in late September but is already worried about how her high-risk classification might lead to multiple interventions during labour and delivery if COVID-19 remains a major concern in the fall.
“I have a feeling that they’re not going to be as lenient if I say, ‘Hey, I don’t want to be induced, maybe can we push it another week?’ I think it’s going to be very stringent: ‘We’re going to induce you here, and we’re going to let you labour this long and if you don’t have the baby by then, you’re gonna have a C-section,’” she said.
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