Happy Friday! I hope everyone is well….this Five is full of resources. Let’s do it.

1. The American College of Nurse Midwives (ACNM) hosted a webinar on: Clinical practice challenges and solutions during the COVID-19 pandemic. This was the first webinar in a series aimed at helping midwives navigate the issues/struggles with COVID-19 and their clinic practice. I know not all midwives are members of ACNM and I think their information is really valuable. The webinar is an hour and half long…so here’s my tl:dr (too long: didn’t read) if you’re interested:

• We need to consider alternative birth settings for women in labor. If a community hospital is inundated with COVID-19 patients, what processes should be in place for pregnant, laboring women to enter safely? Additionally, are our labor and delivery nurses prepared to give care safely and with appropriate PPE (personal protective equipment)?
• If alternative settings are utilized, labor and delivery staff (nurses, midwives, providers and patients) must be adaptable – example given: our normal birth environment may not be available (i.e. a birthing suite is now unavailable) and we must adapt to environments available in our community – birth in a surgical suite, a birth center, etc.
• Organization, planning and communication amongst your provider team is imperative to successful patient care and team success. Anticipate and plan as you are able. Communicate efficiently. Be prepared.
• The Q+A portion was great! This is my summary of the Q+A portion:
  • How contagious are symptomatic and asymptomatic people?
    • People are able to shed the virus (be contagious) before their symptoms appear (this period can last up to five days before symptoms appear) and people may continue to be contagious after the symptoms start to improve.
  • Can you get the disease once you have recovered?
    • We aren’t sure. In short, it is unclear what type of immunity process takes place after the viral infection.
  • If you are asymptomatic or potentially exposed, what are the recommendations for social distancing, quarantine and isolation? When should you go back to work?
    • An exposure is defined as within 6 feet of someone for more than 10 minutes to a person with known COVID-19. Quarantine is recommended for these individuals for 14 days with close monitoring of symptoms
    • Social distancing is practiced by staying at least 6 feet away from another person and avoiding all group activities.
    • Isolation is for people that are symptomatic – you may or may not be tested for COVID-19; it is recommended you are not in contact with anyone else in your house or with your pets; and that you use your own bathroom and dishes at this time.
  • How do we counsel our families?
    • Counseling depends on which category you fall into as discussed above.
  • Can I refuse to care for a patient with COVID-19?
    • It is unethical to do so without finding another provider to care for the patient. The example provided was great: the provider is 60 years old and is an asthmatic – this person is already at high risk for contracting the virus.
  • Are newborns at risk? Should mothers and babies be separated from each other after birth?
    • There’s not a lot of good info out there. Some studies have identified that COVID-19 is not in breastmilk or that there has been any transmission of COVID-19 documented while the baby was in utero before birth. This is also called perinatal or vertical transmission. At the time of the webinar, there is not evidence to support separating mothers and babies after birth.
  • Should women be encouraged to continue breastfeeding even if mother or baby are separated?
    • YES. Breastmilk is still recommended for infants!
  • How are providers supposed to protect themselves in light of shortages of protective gear?
    • Shortages are different across communities; if you have the ability to get fitted for a N-95 mask, you should do so and an N-95 mask is recommended for all midwives on the frontline providing care. Some cities are reaching out to construction companies, restaurants…any company that uses a mask…and donating these to your local hospitals.
  • What is the ideal way to change how clinic is seen? Are routine exams (like the well woman exam) or other non-urgent visits a priority?
    • In short, all non-urgent visits or annual visit like a well woman exam should be moved to the future. Specific dates can be determined by each practice.
    • Offer telehealth whenever appropriate and possible.
    • For OB care, the World Health Organization recommends 8 scheduled visits; these are considered “essential visits.”
    • Labs, ultrasounds and other testing should be combined whenever possible during obstetric care.
    • Most practices are seeing pregnant patients weekly after 36 weeks because of concern for hypertensive disorders.
    • There are challenges with regular obstetric care. One, many patients want to come into the office to hear their baby’s heartbeat on a more regular basis. For blood pressure monitoring, cuffs at home may be most ideal but this could present a cost issue (some insurances may cover this cost). Patients can also consider other community organizations to help with this purchase if income an issue.
  • What does virtual health or telehealth look like? What does that visit need to look like in the EHR and how can it be coded?
    • Common platforms for telehealth might include EPIC or Zoom. Regarding CMS, many restrictions are being lifted and this visit should focus on the patient and much less on coding at this time.
    • Regarding documentation, document in the same way you would a visit in person and make sure to document in the chart that is it a telehealth visit. (Not addressed in the webinar but more information on telehealth and coding as a provider is available from this toolkit; more guidance on telemedicine and pregnancy is also available from the Kaiser Family Foundation).
  • How do you help your provider team transition to a telehealth platform?
    • Look at the visit as a screen. The patient can always be seen for an appointment if concerns arise during the screen. The goal is to keep patients out of the hospital or clinic.
  • What about postpartum visits? What about contraception?
    • For long acting birth control, commonly called a LARC, consider offering these while mamas are inpatient (either as a post-placental IUD or placing a Nexplanon before the mother leaves the unit). When LARCs are not appropriate while inpatient, consider counseling on bridge options to provide contraception until the mother is seen for her postpartum visit.
  • What are the concerns regarding the use of nitrous oxide use?
    • The concern with nitrous oxide is two-fold: one, that since COVID-19 is droplet transmitted, the use of nitrous oxide may spread the COVID-19 virus in patients or family members that are asymptomatic and otherwise shedding the virus without knowing it; and two, that the nitrous oxide machine is moved from across different patient rooms for multiple uses in a shift and should be cleaned thoroughly before each use.
    • Regardless, this should be addressed at each institution individually.

The next webinar town hall is supposed to focus on midwifery education and the well-being of midwifery students (tentatively set for March 25th). Let’s band together during this pandemic! Check out ACNM’s Responding to COVID-19 page too! It’s chock full of resources for any practicing provider.

2. The American Journal of Obstetrics and Gynecology Maternal Fetal Medicine published a draft guideline for obstetric care on March 20, 2020. They offered these enlightening recommendations to guide routine obstetric care as well as a recommended schedule for reduction in prenatal care visits. I like that the guidelines are clear and the obstetric visits are outlined with details

Check out their recommendations!

Abbreviated obstetric visits are below (note, the postpartum visit is recommended via teleheath):

3. What are the individual states doing differently to prevent the spread of coronavirus? Read this table by the Kaiser Family Foundation. I didn’t know there were so many differenes. Examples: some states are offering paid sick leave and some are not; some states are planning to offer a free COVID-19 vaccine when it is available…some are not; some states are allowing for early prescription refills…where does you state fall? Also check out the number of hospital beds available by state. Awesome job KFF. Keep the good data coming.

4. This podcast: Anthony Fauci: Talking with patients about COVID-19. It’s only a 13 minute listen (that’s your getting ready time in the morning)…but here are my notes if you’re short on time:

• What can providers tell their patients to convey COVID-19 risks as well as provide assurances?
  • Approximately 80% of people infected have mild, flu like symptoms, and appear to recover spontaneously. If you have underlying diseases, you have a much higher chance of becoming infected.
  • COVID-19 differs from the flu in that young people and children tend to do okay with the infection.
  • There is clear community spread across many places in the United States – we have to start practicing social distancing; wash your hands as much as you possibly can; and if someone in your home becomes infected, you must protect yourself and the rest of your family.
  • With community spread, we don’t know the spread of community infection. The only way to know the spread in the community is to test more people.
• What do you consider the best source of information for the public and for providers?
  • Dr. Fauci recommended two websites: coronavirus.gov and CDC.gov.
• What should clinicians do to balance continuing giving excellent health care while preventing infection in themselves?
  • Dr. Fauci recommends wearing a N95 mask; washing your hands as often as possible (he states in the podcast until your hands go raw!); and give good guidance to people over the phone to prevent unnecessary access of the emergency room.
• What do you recommend people do?
  • Don’t panic – it can causes overwhelming of systems.
  • Pay attention to the fact that you have to act differently than you have acted before – possibly for the next few months. Be prepared to hunker down.

5. A letter to the President of the United States. The letter is to President Trump requesting the removal of barriers preventing access to midwifery care and midwives from practicing full scope midwifery. If you’re stuck at home and need a really proactive cause to rally too – find one of the 24 states that are struggling to break down these barriers and send their congress member a letter in support of midwives, full scope practice, and increasing access for women everywhere.

Other goodies:

• A webinar hosted by NACPM: Coronavirus: Midwives on the Front Line. This one is almost 3 hours long. If I get a chance to listen, I’ll post notes as well.
• New scholarship opportunity from the National Health Service Corps!
  • Applications due April 23, 2020! Want more ideas on ways to help pay for school? Check them out here.
• This yummy, HEALTHY snack – great for anyone – women, mamas, littles, pregnant mamas! We made a double batch on Tuesday this week.
• Paperbackswap.com – another way to get some books you want sent to you door…while clearing out your own bookshelves at the same time. I used to use this website 10 years ago and recently thought of it. I really thought they would have gone out of business but they’re still going strong. The premise is this: you make an account, list your books, and the site cross matches to see what other readers want your books! Once a reader requests your book, you print the shipping label (with postage if you’d like!) and drop it in the mail. Now, in times like these, the post office may be the last place you want to go. Have no fear – you can pay for the media mail postage (about $2-3) online and then have the post office pick the package up off your porch during regular mail hours. It’s so easy. And who doesn’t like to get books in the mail?
• This awesome midwife and her amazing success at starting and running a birth center in her community! Keep up the awesome work Stephanie. We are rooting for you.
• For healthcare workers…or anyone going to a hospital where personal protective equipment is worn…this is a reminder on how to put on/take off PPE!

Keep your spirits high. Wash your hands. Social distance it like a pro, and have a good weekend!

Jamie

References

Boelig, R.C., Saccone, G., Bellussi, F., & Berghella, V. (2020). MFM guidance for COVID-19. American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine. doi: 10.1016/j.ajogmf.2020.100106