Midwife Musings on Trends in Obstetric Practice During the COVID -19 Pandemic


shout to an awesome mama making these – she crafted one for each of my babes!
https://www.ericasara.com/

Hello hello! It was a quiet week on the blog last week. I did two weeks in a row of clinic to spin up for the new job and I didn’t have any brain power leftover. But, I did run into a lot of frustrations related to the pandemic that I thought it would be good to share here on the blog. Most of these musings have been ongoing for me, but some of them got a spotlight last week and did some extra ping-ponging around my brain.

It’s safe to say the pandemic has affected everyone. It’s something we all will all look back on and remember – especially those that were practicing in the healthcare field prior to the pandemic. From my perspective as a midwife, a mama, and a patient (my 3rd baby was conceived and birthed in 2020), there are the themes that keep echoing around in my head. They are my own opinions, but I like to think they are shared by some.

Masks

Oh masks. I feel like you are the visitor that moved into my house for a few weeks during a transition time period of life and now I can’t get rid of you. Unfortunately, you aren’t going anywhere anytime soon. Here are the things that keep bugging me about masks.

It is hard enough to coach someone through having a baby. It’s even harder to do it with a mask on.

It is hard enough to counsel someone about medicine, interventions and their plan of care. It’s even harder to do it with a mask on.

It is hard enough to read people’s facial expressions and everything that is unsaid in interactions with people and patients. It’s even harder with masks on. (I always wonder what I am missing in the patient interaction that was unsaid and is hidden beneath their mask).

I hope masks go away in the future and this isn’t a standard for the future of obstetric care, or all health care. We have to go back to normal at some point. But until that time, we can’t lose focus of what is harder with a mask on and how much more important it is to make sure we’re giving the same care as you would when you could see someone smile or not.

I think we also need to take better care of people who struggle to wear a mask. When I was very pregnant last year, it was really hard to counsel patients sometimes because I was so short of breath. I would have to stop, pause and breath because I couldn’t catch my breath in regular conversation. People will struggle for different reasons – pulmonary disease, old age, pregnancy, pushing a baby into the world…. Take time to let them say what they need to say, when they are able to say it.

And lastly, don’t let what the mask represents stand in the way of what a patient needs. An example of this is patients that are experiencing loss. Miscarriage, stillbirth, loss of a loved one. Sometimes people need a hug. But if you’re giving them a 6 foot radius, they are seeing the physical distance and not the compassion they need.

Use your common sense about masks, but understand what patients and people need too.

Visitors

I will be totally honest here. I am at my wits’ end with visitor policies in obstetrics. It’s not right to require that a woman labors alone. In fact, I would argue, it’s actually harming the labor, birthing and bonding process for the mother, the partner and the family unit. It’s taking a normal event in life and making the situation abnormal and stressful. I know the policies differ across the globe. I just encourage people to really examine those policies and the evidence. And then consider what is supportive for normal, physiologic birth.

In instances where you are not allowed visitors, consider adding these to your practice:

  • Encourage the woman to call her partner or support person and put them on speaker phone during a clinic visit or during conversations about plans of care in triage or on labor and delivery. This only takes an extra 30 seconds and will probably bring some calm and relief to the mama. And appreciation to you and your team.
  • Offer for the mama to take a video of the doptones (fetal heart rate) in the clinic setting if this is allowed in your clinic. She can replay this for her friends, family and partner and get a sense of support from that small 10 second clip of “whoosh, whoosh, whoosh.”
  • Talk with your patients about the visitor practices in your clinic and birth unit often. It shouldn’t be a surprise to your patient that they aren’t allowed visitors or that they are limited to just one person. But, I find that miscommunication or lack of communication are almost always the causes here. Communicate early and often.
  • Talk about how the hospital experience may de different for everyone supporting the family because of the pandemic. Are grandparents coming to help? If they aren’t allowed visitation at the hospital, talk about how they can help at home – cleaning the house, doing some meal prep, buying postpartum supplies. Remember, before the pandemic, family, church friends, work friends…everyone…used to come up to the postpartum units. That’s in the past now. A focus on preparation is needed for the mama and the whole support system.

Lastly, make sure you are advocating for the right practices. This is different for everyone and every hospital or birth center or home. For example, stringent visitor restrictions in a place where COVID cases are very low, may need to be examined. Or, in high risk populations and units with flexing COVID rates, only one or two visitors may be the most appropriate.

Prenatal Care

The pandemic has changed how prenatal care is given. It’s hard to predict which changes will be the normal in 10 years, but here are some of my thoughts.

Telehealth is here to stay and most people appreciate telehealth when it is used appropriately. An example is a new OB intake with a nurse. This is often a brief telephone visit about the patient’s history that prevents an office visit and maybe an instance where a mama might have to get a sitter because her kids are not allowed in the clinic setting. Another benefit about telehealth is counseling about problems or interventions that don’t necessarily need a physical exam. Contraception is a great example of this. Almost all contraception can be prescribed or scheduled without an exam – IUDs (intrauterine devices) are the exception. Postpartum care is another example. The clinic I was a part of in Alaska trialed a postpartum initiative to complete a 2 week and an 8 week visit during the postpartum period for all our patients. It was great. The patients loved it. We also caught postpartum depression/anxiety and breastfeeding issues early, and were able to capture more mamas that wanted or needed contraception before their fertility returned. The program ultimately didn’t continue for a number of reasons, but it was wonderful while it lasted.

Electronic health records should build video or telehealth components into their systems and obstetrics needs to focus on the potential here for group prenatal care. There is so much education in group prenatal care, but in person groups aren’t exactly feasible for some hospital or clinic settings right now. And pregnant patients are considered a high risk population in the pandemia. But, tuning in from your couch is perfectly safe and it allows the bonding, education and benefits (lower rates of preterm birth, higher rates of breastfeeding, better preparation for birth, and lower rates of postpartum depression). This is something that could revolutionize prenatal care – but the behind the scenes work is a big, big mountain. It’s a worthy goal to think about.

We can’t stop screening for depression and anxiety. We must be more vigilant than ever before. One of the first things to drop off from routine screening in place of the “travel or COVID questionnaires” were the depression screenings, often known as the EPDS or the PHQ. I spend more time tracking down these screenings to see if they were done and what people scored. Is there a better way to screen? Can we send patients a screen before their visit? Should we be screening people at every visit? I just keep thinking there is so much room for improvement.

Postpartum Care

Oh the land of lochia. The road to improving postpartum care was long and rocky before the pandemic – now the road is almost unsafe for passage. I see women stranded on it all the time and providers trying to tell them which direction to go (because after 8 weeks, everyone thinks postpartum women should go to primary care for everything).

I don’t have enough words to go into this aspect. It’s a whole post itself. Just don’t forget about this group of women and the love and care they need.

Ok, that’s all I have for the musings. I just wanted to share some thoughts from someone on the front lines.

Yes, I know that policy changes are annoying and always changing. I get emails every day about the updates and nuances. It’s exhausting.

Yes, I know that you are tired of wearing a mask and no, you don’t want to wear one during pushing. I think that is unfair too.

Yes, I do think it’s going to be better, but I don’t know when.

Just remember we’re all in this together. Don’t be afraid to hug someone. You can keep your mask on while you hug them.

Cheers,

Jamie


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