Birth Doesn't Wait

[Linda Mellace Rice]

For better or worse

Birth doesn’t wait. Not for traffic, birthdays, baby showers. Not for other deliveries. And certainly not for good times. In 21 years as a midwife, I’ve witnessed pregnancy proceed through desertion by spouses, death of loved ones, job losses, homelessness, and yes through pandemics. Its never-ending persistence is both tragedy and hope.

Obstetrics is kind of a weird specialty

We tend to be in a bubble from the rest of the hospital, yet everything passes through. Disease, accidents, grief, abuse and all of life and medicine don’t pause for pregnancy. And, midwifery is somewhere between medicine and art. It’s the only job in the hospital where most of the time I have a duty to actively do nothing. To honor the wisdom of the body, and protect the ancient process from outside influence while also minimizing risk. It’s normally a tightrope that hospital-based midwives walk gingerly. Since Corona, I feel the tightrope snapping.

Birth is above else a letting go

The less safe a woman feels, the less her body is able to toil through the work of labor. Worry is always part of the price of parenthood. When women tell me they’re worried about being a good mom, or worried that something will go wrong, after listening to their concerns and making sure they don’t have real anxiety, I reassure them that worrying is how I know they will make good mothers. It is our mother bear instinct that made me, a woman who handles babies for a living, worry about dropping my newborn son as I carried him up the stairs.

The normal worry of motherhood is work enough

My first rule for my patients is not what they eat or how much they lift, it’s “no googling”. I started as a labor and delivery nurse in 1989, and too much information, especially bad information, always caused more angst than it was worth. Back in the early nineties, the culprits of this excess of data was your mom, your co-workers, or your aunt Linda. As I’ve told my patients, in 21 years of midwifery, not one woman, according to her coworkers, has ever been the correct size. Most are “huge”, some are too small, but I’ve never had a woman tell me, “you know everyone tells me I look perfect for my gestational age”. However, the more modern barrage of internet experts and social media opinions makes for plenty of crazy.

It's all about Covid

Now we’re faced with many women home, on devices or TV, and it’s all Covid, all the time. And after 21 years of saying, no, the media, or web MD, or aunt Karen is blowing the risk way out of proportion, I now have to say, this time it’s real. If a pregnant woman becomes infected, she knows what the worst case scenario is. The thing about this epidemic is, even the best case scenario is somewhat dismal.

Much of it has to do with the environment of birth which has suddenly shifted under our feet. For the first time, women may have limited or no support persons with them in labor. Family that was supposed to come help with other children are now quarantined in other locations. Women that were just visiting are now stranded here away from home, family, and their own healthcare providers. Women who test positive are told they must be separated from their newborns. I know many of us are postponing life events. As heartbreaking as it is to postpone a wedding, graduation, or vacation, birth doesn’t wait. For most of us, the most significant event in our life can no longer be shared by fathers, wives, or grandmothers. The missed, precious first few days of our children’s life can never be recaptured.

Difficult decisions

Both pregnant women and health care providers are left with agonizing decisions. Should we cut down on prenatal care? If she has abdominal pain, which 99% of the time is normal and 1% is perilous, does she come to the hospital? And then there are the women who have the virus. Everyone else who has mild symptoms is being told to stay home, but birth won’t wait. As the rest of the hospital is organizing around the epidemic, separating into “corona” wards, labor and delivery continues to pulse through the rhythms of labor, birth, complications, and cesarean sections, whether we have an isolation room or not. Like the rest of healthcare, like the rest of the world, we grapple with questions which have yet to be answered.

What happens when our first patient goes on a ventilator?

Who takes care of the baby after?

The mothers who test positive are being separated from their infants, but by definition, aren’t their other family members at risk for being carriers?

I sat with a patient to take her history, and for the first time in my career, instead of shaking her hand or giving her a reassuring pat on the shoulder, I sat on the other side of the room. We weren’t wearing masks yet for symptom-free women, because we didn’t have enough. She was alone, had the trepidation of any first-time mom, and instead of getting a midwife, a word that literally means “with woman”, she got a bank teller.

This is not our first pandemic ...

... and won’t be our last. Birth doesn’t wait. Not until we have enough masks, not until we have enough nurses, and not until we feel safe to take our infants home. It won’t wait until your husband can share it with you, or until your mother can help you at home. It has persisted through war, slavery, and poverty and disease. Birth is humanity persevering from our ancestors to our grandchildren. Birth is hope when we feel hopeless.

[ArreisBSN]

The truth is, a lot of prenatal care can be done by moms for themselves and by nurses. The decentralized approach to maternity care is the norm in most of the world. You can literally fit a portable ultrasound in your pocket now. Women can dip their own urine at home, and auscultation FHTs with a Doppler themselves (many women own their own dopplers now a days). Our culture around pregnancy and birth as a disease state cripples women from realizing their true power as life bringers. The truth is that birth is the number one reason for hospital admission, and that HAS TO CHANGE. Those nurses are needed for the few, not for the majority. And what exactly is the scientific evidence that supports the prenatal appointment schedule ??? Women don’t need to labor in the hospital. This practice- research shows, actually hurts women.

[adventure_rn, MSN, NP]

This is going to be especially tricky if we start seeing critically-ill pregnant and post-partum moms due to CV-19.

My NICU view is limited, but I have cared for babies whose perinatal moms ended up in the ICU as a result of HELLP, abruptions, or full-blown cardiac arrest (I've actually seen a baby crash-sectioned while the mom was getting chest compressions).

Even under the best of circumstances, these cases are incredibly tricky because L&D and ICU have to collaborate to manage the patient. If we see an uptick in pregnant or post-partum moms with covid who require ICU care, it's going to be bad news. When we have cross-over L&D/ICU patients, who often have staff float to the alternate unit to help assist (for instance the L&D nurse floated back and forth to the ICU as a resource person for the ICU nurses). However, I'm sure that's not going to be well-received, seeing as covid is concentrated in many ICUs and we're trying desperately to keep infection out of L&D/post-partum.

I know that pregnant women haven't appeared to be at a significantly increased risk in other countries. Still, I worry about the US in particular because we see so many high-risk moms with comorbid conditions (I.e. uncontrolled diabetes or hypertension) that are also risk factors for poor covid outcomes.

[pastudent]

Are any hospitals not allowing one support person in for the birth? I don't work in OB, but our local hospitals are allowing 1 person that has to have their temp checked. Just wondering if that is what most facilities are doing.

[NRSKarenRN, BSN, RN]

NY Governor Andrew Cuomo developed an executive order allowing 1 support person for birthing mother in response to 2 NY city hospital systems denying birthing support person. Karen

Partners Will Be Allowed to Support Women Giving Birth in New York Hospitals

Quote

“In no hospital in New York will a woman be forced to be alone when she gives birth,” says Governor Andrew Cuomo. “Not now, not ever.”

In response to two of New York City's largest hospital systems, NewYork-Presbyterian and Mount Sinai, banning support people for women in labor during the coronavirus pandemic, Cuomo announced an executive order mandating that hospitals allow partners in delivery rooms. According to the directive, mothers-to-be can have one support person—including a spouse, partner, family member or doula—with them throughout labor and delivery.

https://www.vogue.com/article/partners-allowed-delivery-covid-19-governor-cuomo-executive-order

[Linda Mellace Rice]

Ours are allowing one support person. I hope all hospitals continue to do so. Its still more complicated. If other relatives can't come to watch other children, spouses may not be able to be with the mother. Pregnancy, birth and early parenthood are just going to be very different over the next few months.

[adventure_rn, MSN, NP]

On 4/7/2020 at 10:09 PM, adventure_rn said:

This is going to be especially tricky if we start seeing critically-ill pregnant and post-partum moms due to CV-19.

Just read this really interesting article in the New York Times about pregnant patients who have bounced back and forth between L&D and ICU because they required intubation. In one case, they talked about delivering a baby at 30-ish weeks so that they could treat the mom more aggressively. You might have to make an account to view (no payment required), but IMO it's worth it because their covid coverage is fascinating.

https://www.nytimes.com/2020/04/12/nyregion/coronavirus-births-mothers.html

[adventure_rn, MSN, NP]

I also found this interesting article where moms who have are pregnant or have delivered during the pandemic discuss how challenging it has been.

https://www.buzzfeed.com/daniellaemanuel/pregnant-people-coronavirus?ref=hpsplash&origin=spl

[toomuchbaloney]

Our newlywed soon and his wife were very much planning a pregnancy for this year. Now they are not.