Sunita and John waited a long time – four years – to get pregnant, an effort that included several early miscarriages and four rounds of in vitro fertilization. So when the baby girl Sunita is now carrying was healthy and growing at 12 weeks gestation last fall, the Shoreline couple was elated.
“We were literally over the moon,” says Sunita, who asked that the couple's real names not be used to protect the family’s privacy. “It was the first time we could stop worrying about every twinge and enjoy some actual dreaming.”
The couple opted to deliver at UW Medical Center-Northwest just a few miles from their home and started planning for a low-fuss (they hope no-fuss) labor and delivery in mid-April.
They hired “our perfect match” doula by week 20 and took several courses to prepare them for their daughter’s arrival, including Hypnobirthing and mindful birthing courses. Sunita joined a prenatal yoga class and contractors started remodeling the back of their small house to include a nursery. In early February, the couple bought tickets for Sunita’s parents to fly in from Bangalore, India, a week before her due date. Friends planned an 11th-hour shower so her mom could attend.
Their hopes for the birth portion of the transition into parenthood fit nicely on a one-page birth plan: no or very minimal intervention during her labor; baby skin-to-skin immediately after birth, they wanted their doula (also a lactation educator) to help them with the baby’s first latch; Sunita’s parents would wait in the hospital and come into the labor room soon after delivery to participate in a baby blessing.
And the thing they looked forward to most? When they returned home with their baby, her grandparents would be there, cooking traditional postpartum foods from India and meeting household needs while the new mom, dad and baby cuddled up for the 2020 version of the ancient Hindu 40-day lying-in period known as jaappa.
Sadly, since the arrival of the COVID-19 virus in King County, much of the couple’s plan has crumpled.
Almost two weeks into Washington’s stay-at-home order, Mark pondered: “It’s like what part do we have to give up next?”
With the entire state on lockdown, the baby shower has been canceled, nursery construction was abruptly halted, and their doula is connecting with the couple virtually to lessen everyone’s potential exposure to the virus. Forced to choose between having their support and risking her parents health, Sunita this week asked them to stay away.
Last week UW Medicine announced that laboring moms can have only one support person in the hospital; moms have to choose between their partner and their doula.
“Of course John will be there, but honestly, we’re all devastated,” the expectant mother says. “I mean, can it get any farther from what we hoped?”
The truth is, it could. The virus has not yet reached its peak in Washington state and certainly not around the United States.
Doctors here say there are far more questions than absolutes about COVID-19, also known as coronavirus. They are scrambling to translate guidelines set out by the Centers for Disease Control and Prevention, the state health department, and other key sources into policies and procedures to keep the public safe and prepare for a worst-case scenario they hope never comes. But those guidelines are ever evolving as more information and data becomes available.
That means hospital policies are a moving target as cases continue to rise, facilities seek to protect patients and staff from contracting COVID-19, and the need to keep critical emergency equipment like respirators available to those most in need becomes more and more pressing.
“This is unprecedented, obviously,” says Dr. Ali Lewis, an obstetrician and medical director of the midwives clinic at UWMC-Northwest. “We've never had anything this acute and this rapid. That’s why I always preface everything by saying to families, ‘This is literally changing daily. So here's what I know today.’”
She points out that COVID-19 is not the only situation in which respirators may be necessary. Surgical birth also requires that respirators be at the ready. One of the main focuses of hospital COVID-19 planning is to ensure that respirators are available wherever there is need.
Who can be in the delivery room?
One pressing concern for pregnant women due in the next few weeks and months is: Who will be allowed in the hospital with me?
As of this writing, several King County hospitals, including Swedish Medical Center, which has the highest volume of births in Washington, are allowing the spouse (or other birth partner) and one professional labor support person (doula) to join a mother in the labor room.
But such policies are being examined daily. As of April 2, UWMC-Northwest, UWMC-Montlake and Multicare’s Auburn Medical Center reduced that to just one person.
UW Medical Center acknowledges that the one-support-person rule will be “hard on all of us,” says Lewis. “We work closely with doulas and consider them part of our team. They will be greatly missed but I understand that this decision was not made lightly and trust UW Medicine to keep us safe.”
Lewis says she hopes families will work with their doulas during early labor at home, connect remotely while in the hospital and again once they go home.
Representatives from Swedish tout the presence of doulas in their hospitals and point to research that shows doula presence leads to healthier outcomes for moms and babies. They say they will push hard to keep doulas in the rooms but cannot rule out a future change.
Hospital-based maternity providers do not expect to see any scenario in which a mother would be forced to labor alone without at least one partner for support. The state of New York recently overruled “no support person” policies that hospitals in New York City sought to enforce, but the news that such a measure was even attempted naturally was concerning.
Dr. Tanya Sorensen, Swedish Medical Center’s executive medical director for women’s health, says, “that is just not going to happen.”
Concerns about infection
Beyond the question of who can go into the hospital when the big day comes, expectant families have many other concerns:
What if I get the virus? What if my baby gets it? Will I be separated from my baby if I am positive? If so, would my baby even get to breastfeed? If all goes well with my birth, how will we manage the first weeks after the baby arrives with little or no one hands-on help?
“Overwhelmingly parents want to know ‘How are you keeping me safe?’ How are you keeping my baby safe?’” says Short who is in the second trimester of pregnancy herself. She says the most important message to pregnant women is to self-quarantine, even if the statewide stay-at-home order is lifted.
“We are educating our pregnant moms that especially in the last month of pregnancy that they do need to stay as socially isolated as possible so they are as healthy as possible when they come in to deliver their baby,” says Short.
Lewis concurrs: “It is so very important for this group to really stick to the social distancing because if a mom has signs of the virus or tests positive around the time of the birth there are so many new considerations that have to be navigated.”
Even so, Lewis does her best to reassure the women in her care:
“I have a lot of transparency with my patients. I don't hide things from them. We don’t know a lot about COVID, but what we do know is very reassuring,” Lewis says. “I tell them we haven't seen a lot of severe cases in pregnant women. We have not seen deaths in babies. I try to not get too bogged down in the details but instead say, ‘I think if you do get COVID, it is probably not going to be a big deal for you. But because it's new, and there are things we don’t know, we really don't want to take risks. ’”
Officials at UWMC-Northwest, Swedish and other local hospitals say they are taking every precaution to protect moms and babies once they arrive at the hospital.
For example, Swedish is the temperature of everyone who enters the hospital. They have set procedures in place to isolate moms who have symptoms or test positive for COVID-19. Women are required to stay in their labor rooms and not walk the halls to keep contractions coming, a common sight just months ago.
Where there is a question of possible infection, staff will don full protective gear. Doctors will also follow the CDC guideline that says babies should be separated from COVID-19 positive moms by at least 6 feet. But Swedish’s Sorensen and UWMC-Northwest’s Lewis both stress that the choice to do so or not will remain fully with the mother. “We will make the recommendation. But I want to stress that we are not going to force anyone,” Soreneson says.
UWMC-Northwest and UWMC-Montlake hospitals will use a quick-turnaround test on patients arriving for labor and delivery.
Home and birth-center deliveries
As worries have grown about what care will be like for laboring women in Seattle hospitals, so has the rate of transfer to community-based midwifery care, that is to certified professional midwives (CPMs) who attend women at home and in freestanding birth centers.
Community midwives work only with healthy, low-risk pregnant women. They carry basic resuscitation equipment in case of emergency. They do not, however, use medications to relieve labor discomfort.
“We have been getting quite a few transfer requests in the last couple of weeks, as are many midwives in our community from what we hear,” says Licensed Midwife Lynn Hughes of Rainy City Midwifery. “We’re doing our best to safely accommodate as many families as possible while continuing to maintain a reasonable census that is safe for our midwives and allows us to continue to provide safe, respectful care.”
Hughes and other midwives say they are using virtual consultation platforms to carefully screen families and ensure “that they are truly low-risk and appropriate for birthing outside of a hospital setting. The midwives say that during screening they seek to fully understand the reasons a family is requesting to change to home or birth center from a planned hospital birth.
“A transfer may not be advisable if they are simply afraid of COVID and wanting to avoid a hospital,” Hughes explains. “We want to be as sure as possible that they understand what it means to make the commitment to birth at home or in a freestanding birth center.”
Says Hughes of whether home birth is safer than hospital birth in this crisis: “I don’t think there is a black and white answer to that now any more than there is during life as usual. I believe each family needs to draw their own conclusions and discuss the safety issues with their current providers and any of us who they are interviewing for a possible change in care."
Like hospitals, community midwives are doing all they can to keep themselves and their clients safe.
“Our practice, like most midwives we know, is greatly minimizing the number of in-person visits we do, reserving in-person encounters for points in a pregnancy when lab work or a physical exam is indicated,” Hughes says. “We are leaving more time between visits to clean rooms and equipment after visits and to minimize encounters between clients coming and going. Other regular prenatal and postpartum visits are being conducted virtually. We are doing more frequent in-person visits in later pregnancy when regular physical exams are important.”
Clients are pre-screened by phone or email prior to in-person visits to be sure neither they nor anyone in their home is experiencing any symptoms of concern.
“We ask them to carefully wash their hands upon arrival and we check their temperature and maintain social distancing except for their exam,” Hughes adds. Rainy City Midwifery is asking that only the mother attend in-person prenatals with family joining virtually. The midwives wear masks and gloves during visits and births. Between visits with families, the midwives clean their vehicle seats and equipment and change clothes.
Home births often have multiple family members and children present. But Hughes says during the pandemic they are asking that families decide on only two people to be with a mother in labor. “While this is disappointing for our pregnant clients, they do understand and want to play their part in keeping everyone healthy – including their midwives,” says Hughes.
One thing Lewis does worry about is the times when it's necessary to transfer a laboring mother to the hospital when things move away from normal.
The Midwives Association of Washington State has created new safety guidelines for those instances.
The midwife's model of care pays close attention to the mental and emotional well-being of the mother, Hughes points out.
“We are checking in with all our families about how they are managing during the pandemic,” she says. Many are sharing feelings of a lot of added anxiety as they approach the time of their baby’s birth. We do our best to regularly address the mental and emotional health aspect of bringing a new baby into a family. We are and will continue to be especially conscious of this right now.
Controlling What They Can
For now Sunita and John are doing what they can to keep calm and carry on. Their doula plans to labor with them at home until it is time to go to the hospital. She will then join them in the labor room virtually through Zoom.
As John puts it: “If she can’t put her hands on Suni, she can at least remind me how to best support her. We both need her there.”
They will use the same technology to get Sunita’s parents in the room for the blessing.
This week friends signed up a “ring and run” meal drop-off service. They will wear gloves, leave food on the back porch and then drive away. They will also leave their individual shower gifts when they drop their first meal.
Neither parent has any symptoms of coronavirus and they are actually enjoying their isolation together. They’ve filled the refrigerator with the first postpartum week’s meals.
“This wasn’t my plan,” says Sunita. “But I will say I am amazed how people step up in a crisis. We are so disappointed that things have had to change, but we feel lucky for what we have.”
Cheryl Murfin, CD, is a longtime writer, a certified doula and mother of two grownup humans, including a King County Public Health nurse. She owns Nesting Instincts Seattle.