News: PQI Profiles

Preparing for Perinatal Patients with COVID-19: Insights from Washington State

Tuesday, March 24, 2020  
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By Lauren Hamilton


Michele Kulhanek, MSN, RN-C, C-EFM, is a QI leader on the front lines of the COVID-19 pandemic in Washington state. Her work as the Director of Safety and Quality, Maternal Infant Health at Washington State Hospital Association is to improve outcomes and promote quality improvement throughout her state, work that has looked dramatically different in this crisis.



“You almost want to beat your head against the wall sometimes because the changes are happening so rapidly-by the minute-and I think that we really are in new waters. We’re trying to balance between finding out more information, learning what our sources of truth are, and being able to collate these and get it out to the hospitals. It can be overwhelming and it can be frustrating because we just don’t know how this virus really affects pregnant women or newborns.”


ACOG has released a statement that although it does not appear from the evidence available that pregnant women are at greater risk of complications with COVID-19, pregnant women do need to be placed in a higher risk category because the natural state of pregnancy carries greater risk for respiratory infections such as influenza. For Kulhanek and her team, the lack of evidence so far means there are no clear answers to questions of preparedness in their hospital’s L&D units. Kulhanek stated that the limited number of cases reported from China and elsewhere indicate no vertical transmission of the virus, as the babies were not found to be born with COVID-19. However, we don’t know if the cases of women in China (where there is a higher c-section rate than the US) experienced skin-to-skin after delivery or were separated, and whether that will impact the data on birthing outcomes.


“Culturally, birth in China may be different than birth in the US. They may not do ‘golden hour’ like we do in the United States, where we’re keeping moms and babies together--we’re not comparing apples to apples. And what’s frustrating, is there’s a lag...a waiting period to see what will happen, if anything, with pregnant people and newborns,” Kulhanek said.


“We have a lot still to learn and unfortunately we won’t know until we know.”


While Kulhanek can confirm there have been COVID-19 cases among the pregnant population in Washington, these have so far been mild, with symptoms like fever and a cough. What still isn’t known is whether COVID-19 poses a greater risk to pregnant women with co-morbidities, such as diabetes, asthma, preeclampsia, and hypertensive disorders. “We have a lot still to learn and unfortunately we won’t know until we know,” she said.


Despite the lack of evidence and the ever-changing landscape Kulhanek finds herself navigating, she has gained some wisdom through her experience dealing with the spread of COVID-19 a couple weeks ahead of the rest of the country. Kulhanek said the first thing perinatal healthcare workers across the country should consider is shifting as much as possible from face-to-face to online appointments with patients, and to cancel events and restrict travel among staff. “We’re seeing some hospitals saying no to elective inductions of labor, and on the flip side of that we’re seeing some hospitals leaders saying let’s get these low-risk women in and delivered as soon as possible so if we do have a surge we’re better prepared,” Kulhanek said.


A Focus on Communication


A possible surge is the greatest concern hospital workers in any department are facing. In order to generate solutions to this evolving crisis, Kulhanek suggested that centralized communication be a focus. She emphasized the need for hospital perinatal leaders to network with other hospitals during this time to learn from each other and keep information flowing to staff and from staff on the front-lines. These frequent updates to their staff and community should include “current as of” that day’s date because things are changing so rapidly. “Staff and patients need to make sure they’re not looking at something that came out 5 days ago,” she said.


She stated that her organization has created a model visitor policy that can be found on its website She advised other organizations across the country to do the same. She noted that most labor and delivery units are restricting visitors to one support person, and acknowledged that this limitation might be uncomfortable for patients. She said she’s seeing that some women are choosing to give birth at home or in a birthing center instead. For healthy, low-risk pregnant women this is an option to discuss with a provider and may reduce bottlenecking in hospitals should we see a surge in capacity on labor and delivery units. She suggested that hospitals strengthen their communication with freestanding birthing centers and midwives and doulas as a way to standardize care as much as possible for patients who wish to transfer.


Adjustments to Care


As far as changes that have been made to adjust how women are cared for before, during, and after pregnancy during the pandemic, Kulhanek said she is seeing providers move the first prenatal visit from 6 or 8 weeks to 10 or 11 weeks, and they’re also looking at how often each person needs to be seen to try and space out prenatal visits. If telehealth isn’t an option, Kulhanek said providers are trying phone visits as an alternative. She said it was important to include information as it develops in these appointments since there are so many new fears surrounding the pandemic. Part of that advice should include encouraging patients to do more laboring at home before leaving for the hospital, so there’s less chance to be exposed to the virus.


She also suggested that hospitals keep their shift huddles to essential personnel only, and said the whiteboard in a patient’s room is more important than ever to keep patients, family and the health care team informed. “Finding new ways to communicate,” she said, “there’s been an adjustment there.” She said there’s been a lot of discussion in labor and delivery units on where to put patients who are COVID-19 positive. “Most units only have a couple of negative air pressure rooms, if any,” she said and emphasized the importance of establishing that protocol now. The Centers for Disease Prevention and Control (CDC) recommends that PUI (patients under investigation for COVID-19) need two negative swabs before being taken off isolation but acknowledged that lack of testing and slow turn around on results might lengthen their stay. 


“Just kind of thinking ahead, in [a provider’s] workflow, and how we can mitigate any issues ahead of time” 


Kulhanek said another consideration in looking at the possibility of a surge, is placing epidurals earlier-even if you’re not starting the epidural pump-to help free up the anesthesiologists to be available if there’s an emergency. “Just kind of thinking ahead, in [a provider’s] workflow and how we can mitigate any issues ahead of time, and making sure everyone is taken care of and everything is going smoothly if a crisis does occur,” she said. Another key adjustment Kulhanek suggested is making sure the door stays closed during any aerosolizing procedure for a suspected or positive COVID-19 patient, and for 30 minutes afterward. “It’s what the CDC recommends for the safety of the patient but that really ties up your staff so thinking about this ahead of time and realizing even beforehand; do you have signage on the OR door, some sort of symbol that lets people know this isn’t a routine C-section?” She also acknowledged that all aerosolizing procedures require N95 masks, a rare commodity right now and warned that hospitals and clinics need to think about where these as well as other PPE are kept and remove them from areas where the public can access them. “These [PPE] are walking really is unfortunate...people are not their best selves when they’re experiencing fear.” She also emphasized that now is the time to start practicing safety protocols, as she said, “as L&D nurses, if you have someone who needs an emergency c-section seconds count. Staff may have the mentality of ‘you know what, I’ll throw on my hat on my way to the operating room because the patient is more important than donning my safety equipment.’ So, staff need to practice how to quickly and correctly put on their personal protective equipment before there is an emergency. Simulation training sessions will help staff practice how to keep themselves safe while responding quickly during an emergency.”


Rethinking Postpartum Support


She said another intrapartum adjustment might be co-location; deciding whether mom and baby are rooming in together if you have a suspected or confirmed COVID positive mom. “Some hospitals, depending on their configuration and the staffing of their unit and the mother’s choice, are keeping the mother and baby together, some are separating them and swabbing the baby at 24 hours of age and waiting for the results to come back.” She suggested that providers and hospitals make sure to inform their patients on whatever the protocol is, to decrease their fears and increase their knowledge, so they’re able to partner in their care during this time. She said hospitals are also rethinking their discharge instructions, and what moms really need to know before being sent home about warning signs and proper hygiene should they become symptomatic, and how to get these patients out of the hospital as soon as possible with as much information as they need, in order to increase capacity and limit the amount of exposure for the mother and baby. “I think hospitals are already thinking about newborn re-admissions for conditions like jaundice and how that may impact hospital capacity; here in Washington, the Washington State Health Care Authority has given the directive for all Medicaid managed care organizations to include home phototherapy as a covered benefit. She also suggested hospitals rethink lactation support, whether it’s possible to have pediatricians step in to offer that support during their visits or if it’s possible to conduct sessions via telehealth.


Women also need to be fully aware of POST-BIRTH warning signs so that they do not ignore potentially life-threatening symptoms that are unrelated to COVID-19. “We need to help women now more than ever be aware of the POST-BIRTH warning signs so that they get treated if they experience symptoms. This information is particularly important to women who may be discharged from the hospital early. If a woman has a POST-BIRTH warning sign they need to ensure they know how and where they can go to be evaluated and treated.


“Don’t re-invent the wheel...share with each other--now is the time more than ever for multi-disciplinary and multi-organizational collaboration…”


The advice Kulhanek offered perinatal health leaders across the country is to think about who they’re screening and what their symptoms are; “we don’t want to be testing everyone, in order to conserve our tests.” She also recommended that as hospitals are developing new protocols: “don’t reinvent the wheel...share with each other--now is the time more than ever for multi-disciplinary and multi-organizational collaboration, and so look to those who have these in place and then adjust them to your own needs and the nuances of your unit.” She also suggested that units walk through their procedures first by considering what steps to take when a COVID-19 positive patient is admitted in labor, and creating a checklist. “It really is important to keep track of what is first, what is second, because this isn’t rote yet.” She also said your state’s Department of Health and Infectious Disease Departments are your new best friends. “Make sure you’re communicating with them and keeping on top of what’s new and latest to help you make decisions, and make sure you’re talking to clinics that feed into your labor and delivery unit and what their role is in triaging patients because that is critical to help with a surge that could overwhelm our healthcare systems.”


Planning for the Unexpected


When asked what she wished she would have known at the start of the pandemic, Kulhanek said, “We’re so used to thinking about what’s happening within the four walls of our hospital unit and preparing for emergencies there that we forget about what happens when a crisis has a ripple effect in our community,” and noted the effect school closures had on the availability of staff who suddenly needed childcare or the problem of certain staff being forced into quarantine after coming into contact with COVID-19. “We needed to think about how to keep our staff coming to work and how to keep their kids safe and how to best support them,” she said. She noted that in Washington, they’re seeing an amazing response from teachers and other individuals who are stepping in to solve this problem by starting day programs to care for the children of first responders and essential hospital personnel. “These are things nobody thought about before, but we’re seeing our community help each other and we’re seeing healthcare workers consider how they can help each other if they’re working opposite shifts; they’re connecting with each other in online forums to make child swapping arrangements.”


As a final thought, Kulhanek emphasized that as this pandemic sweeps across the country, people need to take it seriously. “This is much more dire than we thought it was in the early days and you need to shelter in place as much as you can, even if your state is not recommending it at this time. Stay home. This really needs to be a ‘we over me’ response. Without that approach, situations will become worse.”


Summary of Michele Kulhanek’s advice to perinatal healthcare workers during the COVID-19 pandemic:


1. General Recommendations


  • Leadership needs to communicate with front-line staff, pregnant women, and the community often. Date each document and keep the communications as updated as possible based on the most recent news and recommendations from the CDC.
  • Strengthen communications with other hospitals in the area, as well as local birthing centers, midwives, and doulas
  • Partner closely with your state’s Department of Health and Infectious Disease Departments and check websites frequently
  • Move PPE to a location that is inaccessible to the public
  • Update yourself frequently on information coming from the WHO, CDC, ACOG, AWHONN, and SMFM

2. Prenatal Visits

  • Shift as much face-to-face care to virtual or telehealth forums and give patients clear and updated information to make sure their questions are answered and they know what to expect
  • Consider co-location and separation of suspected or confirmed COVID positive mothers and their babies prior to being admitted to the hospital
  • Postpone elective or non-medically necessary inductions

3. Intrapartum

  • Conduct trainings now on the correct methods of donning and doffing safety equipment
  • Create a checklist for new procedures and protocols implemented to respond to COVID-19; none of it is rote yet
  • Limit shift shift huddles and rounding to essential personnel only
  • Signage on the OR door and the whiteboard in patients’ rooms is more important than ever
  • Consider your workflow; ask yourself, “if an emergency occurs, is staff available to handle it?”
  • Decide where suspected or confirmed COVID-19 patients will go when they’re admitted in labor

4. Postpartum

  • Rethink infant re-admittance for conditions like jaundice
  • Rethink discharge instructions for mothers to include information pertinent to COVID-19
  • Make sure all women are taught the POST-BIRTH warning signs and know where and how they will be evaluated and treated if they have a postpartum complication

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