Labor and Delivery Staff Are Also on the Front Line
A call to protect the health care workers birthing babies across America
“We must acknowledge that every [L&D] admission and delivery presents a real risk for infection to our front-line health care workers.”
— Noelle Breslin, MD et al.
In late March at Columbia Hospital in New York City, and in dispatches from maternal-fetal experts in Italy, we learned that labor and delivery is a vulnerable place in the hospital where Covid-19 patients present for care with a visitor, and also where full personal protective equipment (PPE) is not universally being provided to health care workers. In multiple instances these days, pregnant patients and their partners are passing screening protocols (via questionnaire) and one or both are falsifying information so as not to be separated during labor or postpartum from one another or their infant. We understand how frightening this situation is for patients and we sympathize with them. We also understand that hospitals and healthcare systems need to protect their labor & delivery workforce. Now.
Prior to the Covid-19 outbreak and every day since, the Centers for Disease Control (CDC) has said that aerosolizing (highly contagious) events on labor and delivery are solely those of intubation — placing a breathing tube on a patient during a cesarean section or other operating room procedure. The CDC has not considered the “pushing stage” of labor, when women working with their uterine contractions conduct a Valsalva maneuver — filling the lungs with breath and pushing down on the diaphragm — to be an aerosolizing event.
Those of us working on L&D — doctors, nurses, and midwives — think differently. Nurses hold a patient during epidural placement and are just inches from a patient’s face during the entire length of the procedure; recent data shows that surgical masks do not prevent Covid-19 spread. Often during labor, we are just inches from a woman’s face and are screamed at, coughed on, spit on, and vomited upon, all of which would be considered aerosolizing based on the most recent literature.
According to the American Journal of Obstetrics & Gynecology MFM: “Second stage of labor is likely high risk for aerosolization and N-95 mask should be used.” Given that we know that Covid-19 particles can remain in the air in an enclosed room for up to three hours, and travel up to six feet, there is a clear and present danger in the delivery room. Recently we learned that 45 out of 60 people at a choir practice in Washington state contracted Covid-19. If singing aerosolizes the virus, so too does pushing out a baby for three or four hours.
My OB-GYN colleagues and I are deeply and morally concerned about this. I have heard from OB-GYN colleagues across the nation that their hospital or health care system is not providing N95 masks for health care staff attending to vaginal deliveries (despite data showing that many patients presenting to L&D are asymptomatic Covid-19 positive) because the CDC has not recommended it. When they opt to protect themselves anyway with their own N95 masks, they are threatened with termination. And yet — these masks are all that stands between an infected health care worker, an infected pregnant mother, her support person, and her newborn.
A March 31 letter to the CDC from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse Midwives, and the Association of Women’s Health, Obstetric, and Neonatal Nurses, (among others) reads:
“Physicians and other obstetric care personnel are at risk during the pandemic. Our concern [is that] CDC guidance is being interpreted as suggesting that obstetric care clinicians need not wear N95 masks and face shields when attending to patients with confirmed or suspected COVID-19 during the second stage of labor… Protection of this personnel is essential to ensuring the health and safety of laboring women and mothers in the United States.”
The CDC must come out with a statement confirming the second stage of labor is an aerosolizing event, and allow everyone working in close proximity to laboring women access to the appropriate PPE to protect themselves and their patients from infection.
Labor and delivery wards are — rightly so — viewed as the happiest place in the hospital. You hear it in the chimes that ring through the hospital letting everyone know a baby has been born. You see it in the gift shop filled with pink and blue stuffed animals and balloons. We owe it to the workforce, our patients, and their newborns to protect everyone involved.
