Caring for COVID moms a labor of love
Dr. Rachael Morris remembers well the first pregnant woman positive for COVID-19 to give birth at the Winfred L. Wiser Hospital for Women and Infants.
It was April 14. The gravely ill expectant mother was in the medical intensive care unit, not on a ventilator, but receiving oxygen. Nurses carefully pushed her in her bed to one of the two Wiser operating rooms reserved for COVID patients.
After her baby was born via C-section, the young mother was wheeled back to the Conerly Critical Care Tower, about a five-minute walk from Wiser.
Because the baby was so close to term, “we moved toward delivery,” said Morris, a maternal-fetal medicine specialist and associate professor in the Department of Obstetrics and Gynecology at the University of Mississippi Medical Center.
The baby, born free of the virus but ill enough to need critical care, was whisked to the neonatal intensive care unit on the first floor of Wiser, UMMC’s hospital primarily devoted to women and newborns.
Although many COVID patients who end up in the ICU don’t survive, this mom and her baby did. Since that first delivery, about 56 COVID-positive moms have given birth at Wiser. All told, as of July 22, Labor and Delivery has cared for 92 COVID-positive women.
“Obstetrics in general is very unpredictable. COVID has presented a very unique situation,” Morris said. “An emergency from a fetal or maternal perspective can happen at any time with a COVID patient. Sometimes, you have seconds to intervene on a baby.”
Not one COVID-positive mom giving birth at Wiser has died. All of their babies have been COVID-negative.
Morris and Wiser’s Labor and Delivery team have worked hard to develop a rhythm of care, not just for COVID-positive patients, but hundreds of mothers and babies free of the virus who require their own specialized treatment.
Before COVID, mothers had their babies either through a C-section in a second-floor Wiser OR or down the hall in a Labor and Delivery birthing suite. Unless they needed a higher level of care, they’d go to the Mother-Baby Unit on the third floor following delivery.
Their babies would room in with them unless illness or complications required NICU care.
The highly contagious nature of COVID has given complex care in a very full women’s hospital a whole new meaning. The majority of mothers already are high-risk because of comorbidities including obesity, diabetes, sickle cell, HIV and hypertension.
COVID on top of that presents challenges and scenarios unlike any Labor and Delivery providers have seen, or might ever see. “Our numbers are rising quickly. It’s not slowing down,” Morris said.
“I’ve eaten, breathed and slept this since the week of spring break,” said Leslie Hood, a nurse educator who served as a Labor and Delivery nurse manager for most of the pandemic.
“Having to lead through a pandemic – to be the one to figure out the answers and to support the staff – that’s been an experience.”
‘We are so hands on’
Every day, providers must make a call on where to place moms before and after delivery. “It’s so complex. There are so many situations that come through our doors,” Hood said.
The patients include women receiving prenatal care from UMMC and those who haven’t received it anywhere. There are very sick mothers transferred from other facilities.
There are mothers in an obstetric emergency on top of COVID, or so sick from COVID that they must go straight to the ICU. Some might first arrive at the Adult Emergency Department or at Women’s Urgent Care. On the ground floor of Wiser, Women’s Urgent Care is for moms with obstetric emergencies, including early labor.
The truly sick moms “could go into respiratory failure,” said Dr. Marty Tucker, professor and chair of the Department of Obstetrics and Gynecology. “They can have pneumonia and high fever. The main thing that gets them into the hospital is the inability to breathe. They get fatigued and weak.”
Early in the pandemic, “we had six deliveries where the mother tested positive after delivery,” Hood said. “That drove us to universal testing for all mothers. If a mother comes in and delivery is so imminent that we can’t wait on a standard test, we do rapid testing.”
Those moms require a special Labor and Delivery room with filtering and ventilation that pushes potentially contaminated air outdoors. “Every second counts so far as staff exposure,” Hood said. “We get them into a negative pressure room as soon as possible.
“We are so hands on, and we are so diligent with our PPE. We have all of our other high-risk moms. We’re doing it all on the same unit.”
In mid-March, Hood and Morris began developing and test-driving protocols and processes for COVID-positive moms and their babies. Joining them were Connie Richardson, Wiser’s director of nursing; Yolanda Moore, a Women’s Urgent Care nurse manager; Nital Parrish, Labor and Delivery nurse manager; Dr. Mobolaji Famuyide, chief of pediatric neonatology; Dr. Amber Shiflett, medical director of Wiser; and Alice Chaney Herndon, Mother-Baby Unit nurse manager.
Tucker, who began work at UMMC Jan. 13, had barely had time to settle in. “He empowered us, and then asked us what we needed from him,” Hood said.
“At the time, there was no data out there. We mapped things out and practiced different scenarios – how to safely deliver them, how to transfer them and how to keep employees safe. We did simulations with Women’s Urgent Care.
“We rounded and talked to the staff to make sure they knew were going to do things to keep them safe,” Tucker said. “We wanted their input on how to make things better.”
Morris said she worked closely with Dr. Andrew Wilhelm, medical director of the MICU, “to develop what an obstetrical care plan should look like. We created an emergency care C-section algorithm. We developed a surgery workflow and a multidisciplinary approach to care.”
On April 14, they were as ready as they could be. “We created a C-section simulation video to educate our caregivers based on that first case. We put it on YouTube to help educate other academic medical centers,” Hood said.
They pioneered a continuity of care for COVID-positive moms that stretches far beyond Labor and Delivery.
If a pregnant mom is in the ICU, Labor and Delivery staff come to her. “We’ve had our nurses hold the fetal monitors on these moms because they are coughing so hard,” Hood said. “Our nurses who work with them are rock stars.”
Post-delivery, COVID-positive moms go to University Hospital floors dedicated solely to COVID patients. A Labor and Delivery mother-baby nurse follows them.
It’s a deployment of resources that must be managed carefully. “We’ve had to do creative staffing to make sure our standard of care doesn’t change,” Hood said.
The COVID birth
If a pregnant mom is admitted and subsequently tests positive for COVID, “the entire birth experience changes in a second,” said Meredith Morris, a Labor and Delivery nurse.
“The first thing that happens is that the family member who is with them is sent home, and the mom is put into a negative pressure room,” Meredith Morris said. “When I tell them they’re going to be tested for COVID, I tell them the protocol so they won’t be surprised by it.
“A lot of the time, they’re more anxious that they have to be alone, and that the father of the baby can’t be there, than they are about the actual sickness. They don’t get to see their baby until they go home.”