Feature

Maternity care during COVID-19


Evelyn Lewin


8/04/2020 12:08:41 PM

A number of aspects of maternity care have changed during the pandemic, with telehealth leading the way.

Pregnant woman
Telehealth will comprise the majority of antenatal appointments to limit the potential exposure of pregnant women to COVID-19.

Many routine aspects of maternity care have unsurprisingly changed due to the current pandemic.
 
Dr Wendy Burton, Chair of the RACGP Specific Interests Antenatal/Postnatal Care network, discusses the changing situation with newsGP.
 
Limiting face-to-face care
‘The biggest difference is just going to be needing to pivot quickly to non-face-to-face [appointments], so utilising the telehealth options,’ Dr Burton explained.
 
This move is crucial to prevent people ‘congregating’ at antenatal clinics. 
 
‘That’s some of the lessons they learned from Wuhan and Italy; that they didn’t get women out of antenatal clinics quickly enough,’ Dr Burton said.
 
According to Dr Burton, the Director of Obstetrics and Gynaecology at Mater Mothers’ Hospital (MMH) Brisbane, has worked collaboratively but deliberately to position the service so low-risk women attend only three antenatal visits in person throughout their entire pregnancy.
 
Those visits will be linked to key immunisations:

  • The first antenatal visit will occur to coincide with delivery of the influenza vaccine
  • The second appointment will be at 28 weeks and will include the pertussis vaccine
  • The third visit will occur between 34–37 weeks at MMH and will include a rapid scan to check the baby’s position and growth
Dr Burton is keen to point out this might not be the case for other hospitals around Australia, and this is for low-risk women only.
 
Every one of the face-to-face appointments will still need to be accompanied by a telehealth one.
 
‘Because of the way Medicare is structured, I recommend GPs do their telehealth visit the day before their face-to-face visit,’ Dr Burton said.
 
‘We don’t want to get in trouble from claiming two item numbers in the same day.’
 
Those telehealth appointments should cover the majority of what is needed to be discussed, thus limiting the time needed for the follow-up face-to-face interaction to less than 15 minutes.
 
Use of telehealth
Most aspects of antenatal care can easily be covered via telehealth, which will comprise the majority of maternity appointments, Dr Burton said.
 
‘So you do the education, explanation and follow up of test results all via telehealth,’ she said.
 
Telehealth appointments will also cover issues including drugs, alcohol, smoking, and perhaps mental health, but domestic violence screening will have to be strategically considered on a case-by-case basis.
 
Dr Burton said screening for domestic violence is ‘even more important’ for pregnant women right now, as they may be forced to be in isolation with an offender.
 
Offering reassurance
GPs play a pivotal role in offering patients reassurance during this stressful time, Dr Burton said.
 
She believes the message needs to be conveyed that pregnant women are not at higher risk of catching coronavirus, nor are they at increased risk of having more severe disease if they do. In fact, as a younger population, they are likely to fare well.
 
‘We need to remind women that they will be safe, their babies will be safe, almost always,’ Dr Burton said.
 
‘The message is very reassuring.’
 
However, she said that message must be shared alongside important ones regarding reducing potential exposure to the illness.
 
‘It’s very reassuring to know that, but of course if they do get sick, then we’ve got not just mum to think about, but baby as well,’ Dr Burton said.
 
‘So it’s very important that we do everything we can to protect mum.’
 
As part of that protection, pregnant women should be limiting exposure to others by staying home unless it is necessary to leave.
 
Dr Burton said the ramifications of having a pregnant woman sick with COVID-19 and then needing to, for example, consider a caesarian for a premature baby will place great stress on an already overburdened hospital system.
 
‘It’s almost too hard to think about,’ she said.
 
‘So that’s why we need to stop pregnant women getting the infection and we do that via telehealth now, so they’re protected as the incidence is ramping up in our nation.’
  Wendy-Burton-Hero.jpg
Dr Wendy Burton said the biggest difference in maternity care will be moving away from face-to-face appointments to telehealth.

Routine tests
The usual antenatal blood tests will continue as per normal, with the exception of testing for gestational diabetes mellitus (GDM).
 
(Dr Burton said the following relates to how GDM will be investigated at MMH Brisbane and that guidelines may differ in other facilities. She also points out that this information is valid at the time of publication, but it is likely to change as the situation is rapidly evolving.)
 
Before COVID-19, pregnant women had an oral glucose challenge test (OGTT) at 28 weeks’ gestation to test for GDM. However, because this test involves having a follow-up blood test two hours after the first, it is not ideal at this time.
 
‘The last thing we want is pregnant women hanging around a pathology collection centre, even if they are sitting in their car, for two hours during COVID-19,’ Dr Burton said.
 
Consequently, high-risk women will be asked to have a glycated haemoglobin  (HbA1C) test instead of an OGTT during the first trimester.
 
Low-risk women will have a fasting blood sugar level (BSL) performed at the 26–28-week mark.
 
Dr Burton said if their fasting BSL is:
 
  • equal to or greater than 5.1, that is diagnostic for GDM
  • equal to or less than 4.6, only 5% of women would have a positive OGT, so unless there is high suspicion of GDM, these women will not have an OGTT and be treated as not having GDM
  • between 4.6–5.1, they will be the only women who qualify for an OGTT at this stage.
Patient self-monitoring
In between antenatal appointments, Dr Burton is encouraging pregnant patients to do their own blood pressure monitoring at home.
 
She also wants patients to weigh themselves, and send her photos if they notice swelling in their legs or other changes.
 
Dr Burton is also asking pregnant women to measure their own fundal height starting at 20 weeks, when the fundus should be at the level of the umbilicus. She would like her pregnant patients to mark their fundus and send her photos so she can see the progression.
 
Dr Burton said there are no controlled studies on outcomes related to women measuring their own fundal height, but hopes it can give her an idea of fetal growth.
 
‘And then if I’ve got concerns I can action that,’ she said.
 
Birth
Dr Burton said most hospitals are currently changing their protocols to only allow one support person during the birth.
 
Early discharge post-birth will also be in place.
 
‘Because, again, you don’t want to keep them in a hospital,’ she said.
 
Neonatal care
Dr Burton said it is uncertain how post-birth medical care will continue for both mother and baby, including newborn checks for issues such as follow-up hearing tests.
 
‘They’re just unknowns at this point in time,’ she said.
 
Postpartum women will still be encouraged to bring their babies in for routine immunisations and not to neglect their own checks-ups and wellbeing.
 
‘We may need to separate out the check-up for mum from the check for baby, however, in order to keep face-to-face [contact] below 15 minutes,’ Dr Burton said.
 
‘Again, we can use telehealth to facilitate the discussion around parenting and newborn care. There are some wonderful online resources that women can also access.’
 
Dr Burton said GPs should check with their local service now so they can understand how postpartum contacts, early childhood visits and immunisations will occur within the public system.
 
GPs’ pivotal role in maternity care
As the face of maternity care changes amid the pandemic, Dr Burton has confidence GPs will continue to deliver excellent care.
 
‘Here’s an opportunity for us as a profession to demonstrate what we’re really good at, and that’s comprehensive intergenerational care,’ she said.
 
‘We can step up and do some of the mental health work, while we understand infectious disease, immunisation, complications [and so on].
 
‘Give me a good generalist in a crisis. Seriously, we can multi-task.’

The RACGP has more information on coronavirus available on its website.
 
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Dr Fiona Jane Henneuse-Blunt   9/04/2020 7:33:26 AM

I understand the need to limit face to face consultations however I am suprised that the visit at 28 weeks is linked to Pertussis immunisation, as I thought we were encouraged to offer this ASAP after 20 weeks ?


Dr DRS   9/04/2020 1:30:17 PM

Hi Wendy,
Do you have any guidance regarding the routine 12 week and 20 week ultrasound scans? As women could be exposed to coronavirus by attending a diagnostic imaging facility. Thank you


newsGP   15/04/2020 1:25:06 PM

Hi Dr DRS. Wendy has replied: 'Talk to your local centres to see what precautions they are taking. Mine are spacing appointments, cleaning more, staying open. Women can wait in the car, avoid busy waiting rooms'. Hope that helps. Thank you.