Obstetric anaesthesia during the COVID-19 pandemic
“What a strange time to have a baby!” This has become the new maternity ice-breaker, almost superseding the classic “Are you having a boy or a girl?” The requirement to don a surgical facemask, eye protection, gown and gloves as a minimum for every patient encounter has had an impact on our normal interactions. Trivial small talk used to serve as an anxiolytic whilst siting a cannula or regional anaesthetic. Now facemask-induced silence occurs. We are reluctant to get close to the woman and her partner, and make ourselves understood through 3-ply polyester mesh. Normal facial expressions offering reassurance, jovial humour and rapport are dampened. Parturient, partner and healthcare workers feel on edge as we adjust to this new normal.
As European countries started to become inundated with the mass of critically unwell COVID-19 patients in March 2020, reports came in of the knock-on effects on maternity services. Anaesthetic staff were redeployed to ICU, leaving Italian pregnant women with cancelled elective caesarean sections, restricted options for labour pain relief, and anaesthetic presence only for obstetric emergencies. In the UK, pre-existing midwife shortages have been exacerbated by sickness and self-isolation, resulting in the closure of some midwife-led units and cancellation of home births.
The initial data regarding COVID-19 infection in pregnancy, albeit with low numbers, have been reassuring and suggest that mild-to-moderate disease predominates. But as the virus spreads through the population and the case numbers rise, we see younger and fitter patients requiring mechanical ventilation and multi-organ support. Inevitably we also see pregnant patients who require such interventions, most likely with the need for preterm delivery of their baby to facilitate maternal resuscitation and oxygenation. A few tragic maternal deaths have occurred. Unconfirmed, and sometimes untrue, reports of deaths and complications spread like wildfire through social media and clinical areas, increasing anxiety levels amongst both healthcare workers and pregnant women.
Social distancing measures have meant that pregnant women are required to attend scans and appointments alone. Partners are not permitted on antenatal or postnatal wards in the majority of UK units, and can only stay for the duration of labour and delivery provided they are asymptomatic themselves. Those with a language barrier, a complex pregnancy, or a history of previous problems appear to be most anxious about the impact of COVID-19. Initially, our unit saw many women who were reluctant to report symptoms in themselves or a family member as they were concerned that their elective section or labour induction might be postponed. Many were found surreptitiously coughing in delivery room bathrooms. Since we have been using standardised PPE while assuming all to be COVID-19 positive, and screening for symptoms more diligently, it has been easier to smooth over these concerns.
Initial feedback from women managing single-handed on postnatal wards has been positive. Perhaps it’s the possibility of resting alone with your newborn, rather than juggling your over-enthusiastic visitors with the undiagnosed sleep apnoea of the adjacent patient’s partner inches away.
Many of my colleagues have been redeployed to ICU or intubation teams. They develop facial pressure sores and suffer from dehydration and exhaustion. They continue to be affected by numerous unwell and dying patients in overflow critical care areas and are working intense ‘war-time’ rotas. Whilst continuing on the obstetric anaesthesia rota, I feel guilty for evading some of these harsh working conditions, and strangely envious of the vast new clinical experience that my colleagues are accumulating. It has been rewarding, however, to assist in a small way to safeguard the wellbeing of mothers and babies during this horrendous pandemic, and to reassure women that obstetric anaesthesia has mostly retained a ‘business as usual’ status.
ST4 in Anaesthesia,
Guy’s and St Thomas’ NHS Foundation Trust, London