In the next three months, nearly a million women in the United States will give birth to nearly a million babies: a large group of generally healthy but highly vulnerable patients entering a hospital system that is about to collapse. start a period of unprecedented pressure. Not surprisingly, pregnant women find themselves somewhat anxious. Women who are in their third trimester of pregnancy and will be giving birth during the coronavirus pandemic are almost frantic.
It's hard to remain calm when reliable information is almost as scarce as N95 masks; In addition, prenatal care providers are so busy updating their procedures that it is difficult for them to answer even the most basic questions from their patients. In the last few days I dedicated myself to collecting the most up-to-date information about the coronavirus in terms of pregnancy. In that sense, I had communication with doctors, nurses, midwives, and birth attendants that I have come to know for covering maternal health and mortality issues that formed ProPublica's “ The Lost Mothers” project. Below you will find answers to the most pressing questions (but always keep in mind that you should consult your doctor for your particular situation).
Avaa have during your labor is going to be quite different from what you will have in reality. Your postpartum period will be even more isolating and stressful than it would have been under other circumstances. OB providers are reinventing maternity care in real time to protect you, your baby and themselves.
As for expectant mothers and their loved ones, the key to staying sane is being as prepared as possible for what lies ahead, and that includes the possibility that they may have to throw the best laid plans out the window. “For childbirth, the person needs to know that things can change at any time, and that you need to be flexible,” said Rina Rios, a prenatal educator and trainer for birth attendants in New York City. “You can have your list of what you want, and in the end you could get it all or nothing. What is currently happening (with covid-19) is the same, but more drastic.”
Am I at higher risk of contracting coronavirus because I am pregnant?
The good news, said Christina Han, a specialist in high-risk pregnancies and a professor at the University of California, Los Angeles, school of medicine, is that: “there is no evidence that pregnant women are more susceptible to covid-19 than anyone else. other regular healthy adult.” At the same time, we don't have much information about it, aside from less than three dozen reported cases in China, and anecdotal events from other hotspot countries that are currently being monitored by US doctors through tools like WhatsApp. (A registry has just been started to quantify cases in the United States.)
The bad news is that, based on long-standing experiences with other respiratory illnesses like influenza and SARS, the Centers for Disease Control and Prevention warn that contracting the coronavirus while pregnant could make you more vulnerable to severe respiratory problems such as pneumonia, compared to other women of childbearing age who become infected. This is because pregnant women already have higher heart rates, lower lung capacity, and what one doctor called a "distracted immune system." There may also be an increased risk of miscarriage and premature delivery, said Dr. Romeo Galang, an obstetrician-gynecologist with the CDC's COVID-19 emergency response team. No maternal deaths related to covid-19 have been reported so far.
What does the coronavirus mean for my baby?
More good news: the virus has not been detected in amniotic fluid, umbilical cord blood, placental tissue, or breast milk; that means then that there is no "vertical transmission" (you will not pass it on to your fetus). It also differs from another recent virus that caused great anguish among pregnant mothers and public health officials. “With the Zika virus, we knew there was transmission and we started seeing birth defects right away,” said Houston obstetrician-gynecologist Rakhi Dimino, a multi-state maternity hospital supervisor.
In the UK, at least one newborn has been reported with covid-19, suggesting that babies get it the same way everyone else does, through dripping in their breath that can even come from an infected mother. Until this week, officials had reported that cases in minors were rare and relatively mild. Yet a disturbing new study in China of 2,100 children with confirmed or suspected COVID-19 found that 6% became seriously ill. Most of the sickest children were under the age of five, and about a third of them were under the age of one.
How should I protect myself if I am pregnant?
This advice is the same as for everyone, although even more important. “Maximize your immune system and avoid any situation where you are at higher risk of getting infected,” said Amy VanBlaricom, vice president of clinical operations for the Ob Hospitalist Group of hospitals, who oversees maternity units at several hospitals in the Seattle area, which have been seen at the center of that locality's COVID-19 outbreak. “In that sense, avoid large crowds, avoid sick people. Wash your hands". Ella (ella You'll find more similar tips just posted on the website of JubelHealth, which specializes in fertility issues.)
VanBlaricom added that it's not too late to get a flu shot if she hasn't already. “It is important for pregnant women, or women expecting to become pregnant, to do everything possible to strengthen their immune system as much as possible.” The flu vaccine is not dangerous during pregnancy or breastfeeding, she added, and the other advantage is that "immunity is also transmitted to the baby."
It goes without saying that, if possible, pregnant women should avoid going to work in medical settings or places where they would face a higher risk of becoming infected. During a conference call last week, the CDC's Galang said that "institutions should at least consider limiting the exposure of pregnant women on their staff, and that ... that could be especially important during high-risk procedures involving generate droplets from the breath. In reality, certain understaffed and resource-poor hospitals and practices have been slow to implement these guidelines. (If you know of any, my colleagues and I want to hear from you.)
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Indeed, providers have rushed to create virtual and telemedicine options, aimed at protecting their staff as well as their patients. Her prenatal care and childbirth classes have already begun streaming on YouTube, Zoom and Skype.
It is more important than ever that you continue to communicate with your medical team. If you haven't signed up for your provider's online patient care portal, now is the time. When you're there, download or take a screenshot of all the information in your medical record, and make sure you stay on top of it after every visit or call; print copies of your chart and keep digital versions on all your devices, as well as photos of all your medication labels and anything else you want everyone who cares for you to know.
Expect all of your basic prenatal checkups, as well as other visits that used to take place in a doctor's office with a box of tissues handy, such as genetic counseling, now taking place over the phone or FaceTime . Because she has to monitor herself more than ever before, it would be ideal if her home medicine cabinet had a blood pressure monitor and urinalysis strips, which are essential for detecting pregnancy-induced hypertension, called preeclampsia . This is one of the most common and dangerous complications during pregnancy, which can even put life in danger. Talk to your health care provider about how often you should wear them and what signs to watch for.
In-person dates are likely to be shorter and feel more perfunctory. You should plan to go to these without the friend or partner who would normally support or speak for you, so keep a constant list of all your questions and concerns and discuss them during the visit or call. The Birth Place maternity clinic, run by Jennie Joseph and located 30 minutes from Orlando, Florida, is known for its welcoming atmosphere and the impressive results it has had with low-income African-American women (who are most at risk of maternal and newborn complications). However, Joseph had to ban walk-ins, rearrange visiting hours, and require all visitors to have their temperatures taken. "Normally our goal is to include children," she noted, but right now, "no children, unfortunately."
Can I just skip some of my prenatal visits?
Here's the truth about prenatal care in the United States: There isn't much good scientific evidence about how much a healthy pregnant woman should be monitored, or how best to get that care. The good news is that you and your providers have more flexibility than you might expect to adjust or shorten your appointment schedule without creating risk to both you and your baby. That even frees up resources for other mothers-to-be who need extra vigilance.
Before the pandemic, a typical mother-to-be in the United States might schedule 10 to 13 prenatal visits and multiple ultrasounds. Right now, when it comes to low-risk women, "if she's early in her pregnancy, most likely, instead of seeing her every four weeks, we would see her every six weeks," said Judette Louis, director of the department of obstetrics and gynecology at the University of South Florida, and president of the Society for Maternal and Fetal Medicine.
In-person visits may need to be curtailed, even for women in their ninth month, who are often advised to see their OB/GYN weekly. Similarly, it seems that most ultrasound studies are not necessary for most low-risk women, which contradicts what you read in books on the subject of pregnancy.
The most important ultrasounds for any patient are given in the late first trimester (between 11 and 13 1/2 weeks), in order to detect genetic and fetal abnormalities. Those are followed by an anatomical scan in mid-pregnancy (between 18 and 22 weeks).
Things are different for women with complicated pregnancies, although much depends on the patient's risk profile: someone who is considered high risk just because they are 36 years old is not in the same category as someone with high blood pressure, diabetes, asthma or twins. Although certain consultations for these high-risk pregnancies (such as those related to nutrition) can be carried out virtually, many must be in person.
On that note, make sure all members of your team work together to minimize time and exposure in the office. "The worst case scenario would be for high-risk women to drop their prenatal care without talking to their doctor first," said fetal and maternal medicine specialist Cynthia Gyamfi-Bannerman, who is also co-director of the Center for Preterm Birth. from Columbia University Medical Center.
Women who are at high risk of complications will also need more frequent monitoring with ultrasound. However, Brian Iriye, a Las Vegas high-risk pregnancy specialist and former president of SMFM (the Society for Maternal-Fetal Medicine), cautions that women should not rely on unlicensed ultrasound centers to avoid contracting a possible covid-19 infection in a hospital or doctor's office.
Those places “might not be cleaning equipment in the [proper] way. The equipment may not be up to date. The staff may not have the same standard in terms of training.” (You can see how to find out if a center is accredited here.)
For more details about what women with high-risk pregnancies can expect, check out these newly released guidelines from expert maternity specialists in the United States and Italy. These are the clinical guidelines for COVID-19 issued by the American College of Obstetricians and Gynecologists, as well as instructions for free access to the SMFM COVID-19 Educational Library.
Also included is this PSA from your OB/GYN: Don't be tempted to stick that bottle of hand sanitizer or a roll of toilet paper in her bag. Her provider cannot protect her, or other patients, if she cannot protect herself.
I'm not pregnant yet, but I've been trying. Can I at least continue my fertility treatments?
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1 minute readThat depends, in part, on the process you're in. On March 17, the American Society for Reproductive Medicine (ASRM) recommended that doctors and fertility clinics suspend all new treatment cycles during the COVID-19 crisis. These include in vitro fertilizations, intrauterine inseminations, and egg freezing. Those providers should “seriously consider canceling all embryo transfers, both fresh and frozen,” the Society added.
In addition, the Society invited IVF (fertilization) clinics to do what other medical providers have implemented: suspend elective surgeries and non-urgent diagnostic procedures; minimize interaction between people; and increase the use of remote health consultations (telehealth).
However, the guidelines say that patients who are "on cycle" at this time, or who require urgent ovulation stimulation (for example, because they are about to receive chemotherapy or radiation for cancer, which could render them infertile), may continue with your fertility treatments. “We also understand the aspiration our patients have to achieve pregnancy within a certain time limit,” ASRM stated, “so we will review these recommendations on a regular basis, with the hope of restarting full fertility care as soon as possible. may be possible".
In the meantime, you should contact your provider as soon as possible to see how these guidelines might affect you and your family.
What should I do if I have symptoms of coronavirus and I am pregnant?
“Don't keep quiet,” urged Dr. VanBlaricom of Seattle. “If you are at risk of exposure or have suspicious symptoms, or if you fall into one of the categories of people who should be tested, please contact your personal physician to see if you should be tested.” Call ahead so your medical team can take extra precautions, as they may ask you to stay home if you have mild symptoms or direct you to the hospital.
If you're not already wearing a mask when you arrive (here's a hint), be sure to ask for one, especially if you have respiratory symptoms. Hopefully, your provider will place you in an isolation room (in improvised cases, that could be a bathroom that is being used for that purpose), test you for other respiratory germs, and possibly COVID-19 (assuming that you meet the criteria established by your local health authorities and that tests are available).
If your symptoms are mild, you will likely be sent home to await the results, with instructions to self-quarantine and treat yourself as if you had the flu. She could be sent home even if she tests positive and her symptoms are mild, said Dr. Han, a maternity specialist. However, it is important to stay vigilant. If you start having trouble breathing, call your OB/GYN right away, and go where you're told, probably the emergency room. You and your baby will be watched carefully in the hospital until she is out of danger or gives birth.
Whether you test positive for covid-19, or remain a "person under investigation," chances are when you go into labor you'll be placed in a negative-pressure room (in which the ventilation system is sealed in the room). relation to the rest of the facilities), and is attended by a limited group of providers with full personal protective equipment (we hope so).
In the cases reported in China, almost all women who gave birth after a positive test had cesarean sections. However, the cesarean section rate in that country is generally higher than in the United States, so the type of procedure you have will depend on your symptoms, your doctor, and the medical facility. At VanBlaricom hospitals, "the indications for a C-section would be the same, regardless of whether the mother tested positive or negative for COVID-19," she said.
For many mothers with positive or suspected covid-19, the great difficulty will be what happens after their babies are born. The CDC (Centers for Disease Control and Prevention) recommended segregating mothers and newborns for at least 14 days, either in a separate isolation room or, if that's not possible, using curtains in the mother's room that allow the baby to be kept at least six feet away. (The separation order will be canceled if the covid-19 test is negative).
It will be possible to breastfeed because it has not been shown that the virus is transmitted through breast milk, although the mother will have to clean herself very well and use very effective masks and protective clothing (there will be hospitals that tell them to express their milk). Until she recovers, she may be asked to assign a close family member to take care of the baby's primary care such as bathing, diapering, and skin-to-skin holding.
If I don't have the coronavirus, how might covid-19 affect my labor and delivery experience?
In the field of gynecology and obstetrics, strong debates are taking place about the idea of scheduling labor inductions in women with 39 weeks of pregnancy, before their due date, in order to control the moment of delivery and, if necessary, possible, avoid the lack of beds in the nearest hospital.
Still, that doesn't mean you're going to be forced to give birth earlier than you want, or pressured to have a non-emergency C-section, just because your labor is progressing slowly, Han said. woman going into labor naturally, rather than choosing to induce labor, reduces the length of time she will stay in the hospital. The same goes for facilitating a vaginal delivery instead of resorting to unnecessary surgery.
At Han's hospital, "we are trying to have vaginal deliveries as much as possible, because we can discharge mothers sooner." She added that for both mothers and hospitals, "it's worth spending a few extra hours in labor for the benefits later on."
At the same time, many hospitals are setting strict limits on the number of people who can be present during the birth, usually one or two, often with no exceptions for skilled delivery staff. People mothers would count on to help them through the long hours of labor pain.
“Increasingly, the mother will have to decide if she wants her birth attendant, her husband, or her sister,” said Melissa Harley, birthing educator and president of the Florida-based organization for birth attendants, DONA International. . “I fully understand that hospitals have to limit additional people, but birth attendants are not 'visitors.' We are an important part of the team that cares for the mother, providing emotional support that also relieves the nursing staff a little.” As the Covid-19 crisis worsens, she added, her value can only increase: "The medical system is going to be very overwhelmed."
The hospitals are also restricting the movement of these visitors, no entrances and exits, not even eating or resting if labor is prolonged. Some birth attendants are being barred from entering unless they can prove their certification. Harley spoke with a birth attendant in Seattle who just delivered a labor that lasted 31 hours, without her being able to call a relay. “We are asking that people bring extra clothing and food, as once we get into the delivery room, we might not have a chance to get out.”
This is an option birth attendants are beginning to embrace: in-person support during the early stages of labor, followed by Google Hangout or Skype when the client walks into the hospital. (This is a toolkit that both birth attendants and expectant mothers might find comforting.)
Postpartum visitation restrictions are even stricter. In many hospitals they have been almost completely banned. In some, even birth attendants are asked to leave just an hour after the baby is born.
Don't be surprised if hospital postpartum care, including lactation support, feels more rushed than it did before the covid-19 era (which was already pretty inadequate). Even a doctor specializing in high-risk pregnancies accepted that "everything will be designed so that everyone can return home as soon as possible."
Suddenly giving birth at home seems more appealing. What should I take into account before deciding if I want a natural childbirth?
In the past two weeks, home-based midwives like Amber Berry, who attends births in the Houston area, have seen a groundswell of interest from women fearful of contracting COVID-19. "I just got a call from a woman who is 39 weeks pregnant, due in five days." This mom had all of her medical records and was willing to compromise, so Berry took her on at the last minute. However, when other concerned mothers started calling her, the midwife refused. "They were looking for a backup plan in case the hospital was full." That is not a pleasant situation for members of the maternity care community.
The decision to give birth at home or in an independent birthing center, supported by midwives rather than doctors, is not for the faint of heart. There are safety issues stemming from inconsistency in midwifery training, inadequate supervision, and, in many parts of the United States, poor integration with the medical system (which is important, for example, if it becomes necessary to transfer the mother or the newborn to the hospital, due to an emergency such as bleeding or respiratory problems). There is also the reality of what comes with a drug-free birth, that is, many hours of intense pain with minimal intervention to speed up the process. And then there is the cost. In many places, health insurance does not cover births outside hospitals.
In addition, only future mothers with few risks and who have already had pregnancies without any complications, are candidates to make the change. That eliminates women with high blood pressure, chronic or gestational diabetes, pre-existing conditions like epilepsy or hepatitis B, and, in many places, those who have had previous C-sections or are pregnant with twins. "The list of women I can't accept is pretty long," Berry said.
One of the main problems with changing providers in mid to late pregnancy is that it short-circuits the typical process of working with midwives. “In that model, it's very important for us to take the time to develop a trusting relationship with our clients,” said Wendy Gordon, who delivers at a Seattle birthing center and heads the midwifery department at Bastyr University.
That typically includes spending much more time with expectant mothers, compared to what happens during an OB/GYN appointment. Sometimes we spend up to an hour at each prenatal visit. Having a good relationship is critical if problems arise during labor, for example. “If we say that it is time to go to the hospital, the client must trust us enough to accept.”
Home births could help expectant mothers avoid being exposed to COVID-19 in a hospital, although they could expose midwives to people and environments that put them at higher risk. The coronavirus is forcing them to make the same kinds of changes to their practices, as are hospitals, doctors and nurses, and that includes less in-person care. If a midwife is exposed to the coronavirus, she's likely to be out of commission for weeks, and her clients could face a shakeup at a time when "all equipment needs to be available," Gordon said.
Even if she doesn't want to give birth at her house, it might not be a bad idea to at least plan for the possibility, in case she has no other option. These short guides from the American College of Nurse Midwives, with instructions for “giving birth where you are” and in an emergency, are helpful and sometimes even reassuring (be sure to check out the list of items to keep on hand).
My baby's grandparents were going to be my support team and now they can't travel. How should I deal with this?
There is no easy answer or solution, just one incredibly difficult challenge on top of another. Chances are you're already doing the basics, like connecting with other parents through social media, FaceTime all the time, shopping as much as possible online. The already well-known advice of always, like get enough sleep! and take time for yourself! they seem to be very disconnected from the context of an ongoing pandemic. As the news gets harder, day after day, the feeling of helplessness and despair could only get worse.
If you haven't had your baby yet, you still have time to figure out ways to deal with the massive upheavals that are coming your way. Set two priorities: get a new support group together, mostly virtual, so those people will keep in touch with you if your Plan A support team gets stuck in another state; and understand basic health care information, such as the telemedicine options your pediatrician offers for newborn visits and what your insurance does and doesn't cover.
Karen Hays, a certified nurse midwife and Seattle-King County disaster preparedness and response expert for midwives, said this is not the time to be shy around her neighbors. "I think people will really want to help if they know there's a new baby on the block, with new parents in need."
This is also not the time to worry about the effects of antidepressant or anti-anxiety medications on the fetus, or when nursing a newborn. The consensus among doctors and researchers is that it is much more dangerous for your mental health to spiral out of control, both for the baby and for the rest of the family and, of course, for yourself, than transmitting Prozac or Zoloft through the amniotic fluid or the milk. (You can find a couple of helpful articles on this here, as well as a support group with many more great resources.)
If you are suffering, do not hesitate to consult your doctor about the possibility of taking these medications. However, pills alone are not ideal, nor are they enough, said Catherine Monk, a perinatal psychologist at Columbia University who specializes in mood disorders in pregnant women and new mothers. “A demasiada gente, sobre todo a las mujeres, se les recetan pastillas rápidamente sin proporcionarles herramientas para controlar la ansiedad. Hay evidencia que sugiere que cuando algunas mujeres optan por dejar el medicamento, realmente no han desarrollado ninguna habilidad para tolerar ese estado de ánimo. Solamente la han amortiguado”.
Por supuesto, poder costear ayuda profesional para manejar los problemas del ánimo en el periodo perinatal ya era bastante difícil cuando las cosas eran normales. Ahora, aun con el aumento de los servicios psicológicos a distancia, podría ser imposible. Monk recomienda varias herramientas relativamente fáciles (y gratuitas) del arsenal de la terapia cognitiva conductual que los investigadores han demostrado que son eficaces.
Indicó que una estrategia clave es reconocer que, cuando se siente ansiosa y deprimida, está viendo al mundo a través de lentes cubiertos de hollín, y que el mal humor hace que las malas noticias suenen aún peor. Una forma que ayuda a combatir el pesimismo, por lo menos por un ratito, dijo, es obligarse a tomar un breve descanso mental. “Por ejemplo, diga: 'solo por 30 segundos voy a observar lo que huelo, lo que veo, lo que toco, lo que saboreo'. Es duro hacerlo durante 30 segundos, pero por lo menos practíquelo, cierre los ojos y quizás sienta la tela de sus pantalones o el sillón en el que está sentada. Mejorar esta habilidad es una estrategia útil que realmente puede ayudar”. (Estas técnicas de TCC también podrían ayudarle).
Otra preocupación para las mujeres después del parto es su salud física. “Sabemos mucho acerca de la mortalidad materna, y las [complicaciones graves] son ocasionadas directa e indirectamente por el aislamiento social”, dijo Neel Shah, ginecólogo obstetra y profesor asistente de obstetricia, ginecología y biología de la reproducción de la facultad de medicina de Harvard. “Durante un periodo de distanciamiento social y físico, eso puede exacerbar la dificultad”. Las mujeres en posparto ya “eran desde el principio un grupo de población vulnerable”, agregó, “y están a punto de serlo aún más”.
Esto no solo se debe al coronavirus. Más que nunca, usted y su comunidad inmediata tendrán la responsabilidad de mantenerse alertas a los síntomas que puedan surgir después del parto, como dolores de cabeza, dificultades para respirar, fiebre e inflamación, los cuales pueden ser señales de problemas potencialmente fatales, como la preeclampsia de posparto, infecciones, coágulos o problemas del corazón.
Esta lista de cuna con señales de alerta que hay que observar, fue creada por enfermeras que se especializan en salud materna y neonatal y puede realmente ser un salvavidas. También querrá marcar esta página web del 4th Trimester Project (Proyecto del cuarto trimestre). Y recuerde, “haga todo el ruido que necesite”, dijo Hays. “Mucha gente no llama a sus profesionales de salud porque no desean molestarlos. Al contrario, eso hace que estos piensen que todo está bien, cuando en realidad no es así”.
Una cosa más: es de vital importancia que no se salte sus consultas de seguimiento regulares después de dar a luz, dijo Han, aunque las tenga que hacer en línea. Hasta las necesidades más urgentes, como infecciones en la incisión o en los senos, pueden monitorearse por FaceTime o Zoom. Es posible que no sean las opciones que desearían escoger las mujeres ni quienes las atienden, pero tendrán que servir hasta que venga algo mejor. Todos tenemos que hacernos a la idea de que “estamos en un mundo nuevo” en lo relacionado con la atención de maternidad.
Corrección del 19 de marzo de 2020: este reportaje indicó incorrectamente la profesión de Catherine Monk. Ella es psicóloga perinatal en la Universidad Columbia, no psiquiatra.
Nina Martín trabaja para ProPublica. ProPublica es un medio independiente y sin ánimo de lucro que produce periodismo de investigación en pro del interés público. Suscríbete para recibir sus historias en español por correo electrónico. Traducción al español: Mati Vargas-Gibson Edición y corrección de estilo: Mónica de León
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