Dr Sarah Buckley -

(Published April 30, 2020) We are living in uncertain times with the pandemic of Covid-19 illness, and this is especially intense for expectant families. This blog is intended to provide information so that you can make the choices that are right for you, during these times. Q: I am planning to give birth in a hospital. Will this be safe? Congratulations on your pregnancy and for thinking hard about the best place to give birth right now. The main issues with birthing in hospital are the theoretical risk of becoming infected in hospital, and the impacts, for your birthing experience, of the precautions that hospitals are taking to protect patients and staff. At present, I have not seen any reported cases of mothers or babies becoming newly infected from birthing in hospital. I think this is possible but unlikely. However, hospitals in most countries are needing to dedicate enormous resources to care for people with Covid-19 complications. In some places, hospital resources are already stretched, including resources that keep staff and patients safe such as personal protective equipment (PPE). In addition to PPE, protecting staff and patients may require infection-control policies that limit the number of visitors who enter a hospital. Limiting extra people in the hospital helps to reduce the risk of the virus entering non-infectious areas of the hospital, including from visitors who do not know that they are infected. This is especially important in birthing rooms and postnatal wards to protect vulnerable mothers and babies, as well as our precious front-line nurses, midwives, physicians and other staff. It is possible that, at the height of outbreaks, infection control guidelines in some hospitals may limit you to bringing just one birth support person with you in labour, and you may need to consider how to adjust your birth plans. You might consider having your partner plus a "virtual doula"- see here for more information. In extreme situations, some women have been asked to birth with no support people. This is against the World Health Organisation recommendations, which state : "All pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth. This includes antenatal, newborn, postnatal, intrapartum and mental health care.A safe and positive childbirth experience includes: Being treated with respect and dignity; Having a companion of choice present during delivery; Clear communication by maternity staff; Appropriate pain relief strategies: Mobility in labour where possible, and birth position of choice. If COVID-19 is suspected or confirmed, health workers should take all appropriate precautions to reduce risks of infection to themselves and others, including hand hygiene, and appropriate use of protective clothing like gloves, gown and medical mask." (Full WHO guidelines here) Your maternity unit or hospital will be considering all of these issues to make your birthing experience as safe and smooth as possible. Q: Should I switch to having a homebirth? If you live in a place that offers homebirth, ideally within the healthcare system, this is a good option to avoid these issues in hospitals, and to reduce your chance of infection. In some places, women are even being encouraged to birth at home, to take pressure off the hospital system. Homebirth is a safe choice for healthy mothers and babies! There is a large body of evidence supporting the safety of homebirth, including this recent review. (See also this homebirth article and the Homebirth chapter in my book Gentle Birth, Gentle Mothering, including my four homebirth stories!) and check out this fabulous film Why Not Home? Homebirth is not just about the environment- it involves being willing to take more responsibility, including having your own supplies and facilities. See typical list here. The safety of homebirth is strengthened by the trusting relationship that builds between the midwife and birthing family, ideally from early pregnancy, and having an integrated system that makes it easy to transfer to hospital if needed. (Please keep in mind your hospital birth plan, in case you do need to transfer.) This is a great discussion of these issues with Melanie Jackson of Transformative Birth Work here See also more links and resources below. Sign up to my newsletter to get notified for my next blog! Q: What if homebirth is not an option for me? In some places it may not be so simple to switch from hospital care to homebirth. This option may not be available, especially if you live in outside major centres, or may not be easy to find a homebirth midwife because so many women now considering this option. In addition, some risk factors may make homebirth less safe. More info here I recommend that you make your hospital birth as much like home as possible by reducing the amount of time you spend in hospital! You can reduce all the infection risks by labouring at home for as long as possible. This has also been shown to reduce your chances of needing interventions such as caesarean. More information about the physiology in my Covid webinar It can be tricky to know when you are ready to move to hospital, as arriving in hospital too early can slow labour, and leaving too late can risk an unexpected birth at home or on the way to hospital. For these reasons, it is ideal to have your own birth attendant (doula, midwife or "virtual doula" (see here for more information) to support you at home or at least to advise you by phone. Your hospital maternity team may be very happy to help you to stay home as long as possible by providing phone support. These considerations are complex and there is no one-size-fits all. It is important that you can feel safe in your birthing environment. Please talk to your care providers so that you get the information you need to make the choices that are right for you, your baby and family. Q: Should I have a caesarean or induction to avoid some of the effects of Covid-19 on hospitals? These are also difficult decisions. It is true that hospitals may be very busy with Covid-19 infected patients. In addition, there may be restrictions on birth support people for the reasons discussed above. However, bringing your baby's birth forward with induction or pre-labour (elective) caesarean has its own risks for mothers and babies. These include higher risks of newborn breathing difficulties after a prelabour caesarean, (See this study and this study) which can require separation from the mother and NICU care for your baby. Following a caesarean, women have higher risks of potentially serious complications and readmissions, including infections and blood clots (see this study). In addition, breastfeeding may be less successful (see this study). In relation to induction, some studies have suggested that this may reduce the risks of caesarean, (see my critique here) but real-world figures show that women have higher risks of caesarean and complications, compared to non-induced (e.g. see this study and this study) These can all affect newborns as well. What makes these decisions even more difficult is that it is almost impossible to predict whether you and your baby will be the ones to have a smooth experience, or or whether you will be in the minority that have complications. In general, induction is more likely to be successful in women who are closer to the natural onset of labour, with a more "ripe" cervix on vaginal examination (see this study). Also, first-time mothers may have more difficulties with induction (see this study), likely because their birthing physiology is inexperienced. I also believe, based on understandings from animal studies, that it may be more consequential to disrupt the hormonal physiology of first-time mothers, compared to experienced mothers, and more likely to disturb bonding and breastfeeding with their newborn babies although this has not been studied. (See chapter 2 in my Hormonal Physiology of Childbearing report for more detail.) In conclusion, this is not a straightforward decision, and again talk to your maternity care provider about the benefits, risks and alternatives. Q: How can I protect myself and my family? Covid-19 is spread by the secretions from the respiratory tract of infected people- nose, throat, breathing passages and lungs. When people cough or sneeze, these secretions go into the air as droplets, which can travel 1-2 m (3-6 feet). For this reason, ‘social distancing’ rules are designed to keep people 1.5-2m (5-6 feet) apart. If an infected person touches their mouth or nose, or coughs into their hands, and then touches another person, especially if that contact then touches their face, the virus could get into their respiratory tract and spread the infection. One of the best ways to protect yourself and others is by wearing a well-fitting, triple layered mask, ideally N-95 standard or equivalent. With the new variants, this is more effective than ever! In addition, the virus can stay alive on some surfaces for hours to days, at least in theory. (More info) If an uninfected person touches a surface that has been contaminated by someone with the virus, and then touches their face, the virus could cause infection. Because of this risk, it is recommended that we all wash our hands frequently and especially avoid touching our faces when out in public. It is safest to presume that anyone you meet could be infected, especially because people can be contagious before they develop symptoms, and because some people will have very mild or no symptoms. In summary Keep a safe distance from others Wear high-quality N95 or equivalent mask when away from home. Avoid touching surfaces when out in public as far as possible. Wash hands frequently : see this video for effective technique Stay home as far as possible There are many more questions, including in relation to labour and birth, whether...

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