Introduction
On 11th of March 2020 the World Health Organization
declared the Coronavirus disease (COVID-19) outbreak a
pandemic(1). Human-to-human transmission of COVID-19
has been established and from the 16th of March Public
Health England (PHE), declared that vulnerable individuals including the
pregnant population should be even more stringent about following the
social distancing rules(2). This decision was most
likely informed by the knowledge that pregnancy changes the immune
system, which can lead to the development of more severe symptoms
following a viral infection. To date 148,377 people have tested positive
for SARS-CoV2, with 20,319 of those hospitalised having sadly died in
the UK(3). The numbers of infected will no doubt
include pregnant women and so every maternity unit should be as prepared
as possible, in an ever evolving situation.
The Royal Surrey NHS Foundation Trust has a maternity unit that delivers
approximately 2,700 babies annually. As a smaller obstetric unit we face
different challenges in regards to our physical facilities and staffing,
compared to larger obstetric units. We approached the need for rapid
adaptation of our services using the following concepts as highlighted
by the Centers for Disease Control and Prevention
(CDC)(4): 1) limiting the entry of pathogens on to the
unit, 2) isolating symptomatic patients or patients living with a
symptomatic individual and 3) protecting our staff. We also, implemented
the recommendations by the Royal College of Obstetricians and
Gynaecologists (RCOG)(5), which aligned with the
aforementioned concepts.
This article shares the practical steps we took , as well as the
challenges and successes a small maternity unit have had so far in a
dynamic climate, with constantly emerging and changing guidelines for
providing evidence-informed clinical care during the COVID-19 pandemic.
Limiting the entry of pathogens onto the maternity unit
Structural changes that reduce patient flow throughout the maternity
department were instigated early on, to minimise infection opportunities
for both our women and staff, in groups thought to be negative,
suspected or confirmed SARS-CoV2 positive. The hospital now only has two
main entrance points. All patients arriving at the Accident and
Emergency department (A&E), are screened for symptoms and have their
temperature taken. At the main entrance, entry is restricted to those
with an appointment and visitors are only allowed under extraordinary
circumstances.
Our pregnancy advice telephone service has COVID-19 symptom screening
questions; aiding in the direction of pregnant women to designated ‘hot’
or ‘cold’ assessment areas in our unit. Details of these are discussed
later in the commentary. Initially labelled ‘dirty’ and ‘clean’, our
‘hot’ areas are where patients suspected to have or with confirmed
COVID-19 are reviewed and managed. Conversely, ‘cold’ areas are where
women who are deemed low risk for having COVID-19 are seen.
In line with national guidance, the unit has streamlined obstetric
antenatal clinics – offering telephone consultations as a default. Any
woman who requires a face-to-face consultation as per clinical need is
screened on arrival by the entrance to the outpatient department with
questions and her temperature is taken.
Much of our community midwifery care is run from General Practice
surgeries. As many reduced their face-to-face services, and we planned
for lower staff numbers; we concentrated our community provision into
two existing sites and one new central one – procured from a local
private provider so as not to unduly increase footfall at the hospital.
Informal feedback from our women via social media has been
overwhelmingly positive, as they feel safer avoiding the main hospital.
Where telephone consultations have replaced face to face appointments,
as per the RCOG guidance(6), a temporary
‘drive-through’ service allows blood pressure and urine dip checks.
Isolating patients with a contact history or symptoms
One of our main ‘hot’ areas is our designated ‘pregnancy pod’. It is a
stand-alone suite of clinical rooms that are situated directly behind
our A&E, that were repurposed. The suite is fully equipped with an
assessment room, ultrasound machine, cardiotocograph and trolley
available for emergency transfers. This area is for both emergency and
routine attendances that cannot be postponed beyond the self-isolation
period recommended by the Government. All pregnant women who have had
contact with or are suspected of or confirmed COVID-19 enter via A&E.
As an extension of the ‘hot’ A&E area, all staff working in the
‘pregnancy pod’ wear the appropriate personal protective equipment
(PPE). We offer acute gynaecology, early pregnancy, antenatal and
postnatal care in this environment.
On delivery suite, all rooms have ensuite bathrooms. Those with a double
door were prioritised for COVID-19 suspected or confirmed cases.
Retrofitting additional doors has also increased our isolation capacity.
Protecting our staff
Screening all women at entry and adequate provision of PPE are key to
staff protection. Staff who require shielding, work from home completing
telephone consultations. Those who do not meet criteria but nonetheless
have medical comorbidities are prioritised to work at the
‘drive-through’. The woman remains in her vehicle whilst blood pressure
checks, blood tests and urine dips are carried out. Adjacent to the
maternity ‘drive-through’, the pharmacy ‘drive-through’ allows
collection of prescriptions from telephone consultations. All services
are by appointment only to reduce congestion.