The Covid-19 pandemic has changed the shape of healthcare enormously almost overnight. No single element of healthcare provision is untouched, not least maternity services.
During pregnancy and childbirth there is an unavoidable need for physical, face-to-face care in order to check on the wellbeing of both mother and baby, with standard antenatal appointments generally taking place sporadically during the first and second trimester and at regular intervals during the third. These appointments run alongside ultrasound scans at 12 and 20 weeks, if the baby is well. If the pregnancy is high risk, the mother may need to attend these scans every two to four weeks for appropriate monitoring. This represents significant ongoing and necessary contact with healthcare professionals, which is not always easy to replicate by virtual means (it is very difficult to perform ultrasound scans, check a mother’s blood pressure and urine sample, listen to a baby’s heart rate and measure a baby’s growth over Skype).
New guidance on antenatal and postnatal services during the evolving coronavirus (Covid-19) pandemic was released on 30 March 2020. During the crisis, the recommendation is for there to be a minimum of six face-to-face antenatal consultations, with remote means encouraged to provide additional antenatal consultations. These may be by telephone or video consultation to ensure that there is compliance with social distancing wherever possible. These calls are to be used for:
Efforts are also being made to join up services where possible. For example, physical checks will be undertaken at ultrasound scan appointments to limit separate visits to the hospital. Women who are post-dates should have their post-dates appointment married up in a way that induction of labour can take place at this appointment to reduce the need for an extra appointment to achieve the same result.
Whilst virtual appointments are being offered where possible to maintain contact, this cannot match up to the level of care expectant mothers are usually given during pregnancy. Importantly, women should remain vigilant about the health of their baby - if a woman raises concerns about fetal movements or her physical wellbeing, the guidelines indicate physical attendance should take place.
Pregnant mothers are considered to be in the ‘at risk’ group for Covid-19 by the government as a precaution (although there appears to currently be no evidence that pregnant women and unborn babies are at a higher risk than anyone else, this is felt to be the safest way to manage any uncertainty surrounding the issue). Whilst face-to-face contact may be needed to carry out checks on mother and baby, obviously, face-to-face contact with anyone outside of your own household will increase the likelihood of exposure to the virus, which will be especially significant to pregnant women with underlying health problems.
This also has to be factored in when making choices about how to deliver care, to ensure that expectant mothers are not unnecessarily exposed to the virus. Keeping in balance the need for necessary physical examinations to deliver care safely versus appropriate shielding from exposure to the virus may be one of the most difficult tasks for midwives working in the NHS over the coming months.
It is clear that significant thought is going into how to deliver care safely in the current climate. However, the Nursing and Midwifery Council seems to acknowledge that this care may not match up to the levels usually expected as - along with many other regulating bodies including the General Medical Council – it has signed up to a joint statement dealing with regulation during the crisis. This statement accepts that medical professionals may need to depart from established procedures in order to care for patients during the epidemic. The regulating bodies have assured professionals that where concerns are raised, the specific factors surrounding the environment in which they are working will be taken into account when assessing the need to be redeployed from established procedures or departments. It is vital, of course, that the health professionals of the NHS feel safe to act in these challenging times without fear of retribution, but it is equally important to make sure that care is delivered as safely as possible.
Midwives are asking for maternity services to be ring-fenced during the crisis: women do not stop becoming pregnant and having babies because there is a pandemic, and there needs to be care available for these babies to be brought safely into the world. This care has already been scaled back from the usual standards, therefore it is doubly important to make sure that the new standards can be met. On the recent BBC Radio 4 Women’s Hour, Dr Mary Ross-Davie, Director for Scotland, Royal College of Midwives (RCM), spoke about the current situation and the challenges the RCM is facing. Dr Mary Ross-Davie explained that before the pandemic, there was a shortage of around 2,500 midwives in England, and this has increased significantly due to the need for a large number of staff to self-isolate, meaning that maternity services are under significant pressure. The NHS is understandably diverting care to support frontline services during the pandemic, but the Royal College of Midwives is asking that midwives are left out of this and that staff are instead diverted from areas where care is less urgent and less time-sensitive.
Helen Hammond, senior associate at Penningtons Manches Cooper, said, “As a clinical negligence solicitor with experience in obstetric and midwifery care, I know that when things go wrong during pregnancy and labour the results can be devastating, potentially leading to stillbirths and life-changing conditions such as cerebral palsy. Any of these unexpected outcomes have wide reaching implications not only on a human level for the family and medical professionals involved, but also on a societal level. When a child is injured at birth, whether a legal claim follows or not, the reality of the situation is that the injured person will require support with their additional needs for the rest of their life, including benefits, specialist support at school, complicated care packages and the impact on parental ability to work. Ultimately, the consequences of the standards of care for pregnant mothers and their babies being scaled down will have significant ramifications for decades after the crisis is over, and this is something that should be considered when making choices about where care is needed most. The ring-fencing of maternity services will give the best opportunity for care to be delivered safely to mothers and babies during this challenging period.”