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Safe births at short hospitalization in pandemic

Hospitalizations for both mothers and babies after vaginal deliveries and c-sections decreased in US

By Erin Michael

During the COVID-19 pandemic, hospitals across the United States implemented measures to prevent the spread of the novel coronavirus in labor and delivery units. These measures have led to shorter hospitalizations for labor and delivery, researchers at Cedars-Sinai found, but these shortened hospitalizations have not increased the rate of adverse outcomes in mothers or infants.

“What we found was that complications, at least in the short term, did not go up, but that [length of] hospitalizations for both mothers and babies after vaginal deliveries and c-sections actually went down,” Mariam Naqvi, MD, a maternal fetal medicine specialist in the department of obstetrics and gynecology at Cedars-Sinai, told Healio Primary Care.

Shortened hospitalizations after delivery

The retrospective cohort study, published in the American Journal of Obstetrics and Gynecology Maternal Fetal Medicine, evaluated and compared deliveries at Cedars-Sinai Medical Center from January 2020 through February 2020 — before modifications were implemented due to the COVID-19 pandemic — with deliveries after the modifications were implemented, from March 2020 through April 2020. A total of 1,936 deliveries were included in the study, 1,016 of which occurred during the pre-implementation period and 920 of which occurred in the postimplementation period.

The changes included the institution’s policy on the use of personal protective equipment, the use of designated rooms to triage and deliver patients with confirmed or suspected COVID-19, changes to delivery management, newborn care, and the allowance of one support person for delivery and no visitors after delivery.

Naqvi and colleagues also compared delivery outcomes in 2020 with outcomes from the same period in 2019 and 2018 to determine whether any of the observed differences were unique to the COVID-19 pandemic.

They found that the length of stay for delivery was significantly different after implementation of COVID-19 protocols.

Among deliveries during the 2020 study period, the researchers found that postpartum stays 1 night after vaginal delivery occurred in 24.9% of the pre-implementation group compared with 48.5% of those in the postimplementation group.

Naqvi and colleagues also found that the percentage of patients who stayed 2 nights or fewer after cesarean delivery was 11.8% among women in the pre-implementation group compared with 40.9% of women in the postimplementation group.

The researchers also found that the length of stay was shorter among newborns who were born after COVID-19 protocols were put in place, with 49% of newborns in the postimplementation group and 24.9% in the pre-implementation group being discharged 1 night after vaginal delivery. For cesarean delivery, 42.5% of newborns in the post-implementation group and 12.5% in the pre-implementation group were discharged after 2 nights or fewer.

According to the researchers, there were no differences between the groups for NICU admission, neonatal hypoglycemia, unexpected newborn complications, readmission within 28 days or abnormal cord blood gas.

They did not identify a significant difference for neonatal or maternal length of hospital stay between January to February and March to April in 2018 or 2019 for cesarean section or vaginal deliveries.

“Delivery is a really special reason for admission, because it’s not just about recovering from a medical standpoint. There’s a lot of teaching that goes on during the postpartum period,” Naqvi said. “We have nurses helping moms learn how to nurse, change diapers, bathe the baby, so there’s a lot more than just recovery of the mom that goes into the postpartum course after both vaginal and cesarean deliveries.”

However, she noted that in light of the pandemic, “for a multitude of factors that we alluded to, those hospitalization times went down.”

Recovery at home

In general, Naqvi said that “low-risk patients can recover really well” at home, as long as it is a safe environment.

“So, it’s a great benefit when we can, and when we’re able to safely reduce the length of stay for a patient,” she added.

Other facilities have also observed shorter hospitalizations for labor and deliver after implementing COVID-19 protocols. Richard Beigi, MD, MSC, professor of reproductive sciences in the department of obstetrics, gynecology and reproductive sciences and president of the UPMC Magee-Womens Hospital, told Healio Primary Care that his institution is one of them.

“We really looked at our operations and made adjustments around our operations to enable women who wanted to go home quickly or more quickly than usual, to be able to do that if it worked [for them],” he said.

So far, shortening hospitalizations for delivery when possible does not appear to adversely impact patients’ health, Beigi added.

“Most women who deliver babies are otherwise healthy individuals, and most people like to recover in the comfort of their own home,” he said. “I think those two things combined suggest that the majority of women can do just fine, and even have a more favorable recovery in the comfort of their own home at a sooner point.”

When longer delivery is necessary

While otherwise healthy women may want a shorter hospitalization for delivery, Beigi noted that some still require longer stays.

“There are women who either have conditions when they come in to delivery or develop conditions during the delivery or immediately thereafter that some of these more rapidly discharge-facing protocols do not apply to,” he said.

For instance, women who experience significant bleeding during delivery, develop hypertension or have signs of infection, surgical complications from a cesarean delivery or other high-risk conditions may benefit from longer hospitalizations so they can be monitored and treated after birth, according to Beigi.

Therefore, while shorter hospitalizations may benefit some women, Beigi said that legislation should not change to lower the minimum coverage requirements for insurers.

Current legislation — the Newborns’ and Mothers’ Health Protection Act of 1996 — mandates that group health plans and health insurers cannot restrict hospitalization for childbirth to less than 48 hours for vaginal deliveries and 96 hours after cesarean deliveries.

“There are women who really do require a longer length of stay, and there are some women who want to stay longer,” Beigi said. “We have approached this with a patient-centric manner, which is, we made changes in our processes to allow, permit and enable women who want to go home earlier to be able to do that — we never mandated this. We wanted this to really be the patients’ choice.”

Long-term implications

Currently, it is unclear whether COVID-19 protocols will remain in place after the pandemic to help reduce the length of hospitalization for delivery, according to Naqvi.

“As obstetricians and nurses and anesthesiologists — the multidisciplinary team that takes care of pregnant patients in the hospital — our goal is always to have a safe delivery, a healthy mom and a healthy baby,” Naqvi said. “And so, ultimately, if a shorter hospitalization comes out of us trying to achieve that, then that’s just sort of icing on the cake. Whenever we establish or implement any kind of protocol changes to our labor and delivery unit, our main goal is patient safety.”

She added that if they identify negative long-term effects of shorter hospitalizations, “then we’re going to have to go back to the drawing board and think more about what we’re doing on the labor floor.”

Beigi said that his institution may keep some of its new protocols in place after the pandemic.

“The changes we made rapidly in the face of the pandemic, according to the data and our own personal experiences, have shown that we have shortened length of stay overall, and I do think that the majority of patients have enjoyed and desired that,” he said.

He added, therefore, that these protocol changes “could stay up after the pandemic is over, and some of those changes could become more permanent, because some of it will be driven by patient expectation.”

References: Greene NH, et al. Am J Obstet Gynecol MFM. 2020;doi:10.1016/j.ajogmf.2020.100234.

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