ATLANTA – As the fight against coronavirus disease 2019 (COVID-19) continues across the U.S., obstetricians on the front line must determine what personal protective equipment (PPE) should be worn to protect themselves, their co-workers and their patients, as shortages of PPE linger. Five medical experts, including two from Emory University School of Medicine, share their thoughts in a current commentarypublished in the Journal of Obstetrics & Gynecology, the official publication of the American College of Obstetricians and Gynecologists.
“Although many things have slowed down during this pandemic, obstetrics practice has not,” says Denise Jamieson, MD, MPH, James Robert McCord Professor and Chair of Gynecology and Obstetrics at Emory and first author on the commentary. “The babies keep coming! It is not possible to deliver a baby ‘remotely’ and it is often not possible to maintain six feet of physical distance in the delivery room or the operating room.”
Jamieson goes on to say, “Therefore, it is critical that we do everything possible to protect our providers and staff on the front lines of obstetric practices. A critical component of this ‘recipe’ for staying safe is the correct and consistent use of PPE.”
A face mask is the standard, FDA-approved medical mask used by health care providers on labor and delivery units, with or without a face shield. However, when caring for persons with known or suspected COVID-19 infection, current PPE recommendations from the Centers for Disease Control and Prevention (CDC) include an N95 respirator, if available (or face mask if a respirator is not available), eye protection, gown and gloves.
CDC guidance suggests that N95 masks are important for health care providers to use when aerosol-generating procedures are performed. In labor and delivery units, intubation for general anesthesia has been shown to produce aerosols, and there has been some suggestion that labored breathing and pushing during delivery may generate aerosols.
“Because this is a new virus and a lot is unknown about exactly how it is transmitted, there has been uncertainty around PPE wear,” says James Steinberg, MD, professor of medicine in the Division of Infectious Diseases at Emory and author on the Journal of Obstetrics & Gynecology commentary. “As more information is learned, the recommendations for PPE change. Messaging the many changes can be difficult and it is important to do clearly to avoid confusion.”
The experts also recommend that all women with COVID-19 infection should wear a face mask during their entire hospitalization, including during the laboring process, when possible.
Because of PPE shortages and conservation means, many health care organizations are following CDC guidance on extended use and limited reuse of N95 masks. Extended use refers to wearing the same N95 masks for repeated contact with several patients. Limited reuse involves using the same N95 masks for contact with several patients by removing it between patient encounters. The experts say the primary risk for reuse or extended use of these masks is self-contamination by staff from touching the mask, if it becomes contaminated, and then touching their faces.
“It is critical that health care professionals practice correct donning (putting on) and doffing (taking off), good hand hygiene and avoid touching the N95 mask or their faces during use,” the commentary states.
“While PPE is important, I would emphasize that we shouldn’t just focus on it,” says Steinberg. “We need to prioritize basics such as hand hygiene, which may be more important, and be sure to socially distance. Patients with known or suspected COVID-19 infection are only one risk. Another risk is exposure to others, including co-workers, if we don’t pay attention to the basics.”
While CDC has recently recommended wearing cloth masks in public, hospital systems should be cautious about using cloth masks for direct patient care in COVID-19 settings, according to the commentary.
In the ambulatory care or clinic setting, the experts in the commentary recommend that patients with symptoms should be assessed to determine if an in-person appointment is needed or whether patients can be seen by telemedicine and managed at home. If an outpatient appointment is necessary, a face mask should be placed on the patient with respiratory symptoms immediately, and she should be quickly isolated in an exam room with the door closed. In areas of high community transmission, placing a mask on all patients should be considered to minimize potential transmission.
Triage areas should be separate, well-ventilated spaces with patients separated from staff (such as plexiglass barriers) during the screening process. Patients in triage should sit six feet apart from each other with ample hand hygiene dispensers available for use.
In conclusion, where much of the focus on PPE has been on facial protection, data from the SARS (severe acute respiratory syndrome) outbreak in 2003 suggests that it is the “bundle” of PPE with hand hygiene and environmental cleaning that leads to decreased risk of transmission of respiratory viruses, and this is likely true for COVID-19, according to the commentary.
“As an overarching message, obstetricians need to be familiar with the PPE that is available to them on labor and delivery, to train and practice using that PPE, and to use the PPE correctly and consistently for best outcomes,” says Jamieson.
Other authors in the commentary include Richard Martinello, MD, from Yale School of Medicine, Trish Perl, MD, MSc, from University of Texas Southwest Medical Center (Parkland Health & Hospital System) and Sonja Rasmussen, MD, MS, from University of Florida College of Medicine.