Clinical Expert Series

Practice Modification for Pandemics

A Model for Surge Planning in Obstetrics
Christina M. Duzyj, MD, MPH, Loralei L. Thornburg, MD, and Christina S. Han, MD

This review highlights proposed pandemic-adjusted modifications in obstetric care, with

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discussion of risks and benefits based on available evidence. We suggest best practices for
balancing community-mitigation efforts with appropriate care of obstetric patients.
(Obstet Gynecol 2020;136:237–51)
DOI: 10.1097/AOG.0000000000004004

T he likelihood of pandemics has increased over the

past century as a result of international travel,
urbanization, and exploitation of the environment.1
Implicated pathogens include severe acute respiratory
syndrome coronavirus (SARS-CoV) (2002), influenza
H1N1 (2009), Ebolavirus (2014), and severe acute
respiratory syndrome coronoavirus 2 (SARS-CoV-2)
(2019).2 In addition to strains on the health care sys-
tem from care of affected individuals, community-
mitigation efforts such as social distancing and “shel-
ter-in-place” policies also affect medical operations.
Because obstetric health care is among the most fre-
quently used service in the United States, with more
than 18 million visits annually,3 it is a logical target for
pandemic-adjusted modifications.
In 2017, the American College of Obstetricians and
Gynecologists (ACOG) published a Committee Opin-
ion on hospital disaster preparedness to provide guid-
From the Departments of Obstetrics and Gynecology, Massachusetts General
Hospital, and Harvard Medical School, Boston, Massachusetts; the Department
of Obstetrics and Gynecology, University of Rochester, Rochester, New York; and
the Department of Obstetrics and Gynecology, University of California at Los
Angeles, and the Center for Fetal Medicine and Women’s Ultrasound, Los An-
geles, California.
Each author has confirmed compliance with the journal’s requirements for authorship.
Published online ahead-of-print June 2, 2020.
Corresponding author: Christina S. Han, MD, Department of Obstetrics and
Gynecology, University of California at Los Angeles, and the Center for Fetal
Medicine and Women’s Ultrasound, Los Angeles, CA; email: cshan@
mednet.ucla.edu.
Financial Disclosure
Christina S. Han reports serving on the Advisory board for Jubel Health, a digital
health company. The other authors did not report any potential conflicts of
interest.
© 2020 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/20
ance regarding care during infectious disease surges.4
However, without specific recommendations, guidance
during pandemics often depends on expert opinion.5–7
This evidence-based review proposes pandemic-
adjusted modifications in obstetric care, with discus-
sion of risks and benefits. Because data remain limited
to inform these suggestions, we acknowledge the
potential for liability in deviating from standards of
care, especially if failing to provide alternative access
to health care. We use available data to recommend
best practices for balancing community-mitigation
efforts with appropriate care of obstetric patients.
TELEHEALTH IN OBSTETRICS
When community-mitigation efforts are in place,
elements of obstetric care can be transitioned to
remote monitoring. Telehealth refers to any health
care delivery enhanced by telecommunication,
including smartphone apps, text messaging, wearable
devices, and audio–visual communication. In a sys-
tematic review, telehealth interventions improved
outcomes related to breastfeeding, access to family
planning services, and decreased office visits without
compromising maternal and fetal outcomes.8
Implementing telehealth requires evaluation of
equipment readiness, compliance with Health Insur-
ance Portability and Accountability Act regulations,
technological on-boarding, and credentialing.9 Guid-
ance regarding billing for telehealth services is avail-
able from ACOG and the Society for Maternal-Fetal
Medicine (SMFM).10,11
EARLY PREGNANCY
The American Academy of Pediatrics and the ACOG
Guidelines for Perinatal Care recommend that the

VOL. 136, NO. 2, AUGUST 2020 OBSTETRICS & GYNECOLOGY 237

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
initial prenatal visit take place in the first trimester,
with gestational age and follow-up frequency based on
risk factors.12 It is recommended that individuals at
increased risk for pregnancy complications be seen
“as early as possible.”
During pandemics, the in-person prenatal care
schedule may be abbreviated to minimize excursions
for pregnant patients and demands on the clinical
workforce. Strategies must be in place to counteract
the potential sequelae of delaying the first prenatal
visit, including missed opportunities for ultrasound
screening, management of maternal comorbidities,
and family planning discussions.
First Prenatal Visit and Ultrasound Examination
Obstetric societies recommend that imaging occur
before 14 weeks of gestation and include evaluation of
viability, location, dating, number of fetuses, nuchal
translucency, and pelvic anatomy.13–15 Pandemic-
adjusted modifications include a telephone intake
appointment at less than 11 weeks of gestation and
an initial in-person visit and ultrasound examination
at 11–13 6/7 weeks of gestation.6,7 This guidance,
although in compliance with ACOG recommenda-
tions, differs from typical care, where first visits are
often at 6–7 weeks of gestation.16
Potential sequelae of later prenatal visits include
incorrect dating, delayed management of Rh-D–
negative status, and delayed diagnoses of mis-
carriage, multifetal gestation, and ectopic, cesarean
scar, or molar pregnancy. To mitigate risk, the con-
tents of the proposed initial telehealth visit should be
adapted and standardized from the ACOG Guidelines
for Perinatal Care (Box 1). Risk factors for complica-
tions should be assessed to determine whether the
patient should be seen earlier than the pandemic-
adjusted schedule (Appendix 1, available online at
http://links.lww.com/AOG/B937).
Genetic Counseling
The American College of Obstetricians and Gynecol-
ogists notes that the increasing complexity of genetic
testing must be accompanied by a firm comprehen-
sion of tests, as well as pretest and posttest counsel-
ing.17 Given the volume of information that must be
shared with patients, telegenetics consultation with
a counselor should be considered.18 During
community-mitigation efforts, screening bloodwork
such as carrier screening or cell-free fetal DNA testing
may be delayed until the in-person visit or performed
using outpatient laboratories. The SMFM also states
that, in patients who have had a negative cell-free
DNA test result, ultrasound examination solely for
238 Duzyj et al Practice Modification for Pandemics
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
the purpose of nuchal translucency measurement is
not recommended.19
Early Pregnancy Loss
Miscarriage occurs in 10–20% of clinically recognized
pregnancies, with 80% occurring before 12 weeks of
gestation.20,21 The risk of miscarriage approaches 50%
in women aged older than 40 years. Because the diag-
nosis is ultrasound-based,22,23 an in-person visit earlier
than the pandemic-adjusted schedule may be required
in at-risk or symptomatic individuals. Risk factors for
early pregnancy loss, including advanced maternal
age, prior miscarriage, and vaginal bleeding, should be
assessed at the first telehealth visit. Patients with recur-
rent pregnancy losses are at risk of depression, and in-
person reassurance regarding viability is warranted.24
Management of early pregnancy loss may also be
modified during pandemics. No-touch protocols for
management of early pregnancy loss should be con-
sidered, including expectant management or medical
management with mifepristone and misoprostol.25 If
preferred, surgical completion using dilation and curet-
tage is an essential service that should be offered even
during surges. Outpatient manual vacuum aspiration is
a safe and acceptable alternative. Discussion and writ-
ten instructions must be provided for patients on when
to seek care to avoid complications.
Ectopic Pregnancy
Ectopic pregnancy accounts for approximately 2% of
pregnancies and contributes to 2.7% of maternal
deaths in the United States, making it the leading
cause of deaths from obstetric hemorrhage.26 The risk
of recurrence is approximately 10% in patients with
one prior ectopic pregnancy and rises to more than
25% with two or more.27 Additional risk factors
include damage to the fallopian tubes, ascending pel-
vic infection, and pelvic or fallopian tube surgery.26
The evaluation of a pregnancy of unknown
location requires transvaginal ultrasound imaging. In
individuals at risk by history or symptoms, an early
visit and ultrasound examination to determine preg-
nancy location is warranted. Suspicion for an ectopic
pregnancy should prompt in-person evaluation for
peritoneal signs, hemodynamic instability, serial
human chorionic gonadotropin (hCG) measurement,
and possible medical or surgical intervention.26
Management of ectopic pregnancy should follow
routine protocols. Expectant management can be con-
sidered in appropriate candidates with hCG levels less
than 200 international units/L, because 88% of these
pregnancies would be expected to resolve spontane-
ously.28 Expectant management may obviate the need
OBSTETRICS & GYNECOLOGY
 Box 1. Recommended Elements for the Initial
Obstetric Telehealth Visit(s)
The following information should be obtained from the
patient during the initial telehealth visit:
 Last menstrual period and determination of accuracy
of report
 Past medical history, surgical history, obstetric history,
gynecologic history, medication history, family his-
tory, genetic history, allergies, psychiatric history,
and social history; in particular, we recommend eval-
uation for risk factors that would predispose to con-
ditions requiring early imaging
 Vital signs, if possible:
B Self-report of height and weight, with calculation
of body mass index (BMI, calculated as weight in
kilograms divided by height in meters squared)
B Self-report of blood pressure and heart rate, if
a blood pressure cuff or wearable heart rate mon-
itor is available
 Assess desire for pregnancy
 Assess desire for genetic screening or diagnostic
testing
 Social assessment:
B Food and shelter security
B Access to technology necessary for telehealth visits
B Risk of intimate partner violence
B Home structure, including ability to have safe
space for future visits
The following general information should be discussed
with each pregnant patient during the visit or shared
through documents:
 Routine discussions
B Logistics
B Scope of care that is provided
B Role of the members of the health care team
B Physician or midwife schedule
B Labor and delivery coverage
B How to contact the health care team
B Pregnancy care
B Expected course of the pregnancy
B Signs and symptoms to be reported to the
health care team
B Practices to promote routine health mainte-
nance (eg, safety restraints)
B Recommendations based on obstetric history
B Review of genetic screening and testing op-
tions, including appropriate planning for diag-
nostic testing if desired
B Risk counseling, including substance use and
substance use disorders
B Psychosocial topics in pregnancy and the post-
partum period
B Referrals to appropriate subspecialists based on
risk factors, such as poor obstetric history or desire
for genetic testing
 Elements potentially affected by pandemic and surge
planning
B Logistics
B Anticipated schedule of visits, including
adjusted timelines
VOL. 136, NO. 2, AUGUST 2020
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and Gynecologists. Published by Wolters Kluwer Health, Inc.
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Box 1. Recommended Elements for the Initial
Obstetric Telehealth Visit(s) (continued)
B Adjusted coverage schedules for cohorting of
health care professionals
B Cost to the patient of prenatal care and delivery,
including telehealth coverage by insurance; pa-
tients should be encouraged to discuss this with
their insurer and specific plan
B Office policies for social distancing and infec-
tious disease screening
B Current and shifting nature of hospital policies
during the pandemic
B Pregnancy care:
B Laboratory studies and their indications,
including adjusted timelines
B Self-monitoring of pandemic-related symptoms
B Self-monitoring of urinary symptoms
B Practices to promote community mitigation of
pandemic
B Available data on the pandemic’s potential im-
plications in pregnancy
B Psychosocial topics related to pandemic
B Recommendations for vaccines (such as influenza
vaccination during a pandemic respiratory illness)
The following discussions should be tailored to the
characteristics and needs for each patient or shared
through documents:
 Nutrition
 Exercise
 Nausea or vomiting
 Vitamins
 Mineral toxicity
 Teratogens
 Safety and intimate partner violence
 Dental care, with recommendation to delay if possible
 Precautions to take for essential workers who are
working during a pandemic
 Air or remote travel during pandemic
Data from American Academy of Pediatrics and American
College of Obstetricians and Gynecologists. Guidelines for
perinatal care. 8th ed. Washington, DC: American
Academy of Pediatrics and American College of
Obstetricians and Gynecologists; 2017.
for administration of an immunosuppressive medication
or general anesthesia for surgery during a pandemic,
with concern for viral aerosolization. Candidates for
expectant management must be asymptomatic, have
objective evidence of resolution (plateau or decrease in
hCG levels), and be willing to accept the potential risks
after counseling.26 Strains on blood bank resources and
emergency services during a pandemic must also factor
into the threshold for surgical intervention.29
Rh-D–Negative Status
Experts recommend administration of RhD-
immune globulin (Ig) within 72 hours of suspected
Duzyj et al Practice Modification for Pandemics 239
miscarriage or fetomaternal hemorrhage. In- who are Rh-D–negative. Table 1 addresses poten-
person visits may be necessary to determine Rh- tial cautions regarding RhD-Ig availability during
D phenotype or to administer RhD-Ig to patients pandemics.
Table 1. Suggested Modifications in Common Medications Used in Obstetrics During Pandemics
Medication Background
RhD-Ig129–131 A shortage may arise during times of
pandemic and lockdown, when the
supply chain from blood donations is
limited.
Although RhD-Ig is on WHO’s model
list of essential medicines, it is
unknown how much RhD-Ig is
available regionally, nationally, or
globally at any time.
Antenatal corticosteroids132 Caution has been raised regarding the
use of antenatal corticosteroids in
patients with viral acute respiratory
distress syndrome owing to concern
about increased risk of respiratory
shedding.
Magnesium sulfate for seizure Some systemic viral infections can be
prophylaxis or fetal associated with renal insufficiency.
neuroprotection41,133,134
Nitrous oxide135 During viral pandemics, use of nitrous
oxide may increase aerosolization of
infectious agents and further requires
stringent sterilization procedures.
Labetalol for Labetalol is commonly used for
hypertension136 hypertension in pregnancy and
postpartum but should be avoided as
1st-line treatment in patients with
asthma owing to beta-blockade.
TXA137–139 Contraindications for TXA are a known
thromboembolic event during
pregnancy, history of coagulopathy,
active intravascular clotting, or
known hypersensitivity to TXA.
RhD-Ig, Rh-D immune globulin; WHO, World Health Organization; TXA, tranexamic acid; COVID-19, coronavirus disease 2019.
240 Duzyj et al Practice Modification for Pandemics
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Pandemic-Adjusted
Recommendations
Regular communication with
institutional or regional blood banks
to ensure adequate supply of RhD-Ig.
In the case of a significant shortage, the
practice of routine RhD-Ig
administration during early
pregnancy should be reassessed to
reserve RhD-Ig for deliveries of Rh-
D–positive offspring at higher gesta-
tional ages.
During pandemics with pulmonary
effects, steroids should generally be
reserved for 24–34 wk of gestation,
and only when delivery within the
next 7 d is anticipated.
In patients with respiratory
compromise, decision to use
antenatal corticosteroids needs to be
made on a case-by-case basis.
Dosing of magnesium sulfate should be
adjusted as needed for signs of renal
insufficiency.
During viral pandemics, consider
cessation of nitrous oxide use in the
labor and delivery unit.
Given the associated airway disease of
some viral pandemics, caution
should be taken with choice of
antihypertensive agents.
Systemic viral inflammatory states have
been associated with potential for
both prothrombotic and
coagulopathic states. Although TXA
should be used in patients at risk for
postpartum hemorrhage to decrease
blood product needs during times of
surge, caution should be taken in
patients who have active infection
with some viral pathogens.
Emerging data suggest that COVID-19
is associated with an increased
hypercoagulable state, including
elevations in procoagulant factors
and increased thrombosis risks. Effect
of TXA on patients with COVID-19
infection is not yet known.
OBSTETRICS & GYNECOLOGY
Multifetal Gestations
Twin pregnancies should be assessed for viability,
dating, and chorionicity between 11 and 13 6/7 weeks
of gestation.30 Ultrasonographic accuracy in deter-
mining chorionicity at less than 14 weeks of gestation
has been reported at 99%, but this falls to only 77%
sensitivity after 14 weeks of gestation.31 Pandemic-
adjusted recommendations comply with these stan-
dard schedules.
Maternal Comorbidities
The Guidelines for Perinatal Care note that consulta-
tions with obstetricians or maternal–fetal medicine
subspecialists should be considered for comorbid risk
factors, including asthma, cardiac disease, diabetes,
drug or alcohol use, epilepsy, family history of genetic
disorders, hemoglobinopathy, hypertension, throm-
boembolic disorder, psychiatric illness, pulmonary
disease, renal disease, and poor obstetric history.12 An
initial telehealth visit can establish presence or
absence of these risk factors and inform the timing of
the first in-person visit, frequency of follow-up visits,
or need for subspecialist consultation. Medication his-
tory should also be clearly elicited to ensure appro-
priate adjustments or cessation as early as possible.
Furthermore, preconception telehealth consultation
should be considered in reproductive-aged patients
with comorbidities to develop contraception and post-
conception plans.
Desire for Pregnancy
Family planning is an essential component of repro-
ductive health care. Both ACOG and SMFM affirm
that safe abortion should be categorized as an essential
procedure and should not be delayed due to
pandemic-related modifications.32,33 Telemedicine
can be used safely for early pregnancy termination
in settings where there is no access to safe services.34
When resources are further restricted during pandem-
ics, including equipment or procedure room availabil-
ity, a network of referrals should be established to
ensure access.
ANTEPARTUM CARE
The goal of this section is to review pandemic-
adjusted schedules regarding antepartum surveillance
and management of obstetric complications.
Preparation for Normal Childbirth and
Parenting Transitions
With decreased in-person visits, the normal prepara-
tion and guidance provided during routine care could
be lost. Online and virtual education options, includ-
VOL. 136, NO. 2, AUGUST 2020
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Unauthorized reproduction of this article is prohibited.
ing childbirth preparation, the parenting transition,
and breastfeeding, are available and can fill this gap.
Text services providing daily updates based on
gestational age are also available. Health care teams
should work to develop access to these health-literacy
resources.
Preeclampsia
The U.S. Preventive Services Task Force found no
increase in adverse outcomes related to preeclampsia
among patients with a decreased number of prenatal
visits.35 During surges, home blood pressure (BP)
monitoring with proper education may achieve early
detection and is well accepted by patients.36,37 Blood
pressure self-assessment can be performed weekly
among low-risk patients and daily or as needed for
symptoms among patients at risk. Urine protein
assessment may be deferred because results will often
not change management.38
Precalibrated sphygmomanometers should be
used. Experts recommend upper-arm cuffs, although
wrist cuffs may be considered if upper-arm measure-
ments are not feasible and technique is appropriate
(ie, the monitor is directly over the radial artery and
the wrist is in neutral position at the level of the
heart).38–40 An abnormal BP or symptom should trig-
ger an in-person visit to confirm cuff accuracy and, as
appropriate, laboratory evaluation and fetal assess-
ment. Written and verbal education about symptoms
of preeclampsia is necessary.
For patients with diagnosis of gestational hyper-
tension or preeclampsia without severe features,
ACOG suggests monitoring with serial growth ultra-
sound examinations, weekly antepartum surveillance,
close BP monitoring, and weekly laboratory tests.41
Outpatient surveillance has been demonstrated to be
safe for such patients.42 The patient’s ability to achieve
rapid access to health care facilities should be assured.
Additionally, patients must be availed of ready com-
munication with their management team.
The frequency of outpatient antepartum surveil-
lance may be adjusted based on risk assessment.43 In
patients whose diagnosis of preeclampsia is made
before 34 weeks of gestation, an increased risk of still-
birth may be seen,44 for which antenatal testing can be
alternated with an additional weekly intervening tele-
medicine visit to review BP logs, symptoms, and fetal
movement. The utility of weekly bloodwork for pre-
eclampsia has also been called into question,45 poten-
tially allowing for diminished bloodwork surveillance.
In patients with severe features, the usual goal of
delivery at 34 weeks of gestation requires shared
decision making and appropriate patient
Duzyj et al Practice Modification for Pandemics 241
selection.38,46 Some experts call for earlier delivery in
this population.38 However, if expectant management
is deemed appropriate and safe, home monitoring and
virtual visits have shown similar outcomes to in-
person visits.47
Fetal Growth Restriction
In low-risk, nonobese patients with singleton preg-
nancies who have normal weight gain, fundal height
surveillance can be performed safely at 6–8-week in-
tervals. Patients with known risk factors for fetal
growth restriction and stillbirth or with anatomical
confounders (eg, morbid obesity, uterine leiomyomas,
or multifetal gestation) should receive regular ultraso-
nographic assessments of estimated fetal weight,
although the optimal frequency has not been deter-
mined.48,49 When using a pandemic-adjusted sched-
ule, ultrasound screening every 4–8 weeks in women
with at-risk pregnancies may be appropriate, with de-
cisions based on level of risk rather than a reflexive
“one size fits all” approach.
There remains a lack of consensus on the
frequency of ultrasound examinations, umbilical
artery Doppler velocimetry, or antenatal testing after
diagnosis of fetal growth restriction.43,44,50 Consider-
ation should be made to evaluate the growth of fetuses
with fetal growth restriction every 3–4 weeks, because
assessments at 2-week intervals have a false-positive
rate greater than 10%.48,51 Umbilical artery Doppler
intervals of 1–3 weeks are recommended by some,
with increase to twice or thrice weekly if abnormalities
are appreciated.50,52,53
Society for Maternal-Fetal Medicine guidelines
released in May 2020 recommend the following for
delivery timing: 1) 30–32 weeks of gestation for fetal
growth restriction with reversed end diastolic flow on
umbilical artery Doppler, 2) 33–34 weeks of gestation
for fetal growth restriction with absent end diastolic
flow, 3) 37 weeks of gestation for fetal growth restric-
tion with decreased, but not absent or reversed, dia-
stolic flow, and 4) 37 weeks of gestation for severe
fetal growth restriction with estimated fetal weight less
than the third percentile.50 The ranges of recommen-
ded timing afford some flexibility in the timing of
delivery during periods of surge.49,50 Fetal growth
restriction is not an automatic indication for cesarean
delivery, and mode of delivery should remain per
routine indications, even during a pandemic.
Prelabor Rupture of Membranes and Preterm
Prelabor Rupture of Membranes
Multiple systemic viral infections, such as those seen
during pandemics, may increase the risk of preterm
242 Duzyj et al Practice Modification for Pandemics
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
labor.54 In general, among patients who present with
preterm contractions, fewer than 10% deliver within 7
days of presentation.55,56 The negative predictive
value of fetal fibronectin may be leveraged to evaluate
candidacy for outpatient management.57
Preterm prelabor rupture of membranes is tradi-
tionally managed in the hospital.58 Delivery within
the first week of hospitalization occurs in 50% of pa-
tients.59 Appropriate candidates can be evaluated for
outpatient management. One meta-analysis demon-
strated no worsening of outcome with outpatient man-
agement but was underpowered to detect
differences.60 Before attempting an outpatient man-
agement protocol, patients must be carefully coun-
seled regarding potential risks and informed that this
is a management algorithm that is offered only during
extenuating circumstances.
Telehealth options may include temperature, fetal
kick count, and maternal heart rate logging every 6–8
hours, with daily in-person or virtual evaluations for
contractions, abdominal pain, bleeding, or abnormal
discharge. Again, access to a direct communication
line, appropriate calling guidelines, and close and con-
sistent transit to the hospital would be required, high-
lighting the importance of careful patient selection.
A meta-analysis of multiple studies has demon-
strated that expectant management to 36 6/7 weeks of
gestation, rather than 34 weeks, may, in the well-
selected patient, improve obstetric outcomes.58,61 This
strategy, in combination with close monitoring, may
reduce the duration of both maternal and neonatal
hospitalization.
Diabetes Mellitus in Pregnancy
Diabetes self-management education lends itself well
to a telemedicine approach, using virtual visits and
glucose or food-log communications with the health
care team.62 For centers offering group prenatal care
for gestational diabetes mellitus,63 in-person care is
not recommended during pandemics because this vi-
olates social distancing policies.
Patients should be reassured that gestational
diabetes mellitus that is well-controlled without med-
ications neither incurs risk nor requires additional
surveillance.64 In patients with optimal glycemic con-
trol with medication, delayed initiation of surveillance
(eg, at 34–36 weeks of gestation) can be considered.
INTRAPARTUM CARE
During surges, three particular resources bear scru-
tiny: bed management, anesthesia, and blood prod-
ucts. We may consider these in the context of labor, as
well as in anticipated cases of complex delivery.
OBSTETRICS & GYNECOLOGY
Labor
Normalizing the processes of labor and birth is both
difficult and necessary during pandemics. Patients are
fearful that they will be lost among or affected by
those sicker than they, with additional concerns about
visitation policies or temporary separation from new-
borns. The American College of Obstetricians and
Gynecologists advises that hospitals and accredited
birth centers are the safest settings for birth and
discourages home births, but each patient has the
right to make a medically informed decision about
delivery.65
Although low-risk patients may be routine, staff-
ing ratios should reflect their increased needs during
visitor restrictions. For pain management, epidural
analgesia should be available and afforded those who
seek relief in labor,66 but nitrous oxide use is contro-
versial (Table 1). When community transmission is
high and rapid testing resources are available, obste-
tricians should consider universal infection testing in
the labor and delivery unit and early provision of
regional anesthesia in patients at increased risk of
requiring an urgent cesarean delivery. Lowered
thresholds for cesarean delivery may prevent emer-
gent transfers to the operating room, rushed donning
of personal protective equipment, and intubation dur-
ing viral pandemics.
Induction
Although medically indicated induction of labor must
be available as indicated, consideration should be
given to minimization of elective induction of labor in
a surge situation. Outpatient cervical ripening proto-
cols can be considered in the appropriately selected
patient.67
Complex Delivery
Teleconference consultations with the anesthesia and
subspecialty teams during pregnancy may permit
early multidisciplinary planning for deliveries antici-
pated to be complicated by maternal or obstetric
comorbidity. Complex surgical delivery includes
cesarean deliveries for patients with previous abdom-
inal surgery or transplant, significant leiomyomas, or
placenta accreta spectrum disorders. For these cases,
management may include planned delivery at the
earlier end of recommended gestational age to avoid
emergent deliveries. Predelivery viral testing is rec-
ommended to guide the use of personal protective
equipment. If infection status is unknown, consider-
ation may be given to preemptive general anesthesia
or full donning of personal protective equipment for
the safety of the entire operative team.
VOL. 136, NO. 2, AUGUST 2020
© 2020 by the American College of Obstetricians
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Ethics of Triage during Pandemics
Ethical concerns during pandemics revolve around
resource scarcity, including beds, ventilators, personal
protective equipment, and testing abilities. All cur-
rently available guidelines concur that, even during
a pandemic, patients with and without infection
should be treated equitably according to the same
criteria.68 Ethics guidelines invoke respect for the pa-
tient’s will, fair distribution, and maximization of ben-
efits based on chance of survival. For the coronavirus
disease 2019 (COVID-19) pandemic, ACOG pub-
lished interim guidance on ethical concerns, stating
that, whenever possible, institutions should create pro-
tocols for resource allocation that promote uniform
application of standards and minimize the burden of
ad hoc decisions.69
POSTPARTUM CARE
Postpartum considerations include both inpatient post-
delivery considerations and ongoing postdischarge
care. The American College of Obstetricians and
Gynecologists recommends that all patients should
ideally have contact with the health care team within
the first 3 weeks postpartum and a comprehensive
postpartum visit at no later than 12 weeks.70 Telehealth
visits should be encouraged. Recommendations for the
modified comprehensive postpartum visit can be found
in Appendix 2, available online at http://links.lww.
com/AOG/B937.
Postpartum Hemorrhage and Wound Monitoring
Postpartum hemorrhage remains a primary reason
that in-hospital birth reduces the risk of maternal
mortality. However, blood bank resources may be
strained by surges, highlighting the need for man-
agement considerations beyond transfusion. First
crucial measures include early identification of pa-
tients at risk for hemorrhage and implementation of
risk-mitigation strategies.71 Continuous reassessment
of hemorrhage risk affords preparatory options such
as increased intravenous access, in-room uterotonics,
active management of the third stage of labor, anes-
thesiology team awareness, and rapid progression
between management strategies. Use of tranexamic
acid (in patients without prothrombotic risks), bal-
loon compression, vascular embolization, and cell
salvage may reduce blood requirements. In refrac-
tory hemorrhage, team mobilization for early pro-
gression to hysterectomy is vital to maternal safety
and resource conservation.
Postdischarge, bleeding and wound assess-
ments can be performed using audio–visual tele-
medicine modalities. For patients with cesarean
Duzyj et al Practice Modification for Pandemics 243
delivery, many offices perform a 1-week postpar-
tum assessment of wound healing. It has been
shown for general surgery patients that telemedi-
cine saves time and is acceptable and effective in
identifying patients requiring further care. 72 Eval-
uation of the surgical wound by patient or partner
may be sufficient, with the option of image upload
using patient portals or app-based wound-monitor-
ing systems.73–76
Postpartum Care, Early Discharge, and Use of
Enhanced Recovery After Surgery Protocols
Immediate postpartum care should, as before the
pandemic, focus on the healthy transition of the
patient and newborn to postnatal life. In the absence
of comorbidities or active infection concerns,
rooming-in of the newborn may be helpful to decrease
hospital-acquired infections and improve breastfeed-
ing. For patients with active infections, shared deci-
sion making is recommended to discuss the risks and
benefits of rooming-in based on the regional epide-
miology of the pandemic, associated infectious risks to
the mother–newborn pair, potential benefits, and
patient desires.77–80
Safe early discharge has the potential to remove
the dyad from infectious exposure and to free hospital
resources during surges. Early discharge (36–48 hours
after delivery) is associated with higher maternal sat-
isfaction and increased hospital bed capacities. Dis-
charge at less than 24–30 hours is associated with
increased neonatal readmission.81,82 Therefore, tar-
geted discharge at 30–48 hours may be ideal once
necessary work-up is completed (eg, newborn screen-
ing) and appropriate follow-up is in place. Scheduled
home-based care allows for safe early discharge, en-
hances patients’ experiences and support, improves
time to pediatric follow-up, and supports breastfeed-
ing.83–85
Enhanced recovery after surgery bundles
include the use of multimodal analgesia to reduce
opioid exposure, avoidance of prolonged fasting,
encouragement of early mobility, and education of
patients regarding goals and expectations of sur-
gery. These protocols provide for shorter lengths of
stay, return to normal physiology, and mitigation of
surgery-related stressors, thereby improving out-
comes, satisfaction, and postpartum recovery. They
have been shown to reduce opioid use and improve
time to ambulation without worsening surgical out-
comes.86,87 In obstetrics, the decreased length of
stay for both obstetric and gynecologic services re-
duces patient and neonatal exposures and preserves
244 Duzyj et al Practice Modification for Pandemics
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
hospital resources.88 Critical to protocol success is
a system-based approach among surgical, nursing,
and anesthesia services.86
Contraception Access and Long-Acting
Reversable Contraception
Removing obstacles to timely postpartum contracep-
tion is key to preventing rapid recurrent pregnancy
and improving subsequent pregnancy outcomes.89–91
Postpartum contraception must therefore be part of
comprehensive planning after delivery, especially
when patients may be completing further care by
telehealth.
During pandemics, health systems may curtail
offering postpartum tubal ligation owing to per-
sonal protective equipment and operating room
resource shortage, labeling these elective sur-
gery.92,93 These restrictions compound existing
barriers to immediate postpartum tubal ligation. 94
Patients who do not receive desired postpartum
sterilization have high rates (46%) of recurrent
pregnancy in the first year after delivery and expe-
rience significant barriers to completing desired
surgery after discharge.95,96
Long-acting reversable contraception is an
alternative associated with patient satisfaction,
fewer unintended pregnancies, and improved preg-
nancy spacing. 96 Uptake of long-acting reversable
contraception is increased when prenatal educa-
tion and immediate postpartum placement are
available.97
Regardless of the type of contraception chosen,
physicians and midwives should work to remove
barriers to access as much as possible, especially because
follow-up is limited. Injectable medroxyprogesterone
acetate can be provided before discharge or by
“drive up” or “curb-side” administration after tele-
health consultation. Oral or other contraceptive pre-
scriptions, including barrier methods, can be filled
with delivery discharge medications with instructions
to start in 4–6 weeks.
Postpartum Depression and Postpartum
Mood Disorders
Postpartum depression and mood disorders are argu-
ably the most underdiagnosed pathology in the post-
partum period, with a prevalence of 13–16%.98,99
Undertreatment increases the likelihood of persistent
disease,100 which can be exacerbated by conflict,
stress, anxiety, and poor social networks associated
with pandemics. Patients with postpartum mood dis-
orders struggle with medical care compliance and
OBSTETRICS & GYNECOLOGY
have decreased success with breastfeeding and
reduced compliance with childhood vaccine sched-
ules (Yao H, Chen JH, Xu YF. Patients with mental
health disorders in the COVID-19 epidemic [letter].
Lancet Psychiatry 2020;7:e21.).
In pandemic-adjusted schedules, provision of
depression screening and referrals by telehealth is
critical. Experts note that perinatal mood disorders
are likely to increase in the setting of pandemics.101
Obstetricians should partner with pediatricians to
expand screening, because parental mood checks
can be incorporated into well-child checks.102
Assuring access to tele–mental health services is
key when in-person consultations are limited,
although data on effectiveness in postpartum
depression are limited.103 The medical effectiveness
and cost effectiveness for other types of depression
suggests potential application to this population.104
Text-based perinatal mood screening also has been
shown to have good patient compliance and satis-
faction in small studies.105
Preeclampsia and Hypertensive Disorders of
Pregnancy Postpartum Management
When patients with hypertensive disorders are dis-
charged, provision of written resources, counseling
regarding concerning signs and symptoms, and pro-
vision of equipment such as sphygmomanometers
should be arranged. The American College of Ob-
stetricians and Gynecologists recommends BP assess-
ment 3–10 days postdischarge; telemedicine review of
BP logs may suffice.106 Early studies using this tech-
nology have shown excellent patient compliance (80–
95%) with home-based monitoring and medication
adjustments, as well as patient satisfaction (higher than
80%).46,106,107
HEALTH CARE INEQUITIES
Health care inequities across racial, ethnic, and
other minority communities are well documented,
including in maternal morbidity and mortality.108,109
Systemic injustices faced by marginalized communi-
ties are coupled with concern that pandemics may
worsen disparities for African American individuals;
lesbian, gay, bisexual, transgender, queer+
(LGBTQ+) individuals; and women, particularly sin-
gle parents.110–113 Minorities are more likely to face
significant socioeconomic barriers, including lower
income job employment within the service industry
(such as food service, grocery stores, and transporta-
tion) with higher rates of direct public contact, risk for
infection, and job insecurity during pandemics or eco-
nomic downturns.114,115 Social determinants of health
VOL. 136, NO. 2, AUGUST 2020
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
and socioeconomic barriers, as well as the widely
documented systemic racial, cultural, ethnic, and gen-
der biases in medicine all contribute to disparate
outcomes.116
The proposed telemedicine alternatives rely on
patients’ ability to complete self-assessment at home
and to have access to technologies to communicate
with their health care teams. Those in minority groups
are less likely to be insured112 and therefore will not
have a medical “home” with access to telehealth tech-
nologies. More than 20% of Hispanic patients and
25% of African American patients report delaying
care owing to lack of physician access.112
Telemedicine and home-based care rely not only
on technology but also on in-home privacy and safety.
The same disparities that result in living structures
that reduce the ability to socially distance also may
result in inadequate privacy to complete home-based
care. Assurances of privacy and the ability to com-
municate safely and openly are key components of
quality telemedicine-based care and should be in
place before transitioning care.
Experts note that intimate partner violence (IPV)
increases during pandemics and emergencies.117–119
Patients experiencing IPV or childhood abuse no lon-
ger have the respite of work or school and may have
no or reduced ability to leave these situations. Many
shelters are closed or underresourced. Family courts
are closed, have reduced schedules, or are using elec-
tronic communication—all of which may be difficult to
access when in an abusive home situation. Therefore,
during office-based screening, IPV safety must be
assured, and patients at risk or known to be experi-
encing IPV may benefit from in-person visits for ade-
quate screening and timely referrals.
LGBTQ+ individuals are also at risk during alter-
ation of medical schedules. LGBTQ+ young adults
are more likely to be homeless or to be unable to
return from school or other housing to live with fam-
ily.120,121 For those who are not “out” at home, tele-
health visits may not provide the safety and privacy
needed to discuss medical issues or to receive neces-
sary care. Their living situation may also increase the
potential for abuse, and screening is of particular
importance for this vulnerable group.122 Transgender
patients are at additional risk for poor access, inter-
ruptions in hormonal therapy, financial instability,
and medical bias.123 These vulnerabilities may
increase risk of unintended pregnancy or reduce in-
teractions with the medical system for routine care.
Patients with disabilities also face significant
barriers to care, because they are likely to be older,
have less education, have lower household incomes,
Duzyj et al Practice Modification for Pandemics 245
identify as nonwhite, and live in poverty.114,124 These
patients often face the systemic biases and barriers
related to race and socioeconomic status, as well as
those related to their disabilities. Patients with disabil-
ities have become increasingly concerned that they
will be excluded from health care rationing plans
due to a belief that their lives hold less value.125
Increased access to telehealth may increase access
for some patients with disabilities, but that is not uni-
versally true because some disabilities may make
communication or use of these technologies a barrier
to care. Therefore, when adjusting schedules and
decreasing in-office visitation, care must be taken to
avoid inadvertently creating further barriers.
Review of social determinants of health, the home
structure, barriers to care, and assessment of safety in
the home must be part of routine care for all patients,
but especially for members of historically disadvan-
taged communities during a pandemic. In addition to
the typical social work and WIC referrals, many
regions have created websites cataloging available
resources for citizens with food, housing, or psychiat-
ric needs during emergent states, as well as the “211”
access number across the country to put patients in
contact with local resources.126–128 Because these eco-
nomic and social issues are likely to worsen during
pandemics, it is critical that teams become aware of
resources in their area and help direct patients to
appropriate services.
Before implementing telemedicine and altered
schedules of care, health care teams must ensure that
they are providing equal access and equity in testing
and care for all patients, understanding how barriers
to compliance such as technology access and inflex-
ible work arrangements may disproportionately affect
patients.
CONCLUSION
Pandemic-adjusted scheduling of obstetric care may
be necessary during community-mitigation efforts and
can apply to all segments of pregnancy care. Appen-
dix 3, available online at http://links.lww.com/AOG/
B937, summarizes the pandemic-adjusted suggestions
proposed in this review. Candidate selection, risk
stratification, and use of alternative surveillance
modalities are critical to ensuring patient safety when
applying modified algorithms. Thorough patient edu-
cation, evaluation of potential inequities and resource
limitations, and open lines of communication are inte-
gral to ensuring the success of remote patient care
during this paradigm shift.
Although the intention is that these suggested
modifications should be applied only during times of
246 Duzyj et al Practice Modification for Pandemics
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
urgent need and should revert to routine protocols
when restrictions are lifted, it is likely that some of
these changes may persist for extended periods during
pandemics. It is also likely that improved telemedi-
cine access and reimbursement are likely to be
persistent—as a result of both patient and system pres-
sures—and may be welcome additions to improving
access models for some communities and patient
groups. The exact risks and benefits of these adjusted
visitation and care schedules for pregnant patients,
their newborns, and health systems are unknown
and should be an area for active research. As further
data emerge, health systems will need to continuously
readdress and readjust these modifications to optimize
safety and quality outcomes for all pregnant patients.
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PEER REVIEW HISTORY
Received April 28, 2020. Received in revised form May 14, 2020.
Accepted May 20, 2020. Peer reviews and author correspondence
are available at http://links.lww.com/AOG/B938.
CME FOR THE CLINICAL EXPERT SERIES
Learning Objectives for “Practice Modification for Pandemics:
A Model for Surge Planning in Obstetrics”
After completing this learning experience, the involved learner
should be able to:
• Discuss proposed pandemic-adjusted modifications in obstetric care
• Outline risks and benefits based on available evidence
• List ways to avoid unintended adverse sequelae
• Be prepared to implement modifications in early-pregnancy, an-
tepartum, intrapartum, and postpartum care
Instructions for Obtaining AMA PRA Category 1 Credits
Continuing Medical Education credit is provided through joint
providership with The American College of Obstetricians
and Gynecologists.
Obstetrics & Gynecology includes CME-certified content that is de-
signed to meet the educational needs of its readers. This article is
certified for 2 AMA PRA Category 1 Credits. This activity is
available for credit through August 31, 2023.
Accreditation Statement
ACCME Accreditation
The American College of Obstetricians and Gynecologists is accredited
by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians.
AMA PRA Category 1 Credit(s)
The American College of Obstetricians and Gynecologists desig-
nates this journal-based CME activity for a maximum of 2
VOL. 136, NO. 2, AUGUST 2020
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
AMA PRA Category 1 Credits. Physicians should claim only the
credit commensurate with the extent of their participation in the
activity.
College Cognate Credit(s)
The American College of Obstetricians and Gynecologists desig-
nates this journal-based CME activity for a maximum of 2
Category 1 College Cognate Credits. The College has a reciprocity
agreement with the AMA that allows AMA PRA Category 1 Cred-
its to be equivalent to College Cognate Credits.
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In accordance with the College policy, all faculty and planning
committee members have signed a conflict of interest statement in
which they have disclosed any financial interests or other relation-
ships with industry relative to article topics. Such disclosures allow
the participant to evaluate better the objectivity of the information
presented in the articles.
How to Earn CME Credit
To earn CME credit, you must read the article in Obstetrics & Gyne-
cology and complete the quiz, answering at least 70 percent of the
questions correctly. For more information on this CME educational
offering, visit the Lippincott CMEConnection portal at https://cme.
lww.com/browse/sources/196 to register and to complete the CME
activity online. ACOG Fellows will receive 50% off by using cou-
pon code, ONG50.
Hardware/software requirements are a desktop or laptop
computer (Mac or PC) and an Internet browser. This activity is
available for credit through August 31, 2023. To receive proper
credits for this activity, each participant will need to make sure
that the information on their profile for the CME platform
(where this activity is located) is updated with 1) their date of
birth (month and day only) and 2) their ACOG ID. In addition,
participants should select that they are board-certified in
obstetrics and gynecology.
The privacy policies for the Obstetrics & Gynecology website and
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greenjournal.org and https://cme.lww.com/browse/sources/196,
respectively.
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queries related to the CME test online, please contact ceconnection@
wolterskluwer.com or 1-800-787-8985.
Duzyj et al Practice Modification for Pandemics 251