Where is the F in MCH? The Role of Fathers in Pregnancy and Birth (Blair, 10/14/2020)

Many thanks to Dr. Jason Blair, chief resident and father of three (one recently arrived), who gave a thought-provoking Grand Rounds presentation this week on the Role of Fathers in Pregnancy, Birth, and Infancy. 

Dr. Blair made a compelling argument for a link between high neonatal mortality rates in the US and our inclusion (or lack thereof) of fathers in the pregnancy and birthing process. We know that 50% of births in the US are to mothers on Medicaid; these mothers and babies have worse outcomes than women with private insurance (higher mortality, lower birth weight, higher preemie rates and less breastfeeding) and are also statistically more likely to be unwed and get less support at the time of birth and at home.

Dr. Blair also highlighted the effects of paternal participation on maternal breastfeeding rates, peripartum depression rates, and the general health and well being of families. And what about father in the role of continuous birth attendant (aka doula), which we know has strong evidence in reducing surgical birth, length of labor, and birth complications?

The US literature on the topic of fathers in birth is (perhaps not unsurprisingly) sparse, Dr. Blair cautioned, with much of the literature on the role of fathers in birth coming from Europe, where maternity and paternity leaves as well as other policy tends to be more robust.

Here are some highlights and some of my own suggestions in italics below each category.

Navigating fatherhood starts in the prenatal period

• What it means to be a good father extends beyond financial responsibilities to include a hands on role with baby and providing emotional support to their partner. This new role begins long before a baby is born.
• In a study from Iran and Afghanistan, when fathers were engaged in prenatal care, had a positive association between quality of a mother's participation in prenatal care and gestational age at birth, as well as maternal satisfaction.
• In a study from England, greater paternal engagement with associated with earlier access to care, increased number of antenatal checks, attending birthing and parenting classes, and breastfeeding Mothers were also more likely to report feeling very well or quite well at post partum visit
• Many fathers want to be more involved but often feel ignored by healthcare providers and unclear what their role should be. Do you actively engage dads in prenatal visits, birth, and post partum?

While, in theory, we welcome fathers into exam and labor rooms rooms, we all could do a better job of actively including them in the prenatal visits and helping them understand how they can help their partner and new baby.

• Engage father as a crucial member of the process (beyond making sure he received a Flu shot and Tdap, consider including how is his mental and physical health? how may he prepare for the birth of his child?
• Help clarify roles, outline potential tasks dad could participate in in the antepartum and post partum period (e.g. birth classes, sharing night feedings, supporting breastfeeding, etc.)

Paternal health and well-being can have a negative impact on mothers and children.

• A male partner's biological characteristics, work, and non work exposures, and substance abuse have adverse impacts on pregnancy outcomes (e.g. low birth weight, neural tube defects, PTL)
• Intimate partner violence against pregnant women leads to poor birth outcomes
• High prevalence of perinatal depression and anxiety (5-20%) in men is associated with increased struggles for the entire family.
• Verify if father has access to primary care. If he doesn't, offer it to him.

Fathers may understand their negative experiences in the ante and postpartum period as "stress" rather than as depression

• Pregnancy and a new infant can put tremendous strain on fathers in addition to relationships/couples
• Consider inquiring specifically about a father's or family's stress level rather than of depression (or mental health)
• Children with depressed fathers in the peripartum period higher risk of childhood behavior problems 
• Consider screening fathers for perinatal anxiety and depression when you are screening mothers

Fathers taking paternity leave is strongly associated with improved maternal well being at 3 months post partum

• Well, that's not a surprise now, is it?
• California has decent paternity leave; Do you inform you fathers of their rights? Do you encourage them to use it? Do you help them advocate with their employer to take the leave?

Benefit of fathers in support role for mothers

•  Many fathers recognize that the center of focus SHOULD be mother and baby; however helping fathers show up help mothers and babies in birth and beyond
• Labor attendants reduce maternal anxiety and catecholamine levels, minimizing dysfunctional uterine activity and leading to improved birth outcomes 
• A child's father (and a woman's partner) is uniquely able to provide ideal support throughout the pregnancy, during labor and beyond
• Help fathers be the best labor support they can be: this can be by using a professional doula OR by having him participate in reading/classes that help him learn how to support a woman in labor

COVID-19 in Pregnancy (Mason, 8/18/2020)

Many thanks to Dr. Antoinette Mason for her excellent review of the emerging literature on COVID-19 in Pregnancy. As Dr. Mason explained at the start of her presentation, much of the information regarding COVID in pregnancy is based on observational data with recommendations that are expert opinion at best. But as we continue to increase our understanding of this disease, we are gaining a better understanding of its impact on pregnant women and infants. I consider Dr. Mason one of our local experts-- herself having cared for several of our first OB patients with COVID locally this past month. With that, I will do my best to summarize Dr. Mason's key learning points.

Epidemiology

• In the US to date, there have been 16,798 documented cases of COVID-19 in pregnancy, 4,262 hospitalizations, and 37 deaths
• As is true across our country, OB patients of color are disproportionately affected by COVID (Reference: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/special-populations/pregnancy-data-on-covid-19.html)
• Here at SSRRH, we have had 9 total OB patients with COVID ( some only triaged, others admitted). In these patients:
• Gestational age ranged from 22-39 weeks
• 5 have delivered (2 returned later with PROM)
• 2 were picked up by admission screening (asymptomatic)

Is pregnancy a risk factor for COVID-19? Answer: We don't really know. 

The incidence of COVID-19 in pregnancy is similar to that of the general population. Several studies suggest that pregnancy and childbirth do not increase the risk of acquiring COVID-19. There is mixed data on whether or not pregnancy worsens the course of the disease. An MMWR from the CDC June 2020 showed the following: pregnant women were 5.4 times more likely to be hospitalized, 1.5 times more likely to be admitted to the ICU, 1.7 times more likely to receive mechanical ventilation, but no increased risk of death. (Reference: https://www.cdc.gov/mmwr/volumes/69/wr/mm6925a1.htm). Some of these stats are likely impacted by providers being more likely to admit and act more conservatively with sick pregnant women, but it is hard to see that in this data.

What is the clinical presentation of COVID-19 in pregnancy? Answer: The same as the general population

1/3-1/2 of OB patients with COVID-19 are asymptomatic

How to assess severity of disease in pregnant women? Answer: Oxygen saturation, consideration of comorbidities and close follow-up are key

• Oxygen saturation should be >95% on RA for pregnant women. This is a different standard than for non pregnant COVID patients (>92%). Also consider tachypnea (RR>30bpm).  
• Outpatient management is appropriate for pregnant women with COVID-19 with mild symptoms, but women should be monitored  (at least once within 1-2 weeks of diagnosis)
• should have home pulse oximeter if possible
• should have easy access to care if needed
• antenatal testing should be done as per standard recommendations
• Inpatient management: pregnant patients with moderate or severe disease (O2 sat <95% on room air, refractory T>39 despite antipyretics) and/or significant comorbidity (e.g. DM, CKD, immunosuppresion) should be managed in the hospital
• See diagrams below from ACOG and SMFM. Top diagram is indications for testing, bottom diagram is for triage in known COVID disease.

What are the maternal and fetal outcomes in COVID-19?    Answer: we don't really know.

From case reports, observational studies, and some reviews, there is concern that COVID may be associated with an increase in preterm birth, PPROM, cesarean delivery, and stillbirths. We do know that severe viral illnesses (e.g. influenza) have been associated with these outcomes.

One systematic review found aere possible increase in preterm delivery, including spontaneously and medically indicated preterm birth and c-section in pregnant women with confirmed COVID-19 infections. (Reference: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30190-5/fulltext). A UK study looking at outcomes pre and post pandemic preterm found a higher rates of still births-- the authors speculated that outcomes had more to do with access to care and comorbidities directly related to the virus rather than the virus itself.

Is there vertical transmission of COVID-19? Answer: Probably not.

While there is a theoretical risk of vertical transmission, most studies with significant number of cases have demonstrated no evidence of vertical transmission: looking at placenta, cord blood, amniotic fluid, and NP samples. There are a couple of case reports that call question to this, but the data is very limited. In addition, we have little to no data on the effect of COVID-19 infection on the first and second trimesters of pregnancy.

What is appropriate management of COVID-19 pregnant patients? Answer: Treatment for COVID-19 in pregnant women mirrors treatment of COVID-19 in non-pregnant women with slight modifications

• Remdesivir is considered safe in pregnancy (no known fetal toxicity, recommended by SMFM when indicated)
• Convalescent plasma is considered safe (currently under investigation for benefit)
• Steroids if indicated (NIH recommends for "patients needing oxygen")
• SMFM says maternal mortality benefit likely outweighs risk to fetus.
• Can do dexamethasone 10mg IV/PO as per the RECOVERY trial OR
• Some expert opinion recommending methylprednisolone  (see paper for details)(Reference: https://journals.lww.com/greenjournal/Abstract/9000/Corticosteroids_in_the_Management_of_Pregnant.97288.aspx)
• COVID-19 infection is NOT an indication for delivery;  mechanical ventilation is NOT an indication for delivery
• For severe disease, risks/benefits should be weighed
• Caution with magnesium sulfate because can increase risks of respiratory compromise (weigh risks/benefits depending on comorbidities)
• Most standard obstetrical management is safe: internal monitors, amniotomy, forceps/vacuum
• Might consider early epidural if symptomatic patient to mitigate risks of gen anesthesia for emergent c-section
• Nitrous oxide: not recommended for PUI/COVID+ patients (because of risk of aerosolization) but nitrous is okay to use in women who test COVID negative.

Does COVID-19 in combination with pregnancy increase risk of VTE? Answer: Yes, probably.

While there are only a few case reports of VTE in COVID in pregnancy, both COVID and pregnancy are hypercoagulable states and separately increase risk of VTE. Thus current recommendations for VTE prophylaxis: 

• All pregnant women admitted with COVID-19 should receive enoxaparin unless delivery is anticipated in <12 hours. 
• Also all hospitalized pregnant women should be 10 days of VTE prophylaxis after hospital discharge.

How should COVID-19 couplets be managed postpartum? 

• Moms with COVID-19 are prone to hypervolemia (keep strict Ins/Outs, watch respiratory status)
• Infants of COVID moms should be bathed after birth
• Breastfeeding should be encouraged!! 
• Separation of mother and infant is NOT recommended (likelihood of testing positive is the same if separated or kept together, if precautions maintained)
• infant should be tested once at 24 hours of life (no retest indicated)
• mom should use mask/hand hygiene
• baby should be in isolette when not breastfeeding

What about mental health in COVID in pregnancy? Answer: Ah, so much to say. . .

• Social isolation is associated with increased risk of depression and anxiety. Screen and ask!
• PTSD  has been recognized for those who are isolated/quarantined--> be sure to check in with new moms about the impact this may have on their postpartum period