COVID-19 Pandemic—A Gynecologist’s Experience

ABSTRACT

The novel coronavirus with its ubiquitous impact has left no sphere untouched—be it environmental, social, economic, political, or personal. With the healthcare system being worst hit, medical fraternities worldwide have joined hands to prevent its further spread and get ahead of the disease. Whether it was providing emergency care or undertaking colossal research into this unusual disease, our doctors have proved their mettle in these testing times. Obstetrics and Gynecology is one specialty that caters to providing such essential emergency services. With the declaration of the pandemic by March 2020, our facility was converted into the largest dedicated public COVID center in Delhi and since then massive efforts have been undertaken to streamline the services to our patients both clinically and logistically. This heralded new principles and guidelines for patient management following the strict norms of physical and social distancing. Though the basic essence of care-providing was not compromised yet this transition was not smooth for both the patients and the doctors. Whereas on one hand, we were drained both physically and mentally, our patients also continued to suffer from the effects of isolation and also the disease per se. However, with rigorous training modules, evolving treatment practices, and numerous counseling sessions, we gained pace with our modern apprentice. One can only hope that in times to come, we succeed in surpassing this pandemic and go back to our original routine while having learned the lessons this pandemic taught us.

Keywords: COVID-19, Obstetrics and gynecology..

The COVID-19 pandemic has taken a significant toll on the healthcare machinery worldwide with India being no exception. Currently, India stands next only to the United States in the list of having the highest number of positive cases.¹ The present unprecedented times have called for dedicated efforts by all the frontliners and they have shouldered it equally well with utmost determination, hard work, and above all courage. From formulating management policies to physically executing them; from devising different strategies to contain the infection to spending long and exhaustive hours in the suffocating personal protective equipment (PPE) for patient care, the endeavors of our healthcare workers are undeterred.

Maternal and child health is not only the cornerstone of a nation’s health status but also a yardstick for its progress and development.² As humongous efforts are underway to clench the pace of the viral spread, we must also realize the quintessential need of providing essential obstetric services even in these tough times.

With the reporting of the first case of COVID-19, the preparations in terms of logistics manpower and infrastructure were commenced by mid-March and our facility was declared as a Dedicated COVID Hospital (DCH). The initial preparatory phase was an uphill task with the shutting down of routine facilities including both outpatient and surgical services, evacuation of non-COVID Obstetrics and Gynecology patients, and shifting them to other centers. Our COVID Gynecology block was prepared with standard donning and doffing facilities for the healthcare team, negative-pressure ventilation arrangements for patients, and demarcated green and red zones. Now only COVID-19 positive antenatal women and COVID-positive women with gynecological problems who needed hospitalization became the centers of our prime concern.

This transition phase was faced with a lot of trepidation as little was known about the disease and its etiology. Literature was limited in terms of the effect of the disease on pregnancy and the newborn. The initial dilemma regarding the safest mode of delivery, treatment protocols for pregnant women, and newborn care was a challenge but the task had to be done.

Fear and apprehension among healthcare workers, patients, and their attendants were in equal measures. Undoubtedly, there was a fear of getting infected or transmitting the infection to others or family members. Rigorous training sessions, staggered work timings, provision of adequate PPE, and facility for quarantine after exposure provided support and assurance to the workforce. Constant motivation from coworkers and seniors kept the morale of the team high.

As for the patient care the routine protocols could not be followed and had to be modified accordingly. In a specialty like Obstetrics and Gynecology where counseling and care of women in terms of routine antenatal care, contraceptive requirement, treatment of malignancies, and need for adjuvant therapy which requires regular visits to the hospital were to be managed differently. With the highly contagious nature of the disease, communication could not be made directly with the patient, the use of technology and the internet was a boon in these times. Expectant mothers required constant support and counseling, a constant fear of progression of the disease, transmission of the infection to the fetus and newborn, and psychological stress due to social distancing were to be addressed on time to time basis.

Safeguarding the mother and the unborn child from the COVID-19 infection was a tricky and challenging situation; as it required a coordinated effort among the obstetrician, anesthetist, physician, and pediatrician. The decision for termination of pregnancy and mode of delivery varied from case to case basis, weighing the risk vs benefit in a COVID-infected mother.

Conducting deliveries and performing cesarean sections which otherwise is a priced and well-practiced skill of an obstetrician, now seemed like a formidable task. Normal vaginal birth was no longer a cakewalk. It was a different experience altogether. With the entire body drenched in sweat, vision blurred from shield and goggles, and the everlasting sense of suffocation and dehydration in the PPE, COVID-19 did not just test our clinical abilities and patient management skills but also our physical strength and endurance. We felt estranged sometimes as to how our routine obstetric care had now been transformed into a mammoth task that required organizational expertise, prompt decision-making, logistical thinking, and pre-empting the hindrances over and above our clinical skills.

With each passing day, we also became more and more confident and experienced. Our gynecology team of doctors would sequentially get donned to assess the patient and her progress of labor. The entire process of labor is an unforgettable and cherishing experience for a mother to be and she requires constant moral support, motivation, and reassurance and doing so would also sometimes be mentally draining for us given the arduous situation. Sometimes, additional doctors had to be called in to stitch the episiotomy if the previous one was completely exhausted. The team of doctors, nursing, and other support staff worked in a coordinated manner to prevent exhaustion both physically and mentally.

Though we specialize in antenatal patient care but now the more significant job was of reassurance, which was needed not only by the patient but also by her family. They could not meet their patient; they could just talk to them over the phone or ask us about their queries and the well-being of their patient. Relentless counseling of both the patients who were staying in the hospital wards, away from their near and dear ones and of their attendants whose anxiety and apprehension was humanly understandable but at times difficult to allay, kept us all perturbed.

Another limitation we faced was that we could no longer use a stethoscope to hear the fetal heart sounds over the enormous PPE. How would it feel if you take from a gynecologist her most prized possession, her most trusted instrument “the stethoscope”? Exactly, we felt a little handicapped, a little robbed off. Nevertheless, Doppler and CTG machines were now our dependable options for hearing the baby’s heart sounds. However, with the best use of available equipment and our clinical acumen, antepartum fetal and maternal monitoring continued.

While we were still working our ways with normal deliveries, performing a cesarean section was the real challenge. With passing times, there was emerging data revealing peritoneal fluid having the maximum chances of exposure.³ This was scary not only for the obstetricians but also for the anesthetists, pediatricians, staff nurses, and the technical staff along with the newborn. Now, the decisions were weighed more carefully in light of the recent research. However, it never hampered our ultimate aim of delivering a healthy mother and a healthy baby and cesarean sections continued to be performed for crucial indications including fetal distress. So much so that cesarean section was the most commonly performed surgery in our COVID facility as per hospital records. It was not just the surgery per se, but the logistics involved right from the decision-making including availability of relatives, consent and prognostication, patient mobilization, synchronization among anesthetists, pediatricians and technical staff, coordinating patient’s entry into the operation theater, and all these following strict norms of social distancing and to finally making the incision, it was more like a drill that we all slowly learned. What followed next, we thought was a surgeon’s pleasure to be able to cut and knot, handling the scalpel and suture, an art that we had perfected over years of training, now in the hefty hazmat suit did not seem that facile. There was never this rate of consciousness while performing cesarean, as each additional second to achieve hemostasis made it difficult to breathe. We perspired limitlessly under the lights of the operation table, vision impeded from the sweat and expired air, tactile stimulation hampered under the innumerable layers of the gloves and gowns. The alive, crying, and a healthy baby was the fuel driving us through the entire operation. The closure was followed by a long sigh of relief. The doffing process was as though a battle was over. There was unity and absolute team coordination with minimum wastage of time. The doctor was a true savior, and the staff involved had no less role to play.

Postpartum rooming-in and breastfeeding was a decision left to the patient but most patients did not support rooming-in. Even after negative testing, patients were advised to breastfeed after appropriate handwashing and using a facemask during feeding.⁴ With the increasing cases of moderate to severe COVID disease critical care in terms of oxygen therapy,⁵ use of supportive therapies in COVID became a routine.

As a doctor, one ought to perform his/her duties diligently. Using our knowledge and skill to save lives, to help them recover was the best thing we could do, with a challenge to keep ourselves and our family safe simultaneously.

The COVID-19 pandemic has had a gigantic impact on the mental and psychological health of the doctors.⁶ We have embarked upon a new journey of providing obstetric and gynecological care during the COVID pandemic, which indeed is very different from the routine obstetric and gynecological. With hope in our hearts and a wish in our minds, we are positive that this pandemic shall end soon and we can successfully deliver our services for the greater good of our patients.