 We'd love to introduce to our speaker today, Rebecca Dekker, who's going to be talking to us about evidence-based care during the COVID-19 pandemic. During these uncertain times, it can be helpful to focus on the facts and evidence-based information, and in this session, Dr. Rebecca Dekker will be talking to us about the latest research evidence on COVID-19 and pregnancy, as well as the implications of this research for families who are due to give birth during the pandemic. By the end of this session, you will be able to discuss the available research on COVID-19 and pregnancy, as well as the guidelines from professional groups from around the world, and the human rights of laboring families during a pandemic. So thank you so much for joining us, Rebecca, and I'm going to be handing over the... status that you use so that you can take over and start your presentation. Thank you, everyone, and happy International Day of the Midwife. All the midwives out there, as well as the students who will become midwives. My name is Rebecca Dekker, and I'm a nurse with my PhD. I live in Kentucky, USA, and I started evidence-basedbirth.com about eight years ago after the birth of my second child when I discovered the difference between routine care without the use of evidence and evidence-based care. So I had evidence-based care in that second birth with a midwife, and it was so empowering that I thought I wanted to share the research I'd been collecting with other people. So today I'm going to talk about evidence on COVID-19 and pregnancy, and I'll also reserve some time at the end for Q&A. So the research on this is changing quickly. So I made this presentation a week ago. We already have some new evidence, which I'll be able to talk about verbally that are not in the slides. I see some familiar names in the chat box, so welcome to those of you who I know. And if I've never met some of you I'm not familiar with, it's nice to meet you as well. I think even my dad is supposed to be watching today, so I'm excited. So I wanted to hear in the chat box, how are you, your clients or friends or family being impacted by the COVID-19 pandemic? So answer that question first. I know it really depends on where you're located in the world. The map of where the hotspots are is changing and shifting, and some geographic areas are more affected than others. Some geographic areas are on the verge of being able to stop the spread and others, the spread is growing. What is happening with your clients in particular? What's happening in relation to childbirth? I know a lot of people, though, also feel uncertainty in their own personal lives as well. So some people are struggling with difficulty with childcare or having to work while also taking care of their children. Students are losing their clinical placements, doulas can't go with their clients. Some third-year midwives are being asked to work. Let's see. Social life is reduced. There's a lot of isolation. A lot of people are stressed. Women are stressed about having to wear masks. And I know that there's a lot of disadvantaged, marginalized people who are pregnant who are in lockdown and have limited access to food, to healthcare. Some people are really busy. As a case investigator, contact tracer, partner is not allowed for an induction, not being able to observe extra births. People are stressed due to loss of income. No visitors for women outside of labor. So if you have a long hospital stay, such as a long prenatal stay or postpartum stay, that's difficult. So also, what has changed in the last month near you? So many parts of the world started really feeling the effects of the pandemic in March and then it really ramped up in April. And now in the beginning, it felt like things were changing daily in terms of policy changes and practice changes. Now, where I live, it seems to be a little bit more stabilized. There's a little bit more, you know, you kind of know what to expect if you're going into the hospital. Whereas in the beginning, it seemed like there was a lot of uncertainty and parents who had to give birth right at the beginning of the increase of the curve were really panicking. It looks like PPE requirements change daily. So NICU or Special Care Nursery changes are happening. Alice, as I go into work at each time, there's something new. So we'll talk a little bit more about some of the changes that have been happening in the last month. Yeah, I think the masks issue was something that for many places outside of Asia began changing because obviously there are some parts of the world that had already adopted wearing masks. And then other parts of the world are just starting to get on board with mask wearing and the benefits of mask. Trying to smile with your eyes behind your mask. Exactly, that can be difficult. OK, so just a quick disclaimer. Watching this webinar is not a patient care provider relationship. If you're a patient, this is not medical advice. Also, because this is an emerging topic, research and guidelines may change and may have already changed by the time I put this presentation together over the past few days. So these are the things that we're going to cover the latest research on COVID-19 and pregnancy. We're talking about where to access and some of the recent practice guidelines as well as implications for childbirth. Also, talk briefly about human rights when we get to the Q&A section. So the latest research on COVID-19 and pregnancy, I wanted to start with a little bit of background. So we all have the similar terminology. The virus is called severe acute respiratory syndrome coronavirus 2 abbreviated SARS-CoV-2. And the infectious disease caused by SARS-CoV-2 is called coronavirus disease 2019 abbreviated COVID-19. So what do we know about COVID-19? It's actually the seventh coronavirus known to infect humans. There are four human coronaviruses that cause the common cold and three human coronaviruses that cause more severe illness. There's MERS and SARS. And now we have SARS-CoV-2 that causes COVID-19. This is one reason why testing is so difficult. And there's difficulties with test results because some tests are not that good at distinguishing between the different coronaviruses. So the virus mainly spreads person to person. It can be acquired through the air from respiratory secretions and from VCs and from contaminated objects. In one article published in the New England Journal of Medicine, they found that it was detectable in aerosols for up to three hours. Up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel. So it's possible that people may acquire the virus both through the air and through touching contaminated objects. Although some clinicians think that it's primarily passed through the air. So the global situation on April 27 a week ago when I was putting this talk together, the number of confirmed cases had just exceeded 3 million. Today it's 3.6 million confirmed cases. Now, if you look back in time on March 20, the world had just exceeded 200,000 cases. It took about three months for the virus to infect 1 million people and only two weeks after that for the number to double. So one great resource that anybody can use is the map at the Johns Hopkins University and I'll put that in here. This was a screenshot from a week ago and the map, if you click on that link today, click on it later or I don't know if you want to navigate away from this. But it will show you the map around the world and where the cases are. The country with the highest number of confirmed cases is the US with about 1.18 million cases. Followed behind that is Spain at 218,000 cases and then everybody else is less than that. Italy, United Kingdom, France, Germany, Russia, Turkey, Brazil, Iran and China round out the countries with the top number of cases. But close behind them are Canada, Belgium, Peru, India, the Netherlands, Ecuador, Saudi Arabia, Switzerland and Portugal and it keeps going. And so obviously this is a global pandemic. If you look at the map, there's really no place that's not affected. So we are still in the very early stages of research with SARS-CoV-2 because it's a brand new virus. So data on maternal and perinatal outcomes of people who are infected with SARS-CoV-2 in pregnancy is limited to a small number of case reports in series. So we have expert opinion. We have some case reports, but there's not enough research to draw clear conclusions about the course of this disease in pregnancy. We also don't have any research on the effectiveness of any therapy to treat COVID-19 in pregnancy. We also don't have a lot of research on birth outcomes, although we're starting to get some. So moving forward, it's going to be really important for clinicians to participate in pregnancy registries. This will give us better evidence or research as analysis of the data are published. So there may be, there's probably more than this, but these are four that I know of. The priority study in the US, the United Kingdom is asking people to report to the UK obstetric surveillance system. And there's also an international registry called COVID-PREG that's led by researchers from Switzerland. And then IRCEP is the International Registry of Coronavirus Exposure and Pregnancy. That's another registry led by an international group of investigators. Are pregnant people at greater risk? It's important to know that both MERS and SARS had higher rates of pregnant people catching the disease as well as suffering severe illness. In fact, with SARS and MERS, there were very high mortality rates. So there was some concern with COVID-19 that there would also be extremely high mortality rates with pregnancy. But so far, there's no evidence that if you're pregnant, that that alone puts you at greater risk of infection or severe illness. Pregnancy is a physiologic state that does predispose people to respiratory complications when they get a virus. But so far, there's no evidence that you're more susceptible to infection or that you're going to get more severe infection with COVID-19. So that is encouraging. However, those data are preliminary and we do not know for certain if that is true or not. There is evidence for more severe illness from other coronaviruses and from influenza when you're pregnant. Some guidance, for example, the Royal College of Obstetricians and Gynecologists from the United Kingdom or ARCOG, they count people who are pregnant among higher risk groups for COVID-19. And that's purely as a precautionary measure because right now there's not evidence showing that you're more likely to get the disease or more likely to get severe illness. We do have a recent systematic review. A lot of the systematic reviews that have been coming out, you may have seen them published. They basically have very similar results because they're all looking at the same case reports. So this was one that came out two weeks ago. Researchers were looking at the outcomes of 116 people who are pregnant with COVID-19 pneumonia. These all took place in Hubei province in China between January and March. Now, almost all of these people were hospitalized for COVID-19, so these findings do not apply to people who are asymptomatic or have mild illness. We found that the most common symptoms were fever and cough, but 23% had no symptoms when they were diagnosed. Also, it's important to note that not everybody had a cough, so only half of the people had a cough. Sorry, only half the people had a fever and only 28% had a cough. 7% developed severe pneumonia requiring ICU, which is a rate that is similar to the reported rate of severe disease in non-pregnant adults. Eight women were infected before they were 24 weeks. One had an early miscarriage, and the other seven pregnancies were still ongoing at the time of this report. So one of the problems is we don't have data on the effects of having an infection in the first or second trimester because many of those babies have not been born yet. So we won't know for a while still if there is some kind of effect on the fetus or the baby after an maternal infection, earlier in pregnancy. However, all of the seven women who were still had an ongoing pregnancy did not have any abnormal fetal anatomy on growth scans. 21 of the 99 patients who had given birth in the study had a preterm birth for a preterm birth rate of 21%, including six who had spontaneous rupture of membranes between 34 and 37 weeks. I have also heard reports from the Detroit, Michigan area of the U.S., which is one hotspot, where hospital staff have informed me that they seem to be seeing a higher preterm birth rate among people who are pregnant and have COVID-19. The caesarean rates were 86%. The reasons given for the caesareans were COVID-19 pneumonia, prior caesarean, fetal distress, and failure to progress. One thing to keep in mind with the preterm births is that some of those were caesareans, so they weren't necessarily spontaneous preterm labor, but some of them were, they decided to deliver the baby early because of the mother's condition. In this particular study, there were no stillbirths. There was one newborn death at 35 weeks gestation. The baby died within two hours of birth. The mother had severe pneumonia and septic shock requiring invasive ventilation and gave birth by caesarean at 35 weeks. Nearly half of the babies of these mothers were transferred to the NICU, and there was no evidence of parent baby transmission in the study. A lot of people are worried about parent to baby transition, but the evidence is inconclusive. So there is research that it may be possible to have vertical transmission during pregnancy or birth. There was one study where three babies were reported to have IgM antibodies in their blood after birth. However, because IgM does not typically cross the placenta, the researchers think this represents an immune response to in-utero infection. On the other hand, amniotic fluid, cord blood, newborn throat swabs, placenta swabs, genital fluid, and breast milk samples from COVID-19 infected mothers and their babies have so far all tested negative. Researchers are continuing to look at the possibility of vertical transmission. There is a report of one baby who tested positive 36 hours after birth. Whenever you have testing tests that are positive, you know, maybe three days after the birth, that can be difficult to say whether that happened during the birth or it's also equally as likely that the baby contracted COVID-19 from an infected healthcare worker. So that's the problem with trying to figure out if there's vertical transmission or not is where was the exposure? Was it during pregnancy or the birth or was it from the hospital environment after the baby was born? So the earliest report of a newborn testing positive was a case report on April 18, a 41-year-old pregnant woman in Peru. She had diabetes, a high body mass index, and two prior caesareans. The newborn had a positive test 16 hours of birth, so it would be less likely to be healthcare contracted from the healthcare institution. Baby had respiratory failure requiring mechanical ventilation on day five of symptom onset. The baby tested positive despite the fact that they did a sterile, you know, preterm caesarean in immediate isolation from the mother. The newborn required ventilator support for 12 hours and fully recovered. They believed that this was a major finding, that there was a positive test of the newborn as soon as 16 hours after birth. And they really don't think it was related to the caesarean because of the sterility of the procedure and that the baby was immediately isolated from its mother. So this strongly raised the suspicion that it is possible to have in utero transmission of SARS-CoV-2. They did repeat the baby's test 48 hours later and it was still positive, so it was a true positive. And they did not look, they did not test for the presence of the virus and amniotic fluid, cord blood or placental tissue, so we did not have data on that. So some other evidence that's important to talk about is the asymptomatic or more likely pre-symptomatic carriers. There's increasing evidence that infected people without symptoms, pre-symptomatic and asymptomatic can spread the SARS-CoV-2. Most of these people are more likely to be pre-symptomatic. It's not as common to be completely asymptomatic. This has led to some areas of the world implementing universal screening on admission for labor and birth. The small study in New York City, this is New York Presbyterian Hospital in Columbia University Medical Center, they started testing everyone on admission to labor and delivery. And they found that nearly nine in 10 pregnant people with COVID-19 had no symptoms when they were first admitted to the hospital to give birth. The researchers screened all 215 people admitted to the two hospitals over the time span of March 22 to April 4. Four women were symptomatic on admission and all four of them were positive, but overall 29 were positive, 14% of all of the people who came into labor and delivery. And again, only four of the 29 had symptoms, so 25 of them were asymptomatic. The authors say this study has limited generalizability. If you live in a geographic region with a lower rate of infection, these results may not apply to you. Remember, New York City is the epicenter of the pandemic in the United States, so you would expect to have a high level of infection in the population. They took these results to say that we should have universal screening on admission. And they say the benefits would be that you could use the status to guide clinical decision making, including where they're assigned, like their bed assignment, and newborn care, and what PPE or personal protective equipment the staff wear. Unfortunately, universal screening on admission is not going to be perfect. We know that there are high rates of false negatives. There can also be false positives with sample contamination from the healthcare setting. So that is something we could talk more about in the Q&A if you want to go into more detail about those rates. So practice guidelines. I want to talk a little bit about a few of the practice guidelines. These are subject to change and sometimes they change very quickly. I want to focus on the RCOG guidelines because they are continually updated. And after the table of contents, they summarize the updates to each version. So you know exactly what their updates are each time. RCOG states that we should reduce labor inductions that are not medically necessary, increase the use of outpatient inductions, reduce the use of routine growth scans that are not for guidance-based indications, increase efforts to help pregnant people quit smoking because smoking is very likely to be associated with more severe disease in COVID-19, and ask about mental health at every contact with a pregnant person. Specifically regarding childbirth during the pandemic, RCOG states that birthing people should be permitted and encouraged to have a birth partner present with them during their labor in birth. They say the birth partner must not have had any symptoms, which could suggest COVID-19 in the preceding seven days. It's important to explain the need to protect maternity staff and other families from the risk of infection. The symptoms that they suggest asking about are fever, acute persistent cough, hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing or sneezing. RCOG also suggests that if you have suspected or confirmed COVID-19 infection, so this is not everyone's, it's just people who are suspected or confirmed, that you're encouraged to remain at home for early labor, which is already standard practice, to use private transport and notify staff before entering the hospital. The PPE precautions should be used for staff. The mother should wear a surgical mask. Asymptomatic birth partners can attend. They should be asked to wash their hands frequently. If the partner is symptomatic, they should remain at home in self-isolation and not attend the unit. And women should identify in advance, preferably an alternative birth partner should their birth, their partner have symptoms. They should be put in an isolation room with essential staff only. And they recommend continuous electronic fetal monitoring in the obstetric unit. The mode of birth and planned induction should be individualized. So whether or not you're induced, whether or not you have a caesarean should be based on your individual circumstances. Simply having a diagnosis of COVID-19 does not mean that you must have a caesarean or an induction. We recommend that people who have suspected or confirmed COVID-19 avoid birthing pools due to the risk of infection via feces. Epidurals are okay. And arcox is the antinox, which is nitrous gas and air is okay because there's no evidence it's an aerosol-generating procedure. And they recommend delayed cord clamping. You may notice that these guidelines differ from some from other countries. For example, obstetrical groups in the United States are saying nobody should have nitrous because they think it's aerosol-generating where as arcox says it's not. So there seems to be some clinical disagreement there. Arcox recommends keeping mothers and babies together after birth. Even if you have COVID-19, if it's suspected or confirmed unless there's some reason where you're not able to because of severe illness, they say they suggest considering ask someone who's well to feed the baby, wash hands before touching the baby breast pump or bottles, avoid coughing or sneezing on the baby while feeding, consider wearing a surgical mask while feeding or caring for the baby. Where people are expressing breast milk, you should have a dedicated breast pump. And families should be provided with guidance on how to identify signs of illness in their newborn. Families should also self-isolate at home for 14 days after birth and use infection control when caring for the baby. The CDC guidelines in the United States caused a lot of drama here because from February until April 4, they recommended immediately isolating and separating mothers from their babies if the mother had COVID-19. On April 4, they made revisions to their guidelines and they shifted toward a more neutral stance on mother-baby separation and they draw attention to the need for shared decision-making. In this update, they said the many benefits of mother-infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels and maintaining infant body temperature. And the transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern. The risk of transmission and the clinical severity of SARS-CoV-2 infection and infants are not clear. So what are some implications for families who may be giving birth during the pandemic? I'm not sure what they're doing in your area, but in the United States, where I live, many practices are spacing out visits for low-risk clients, asking people to wait in their car instead of their waiting room if they have a car. And there's an increased use of telehealth visits using a blood pressure cuff scale and sometimes even providing a Doppler to the patient and then doing that over the phone or over video chat. This has caused a lot of anxiety among a lot of people who are worried that they're not getting adequate prenatal care. RCOG has some good guidelines on prenatal care during the pandemic and what it should look like and which visits should be in person. So you can visit the RCOG guidelines for that. There was a report of a maternal death in New York City from a mother who had a high-risk pregnancy and for six weeks was not seen in person even though she had a low platelet count at the beginning of that six-week period. She ended up finally going to the hospital with help syndrome and dying after she was not seen for six weeks in person. Universal screening on hospital admission. The evidence on screening comes from those two New York hospitals already talked about. So we are seeing an increase in that in the United States. I would love to hear if that is something that is available or encouraged. I know some countries still do not have access to enough testing to do this, but are they universally screening people in your community to determine their status? Some hospitals are even screening every 24 hours after admission and some hospitals are even beginning to screen partners as well. Okay, some are screening partners. We're using screening questions but not the rapid test and that is a problem is some facilities have a rapid test and others do not. So for some people it could take eight to 12 hours before you get the results back. Some hospitals in the U.S. that do not have rapid testing have a policy that anybody with uncertain test results is separated from their baby. I have heard that some major hospital systems immediately separate mothers from their babies until the test results come back negative. This is a problem for people who come in with precipitous birth and give birth very quickly where there's not time to wait for the test results. This is where it's really important to know exactly what's going on in your community so that you can help families advocate for themselves and so they can be prepared for what is happening although as we all know it can change. Some of you mentioned in our earlier chat wearing a mask during clinical encounters some obstetric guidelines are suggesting that masks should now be worn by everyone in labor and delivery units and many outpatient settings regardless of whether you have symptoms or have the virus. This is intended to protect patients from healthcare workers who may unknowingly carry the virus and to protect healthcare workers from the patients in case the patients are unknowingly carrying the virus. I'll give you an example my sister is a doctor in a family practice so she does family medicine and she wears a mask all day long in the clinic with every patient that she sees mostly to protect the patients from her because she's seeing so many people she could get infected so and although she's not seeing as many as usual her primary reason for wearing the mask is to protect the patients and then patients should be wearing masks to protect the healthcare workers so it's kind of like a I protect you you protect me kind of thing however this can be difficult for people in labor to keep a mask on the whole time especially if you're not used to it especially if you're in the second stage. Some guidelines suggest that staff should be wearing in 95 respirators during the second stage because of the close contact with the person and the shouting and breathing and vomiting and that sort of thing that's happening during the second stage of labor however if there are shortages staff are not wearing in 95 respirators in the second stage and when I talk about wearing a respirator that's for some guidelines are suggesting that you wear that with anybody in the second stage of course if there are shortages of equipment then that's not a possibility and yeah surgical masks for healthcare workers somebody asked whether or not doulas are permitted in the hospital varies from hospital to hospital and policies may change with no notice many people near me are choosing to labor at home as long as possible with their doula however the only works with the spontaneous labor in the United States we typically don't have outpatient inductions that's not an option so typically about 40 percent of laborers in the United States are induced so if you if you have an induction it doesn't necessarily work to labor at home with your doula. Some hospitals with areas of low infection low infection rates are still permitting doulas and many doulas have had to switch to virtual support also a lot of people are switching to a home birth is that something that you're seeing in your area go ahead and put in the chat box if you're seeing a higher rate of clients switching to home birth it's happening everywhere as you can imagine these hospital policies are very stressful for parents to even consider having to birth in these circumstances so a lot of people are saying yes although sometimes they're not able to and then Alice's lower rate is cancelled all home births I saw that some provinces in Canada and other places have cancelled home births I'm curious if anybody also has that problem I know someone in the Philippines who was able to switch to a freestanding birth center although that was difficult because of the many lockdowns and difficulty traveling from one place to another it's difficult to access a freestanding birth center and it's also difficult to get a home birth midwife to come to you if there are roadblocks in some countries a lot of and I see Vicky Penwell is here Vicky came on the evidence-based Perth podcast a few weeks ago and I thought it was really fascinating how she talked about that people are beginning to question long-held assumptions that the hospital is the safest place to go and the pandemic is is making them question these long-held cultural assumptions I also see changes with inductions um some providers are discouraging or refusing inductions for non-medical reasons and hospitals are seeing lots of spontaneous labor other hospitals and providers are pressuring families into inductions at 39 weeks they're even earlier I would say in the in North America I've seen it about half and half so about half of the hospitals I'm aware of are refusing elective inductions and about half of them are trying to get everybody delivered by 39 weeks some families are reporting intense psychological pressure to undergo non-medically indicated inductions other families are requesting inductions and being refused so go ahead put in the chat box if you've seen an increase in um inductions or decrease and of course we've already touched on this a little bit but there are there's been difficulties with being separated from doulas from partners from your baby it is a human right to have a companion during labor you can go to the white ribbon alliance to download a great um article all about that topic it's also considered a human right to be able to keep your baby with you your baby cannot be detained from you without your permission also after birth the hospital should not separate you from your baby without your permission however these rights are being violated in some cases particularly with parents of confirmed or suspected COVID-19 there are major safety concerns of people being left to labor alone or recover alone postpartum and I hear myths being spread saying well you won't be left alone your nurse will be with you but the people I've spoken with who've had COVID-19 in New York City for example are not um given a nurse to stay with them continuously during their labor in fact the staff will hurry in the room to do something with the ivy pump and then immediately leave and I um was able to listen to the story of a very courageous black woman in New York City who had a preeclampsia on magnesium drip and she spent the vast majority of her 24 hour labor alone with the staff just coming in intermittently to check on the pump um she ended up having an emergency cc section and because they she had COVID-19 um they wouldn't let her go to the recovery rooms they sent her back to her labor and delivery room and for the next several hours no staff came in to check on her she was separated from her baby nobody checked on her bleeding nobody checked you know her fundal height nothing her incision she was left alone for hours until somebody finally came in to check on her and then it wasn't until the next day that somebody was like oh you haven't even seen your baby yet so to me um that was a high risk situation for a maternal death not having somebody with that person continuously while they have preeclampsia while they're recovering from major surgery and um that that to me is major safety concerns only is it a um a human rights violation but it these are the kinds of situations that are going to cause maternal deaths not related to COVID-19 but related to our reactions to COVID-19 and violating people's human rights and that just happened a few weeks ago um before the governor in New York state um declared that you cannot separate people from a companion during labor some good news um i think families are enjoying that there are fewer staff present during labor and birth you're not going to have you don't have to worry about observers who are not needed that is a big problem in some academic medical centers where you have lots of people watching you giving birth it's like a audience so people are having a lot more privacy with these smaller groups also postpartum units are quieter so parents can bond with their baby without interruption postpartum nurses are telling me that their their clients in the postpartum units are getting so much sleep and rest and that is a positive change also early discharge is strongly encouraged this is good for parents who want to go home early it's not so good for parents who need extra hospital support but in the past in the united states it's been very hard to get the pediatrician to discharge the baby before 24 or even 48 hours and now people are sometimes even being able to go home the same day all right so i want to just tell you about um i do want to reserve five minutes for questions so this is where i keep all my resources on COVID-19 um we don't have this webinar but we have other past webinars on different topics related to COVID-19 we've got our weekly newsletters so every monday we put out a research report we just had one go out yesterday that had additional info about the new research coming out about maternal deaths and COVID-19 so if you want to check that out just go to evidencebasebirth.com slash COVID-19 and scroll to the bottom and you'll see the archives of every monday's research report so now i'd love to answer your questions so go ahead and i'll scroll through the chat see if i missed any questions oh yes great question from rena um the recent release of the perinatology article suggesting limiting the second stage so i did cover that in yesterday's research update let me pull up my pull it up so i can reference it i'm just going to evidencebasebirth.com slash COVID-19 and scrolling down to the bottom and look for the research update from may 4 and it is in it's below the new york state recommendations in the world health organizations oh no actually it's above the new york state so there was an article published by stevens at all suggesting that providers limit the second stage of labor because they say forceful exhales during pushing could put staff at increased risk of exposure if the mother happened to be infected so they encourage laboring down and they say recommending no more than three hours of pushing in a first-time mom with an epidural the problem is this is that we know that putting tight time limits on pushing can increase the risk of a preventable cesarean so this is based on clinical opinion from three obstetricians it's not binding so you can choose not to follow that recommendation there was a second trimester intrauterine fetal demise and chantel's asking about that she says she's hearing from people that are seeing more second trimester deaths there's only been one research study published on that so this is why again why we need more research i talk about this in yesterday's research update as well this was a 28 year old pregnant woman in switzerland who gave birth to a stillborn infant at 19 weeks after she experienced severe symptoms she began contractions and she gave birth to a stillborn infant after 10 hours of labor the baby tested negative however samples from the maternal side of the placenta did test positive for the virus and it is possible that the maternal infection could cause placental insufficiency resulting in the miscarriage more intrauterine fetal demise um dr varki talks about hearing a more intrauterine deaths because of anxiety and delays i apologize dr decker could you wrap this up in the next one to two minutes because we do have a keynote at the top of the hour okay yeah well i think that's i think that's um enough questions so um thank you all for listening and i i hope that you all stay safe and healthy and you're able to take care of yourselves and your clients and have enough protective equipment and that we begin to see an increase in the amount of resources available to fight this epidemic so thank you everyone for attending thank you so much rebecca for speaking and to all the people who attended i'm sure i can see by the comments that everybody really enjoyed it and i'm going to be switching the recording