key: cord-0976975-1al786br
authors: GREENE, Naomi H.; KILPATRICK, Sarah J.; WONG, Melissa S.; OZIMEK, John A.; NAQVI, Mariam
title: Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the COVID-19 pandemic
date: 2020-09-21
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100234
sha: 8170ba2b95da8873bac146e5c9412a98fcc9c368
doc_id: 976975
cord_uid: 1al786br

Background In response to the COVID-19 pandemic, hospitals nationwide have implemented modifications to labor and delivery unit practices designed to protect delivering patients and healthcare providers from infection with SARS-CoV-2. Beginning March 2020, our hospital instituted labor and delivery unit modifications targeting visitor policy, use of personal protective equipment, designation of rooms for triage and delivery of persons suspected or infected with COVID-19, delivery management and newborn care. Little is known about the ramifications of these modifications in terms of maternal and neonatal outcomes. Objective The objective of this study was to determine whether labor and delivery unit policy modifications we made during the COVID-19 pandemic were associated with differences in outcomes for mothers and newborns. Study Design We conducted a retrospective cohort study of all deliveries occurring in our hospital between January 1, 2020 and April 30, 2020. Patients who delivered in January and February 2020 before labor and delivery unit modifications were instituted were designated as the pre-implementation group, and those who delivered in March and April 2020 were designated as the post-implementation group. Maternal and neonatal outcomes between the pre-and post-implementation groups were compared. Differences between the two groups were then compared to the same time period in 2019 and 2018 to assess whether any apparent differences were unique to the pandemic year. We hypothesized that maternal and newborn lengths of stay would be shorter in the post-implementation group. Statistical analysis methods included Student’s T-tests and Wilcoxon tests for continuous variables and chi square or Fisher’s exact tests for categorical variables. Results Postpartum length of stay was significantly shorter after implementation of labor unit changes related to COVID-19. A postpartum stay of 1 night following vaginal delivery occurred in 48.5% of patients in the post-implementation group compared to 24.9% of the pre-implementation group (p<0.0001). Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in the post-implementation group as compared to 11.8% in the pre-implementation group (p<0.0001). Similarly, after vaginal delivery, 49.0% of newborns were discharged home after one night in the post-implementation group compared to 24.9% in the pre-implementation group (p <0.0001). After cesarean delivery, 42.5% of newborns were discharged after ≤2 nights in the post-implementation group compared to 12.5% in the pre-implementation group (p<0.0001). Slight differences in the proportions of earlier discharge between mothers and newborns were due to multiple gestations. There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the two groups. Conclusion Labor and delivery unit policy modifications to protect pregnant patients and healthcare providers from COVID-19 demonstrate that maternal and newborn length of stay in the hospital were significantly shorter after delivery without increases in the rate of adverse maternal or neonatal outcomes. In the absence of longer-term adverse outcomes occurring after discharge that are tied to earlier release, our study results may support a review of our discharge protocols once the pandemic subsides to move toward safely shortening maternal and newborn lengths of stay.

Results: Postpartum length of stay was significantly shorter after implementation of labor unit 23 changes related to COVID-19. A postpartum stay of 1 night following vaginal delivery occurred 24 in 48.5% of patients in the post-implementation group compared to 24.9% of the pre-25 implementation group (p<0.0001). Postoperative length of stay after cesarean delivery of ≤2 26 nights occurred in 40.9% of patients in the post-implementation group as compared to 11.8% in 27 the pre-implementation group (p<0.0001). Similarly, after vaginal delivery, 49.0% of newborns 28

were discharged home after one night in the post-implementation group compared to 24.9% in 29 the pre-implementation group (p <0.0001). After cesarean delivery, 42.5% of newborns were 30 discharged after ≤2 nights in the post-implementation group compared to 12.5% in the pre-31 implementation group (p<0.0001). Slight differences in the proportions of earlier discharge 32 between mothers and newborns were due to multiple gestations. There were no differences in 33 cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the 34 two groups. 35

Conclusion: Labor and delivery unit policy modifications to protect pregnant patients and 36 healthcare providers from COVID-19 demonstrate that maternal and newborn length of stay in 37 the hospital were significantly shorter after delivery without increases in the rate of adverse 38 maternal or neonatal outcomes. In the absence of longer-term adverse outcomes occurring after 39 discharge that are tied to earlier release, our study results may support a review of our discharge 40 The objective of this study was to compare maternal and neonatal outcomes before and after the 65 implementation of stay-at-home orders and our institutional COVID-19 obstetric and neonatal 66 J o u r n a l P r e -p r o o f 4 policy changes in the labor and delivery unit. Given that efforts to protect staff and patients from 67 infection with SARS-CoV-2 would aim to reduce face to face exposure time, we hypothesized 68 that the COVID-19 labor and delivery modifications directed at reducing the in-hospital 69 transmission rate would be associated with shorter lengths of stay for mothers and newborns 70 compared to mothers and newborns delivered before the modifications were made. 71

This study was performed at a tertiary care, academic hospital with approximately 6200 73 To assess the impact of these changes on delivery outcomes, we conducted a retrospective cohort 80 study of all deliveries occurring in our hospital between January 1, 2020 and April 30, 2020. We 81 divided the cohort into two groups: patients who delivered prior to implementation of these 82 guidelines in January and February 2020 (pre-implementation), and patients who delivered We included all patients in the 2020 study period, regardless of laboratory-117 confirmed SARS-CoV-2 status. We accounted for potential differences in outcomes attributable 118 to infection status rather than Labor and Delivery Unit practice modifications by re-running 119 analyses without laboratory test-positive cases. 120

Results 121

During the study period of January 1, 2020 to April 30, 2020, 1936 deliveries occurred at 122 our institution, with 1016 deliveries during the pre-implementation period and 920 deliveries 123 during the post-implementation period. Baseline demographic characteristics of the study 124 population in the pre-implementation and post-implementation time periods are described in 125 Table 1 . There were no demographic differences between the two groups. 126

Postpartum length of stay was significantly shorter in the post-implementation group. A 127 postpartum stay of 1 night following vaginal delivery occurred in 48.5% of patients in the post-128 implementation group compared to 24.9% of the pre-implementation group (p<0.0001). 129

Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in 130 the post-implementation group as compared to 11.8% in the pre-implementation group 131 (p<0.0001; Table 2 ). The proportion of patients transfused ≥1 unit of packed red blood cells was 132 higher in the post-implementation group than in the pre-implementation group (3.3% versus 7 There were no other differences in obstetric, maternal, or adverse outcomes between the pre-135 implementation and post-implementation groups (Table 2) . 136

Newborn length of stay was also significantly shorter after implementation of practice 137 modifications compared to the pre-implementation group. After vaginal delivery, 49.0% of 138 newborns were discharged home after one night in the post-implementation group compared to 139 24.9% in the pre-implementation group (p <0.0001, Table 3 ). After cesarean delivery, 42.5% of 140 newborns were discharged after ≤2 nights in the post-implementation group compared to 12.5% 141 in the pre-implementation group (p<0.0001). There were no differences in NICU admissions, practice modifications demonstrates that professional societies in the USA, Italy, and Spain are 178 encouraging early post-delivery discharge. 9 In our hospital, early discharge was not among the 179 9 practice modifications we made. Nevertheless, our study results revealed discharge after 1 or 2 180 nights for vaginal and cesarean deliveries, respectively, and this allowed us to study potential 181 short-term adverse outcomes that could be associated with the shorter lengths of stay. This study is not without limitation. It is possible that the current study was 207 underpowered to assess differences in less common but severe adverse outcomes including 208 severe maternal morbidity or stillbirth. Our patient population may also not be generalizable to 209 patients admitted to other labor and delivery units. 210

It is plausible that the reduction in postpartum hospital stay was a random event, due to 211 normal month-to-month variation. However, the marked reduction in length of stay seen in 2020 212 

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