key: cord-0978673-hhkemtc3
authors: Kugelman, Nir; Toledano‐Hacohen, Mirit; Karmakar, Debjyoti; Segev, Yakir; Shalabna, Eiman; Damti, Amit; Kedar, Reuven; Zilberlicht, Ariel
title: Consequences of the COVID‐19 pandemic on the postpartum course: Lessons learnt from a large‐scale comparative study in a teaching hospital
date: 2021-02-23
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13633
sha: 51c21236ba4f50ce5c914baf4d4096f37f56b8c3
doc_id: 978673
cord_uid: hhkemtc3

OBJECTIVE: To evaluate the consequences of COVID‐19 pandemic restrictions on the postpartum course. METHODS: A retrospective cross‐sectional study compared women who gave birth between March and April 2020 (first wave), between July to September 2020 (second wave), and a matched historical cohort throughout 2017–2019 (groups A, B, and C, respectively). Primary outcomes were postpartum length of stay (LOS), presentations to the emergency department (ED), and readmissions 30 days or longer after discharge. Following Bonferroni correction, p < 0.016 was considered statistically significant. RESULTS: In total, 3377 women were included: 640, 914, and 1823 in groups A, B, and C, respectively. LOS after birth (both vaginal and cesarean) was shorter in groups A and B compared to the control group (2.28 ± 1.01 and 2.25 ± 0.93 vs 2.55 ± 1.10 days, p < 0.001). Rates of ED presentations 30 days after discharge were higher in groups C and B compared to group A (6.63% and 6.45% vs 3.12%, p = 0.006). Rates of readmissions 30 days after discharge were 0.78%, 1.42%, and 1.09% (groups A, B, and C, respectively), demonstrating no statistical difference (p = 0.408). CONCLUSION: During the COVID‐19 pandemic, there was a reduction or no change in rates of ED presentations and readmissions, despite the shortened LOS after delivery. A shift in policy regarding the postpartum LOS could be considered.

for pre-term delivery, etc.), gestational age at delivery, Group B Streptococcus (GBS) carrier (positive GBS culture or GBS bacteriuria), intrapartum fever higher than 38°C with the administration of intravenous broad-spectrum antibiotics, induction of labor and its method, epidural analgesia, mode of delivery, type of cesarean delivery, successful vaginal birth after cesarean delivery (VBAC), newborn weight, newborn Apgar score and admission to the neonatal intensive care unit (NICU); (3) postpartum: length of stay after vaginal or cesarean delivery, presentation to the emergency department in the 30 days after discharge, the nature of the presentation, and if they required readmission to hospital.

Women who either sought care in the 30 days after their delivery or were readmitted were classified as follows: surgical site infection (an abdominal scar or episiotomy); infection (urinary tract infection, mastitis, endometritis); abnormal vaginal bleeding; headache; abdominal pain; and general or non-specific.

Data were extracted into a computerized Excel spreadsheet.

Subsequently, an analysis was performed comparing the parameters between the groups.

Patients who were included in the present study were those with a gestational age over 24 weeks at delivery with live births. Records without complete data, gestational age less than 24 weeks, and stillbirths were excluded.

The primary outcome was duration of postpartum admission, presentations to the emergency department, and readmissions in the 30 days after discharge. Secondary outcomes were the rate of labor inductions, mode of delivery, and rates of admission to the NICU.

A statistical analysis was performed using SPSS version 24 (IBM Corp., Armonk, NY, USA). The comparison between the demographical and clinical characteristics between periods was analyzed using the χ 2 test for the categorical variables and the Anova/Kruskal-Wallis tests for the continuous variables. For the correction of multiple comparisons, a Bonferroni correction was applied, and p < 0.016 was considered statistically significant.

The present study was approved by the institutional review board of Carmel Medical Center (Protocol No. 0070-20-CMC). Informed consent was not required due to the retrospective nature of the study.

In total, 3377 cases were identified, of which 640 women gave birth at the time when the first COVID-19 pandemic restrictions where in place, 1823 women gave birth during the matching months in the previous years, and 914 women gave birth during the second wave.

There were no statistical differences with regard to maternal age, BMI, smoking status, parity, and the ratio of primigravida between the three groups. Clinically, there were no differences between subgroups in gestational age, pre-term or late-term delivery, or multiple gestations. Patient demographics and clinical characteristics are presented in Table 1 . No difference was found in the rates of a previous cesarean delivery, successful VBAC, induction of labor, GBS carrier, adminsitration of epidural analgesia, intrapartum fever with intravenous broad-spectrum antibiotics, mode of delivery, type of cesarean delivery, newborn birth weight, Apgar score at 5 minutes, umbilical pH, and admission to the NICU. Clinical and obstetrical characteristics of the delivery are summarized in Table 2 .

The total length of stay after birth (both vaginal and cesarean delivery) was shorter in groups A and B (2.28 ± 1.01 and 2.25 ± 0.93 vs 2.55 ± 1.10 days, p < 0.001). The length of stay after both vaginal and cesarean delivery was significantly shorter in groups A and B Figure 1 ).

In total, 201 cases of presentations to the emergency department 30 days after discharge were identified. They were higher in groups B and C than in group A (6.45% and 6.63% vs 3.12%, No differences with statistical significance were found in the classification of presentations to the emergency department and readmissions presented in Table 3 4 | DISCUSS ION

The present study shows that the implications of the COVID-19 outbreak in the study institution resulted initially in a reduction of postpartum presentations to the emergency department, but showed no significant rates of readmission after birth, despite a shortened length of stay after delivery, compared to previous years. The hospital policy modifications, aiming to reduce the spread of COVID-19, did not alter the rates of labor inductions, nor change the rate of instrumental deliveries or number of elective and emergent cesarean deliveries.

Although one might find the results of the present study to be as expected, it is important to stress the fact that, as a rule, no official limitations were placed on postpartum women and there were no restrictions on visits to the emergency department. Furthermore, these findings are significant since, despite a higher trend towards home deliveries in Israel, 7 a relatively higher number of deliveries has been seen compared to previous years. This is in contrast to what other institutions have reported in the city. 8 TA B L E 1 Comparison of demographic and clinical characteristics between women who gave birth during the first wave of COVID-19, the second wave of COVID-19, and the matching months 3 years before a While previous studies found that the rate of presentation to the obstetrical emergency department antepartum was either similar or lower during the initial wave of COVID-19 (February to

March 2020), this has not resulted in a change of maternal and neonatal outcomes. This is indeed similar to the present study. 16, 17 In contrast, the rate of presentation to the emergency department 30 days postpartum was significantly lower initially, as well as the rate of readmissions (although it has not reached statistical difference). These findings are not surprising as the patients' fear of attending hospitals during the pandemic has resulted in a delayed presentation to hospital, in cases such as acute coronary syndrome 18 and in increasing cases of cardiac arrest 19 as well as in the reduction in numbers of cases of patients being evaluated for acute stroke. 20 Although such fear during the pandemic is understandable, it is the hospitals' role to implement good practice to maintain patient safety and reduce the chances of exposure to infected individuals. 21, 22 The postpartum period can be very challenging when women face physical and emotional discomfort and, TA B L E 2 Comparison of clinical and obstetrical characteristics of delivery between women who gave birth during the first wave of COVID-19, the second wave of COVID-19, and the matching months 3 years before a ing the obstetrical teams into separate groups to limit the spread of COVID-19. However, these restrictions were slightly liberated during the second wave. These can explain why the rate of presentation to the emergency department was initially reduced and later on returned to previously reported rates.

It is believed that this is the first study to assess the impact of the pandemic outbreak on postpartum course and repeat admission.

The present study has some limitations, including the retrospective design. The exclusion of women with missing data may have lead to selection bias. However, it is believed that given the constraints of the situation globally, this was the most pragmatic study design.

Moreover, the research is a single-centre cross-sectional view and there is no information as to whether similar trends were observed in other settings.

The 

The authors have no conflicts of interest. 

Classification of presentation to the emergency department or readmission and comparison delivery between women who gave birth during the first wave of COVID-19, the second wave of COVID-19, and the matching months 3 years before a 

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How to cite this article: Kugelman N, Toledano-Hacohen M

Consequences of the COVID-19 pandemic on the postpartum course: Lessons learnt from a large-scale comparative study in a teaching hospital