A pregnant woman at term with severe pre-eclampsia presents in labor. She tests positive for COVID during standard screening. She is asymptomatic and does not need any oxygen. However, her pre-eclampsia is concerning; she requires several medications to control her blood pressure, and the fetal heart strip is flat, abnormal. The obstetricians worry that she may eventually need a C-section, though one is not emergently required now. They ask what the optimal plan should be.

How much should a COVID diagnosis change care?

One important goal in any pregnancy is to avoid an emergent "crash" C-section - the kind that involves running to the operating room, inducing anesthesia as quickly as possible, splashing iodine onto the belly, and getting the baby out immediately. These scenarios are uncontrolled, stressful, and chaotic. Occasionally they cannot be avoided, but with early identification, prevention, and planning, they can be kept to a minimum.

In any pre-eclamptic with a concerning fetal heart strip, we need to mitigate risk. But how do we take into account asymptomatic COVID positivity? There are several possible decisions we can make. The most extreme would be scheduling a C-section so we could deliver the baby in a controlled, planned fashion. It would avoid pushing, which may aerosolize the virus. A more moderate approach might be placing an early epidural which can be used for anesthesia in the case of an urgent C-section (though there still may be a small risk of needing general anesthesia).

We know from early COVID studies from China that general anesthesia in a patient with COVID has significant mortality. Intubating a patient with COVID, even if she is young and healthy, puts her at real risk. In addition, emergency COVID surgeries place staff at risk. Although we would ideally be wearing all the necessary protective gear, in the real world, such things don't always happen. I've been in "crash" C sections (pre-COVID) where surgeons didn't have time to put on a surgical cap, a mask, or (once) even shoes (they were asleep when the C-section was called). Expecting perfect PPE adherence in an emergency is unrealistic.

So how much does COVID change things? If the patient were COVID negative, I would recommend an early epidural, but if she declined, I would be amenable. But here, I felt a stronger imperative to explain why an epidural could be life-saving. And if the obstetricians scheduled a C-section, it wouldn't be unreasonable. Like all aspects of medicine, decision-making is a shared responsibility between patients and their providers. I'm learning how to incorporate what we know about COVID into that discussion. Medical decisions should not be unilateral, but the invested parties should think of all the ramifications of this disease including protecting the staff from unnecessary exposure, reducing harm, and keeping the health care system sustainable through this pandemic.