Mary Brosnan, the director of nursing & midwifery, writes: “Babies wait for no one, even in a pandemic they will be born.”
WE ARE ALL so aware that we live in a globalised, connected world but it was still hard to imagine how a virus originating in a city in a far-away continent could affect Ireland, an island nation on the edge of Europe.
Everything came closer to home in early February when the scenes began to unfold in Northern Italy. Italian colleagues and friends started posting horror reports on social media of the speed of spread of the disease and the overwhelmed hospitals, with people dying on corridors and emergency departments. The most enduring and terrifying television image for me was the scene of army trucks transporting dead bodies through the streets in Bergamo.
Within the National Maternity Hospital (NMH), we had started discussing how Covid-19 might impact on maternity, neonatal and gynaecology services on 6 February and we had our first preparatory multidisciplinary meeting on 10 February.
Maternity is a unique specialty and the miracle of birth is as old as time. Babies wait for nobody. Even in a pandemic, they will be born. During this pandemic, more than 1,500 have been born at Holles Street alone.
Another 18 were born at home through our home birth scheme.
Therefore, our priority is to maintain a safe, high quality service, and to develop separate care pathways for women and babies who are potentially already exposed to the virus.
The concept of a ‘hospital within a hospital’ was developed extremely quickly by our clinical director.
One of the aspects of managing this disease that I had not anticipated was the fear that many staff were experiencing in the early days of this pandemic. The level of anxiety was palpable some days, especially as we know so many front line workers had contracted the virus or had died in Italy and in the UK.
One of the important decisions we made was to be completely open and transparent about any cases within our walls. We said we would hide no facts. We told everyone this so there would be no rumours. If there was a case, they would hear about it from us directly.
In March, we were waiting for an influx but thankfully it never came.
The first positive test in a patient did come on 9 March but the numbers haven’t climbed above five in any one day. All of those patients were managed and sent home as quickly and as safely as possible.
The total number of positive patients to date has been very small. About 314 women have been screened within the hospital and many more in the community setting. A total of 28 women have been treated as Covid-19 positive.
Thankfully only four women were seriously ill, requiring high dependency care. No maternity patient to date has required ventilation in this first wave of infection. This reflects the research to date, that this virus does not appear to have the same potency as the H1N1 virus which circulated some years ago, when there were some fatalities within the maternity setting.
Fear and safety
We could see the fear in most women coming through the doors in March and April, in particular. They had got the message clearly and strongly about being careful around close contacts and increased handwashing.
However, we did see a drop in the number of unscheduled visits which worried us – were women who needed to see us not coming in?
Although the outcomes have been mainly in the good column, that is not to say the past six months haven’t been tough.
The number of staff who were sick or self-isolating in the first weeks of the pandemic created significant challenges for us in terms of managing to maintain a safe environment. Two clinical staff were hospitalised and needed HDU care, but thankfully recovered.
In the initial week, there was high levels of absenteeism with a high of 107 staff absent (more than 10% of the workforce) due to sickness or the requirement to self-isolate as a ‘close contact’. For the first three weeks until after Easter, this proved to be a major concern.
It was necessary to establish a ‘drive through’ swabbing service in the hospital car park, operated each day by the midwifery and medical team, allowing staff and patients to be tested without having to enter the hospital. This is also a very useful way of conserving the valuable PPE, which also became a national issue, due to supply chain deficits. In total, 208 staff have been swabbed to date. Of these 37 staff have tested positive. All recovered within a short timeframe.
Many staff recounted their struggle with the concept of wearing personal protective equipment (PPE) for all interactions with women, and most particularly with the need to ‘don’ full PPE for treating women who were suspected or confirmed as Covid-19 positive.
Nonverbal communication, eye contact, facial expressions, all of these elements are so important in creating a connection and maintaining human touch. With the use of PPE, this can challenge even the warmest connection, so staff had to work doubly hard when nursing patients in isolation and using PPE. At the same time, there was a lot of nervousness around contracting the virus. Our artist in residence Jeanette Lowe
took some great portrait photos of staff to attach to their PPE which was a lovely gesture.
There has been a lot of personal sacrifice from staff who have had to make some rather radical choices during the crisis in order to protect their loved ones. Many staff feel the need to stay in temporary accommodation in order to protect their families from possible contamination.
A memorable moment for me was from a short story competition we ran in April, when one of our anesthetists, Padraig shared an incredibly moving account of being separated from his wife and new baby. They decided that for safety, Padraig’s wife and new baby should move to Sligo to her parents, in case he potentially infected either of them due to his own exposure. There were many tears shed reading that story which was shared widely on social media.
There was also sacrifice by the parents. Visiting restrictions were very challenging but necessary. With the exception of labour and birth, women were asked to come to the hospital alone. This created a lot of upset for partners who felt excluded. Many dads waited outside the hospital for hours at a time which was distressing for them and their families. Some women were lonely and isolated at a critical time in their journey to become parents.
Since the end of June, we’ve allowed partners back in for visiting hours.
The toughest decision though was limiting access to the NICU – but any transmission to a neo-natal ward would have been the worst outcome.
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For me, the hidden heroes to thank for that are the laboratory and administration staff, the porters, the pharmacists, the radiologists, the bio-engineers, the maintenance teams, the catering personnel and the finance section. HR worked tirelessly, required to create many temporary contracts and manage the very unwieldy absenteeism reporting templates that needed to be returned daily to the HSE.
And, in my mind, the real unsung heroes are the IT team who have so many demands placed on them, from establishing urgent helplines, relocating staff across the hospital, to setting up remote offices with VPNs immediately, thereby allowing so many staff to work seamlessly across the organisation.
As healthcare professionals, we are living through an extraordinary time, providing an essential service to hundreds of families during the crisis. We are meeting that challenge. Staff are going above and beyond their roles every day and night. Many struggle with childcare concerns and do not receive assistance from the Government, despite much discussion right throughout the lockdown, yet they cope by relying on the goodwill of family members and friends where possible.
Despite the hospital’s poor infrastructure and inadequate resources – we badly need our new campus – we continue to provide a high quality, safe and woman-centred service. We can uphold this as worthy of our professions and of what we consider to be essential and meaningful for women and their families.
Mary Brosnan is the director of nursing and midwifery at the National Maternity Hospital. She chairs the hospital’s Covid-19 Communication sub-committee.