Baby-Friendly in the Pandemic: Ingenuity, Flexibility, and Doing Whatever It Takes

Over the past year, BFUSA has engaged in a series of support calls with Baby-Friendly designated facilities to learn about how things have been going at the front line of care during the pandemic. We have been so very impressed by the ingenuity, flexibility and uncompromising commitment to do whatever it takes to best support mothers and babies during this challenging time. And many facilities even found that some good may have come out of the pandemic.

Here are some of their stories…

Going Virtual at NYU/Langone

“We’ve been Baby-Friendly for ten years now, so the Ten Steps have been ingrained in our culture,” says Francine Pasadino, RNC-OB, CNM, C-EFM, IBLCE, LCCE, MA, Nurse Manager of Perinatal Support Services at NYU Langone Health in New York City.

But when New York City emerged as the epicenter of the pandemic in the spring of 2020, the lactation services staff faced unprecedented challenges. By mid-March 2020, in response to local and federal government recommendations to minimize the spread of COVID-19, Langone leadership halted all in-person and support groups.

“Lactation is a hands-on profession,” says Pasadino. “When everything was suspended, we really had to think outside the box to see how we can best support women and maintain our compliance with the Ten Steps.”

Fortunately, as with many other things in our world, virtual communication platforms offered a solution.

“We didn’t have any online or virtual option prior to the pandemic,” Pasadino says.

Undaunted, the Langone lactation team quickly made the transition. They bought an on-demand education platform, converted all in-person classes to virtual platforms, and developed a new 1-hour virtual Q&A session with a lactation consultant called “Ask the Educator” to help address the confusion many families were feeling at the beginning of the pandemic. They also disseminated the latest evidence-based information through their Facebook page and invited families to submit questions directly to their team via a dedicated email account.

Post discharge, mothers needing additional support were invited to register for virtual lactation consultation or to join a virtual Breastfeeding Café. The team also started a virtual support group called “Café Grande” for mothers with babies six months and older, which has become very popular as well.

Pasadino and her colleagues, Gladys Vallespir Ellett and Kathleen DeMarco, wrote about their experience in an article published in the Clinical Lactation journal.

“We were particularly concerned about supporting mothers asymptomatic and positive for COVID-19 and those mothers with mild COVID illness on the Mother/Baby unit since, in an effort to preserve personal protective equipment particularly in the beginning of the pandemic, our in-person interactions with COVID-positive mothers had to be limited,” say the authors.

The authors conclude that, although “the energy from in-person sessions cannot be replicated” and there are some limitations, “a virtual technology format is a viable alternative means of providing lactation education and supporting optimal infant feeding.”

“I believe virtual support is here to stay,” says Pasadino. “It was a bit challenging at first, but it has actually become a very effective option for families. And best of all, the virtual format has allowed us to reach women we wouldn’t have been able to reach before because they couldn’t come in person.”

Moving the Unit (Twice!) at Woodland Memorial

The staff at Woodland Memorial Hospital, a 107-bed facility in a suburb of Sacramento, California, faced a different kind of challenge when COVID-19 hit.

“Last March as the pandemic was unfolding, our leadership got together to discuss how we would accommodate the potential COVID surge,” explains Nova Fox, manager of the Family Birth Center (FBC).  “We were looking at the population of our community and our county, utilizing equations to calculate how many COVID admissions we should expect to receive, and we were concerned that our ICU unit would not be able to accommodate those numbers.”

The ICU at Woodland Memorial was an 8-bed unit, not large enough to accommodate the potential surge. Leadership began exploring ideas and identified that FBC had the necessary medical gases to accommodate intensive care patients. FBC had 7 Labor, Delivery, Recovery and Postpartum rooms, plus three additional shared rooms used for overflow postpartum and an isolation room – the only true isolation room in the hospital.

“We decided that turning FBC into the COVID unit was the best solution because it could hold 20 ICU status patients,” says Fox.

In late March, the hospital decided to take action in preparing for the COVID surge. FBC was transformed into the COVID unit and Fox and her staff relocated to the Outpatient Surgery Center across the parking lot. There, temporary walls were constructed to create two negative pressure delivery rooms, and staff were required to don and doff the proper PPE when entering these designated COVID delivery rooms.

“Patients labored in pre-op, delivered in the OR, and recovered in post-op,” recalls Fox.

The greatest challenge in moving a whole unit, according to Fox was the IT component.

“The equipment, we just rolled across the parking lot and into the next building,” Fox says. “More critical was building the virtual units within the Electronic Medical Record to ensure all service departments knew where to find the patients when orders were placed.”

Laboring patients in the Outpatient Surgery Center was a little bumpy at first.

“We had to figure out our new flow and what worked best for our patients,” Fox says. “But our staff did an awesome job – and our Baby-Friendly practices were not affected at all.”

Fortunately, the surge they were prepared for in the hospital did not materialize and after six weeks in their new setting, Fox and her team were told they could move back into their previous location.

Then, in the middle of December, the hospital began experiencing the COVID surge they had feared and FBC was once again asked to move. This time, FBC was able to stay within the walls of the hospital, trading spaces with the ICU. The ICU space offers eight private rooms where FBC patients labor, deliver and recover.

“The second move was a really easy transition. We knew exactly what to do,” recalls Fox.

Today, FBC remains in its temporary location while the hospital watches its COVID numbers and carefully considers its options for the next few months. In the meantime, Fox says, the Center’s Baby-Friendly practices have continued unabated.

“We had our virtual Phase One assessment when we were back in our unit and we passed 39 of the 40 elements,” she says. “We are now gearing up for our Phase 2 assessment in the virtual setting, which seems appropriate given how mobile we’ve been.”

Converting Mom-Baby Rooms to Med-Surg at University Medical Center

Beginning this past August, University Medical Center in Lubbock, Texas, began experiencing a surge in COVID patients and decided to divert non-COVID patients to other floors in order to open up capacity. The Postpartum unit was among the units selected.

“At first, we had one ICU unit and one med-surg unit designated for our COVID patients,” said Malory Foster BSN, RN, CLC, Perinatal Quality Specialist at University Medical Center. “When the COVID units got overwhelmed, they started spilling over into other units and we had to convert some of the postpartum rooms to med-surg.”

“Our nurses had to take care of things they weren’t used to at that point.” For example…“men,” she says with a laugh. “We all had to adjust a little bit.”

The team also had to convert some regular rooms in the Mom/Baby units to negative pressure rooms to care for mothers who tested positive for COVID. And the hospital added a medical tent to accommodate the increased demand for beds. Through it all, they were able to stay on track with Baby-Friendly practices.

“It was disruptive for sure,” says Malory, “but not to where processes changed.”

The biggest challenge, according to Malory, was the fact that information changed from day to day.

“It felt like every day, possibly every shift, information was changing,” she remembers. “What are the current facts and how do we use that information to effect change?”

In addition, it was also challenging to keep staff focused on daily tasks against a backdrop of larger, global issues.

“Everyone was consumed with COVID, and the worry of transmission from provider to patient or patient to provider. I think the drive to do all the little things like charting felt secondary with everything else at the time,” says Malory. “So, it was a mindset issue we needed to overcome.”

But overcome they did.

“I have to give it to our staff,” says Malory. “They were willing to do what needed to be done. Looking back on it, I feel like it has gone fairly well for a pandemic.”

Supporting Native Culture at Tuba City Health Care

As reported in a November 2020 story on PBS News Hour, the Navajo Nation has been particularly hard hit by the pandemic and its healthcare system has been straining to keep up. This impact has certainly been felt at Tuba City Regional Health Care, a 73-bed facility in Northeast Arizona which serves as a referral center for the western part of the Navajo and Hopi Reservations.

The OB staff were dealing not only with a vulnerable population, but an aging facility as well.

“The structure of our hospital is old,” says Alberta Nez, RN, MSN, Director of Obstetrics for Tuba City. “When the pandemic started, we had to make do with what we had. Things couldn’t be created quickly enough, but we were trying to do things that would be best for our patients.”

Small-scale structural changes were all they could hope for, but they have meant big changes, including the creation of two makeshift negative pressure rooms.

“It wasn’t the best. It was too loud. It took up too much space. But we had to do what we had to do,” recalls Nez.

They also did what they had to do by continuing to support breastfeeding during this challenging time.

“Our Baby-Friendly staff were still committed to encouraging moms to breastfeed and providing the extra care and education that’s important for our breastfeeding mothers,” Nez says.

But what really makes Tuba City unique is the population they care for, the vast majority of which are Native American. The pandemic created some interesting challenges where COVID-19 safety practices clashed with traditional tribal practices.

For Navajo women, it is customary to bury a child’s placenta on the tribe’s reservation as a binder to ancestral land and people. However, it was deemed unsafe for the COVID positive patients to leave with the placenta for fear it might spread the virus. Most women understood the need for this change, according to Nez.

“COVID 19 instilled fear in people,” she says. “We didn’t know, even amongst us providers. It was a scary time.”

The other major cultural change for these women came from the fact that each mother was permitted to have only one support person with her during labor and recovery.

“In certain times, if a mother was having trouble with labor, they would request a medicine person come in and offer a prayer to help the childbirth process move along,” Nez recalls. “But we could no longer allow that because they could only have their one support person.”

The staff is also accustomed to having women labor with large numbers of family members in the room to give them support because the childbirth is seen as a family event. But that changed as well because of COVID.

“Sometimes we would have to turn away family members from the room because there was too many of them,” she recalls. “That was hard on the mother because they had to choose just one. How can you choose? And it was stressful for us too because we are the ones who had to tell them they had to choose.”

But all in all, as with the other facilities featured above, the staff at Tuba City made it work and focused on the positive.

“I’m hoping it will give the mothers that are on the fence about breastfeeding a nudge,” Nez says. “I hear some say, ‘This horrible thing is going on in the world, but this is something that I can at least do for my baby.’”