Alex Murphy has faced many unknowns during her pregnancy — more than most moms-to-be — but what she has described as a “test in dealing with grey area” just got even harder.

At her 20-week anatomy scan, she learned her baby — a boy — has a rare disease that may lead to immunodeficiency. At 28 weeks, she found out he has a bowel obstruction, and will require immediate surgery at Toronto’s Hospital for Sick Children after he’s born, followed by a stay in the neonatal intensive care unit.

Now, at 34 weeks pregnant — just six weeks before her due date — she is confronting the global COVID-19 pandemic, which has prompted hospitals across Canada, including Sick Kids, to take dramatic steps to keep patients and health-care workers safe.

Under the latest guidelines, she’s been told only one of the baby’s parents can be at the hospital for his surgery when he is born in May or to visit him in the NICU; he won’t meet his older sister in person until he comes home.

“It was already a lot before, and the pandemic has doubled it,” said Murphy, who lives in Toronto’s east end with her husband and their 4-year-old daughter, Stella. “It’s tough to talk to people about this.”

As COVID-19 sweeps across Canada, upending daily life and fuelling anxiety, welcoming a new baby into the world now comes with even more unexpected challenges.

Parents-to-be, obstetricians and midwives are grappling with how to keep everyone safe from the new coronavirus while preserving the moments and memories of giving birth.

During pregnancy, mothers will have fewer face-to-face prenatal appointments to minimize the risk of getting or passing on the highly contagious and potentially deadly respiratory illness.

Families are being told to scale back their emotional expectations around giving birth. Many hospitals now allow only one support partner during labour and delivery, siblings can’t meet in the minutes after birth, and grandparents will likely get their first glimpse of a grandchild on a computer screen.

And at home, during those difficult first weeks with a newborn, necessary social distancing measures mean parents will be isolated from family and in-person public health supports, which in turn could lead to an increase in postpartum depression.

For vulnerable women, including new immigrants, low-income and single moms with fewer support systems and resources, these new challenges are magnified, with experts worried how they will cope during the pandemic.

But no matter their background, expectant parents across the country are struggling with how to bring a baby into a world fighting the COVID-19 outbreak.

“It feels like it’s just completely upended everything,” said Toronto mom-to-be Kristin Ostensen, who is expecting her first baby — a girl — in mid-April. “All the things that we could kind of take for granted … all those ways that people had said that they would help us or just come visit and share the joy of it with us — it’s just gone.”

Since the first outbreak of COVID-19 in China in December, scientists have been closely watching how the new coronavirus affects pregnant mothers and their unborn babies.

So far, the findings are reassuring, said Dr. Jon Barrett, head of maternal fetal medicine at Toronto’s Sunnybrook Health Sciences Centre. Unlike with influenza and other respiratory illnesses, pregnant moms don’t appear to have a greater risk of catching COVID-19 than the general population, he said.

Current evidence suggests pregnant mothers with COVID-19 don’t transmit the virus to their baby during pregnancy, and babies born to moms infected with the virus appear to do well after birth, said Barrett, a professor of obstetrics and gynecology at the University of Toronto.

Reports also suggest pregnant women with COVID-19 who have mild to moderate symptoms recover well, he said.

In addition to reviewing scientific studies, Barrett also recently spoke to colleagues in China about their experience caring for 170 pregnant women with the virus.

“Despite the huge number of (COVID-19) cases in China, there doesn’t seem to be a huge impact on pregnant women. Talking to our colleagues, the risk for mothers doesn’t seem to be increased and there doesn’t seem to be a lot of effect on the baby.”

And right now, according to the best available evidence, Canadian guidelines allow new mothers with COVID-19 to breastfeed their babies, he said.

Still, Barrett cautions this is a new virus — just months-old — and doctors and scientists have much to learn about how it impacts pregnancy.

“Things are changing rapidly. What might have been true yesterday, might not be true today. And what might be true today, might not be true tomorrow.

“The best thing for pregnant women to do is speak directly with their own health-care provider about the specifics of their maternal care.”

Physicians in Toronto, in co-ordination with colleagues across Canada and internationally, are launching a registry of pregnant mothers with COVID-19. The database will track all aspects of pregnancy, labour and delivery, as well as the health of mom and baby, to help inform physicians caring for pregnant women with the virus, Barrett said. Currently, several pregnant mothers with COVID-19 are being monitored in Toronto, he said.

The Society of Obstetricians and Gynaecologists of Canada currently recommends pregnant women with COVID-19 deliver their babies in hospital, where physicians can monitor the health and well-being of mother and baby.

Like obstetricians across Canada, Calgary-based OBGYN Dr. Fiona Mattatall is rapidly adapting the way she offers prenatal care during the COVID-19 pandemic.

In the last week, Mattatall said there has been “a lot of tears and a lot of fear” among pregnant moms attending prenatal appointments in her clinic, which has implemented dramatic changes to reduce face-to-face contact — between patients and health-care providers, and among patients themselves.

Her team spent a recent weekend combing through patient files, trying to see, “Who can we delay? Who do we need to see?” Spreading out the time between prenatal appointments, and relying on the phone to provide virtual care has cut the number of patients visiting the clinic each day by two-thirds, from around 70 to 20.

Work is underway to create an “isolation room,” where COVID-19 patients can be treated and the main waiting room, which used to be a community hub where moms-to-be could trade notes, now contains just four chairs, positioned a safe distance apart.

“I had a few patients say, ‘Wow, seeing that physical change in space was kind of shocking, and made it real,” she said.

Jasmin Tecson, a registered midwife with the Toronto-based Seventh Generation Midwives, said her practice used guidelines developed by the World Health Organization to create a modified schedule for prenatal visits, and is also staggering in-clinic appointment times. To keep themselves safe, Tecson said midwives are screening moms-to-be for COVID-19 symptoms by phone in advance of each visit and again at the door.

“We are shortening in-clinic, in-person time. There are more phone interactions,” said Tecson, who is president-elect of the Association of Ontario Midwives, adding that the visit schedule can be adjusted “if there’s a health situation that’s developing or if a client has particular needs.”

Kelli Siegwart, a midwife in Kingston, Ont., said these changes — like all social-distancing measures — are particularly difficult for vulnerable women.

Siegwart’s clinic is asking moms-to-be to come to appointments on their own and without children if possible. And with the waiting area closed, clients are now being asked to wait in their cars until it’s time to meet, part of the overall strategy to limit person-to-person interaction.

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However, that wasn’t possible for a recent expectant mother who didn’t have a car. Siegwart said, in that case, the clinic allowed the woman to wait in a vacant appointment room.

Sunnybrook Health Sciences Centre has recently made the decision to allow just one support person during labour and delivery.

Barrett said the decision to reduce the number of overall people on the ward was difficult to make but is critical to prevent the spread of COVID-19 among patients and health-care workers.

“Everyone is upset about this,” he said. “Birth is a moment to be shared and we’ve spent a long time creating family-centred birthing care. These restrictions are not something anybody is happy about but this is the best way we know of to keep everyone safe.”

The hospital is also limiting the number of obstetrical staff coming to the ward at any one time, with many working at home, seeing their patients via telemedicine, Barrett said.

“We usually try very hard so that your own physician can deliver your baby but now we want people to know it might not be your own obstetrician helping you in labour, though you will still get excellent care.”

At Rockyview General Hospital in Calgary, Mattatall said doctors and nurses are preparing to care for pregnant women with COVID-19 by running through the steps of labour and delivery, practising how each will be done to protect the team from getting the virus.

“Labour is a time of physical closeness by care providers,” she said. “We are close to that mom and we can’t provide care at a distance.”

Part of the challenge, she adds, is they are working with limited information about how COVID-19 may impact delivery. For now, they are acting on the information they have.

In response to early reports from China of high caesarean-section rates among patients with the virus, the team at Rockyview started simulations on Monday to figure out what personal protective gear the team needs to perform the procedure safely.

“We’re talking about a virus that’s been around for months, not years or decades,” said Mattatall. “We’re used to taking time and mulling over research and applying it, but we don’t have time right now.”

Leanne Paola has always been open to the idea of having her baby, due in May, at her Toronto-area home. But the arrival of COVID-19 solidified her decision to have a homebirth.

“It’s probably not the best time to be in a hospital, because we know they are overwhelmed, so if I don’t need to use up that space, I won’t,” she said. “I just thought, if I do it at home it will be more peaceful, and more of an environment that we can control.”

Midwives across Ontario are expecting to see more women with uncomplicated pregnancies choosing homebirth in the months ahead, Tecson said.

However, in general, she notes the ability of midwives to lighten the load on hospitals by caring for pregnant women in the community depends on whether they have access to personal protective equipment to keep themselves safe. Tecson agrees with the recommendation that women who have been diagnosed with COVID-19 deliver in hospital, but in unconfirmed cases, midwives with protective gear can continue to provide care at home at their discretion.

“This is the practical thing that we are all in the health-care system struggling with, but we have a very specific need in order to be able to help the system.”

Homebirth won’t be an option for all women, either because they require specialized medical care or they simply feel more comfortable in hospital, despite the COVID-19 outbreak. (And even those who plan homebirths may wind up in hospital if complications arise.)

But with the many uncertainties tied to the pandemic, having a homebirth is one way some moms-to-be, whatever their circumstances, can retain control of their birth experience as best they can.

In preparation for her planned C-section at Mt. Sinai Hospital this week, Shannon Russell and her parents reached a “reciprocal agreement” so they can take care of her 14-month-son while she recovers.

“We wanted to make sure that my son wasn’t going to give my parents anything. They wanted to make sure that they didn’t give us anything,” she said. “We put ourselves — all of us, as a team — into a self-imposed, self-isolation. It’s reduced my stress greatly.”

She said she is trying to take it in stride, and hopes that one day, being born in a pandemic will be her baby’s “story to tell.”

However, many other women will struggle to find a bright side during the outbreak. Maya Roy, CEO of YWCA Canada, said the situation is dire for those living on the margins, who may be more at risk of contracting COVID-19 and depend heavily on community services that have been suspended due to the pandemic, particularly postpartum.

“We’re going to have to get really creative with solutions, because this is literally life or death,” she said.

The stakes are also high for Murphy, the east-Toronto mom whose son will need surgery at Sick Kids.

A hospital spokesperson acknowledged the restrictions on visitors is “an incredibly difficult situation for everyone involved,” and said “we will consider exceptions for families that would balance compassion with vital infection protection.

“These are unprecedented times.”

Murphy said she understands the need for the new policy, but she is struggling to come to terms with the implications for her and her partner.

“I hope that one of us doesn’t have to make a life-altering decision without the other one there,” she said.