[9 MIN READ]

Updated: March 18, 2020

Working on the front lines of an obstetric unit is fraught with vulnerability and uncertainty during these early stages of the unprecedented COVID-19 pandemic. Your obstetric team has never before been so codependent in maintaining safety for you and your entire community. Arming yourself and teammates with the most current knowledge will help to keep you, your family, and your patients as safe as possible.

Since much is unknown about the novel coronavirus, review of daily updates and evolving information from our health experts is important. Staying knowledgeable and well-informed will require ongoing review of CDC updates and government notifications, as well as guidelines from our own health professionals like AWHONN and ACOG. All healthcare providers and frontline OB staff should work together to help ensure that everyone is practicing using the most current information. Teamwork along with shared learning will help everyone stay informed.

To keep yourself and your obstetric peers current on COVID-19, The Sullivan Group is providing this summary of recent information from the CDC and ACOG (last updated March 18, 2020).

Overview of COVID-19 Recommendations

While it seems that most COVID-19 illness so far is mild, information from China shows that serious illness occurs in 16% of cases; older people and those of all ages with severe chronic medical conditions such as heart disease, lung disease and diabetes are at higher risk for developing serious illness with the COVID virus. The good news is that pregnant patients have not as yet shown increased risk for serious illness; however, high fevers in the first trimester of pregnancy are concerning, so pregnant patients must remain vigilant since much about COVID-19 is still unknown.

These general health and safety practices are recommended for the pregnant population:

• Wash your hands often with soap and water or alcohol based (with >60% ethanol or 70% isopropanol) hand sanitizer.
• Avoid sick people.
• Cover your cough by using your elbow, and place used tissues immediately into the trash.
• Refrain from touching your face.
• Clean and disinfect your home.

ACOG Advisory for COVID-19 OB Patients

ACOG recently released an advisory to assist those caring for pregnant patients who are either suspected or confirmed of having the COVID-19. It includes an algorithm that provides assistance for both assessing and managing these patients. Review the ACOG advisory here.

ACOG recommends that routine prenatal care remain in place for all patients free of high-alert symptoms. Providers should watch for the following high-alert symptoms that require further investigation:

• Cough
• Respiratory difficulty or shortness of breath
• Gastrointestinal symptoms
• Fever ≥100.4°F ( ≥38°C)

Pregnant patients exhibiting any of these symptoms should have an illness severity assessment to stratify them as either low, moderate or elevated risk. Read specifics in the algorithm.

As part of the severity assessment, ask if the patient is experiencing any of the following:

• Difficulty breathing or shortness of breath
• Difficulty completing a sentence without gasping for air or needing to stop to catch breath frequently with walking
• Coughing up more than one teaspoon of blood
• Chest pressure with coughing
• Unable to keep down liquids
• Signs of dehydration such as dizziness when standing
• Less responsive or becomes confused when being spoken to

Answering “yes” to any of the severity assessment questions elevates risk status. High-risk patients will require immediate care via entry into the ED, with immediate transfer to an isolation room. Infectious disease processes should ensue for all those who came into contact with these individuals.

Patients who do not meet the high-risk criteria but have the added complexity of a comorbidity or social risk factor are deemed to be at moderate risk.

Low-risk patients are those who do not meet criteria of a high- or moderate-risk patient (no comorbidity) and do not have any respiratory compromise. These patients can be followed with care at home consisting of hydration and rest; they will be responsible for ongoing self-monitoring of symptoms that would require restart of the algorithm evaluation. Routine obstetric precautions would also be in place for these patients; consider doing routine prenatal visits via telemedicine consultation in times of workforce shortages.

Please review the ACOG algorithm specifics with your coworkers. Print and laminate the algorithm and display it on your unit so it is readily accessible as a resource.

This is current information regarding obstetric patients and COVID-19:

• Respiratory droplet transmission is thought to be the primary source of person-to-person transmission. Viral transmission is strong when an infected person sneezes or coughs. Viral droplets can remain in the air for up to three hours.
• It is unknown if mother-to-fetus transmission is possible.
• It is unknown if the virus can be transmitted during the birth process; however, current information states that amniotic fluid and breast milk samples have remained virus-free. One source also states that cord blood, vaginal fluid, and newborn throat cultures have been virus-free. There is no documented case of transmission of the virus from a contaminated surface. However, the virus can remain on surfaces from hours to days; therefore, disinfecting surfaces is crucial to preventing potential spread. Primary transmission is via respiratory droplets.
• For a mother testing positive for or suspected of having COVID -19 (person under investigation/PUI), transmission via breast milk remains unknown. The decision to start or continue breastfeeding is a decision the mother should make after consulting her healthcare provider.
  
  The CDC provides up-to-date guidance for breastfeeding mothers in the immediate postpartum period and those who contracted the virus after having already started breastfeeding. At this time, it is not known if COVID-19 can be transmitted via breast milk; it has not been detected in breast milk when samples were analyzed. Since breast milk is considered the gold standard for nutrition for infants, the decision to breastfeed or not must be carefully considered by the healthcare team.
  
  The CDC has no specific guidance regarding breastfeeding during previous similar viruses such as SARS-CoV or Middle Eastern Respiratory Syndrome (MERS-CoV). However, it does recommend that mothers with influenza who are outside of the immediate postpartum period continue to breastfeed while taking all precautions to limit spreading the virus. Impeccable hand washing before touching the infant and wearing a mask during breastfeeding are prudent safety measures.
  Another possible option for mothers to consider is to pump and collect expressed milk rather than breastfeed; the breast milk could then be given to the infant via bottle by a healthy person if the mother is infected. Pump parts would require scrupulous cleaning between pumping sessions. Again, it is not known if the virus transmits into breast milk.

CDC Guidance for Inpatient Obstetrics

The CDC has offered guidance for inpatient Obstetrics, including triage, labor and delivery, and postpartum:

• Obstetric units should have a plan in place to prevent transmission of the virus that includes application of CDC infection control guidelines: isolation of confirmed COVID cases or patients who are under investigation for the virus. Single patient rooms with doors closed at all times are acceptable when isolation rooms are not available. Airborne infection isolation rooms will be reserved for those receiving aerosol-generating procedures. Full personal protective equipment (PPE) is required when entering the room.
• OB units should consider precautionary measures for their own staff who are pregnant that limits their exposure to confirmed COVID-19 patients.
• A pregnant patient with confirmed COVID or who is under investigation should be told to notify the obstetric unit prior to arrival so that appropriate preparations for care can begin. This should be a routine teaching point provided to all prenatal patients. They should not just show up unannounced to the labor and delivery unit if they are exhibiting high-alert symptoms; they need to be educated to the fact that there are specific procedures in place to admit these patients to the labor and delivery unit. Staff will need to consider patient placement and staffing issues. There should be a previously agreed upon designated drop-off point for patients arriving by EMS /ambulance.
• Infection Control needs to be notified of admission of confirmed COVID patients and those under investigation for COVID.
• Infection control practices should be reviewed with the OB staff. Donning and doffing of PPE should be reviewed. Staff needs to understand and be correctly trained on infection control procedures.
• There should be a process in place to protect all newborns from risk. Infants born to mothers with confirmed COVID should be considered as PUIs and should be isolated per CDC guidelines. It is unknown if the infant is at increased risk for complications. Post-birth transmission from respiratory droplets should be a primary concern. Mother-baby separation (separate rooms) should be strongly considered until the mother is cleared of transmission potential. The infant should remain isolated until the healthcare team decides otherwise, with guidance from infectious disease and public health officials. Disease severity and lab values should be taken into consideration when discontinuing isolation.
  Visitors should be limited to one person, with all visitors donning PPE. One healthy visitor with PPE can assist with diapering, bathing and feeding. PPE for visitors includes gown, gloves, face mask and eye protection. If rooming-in is decided upon based on the mother’s wishes or due to facility limitations, precautions should be implemented to limit newborn exposure to contaminated respiratory droplets. Keep newborn and mother greater than 6 feet apart or provide a curtain between them.
  If there is no other healthy adult to care for the infant, then the mother should use strict hand washing and wear a face mask prior to any contact with the infant. These precautions should continue until the mother is taken off transmission-based precautions.

• Visitors should be limited for all patients to optimally only one support person – either spouse or partner. Children should not be allowed on the obstetric unit.
• If mother and baby are separated and mother intends to breastfeed post-separation, initiate pumping with strict hygiene practices. Discuss the decision to provide the infant with expressed breast milk with the healthcare provider.
• Postpartum discharge for confirmed cases are to follow CDC guidelines.

OB doctors and nurses will be front-line care providers; they need to take infectious disease safety measures seriously. This is uncharted territory since much information about this virus is unknown and evolving. Strict adherence to safety practices must be mandatory; all staff should understand the importance of adhering to these practices for themselves and their patients.

Summary

“Flatten the curve” and “slow progression” are phrases that Americans are hearing frequently in an attempt to alter the course of the COVID-19 pandemic. Pandemic evolution follows a specific pattern of phases: investigational, followed by recognition phase, initiation, acceleration, and then deceleration phases. Illness will peak at the end of the acceleration phase. To stay ahead of disease progression, mitigation strategies must be implemented. Our leaders and health experts are working tirelessly to ensure that this happens.

The situation with the COVID-19 virus is rapidly evolving. Everyone should realize that today’s current information may be out of date tomorrow and replaced with new alerts and new guidance. Please keep up to date: https://www.cdc.gov/coronavirus/2019-nCOV/index.html.

Latest ACOG COVID Practice advisory (March 13, 2020):

• https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Novel-Coronavirus2019
• https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html
• https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html
• https://www.marchofdimes.org/complications/coronavirus-disease-covid-19-what-you-need-to-know

Questions for ACOG can be emailed to: covid@acog.org

Additional Resources:

• Evaluating and Reporting Persons Under Investigation (PUI)
• Resources for Hospitals and Healthcare Professionals Preparing for Patients with Suspected or Confirmed COVID-19
• Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings
• World Health Organization Interim Guidance on Clinical Management of Severe Acute Respiratory Infection When Novel Coronavirus (nCoV) Infection Is Suspectedexternal icon