Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

M

Name of Activity:

Antepartum, Intrapartum and Postpartum Care of Mother and Infant for Influenza-like Illness (ILI) Outbreak: COVID-19 Positive, Under Investigation for, or Symptomatic of COVID-19 Infection.

Role Performing Activity:

STANDARD WORK

Location: All SHA facilities Department: SHA Maternal & Children’s Provincial Programs

Document Owner: Tanya Anderson, Director, Maternal & Children’s Provincial Programs

Region/Organization where this Work Standard originated:

Date Prepared:

March 15, 2020 Last Revision:

March 22, 2020 Date Approved:

Standard Work Summary: To reduce and contain the spread of influenza-like illness (ILI) (such as COVID-19) while supporting the direct and unique needs of maternal and child populations. The document describes guidelines and algorithms for managing pregnant women and neonates with suspected or confirmed COVID-19 infection in labor. These guidelines may need to be adjusted according to local institution for operationalization; however, the purpose is to have standard principles across Saskatchewan.

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1. The management of antepartum, intrapartum, and postpartum care should be guided by a patient-centred discussion using available evidence.

2. In any setting visitor restrictions are as per the Maternal and Children’s Provincial Program Visitor Restrictions in Obstetrical, NICU/SCN and Pediatric Inpatient Units (including PICU, Pediatric High Acuity Units and Acute Care Pediatric Units).

3. Antepartum In community:

Self-isolation is required for some travellers, for individuals who have been in close contact with a person with COVID-19, and for individuals who are diagnosed with COVID-19 and well enough to stay at home. In order to prevent the spread of infection, tell patients to:

o practice frequent hand hygiene o stay at home o avoid situations where there is a potential to spread the infection to others: work;

school; sporting events; social, cultural and religious gatherings o avoid public places such as restaurants and malls o avoid public transportation o if there is a pressing necessity and the person needs to leave home, they should

wear a surgical mask while out.

Self-monitoring means paying attention to your health so you can identify signs of sickness.

o Self-monitoring is an important way of preventing COVID-19 from spreading in Saskatchewan.

o Ensure patient is taking their temperature properly and tracking new symptoms and temperature.

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

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(Order in which tasks

occur)

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Instruct individuals to access the Government of Saskatchewan website for information and Self-Assessment tool at https://www.saskatchewan.ca/~/link.aspx?_id=6C6BF971659346E0B8E9DE4AE3B2AFF9&_z=z

Expectant management at home may be appropriate for many women with self-isolation; this means the patient is considered well enough to not require admission to hospital and can remain in their home.

If antepartum individual COVID-19 positive: o Self-isolate at home until 24 hours after symptoms resolve – Medical Health

Officer (MHO) will determine whether repeat testing is required. o If symptoms worsen, seek care – call 811.

Prenatal visit frequency in LOW RISK pregnancies. o Recommended visit schedule:

Initial visit – in-person, face to face Alternate in-person visits with virtual visit every 3 to 4 weeks until 30

weeks gestation. Alternate in-person visits with virtual every 2 weeks until 36 weeks

gestation. Alternate in-person visits with virtual visit every week until 40 weeks

gestation. o Must be modified in view of patient risk. If complications develop, recall patient

as needed. o For patients with risk factors for hypertension, consider recommending obtaining

a blood pressure cuff around 30 weeks. If no cuff and risk factors present then require in-person visits in the final month to monitor for development of hypertension.

Lab Testing in antenatal period o Minimize frequency, particularly if less necessary or routine. o Keep women out of the lab when possible (e.g. Combine repeat STI screen with

50g).

If antepartum homecare is required, o Clinicians should consider whether antepartum in-home visits are necessary and

use telemedicine tools as much as possible. This may include telephone consultations or similar, depending on the resources available.

o When care is required in the home (e.g. IV therapy, injections) ensure pregnant woman wears surgical mask and the healthcare provider must ensure Personal Protective Equipment is utilized with DOPLET/CONTACT PLUS precautions including:

Surgical mask Gown Gloves Protective eyewear/Face shield

Presentation/Admission to Hospital:

Pregnant women who are positive, under investigation, symptomatic, or positive verbal screen for COVID-19 will don a surgical mask immediately upon presentation to facility.

The “well” COVID-19 pregnant patient does not require referral to a tertiary care centre for in patient care and/or ambulatory consultation based on COVID-19 diagnosis alone.

The medical management of the “unwell” COVID-19 pregnant patient is similar to any acute viral respiratory illness: supportive therapy and possible hospitalization and transfer to appropriate level of care.

Pregnant women should be triaged quickly and transferred to a single-occupancy room. o One patient per room. o Implement DROPLET/CONTACT PLUS precautions.

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

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o Swab/test according to SHA guidelines.

Personal Protective Equipment (PPE) utilized is DROPLET/CONTACT PLUS includes: o Surgical mask o Gown o Gloves o Protective eyewear/Face shield

If an Aerosol Generating Medical Procedures (AGMP) is taking place, it is ideal for a patient to be placed in a negative pressure room on AIRBORNE precautions.

o An AGMP is any procedure that may induce production of aerosols of various sizes, including droplet nuclei.

o AGMPs considered high risk include: bronchoscopy, continuous positive airway pressure (CPAP), bi-level positive airway pressure (BIPAP), intubation and extubation procedures, CPR with bag valve, optiflow, and nebulization.

o All previously listed Personal Protective Equipment is utilized. o Additionally, an N95 respirator and face shield/protective eye protection must be

used by heath care workers entering the patient’s room for the duration of the AGMP.

o Obstetrical care providers should wear N95 respirators when providing care in the operating room setting (e.g. caesarean section) in case there is an urgent need to initiate general anesthesia or convert from spinal or epidural anesthesia to general anesthesia.

o Preferably utilize an operating room with a negative pressure option. o There is no data to indicate that the second stage of labour generates aerosols,

Droplet/Contact precautions are to be utilized for vaginal delivery.

Close monitoring or initiation of an obstetrical early warning system (e.g. OTAS, MEOWS) is appropriate.

Consideration for the initiation of antepartum corticosteroids for fetal maturation if preterm delivery is indicated or anticipated.

4. Fetal Surveillance for COVID-19 Patient Anatomical scans should proceed as routinely scheduled for all patients, regardless of

COVID-19 infection status, as an essential component of obstetrical care.

Fetal surveillance for COVID-19 patients includes monthly ultrasounds for anatomy, fluid and growth. In the setting of a mild infection in the first trimester, antepartum management similar to that for a patient recovering from influenza is reasonable. For those experiencing illness later in pregnancy, consider sonographic assessment of fetal growth in the third trimester.

Intrapartum fetal monitoring in the form of external fetal monitoring (EFM) should be considered given evidence showing potential fetal distress during labour.

o A dedicated Doppler and/or continuous fetal monitoring equipment will be assigned to this patient.

o Where sharing of equipment is mandatory, equipment will be terminally cleaned between patient use.

5. Intrapartum Care Intrapartum care will be provided in the hospital setting.

o Unnecessary health care personnel in the room should be minimized. o Home births are not permitted due to challenges associated with ensuring

appropriate personal protective equipment in the home setting and high rates of fetal distress reported in the literature.

There is no evidence that the use of Entonox is an aerosol-prone procedure. Entonox should be used with a single-patient microbiological filter.

Consider provision of empiric antibiotic therapy for superimposed bacterial pneumonia in confirmed COVID-19 infection or severe respiratory disease.

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

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Caesarean delivery for obstetrical indications only. The diagnosis of COVID-19 itself is not an indication for delivery.

Following individual assessment to determine safety of mother and fetus, elective caesarean delivery should be delayed, if possible, for those who are positive, under investigation for, or symptomatic of COVID-19. Prior to elective caesarian delivery, a COVID-19 positive patient should receive two negative tests, 24 hours apart, to no longer be considered infectious.

Droplet/Contact PLUS precautions for delivery outside of operating room

N95 respirator for delivery in operating room (e.g. caesarean section).

6. Immediate Postpartum Care of Infant Make provision for resuscitation of baby in location of delivery, do not move baby to

another location for resuscitation if possible. o Commonly used equipment for neonatal resuscitation and stabilization should be

readily available (e.g. located in disposable grab bags) to avoid taking the full resuscitation equipment into the room unless required.

o A dedicated pulse oximeter should be located on the infant warmer or resuscitaire to avoid moving equipment in and out of the delivery room unnecessarily.

Appropriate PPE for Droplet/Contact protection is used.

Neonatal resuscitation/stabilization should proceed as per Canadian Neonatal Resuscitation Program (NRP) guidelines and one (1) staff should be available to provide NRP in the delivery area.

In the absence of evidence, it is reasonable to treat an infant’s respiratory illness in a manner similar to the non-exposed infant.

Based on available evidence, continue with usual postpartum care for “well” infant including:

o Delayed cord clamping; o Skin to skin after risk/benefit discussion with mother.

mother completes hand hygiene prior to receiving infant mother wears a surgical mask

o Bathing baby as per facility practice.

7. Postpartum Care of the Mother/Infant Dyad The infant born to a mother who is positive, under investigation for, or symptomatic of

COVID-19 during the intrapartum period, or was positive for COVID-19 (or suspected of being COVID-19) at any time in pregnancy, will be tested for COVID-19 at birth.

o Nasopharyngeal swab and umbilical swab for COVID-19 polymerase chain reaction.(see Appendix Specimen Collection for COVID-19 Umbilical swab)

o Newborn will be considered under investigation.

Infant feeding as per the Maternal and Children’s Provincial Program Infant Feeding, including Breastfeeding and Expressed Breast Milk, when Mother Positive, Under Investigation, or Symptomatic for COVID-19.

If maternal patient confirmed COVID-19 positive, two (2) negative tests, 24 hours apart, are required before lifting infection prevention and control (IPAC) precautions.

“Well” infant/“Well” mother:

Newborns do not routinely require separation from the mother following birth. o Healthy mother/infant dyad to remain together in single occupancy room. o Transfer baby in incubator. o DROPLET/CONTACT precautions remain. o Bassinette is kept more than 6 feet from mom’s face if feasible at all times.

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

Task Sequence

(Order in which tasks

occur)

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o Ensure family wash hands/use alcohol-based hand sanitizer before and after providing newborn care and feeding.

o Mother to wear surgical mask within two (2) meters of infant, when providing newborn care and feeding.

Should the family request separation of mother from infant to reduce risk of COVID-19 transmission, this should be accommodated upon availability of resources.

“Unwell” infant/“Well” mother:

Infants who are medically unstable and require NICU care will be admitted to a single occupancy room for stabilization.

o Transfer baby in incubator. o Initiate DROPLET/CONTACT precautions o If infant ventilated, admit to negative pressure room under AIRBORNE

precautions if infant ventilated. Consider admitting all infants to negative pressure room in case of

aerosol generating procedure. o If infant requires transfer to a higher level of care, inform receiving centre/unit

that mother is COVID-19 positive, under investigation or symptomatic/positive verbal screen.

o COVID-19 positive, under investigation, symptomatic or positive verbal screen parents are not permitted to visit in NICU.

This would be re-evaluated as needed in cases where the infant is critically ill or receiving palliative care

o Arrange for “usual” postpartum care of mother. Mother may transfer with infant if capacity at receiving site available.

“Well” infant/ “Unwell” mother:

“Well” infants born to mothers who require medical care due to moderate/severe ILI (COVID-19) medical illness will be admitted to NICU for monitoring.

o Facilities may consider keeping healthy infant in single occupancy room under care of non-symptomatic family member/delegate.

o Transfer baby in incubator. o Initiate DROPLET/CONTACT precautions o If mother requires transfer to a higher level of care, inform receiving centre/unit

that patient is COVID-19 positive, under investigation or symptomatic/positive verbal screen.

o Infant may transfer with mother if capacity at receiving site available.

“Unwell” infant/ “Unwell” mother:

Follow steps for both “unwell” infant and “unwell” mother as indicated above.

8. Discharge

If mother positive, under investigation for, or symptomatic of COVID-19 infection, coordinate discharge of mother and infant with primary care/public health to ensure appropriate follow-up in community.

Clinicians should consider whether postpartum home visits are necessary and, if so, use telemedicine tools as much as possible. This may include telephone consultations or similar, depending on the resources available.

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

Task Sequence

(Order in which tasks

occur)

Task Definition (Brief summary of task )

Task Cycle Time (Define unit of

measure -

seconds, minutes,

etc.)

The management of postpartum care should be guided by a patient-centred discussion about the available evidence and its limitations.

Guidance for mother and infant being discharged to home: o If other individuals at the home are positive or under investigation, discuss with

the mother/infant that relocation for the duration of the individual(s) 14-day home isolation period is advised to reduce the risk of severe illness.

o If the mother and newborn decide to return to a home where someone present is positive, under investigation, or symptomatic of COVID-19, this individual must continue to self-isolate.

o If the mother and/or infant reside with others and are the first in the household to have symptoms of COVID-19, both mother and infant must stay at home for 14 days and self-isolate. All other household members should relocate if possible.

o Staying at home for 14 days will greatly reduce the overall amount of infection the household could pass on to others in the community.

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

Appendix Umbilical Swab Testing

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

Rev 20160210 © 1996-2015, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

References

Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN). (March 15, 2020). COVID-19: Suggestions for the care of the perinatal population. Retrieved March 15, 2020 from https://capwhn.ca/covid-19-suggestions-for-care/ Centre for Disease Control (March 14, 2020). Interim considerations for infection prevention and control of Coronavirus Disease 2019 (COVID-19) in inpatient obstetric healthcare settings. Retrieved March 15, 2020 from Government of Saskatchewan. COVID-19 Retrieved from https://www.saskatchewan.ca/government/health-care-

administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-

coronavirus/~/link.aspx?_id=6C6BF971659346E0B8E9DE4AE3B2AFF9&_z=z

Government of United Kingdom. (Published 12 March 2020; Last updated 18 March 2020). Guidance COVID-19: guidance for households with possible coronavirus infection. Retrieved from https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance Royal College of Paediatrics and Child Health. (Last modified 19 March 2020). COVID-19 - guidance for paediatric services. Retrieved from https://www.rcpch.ac.uk/resources/covid-19-guidance-paediatric-services Royal College of Obstetricians and Gynecologists. (Version 3: Published Wednesday 18 March 2020). Coronavirus (COVID-19) Infection in Pregnancy. Guideline for Healthcare Professionals. Retrieved from https://www.rcog.org.uk/globalassets/documents/guidelines/coronavirus-covid-19-infection-in-pregnancy-v3-20-03-18.pdf Saskatchewan Health Authority. (March 18, 2020). DrugLine 27 Interim Update (1.5). Society of Obstetricians and Gynaecologists of Canada (n.d.). Updated SOGC Committee Opinion – COVID-19 in Pregnancy. Retrieved March 15, 2020 from https://www.sogc.org/en/content/featured-news/Updated-SOGC-Committee-Opinion–%20COVID-19-in-Pregnancy.aspx