standard protocols and specific measures to be followed
TRANSCRIPT
National Health Mission
Uttarakhand
Standard Protocols and specific measures to be followed for Antenatal, Intra natal and Post natal care in view
of COVID-19
1
Contents
1- Guiding Principal………………………………………………………...2
2- Community Level Consideration…………………………………………3
3- Facility Level Consideration along with Temporary Labor Room……….4
4- Treatment Protocol……………………………………………………….9
5- Breastfeeding and the COVID-19 infected mother……………………21
6- Postnatal Care………………………………………………………….22
7- Referral Protocols………………………………………………………23
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1. Guiding Principal
This has been observed that most of the maternal deaths occurs due to
-Not getting tested at the Community Level even appearing of mild symptoms
- Denial of Admission especially Covid suspected and positive pregnant women
- Increase in Home Delivery due to fear of getting infected at the facility
- Late arrival at the Dedicated Covid facility
Considering the high morbidity and mortality due to pandemic along with resuming the MCH
services two pronged strategy is the need of the hour that is community and facility based
strategy as outlined below-
The Guiding principal for management of all Maternal Cases during Covid-19
pandemic-
No Pregnant women should be denial for hospital admission irrespective of her Covid
status
The fear in the community would be minimize so the pregnant women can visit the
facility for seeking necessary services
Proper follow up of all covid -19 positive deliver cases as well as pregnant women
Every Facility must have triage facility for all pregnant women
As far as possible every FRU/ Block Level Facility should have separate temporary
Labor Room for conducting delivery of Covid Positive even suspected
There should be dedicated covid MCH facility in each districts for the management
of any complications and serious cases
Dedicated Ambulances should be arranged for transportation of pregnant cases
ASHA & ASHA Facilitators must be aware about all pregnant women and their Covid
status. Prior information must be communicated to all facilities before any covid
pregnant women visit to facility.
3
2. Community Level Consideration
The primary step for Covid-19 management for all maternal health services is that there should
be very less fear in the community about Covid-19 and they should follow all guidelines
/protocols. The Role of frontline health workers are very critical for building the faith within
the community for availing necessary maternal health services.
ROLE OF THE FRONTLINE WORKER
A) ANM-
(a) Follow up and coordination with ASHA on Delivery of quality ANC services, especially
on ANC SaMMAN Diwas
(b) Preventive and control measures including social distancing during routine ANC check-
up along with birth planning.
(c) Line Listing of all pregnant women along with Birth Planning
(d) Support Block Surveillance team for early testing of suspected pregnant women
(e) Coordination with Block MOI/c ,AWW and ASHA for conducting ANC session on
VHND day keeping Covid Appropriate Behavior
B) ASHA-
ASHA must be very watchful in this critical time of pandemic especially in case of pregnant
women as it was observed that most of the Covid pregnant cases approached the appropriate
facility only after when their condition became worst due to covid. So it is utmost important to
detect the women as early as possible. ASHA has to perform following two activities
(a) Line Listing of all pregnant women, their regular follow up and measuring of Oxygen
saturation of all suspected cases, Oxygen below 94 would be referred immediately to DCC,
all suspected cases would be referred to Block CHC/FRUs and informing the concern
ANM/AF along with State RCH Call Centre-104
(b) Follow up of all confirmed and suspected pregnant cases (In case of any alarming situation
ASHA has to contact State RCH Call centre (104)
(c) ASHA should also aware about the category of Covid illness that is asymptomatic, mild
moderate and severe cases and should refer all category to Block level facility. Any pregnant
women who is having any past history of illness such as heart, liver kidney problem and present
with Covid like symptoms should be referred immediately to FRU/DH.
(d) ASHA Facilitator will be responsible for monitoring and data reporting from all ASHAs
and provide coordination support to ASHAs. Any pregnant women who is covid positive and
detected in severe condition AFs would be answerable for late detection/ no detection.
4
3. Facility Level Consideration
Following key activities are to be undertaken for facility level consideration-
The suggestive guideline for temporary covid LR are presented along with necessary items.
.Base Hospital Kotdwara and STM Haldwani are two example taken in the consideration for
established the temporary Covid LR. For any support these facility can be contacted.
3.1. Guidelines forDevelopment of Temporary Labour Room (TLR)
The decision to set up TLR would be based upon reduction in institutional deliveries, covid
positivity amongst pregnant women, space and other infrastructure at the facility level.
Moreover due to conversion of major high case load facilities into Covid Hospital and not
conducting non covid deliveries which are always in higher percentage. So to mitigate the
impact on non covid delivery cases it is suggested to those facilities to take necessary steps in
conducting non covid deliveries by setting up temporary labor room as per their
feasibility.The provision of temporary labor room is required in order to conduct the delivery
of covid positive pregnant women or any suspected cases so that the non covid pregnant
women can come to the facility without any fear of getting infected. The basic steps for
setting up temporary labor room are as under-
Identification of Space- Preferably the LR and adjacent ward should have separate entry
and exit. Any room within the hospital complex or nearby facility can be set up for
temporary LR.
The temporary LR should be labeled as Covid LR, necessary items such as Labor Table,
Radient Warmer, delivery trays, medicine trays, PPE kits must be arranged. The
Appropriate isolation of pregnant patients who have confirmed COVID-19 or are
Persons under Investigations / present with symptoms. Admit in isolated temporary
LR. Referrals would be done only after stabilize the case.
Basic and refresher training for all healthcare personnel to include correct
adherence to infection control practices, Personal Protective Equipment (PPE) use
and handling (preferably by a video presentation/ Using Safe Delivery App)
Sufficient and appropriate PPE supplies positioned at all points of care
Processes to protect new-borns from risk of COVID-19
5
suggestive checklist also provided for the same.
Duty roaster of staff should be prepared for the temporary covid LR
Place appropriate waste bags in a bin. If possible, use a touch-free bin. Ensure that used
(i.e. dirty) bins remain inside the isolation rooms.
Place a puncture-proof container for sharps disposal inside the temporary LR and bio-
medical waste should be managed as per the BMWM guidelines.
Keep the patient’s personal belongings to a minimum. Keep water pitchers and cups,
tissue wipes, and all items necessary for attending to personal hygiene within the
patient’s reach.
Patient-care equipment (e.g. stethoscope, thermometer, blood pressure cuff, and
sphygmomanometer) should be dedicated for the patient, if possible. Any patient-care
equipment that is required for use by other patients should be thoroughly cleaned and
disinfected before use.
Place an appropriate container with a lid outside the door for equipment that requires
disinfection or sterilization.
Ensure that appropriate hand washing facilities and hand-hygiene supplies are
available. Stock the sink area with suitable supplies for hand washing, and with alcohol-
based hand rub, near the point of care.
Ensure adequate room ventilation in the temporary LR. If room is air-conditioned,
ensure 12 air changes/ hour and filtering of exhaust air. The principle of natural
ventilation is to allow and enhance the flow of outdoor air by natural forces such as
wind and thermal buoyancy forces from one opening to another to achieve the desirable
air change per hour.
The temporary LR should have a separate toilet with proper cleaning and supplies.
Avoid sharing of equipment, but if unavoidable, ensure that reusable equipment is
appropriately disinfected between patients.
Train all staffs including maternity, neonatal service providers in use of PPE. The safe
delivery App can be used for trainings.
In some of the facilities where due to space constraint temporary LR could not be established in that case the same
LR could be used for eminent delivery cases otherwise the case can be referred to nearby higher centre where there
is a facility of temporary Covid LR. For those facilities which cannot arranged the temporary LR needs to adhere
strictly on infection control protocols presented below-
Environmental Cleaning: Labour Room (LR)
Frequency Process / Additional guidance
Every two hours Clean floor (Phenyl or another phenolic disinfectant).
At least once daily (e.g., per 24-hour
period)
Clean with detergent and copious amounts of water
After each Spill, and as needed 1 in 5 dilution of 5% {1%} Sodium hypochlorite for 20 minutes, or
aldehyde like bacillocid for 10 mins; Mop dry and clean thoroughly
with detergent and water.
Before and after (i.e., between*) each
procedure
Wipe clean bed with detergent and water and then with available
disinfectant after each patient. Wear gloves for this procedure. Use
fresh linen for each patient.
End of the day (terminal clean) Environment and equipment should be maintained dust free.
6
The indicative pictures from BH Kotdwara and STM Haldwani (These two facilities are
taken as example) is presented below for replicating the same.
Temporary Covid LR in BH Kotdwara
Temporary Covid LR in STM Haldwani
Checklist for Development of Temporary Labour Room
A. Infrastructure (Space or area to be developed or identified)
S.N Particualar Required Space Availability Remark
1
Total space for Labour room complex in
female ward & also take two photogarphs
of outer & inner area As per availability
2 Attached toilet with western commode &
washbasin
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3 NBCC Area for Radiant Warmer
4 Space for Prenatal & Postnatal care
5 Elbow tap Hand washing station for staff
6 Nursing station with storage capacity
7 Aluminium/glass partition/curtains for privacy
B. Equipments & Consumables
S.N Equipments required for LDR Required Quantity Availability Remark
1 All time weather 1.5 ton A.C Desirable
2 Labor Table 1 or 2
3 Foetal doppler 1
4 Digital BP instrument 1
5 Drum for Autoclave 1
6 Autoclave 1
7 Ambubag with 0,1 mask 2 sets
8 Pulse oxymeter 2
9 Infrared thermometer 2
10 Focus lamp 1
11 Labour Table 1 or 2
12 Kelly's Pad 2
13 Suction device 1
14 Radiant warmer 1
15 Refrigerator (Small) 1
16 Stretcher 1
17 Normal Beds with Mattress 2
18 Oxygen Cylinder/ Concentrator 2
19 Hub cutter 2
20 Wall clock 1
21 Mucus extractor 20
22 O2 mask 2
23 Crash cart trolley 1
24 Cord clamp 12
25 Exhaust fan 2 to 4
26 LED TV 1 (Desirable)
27 Side rack 3
28 Charging points in each cubicle 4
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29 Bed side locker 2
30 Sutures 12
31 3-bucket mopping trolley 1
32 Emergency Calling Bell 4
33 Cubicle curtains 4
34 PPE including face shield and N-95 respirator
10
35 Hand Sanitizer 10
36 BMW bags with puncture proof container for
sharp items 1
37 Detergent and Lysol/phenolic disinfectant 1
38 IV sets 20
39 Sodium hypochlorite solution As per requirement
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4 Treatment Protocols
Letter No: GDMC/PS/2021/ Dated:31-05-2021
Recommendations of Committee constituted vide Letter No.
426/SEC-MH/2020 dated 26.5.2020 and Letter No. 430/SEC-MH/2020
dated 28.05.2020 and further letter no. 404/PS-SEC/2021 dated 17 May
2021, regarding technical inputs and decision support
(Date 31ST May, 2021)
A committee was constituted vide Letter No. 426/SEC-MH/2020 dated
26.25.2020 and Letter No. 430/SEC-MH/2020 dated 28.05.2020 and further
reconstituted vide letter no. 404/PS-SEC/2021 dated 17 May 2021, regarding
technical inputs and decision support for informed policy making for Covid-19 in
Uttarakhand State. A meeting was held on 31.05.2021 at 2.45 P.M under the
chairmanship of Prof. (Dr.) Hem Chandra, Vice Chancellor, Hemwati Nandan
Bahuguna Uttarakhand Medical Education University, and Prof. (Dr.) Ashutosh
Sayana, Principal, Govt. Doon Medical College & Coordinator of committee through
mutual discussions with following expert representatives from different
hospital/organisation of State of Uttarakhand.
1. Prof. (Dr.) M.K. Pant, Deputy Director, Medical Education
Uttarakhand.
2. Prof. (Dr.) Anurag Agarwal, Nodal Officer Covid-19, GDMC,
Dehradun.
3. Prof (Dr) Chitra Joshi, Head, Obs & Gynae Department, GDMC,
Dehradun.
4. Prof. (Dr) Debabrata Roy, Prof & Head, Community Medicine
Department GDMC, Dehradun.
5. Dr Shekhar Pal, Prof. & Head, Microbiology Department GDMC,
Dehradun.
6. Prof. Ashwani K Sood, Department of Paediatrics, HIMS
Dehradun.
7. Dr. Paramjeet Singh, Associate Prof. Department of Medicine,
8. Dr. Nidhi Uniyal, Associate Professor, Department of General
Medicine GDMC Dehradun.
9. Dr. Atul Kumar Singh, Associate Professor, Department of
Anaesthesia GDMC.
10. Dr. Sanjoy Das, Representative from HIMS, Dehradun.
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11. Dr Ritu Rakholia Associate Professor, Department of Paediatrics
DMC .
12. Dr. Pankaj Singh, State surveillance Officer IDSP
13. Dr. Pradeep Chandra Sharma, Assistant Nodal Officer, COVID-
19, GDMC, Dehradun.
14. Dr. Ashok Kumar, Associate Professor, Department of
Paediatrics, GDMC, Dehradun.
15. Dr. Vishal Kaushik, Assistant Professor, Department of
Paediatrics, GDMC, Dehradun.
16. Dr. Tanvi, Assistant Professor, Department of Paediatrics, GDMC,
Dehradun.
17. Dr. Amit Suyal, Consultant Paediatrician, Haldwani.
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Management of Obstetrics Covid-19 Patient
The recommendations regarding management of Antenatal Covid-19 Positive
Patients are formulated by following Sub-committee members on the basis of
guidelines given by ICMR, AIIMS, State Covid Protocol.
1. Prof (Dr) Jaya Chaturvedi, Head, Obs & Gynae Department AIIMS,
Rishikesh.
2. Prof (Dr) Geeta Jain Head, Obs & Gynae Department, GMC, Haldwani.
3. Prof (Dr) Vineeta Gupta Head, Obs & Gynae Department SGRR Medical
College, Dehradun.
4. Prof (Dr) Ruchira Nautiyal, Head, Obs & Gynae Department HIMS Jolly
Grant, Dehradun.
5. Prof (Dr) N.Bora, Head, Obs & Gynae Department VCSGGMS & RI, Srinagar
Garhwal.
6. Prof (Dr) Chitra Joshi Head, Obs & Gynae Department, GDMC, Dehradun.
At the outset, the committee would like to emphasize that pregnancy, though a
physiological state constitutes a very susceptible and hemodynamically unique
group of patients. Thus management of Covid-19 positive pregnant patients should
be a team work between the obstetrician neonatologist physicians and
anesthesiologists. These recommended Protocols are based on the guidelines
provided till date and may change with upcoming evidence in future. The
recommendation of sub-committee was discussed and finalised by Advisory
committee.
Recommendation -
Following four conditions should be considered while categorizing and
managing the Covid-19 positive antenatal patients:-
a) Severity of Covid19 infection.
b) Gestational age.
c) Any obstetric complaint or indication.
d) Presence and extent of any co-morbidity any medical/ surgical
condition like:-
Diabetes / other Immuno-compromising conditions
Liver diseases
Renal disease
Respiratory disease
Cardiovascular / haematological disorders
Obesity
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The infection is categorized into 4 broad categories:
Category I- Asymptomatic
I a- No Co-morbidity/ No Obstetric complaint or complication
I b- With Co-morbidity / With Obstetric complaint or complication
Category II- Mild disease
II a- No Co-morbidity/ No Obstetric complaint or complication
II b- With one or more Co-morbidity/ With Obstetric complaint or
complication.
Category III- Moderate disease
Category IV- Severe disease
Category I –Asymptomatic
Category I a - Asymptomatic/ No Co-morbidity/ No Obstetric complaint or
indication/All trimesters
Clinical features- No signs or symptoms suggestive of Influenza like illness (ILI)
Investigations-After diagnosis of Covid-19
Routine antenatal investigations only
No additional blood tests/ chest imaging are recommended.
Management- Supportive care, adequate nutrition, plenty of oral fluids to maintain
adequate hydration, routine antenatal care.
Home isolation( provided all criteria fulfilled)
Self monitoring chart to be maintained.
Tab Vitamin C 500 mg OD
Warm saline gargles, steam inhalation.
Tab. Iron and Tab. Calcium + Vitamin D.
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Routine antenatal care through telemedicine.
Report to facility – Appearance of symptoms, Obstetric complaint.
Category I b- Asymptomatic with Co-morbidity and/or Obstetric
complaint/Indication
All trimesters
Complete initial work up at the facility.
Admission and facility based care, if Laboratory or clinical parameters not within
the normal limits and/ or obstetric indication.
Management of obstetric condition as per standard obstetric guidelines.
If parameters normal and no obstetric indication then Home isolation with self
monitoring
Daily checking of monitoring chart by HCW.
Steam inhalation, warm gargles
Vitamin C 500 mg OD
Tab. Iron and Tab. Calcium + Vitamin D.
Routine antenatal care through telemedicine.
Report to facility in case of appearance of symptoms/ obstetric indication.
Eligibility criteria for Home Isolation-
There should be no fast breathing/ hypoxia
Absence of all Co morbidities/ obstetric complaint.
Requisite facility for isolation is available,
Caregiver is available -to provide care on 24X7 basis
Caregiver has agreed to monitor health of the patient
Regularly inform the health authority about the same,
Patient and care-giver have filled an undertaking after understanding the
aforesaid.
If home isolation is not feasible, patient should be taken care of in a Covid-19
healthcare facilities or Hospital.
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Self monitoring chart
Day/
date
Pulse
rate
Respiratory
rate
SpO2 Temperature Feeling
of well
being
Any fresh
complaint
ASHA workers to be sensitized about importance and interpretation of
self monitoring.
Report to treating doctors in case of any problem.
Category II- Mild disease
Category II a- Mild disease / No Obstetric complaint or indication/ No Co-
morbidity
Clinical features-
Cough, malaise headache, myalgia, fatigue, sore throat, nasal symptoms fever
(>37.8), chills, loss of smell/taste, diarrhoea.
No shortness of breath or hypoxia.
Investigations*-Routine antenatal investigations + CBC, CRP (if possible)
*Additional investigations (if symptoms persist for > 5 days or the symptoms
worsen)- CRP, LFT, KET, X ray chest with abdominal shield ( as per adv of
physician)
Management- Supportive care, adequate nutrition, plenty of oral fluids to maintain
adequate hydration
Oral Paracetamol 650 mg; may be repeated every 4-6 hours.
Tab Azithromycin 500 mg OD x 5 days,
Tab Vitamin C 500 mg OD
Tab. Iron and Tab. Calcium + Vitamin D.
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Warm saline gargles, Betadine gargles, steam inhalation.
Other symptomatic treatment may be given accordingly.
Routine antenatal care though telemedicine.
Report to facility – Persistence of symptoms, Worsening of symptoms,
Danger symptoms and signs (specified as below) or/ and any obstetric
complaint.
Danger symptoms and signs- (ASHA workers to be sensitized)
Difficulty in breathing with RR>24
Oxygen saturation below 94% on a fingertip pulse oximeter,
A persistent fever of 100.4 or higher for more than 24 hours,
Persistent pain or pressure in the chest,
Unremitting cough,
Mental confusion or inability to wake up, slurred speech, seizures,
weakness or numbness in any limb or face,
Bluish discolouration of lips or face,
Signs of onset of any organ dysfunction such as hypotension and
drowsiness, decreased urine output.
Any obstetrical complaint such as Preterm contractions, Vaginal Bleeding
or decreased fetal movements.
Category II b- Mild Disease with Co morbidity and/ or obstetric
complaint or indication
Clinical features-
Cough, malaise headache, myalgia, fatigue, sore throat, nasal symptoms
fever (>37.8), chills, loss of smell/taste, diarrhea.
No shortness of breath or hypoxia.
Investigations*- Routine antenatal investigations + CBC, CRP (if possible)
Facility based care.
Complete initial work up at the facility.
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Supportive care, adequate nutrition, plenty of oral fluids to maintain
adequate hydration
Oral Paracetamol 650 mg; may be repeated every 4-6 hours.
Tab Azithromycin 500 mg OD x 5 days,
Tab Vitamin C 500 mg OD
Tab. Iron and Tab. Calcium + Vitamin D.
Warm saline gargles, Betadine gargles, steam inhalation.
Other symptomatic treatment may be given accordingly.
Management of obstetric condition as per standard obstetric guidelines.
Category III - Moderate disease
(All Trimesters)
Clinical feature-
Shortness of breath,
Pneumonia,
Loose stool, vomiting, severe headache,
Respiratory rate≥ 24/min
Saturation 90-94% on room air with no signs of severe pneumonia/ illness.
Mild disease symptoms persisting beyond 5 days.
Investigations-
CBC
Blood sugar
CRP– 48 to 72 hourly
D-dimer– 48 to 72 hourly
S. Ferritin 48-72 hourly,
LFT, KFT 24-48 hourly,
IL-6 if deteriorating ,
Chest X-ray, HRCT (With abdominal shield) in consultation with physician.
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Management-
Facility based management- Dedicated Covid Health Centre (DCHC) or
District Hospital or Medical College.
Multidisciplinary approach.
Oxygen support to maintain SpO2 >95%- Non Re breathing Masks( NRBM)
Awake proning with 2 hourly change in position.
Steroid therapy-
a) Start in consultation with physician.
b) Inj. Methyl Prednisolone 0.5 – 1 mg/kg in 2 divided doses (or Inj.
Dexamethasone)
c) Switch to oral when stable or improving.
Anti coagulation- start in consultation with physician
a) Not to be started if patient is in labour or labour is imminent in next
24 hours.
b) Rule out any blood dyscrasias.
c) Rule out – Hemorrhagic Obstetric conditions eg- APH.
Monitoring –
a) Clinical – Pulse rate, Blood Pressure, SPO2, Temperature, fetal
monitoring
b) Laboratory investigations/ imaging- as per protocol
Antivirals – As per recommendation of physician
Remdesivir – In pregnancy, the use of remdesivir has not been well tested
however, the discretion lies on the treating physician based on the severity of the
disease and the risk benefit ratio, after ruling out any other contraindication like
deranged hepatic and renal function. However, no fetal toxicity has been reported
till date.
Referral- a) Information to be sent to the referred centre
b) All the documents explaining in detail the findings, treatment given
and investigations done, to be provided to the patient.
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c) Patient to be sent with oxygen support.
d) Tab. Dexona 6 mg stat or Tab Methylprednisolone 16 mg stat or
Inj.Methyl prednisolone 0.5 to 1 mg/ kg x stat ( as per the
availability)
e) Injection Ceftriaxone 1 gram,IV stat.
Category IV- Severe Disease
Clinical Feature – Clinical signs of pneumonia with Respiratory Rate ≥ 30/min, SpO2
<90% or ARDS, Sepsis, Septic shock, MODS.
Investigations: CRP, D-dimer, S. Ferritin 48-72 hourly, CBC, LFT, KFT 24-48 hourly,
IL6 if deteriorating, Chest X-ray, HRCT with abdominal shield.
Management
Facility based care-Tertiary level healthcare facility.
Multidisciplinary approach with physician and intensivist .
Patient to be shifted on oxygen to a Covid care equipped centre.
Ensure that there is no obstetric emergency or delivery is not imminent prior to
shifting.
Give supplemental oxygen therapy to target SpO2 >94% during resuscitation
and >90% for stable and recovering patients. Choice of oxygen support HFNC,
NIV, Mechanical Ventilation as per the condition of the patient and decision of
Anaesthesiologist/ Intensivist.
Injectable antibiotics as per institutional protocol.
Steroid therapy as per protocol in consultation with physician.
Anticoagulation as per protocol in consultation with physician and intensivist
after ruling out labour/ imminent labour/ obstetric hemorrhagic conditions.
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Referral criteria:
Assess the clinical status prior to referral to a designated Covid facility.
If the patient is in active labor or any other high risk related to obstetrics that
needs to be attended on priority before referral.
Inform the facility beforehand about the transfer.
Patient with Moderate illness (RR>24, SPO2-90-95%) should be referred to
DCH/Medical College on O2 therapy.
Patient with Severe illness (RR>30, SPO2<90%) should be transferred to
DCH/Medical College on HFM on O2.
Tab. Dexona 6 mg stat or Tab Methylprednisolone 16 mg stat or Inj.Methyl
prednisolone 0.5 to 1 mg/ kg x stat ( as per the availability)
Injection Ceftriaxone 1 gram,IV stat.
Intra-partum Care:
The timing of delivery will be determined as per the clinical condition of the
mother and the standard obstetric guidelines. It is reasonable to postpone
delivery if there are no other medical or obstetrical indications for the same.
However, if indicated, decision of delivery should not be deferred just
because of Covid positive status of the patient
Once settled in an isolation room, a full maternal and fetal assessment should
be conducted to include:
a) Assessment of the severity of COVID-19 symptoms, which should
follow a multi- disciplinary team approach including a physician and/or
critical care intensivist.
b) Confirmation of the onset and stage of labor, as per standard care.
c) Fetal monitoring
Maternal observations including temperature, respiratory rate & oxygen
saturation.
Hourly oxygen saturation has to be monitored during labor.
Aim to keep oxygen saturation >94%, titrating oxygen therapy accordingly.
Avoid volume overload in all stages of labor.
Electronic foetal monitoring using cardiotocograph (CTG) as per standard
protocol.
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There is currently no evidence to favour one mode of birth over another.
Mode of birth should not be influenced by the presence of COVID-19, unless
the woman’s respiratory condition demands urgent delivery. Hence the
interventions and decisions will be as per the standard obstetric guidelines.
In case of deterioration in the woman’s symptoms, make an individual
assessment regarding the risks and benefits of continuing the labor, versus
emergency caesarean birth if this is likely to assist efforts to resuscitate the
mother.
Regional anesthesia to be preferred as far as possible in case of caesarean
section as GA can be an aerosol generating procedure.
Baby Trolley should be placed 2 meter away from delivery table/ operating
area.
Delayed cord clamping should be done unless indication for early clamping.
Active management of third stage of labor (AMTSL) for all patients. Avoid
Carboprost in cases of PPH.
Breast feeding taking care of Covid appropriate precautions.
Postpartum Care:
Illness to be classified as mild, moderate and severe based on symptoms
and to be treated similar to non pregnant patients.
Breastfeeding and Rooming-in to be allowed following Covid appropriate
behavior.
Counseling for PPIUCD should be done for stable patients.
Vaccination.
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5. Breast-feeding and the COVID-19
infected mother
There is no evidence that COVID -19 is secreted in breast milk. As breast milk is the
best source of nutrition and general immunity for the infant, early initiation of breast
feeding should be done and initiated in golden hour.
In the light of the current evidence, it is advised that the benefits of breast feeding
outweigh any potential risks of transmission of the virus through breast milk.
Adherence to infection prevention and control measures essential while breast feeding
should be followed.
WHO recommends that mothers with suspected or confirmed COVID-19 should been
courage to initiate or continue to breastfeed. The main risk for infants of breast feeding
is the close contact with the mother, who is also likely to share infective air borne
droplets.
The following precautions should be taken to limit spread to the baby:
I. If the baby is roomed-in, it is better to keep the baby at a distance of more
than one metre from the mother except for the duration of breastfeeding.
II. Pregnant woman should wash her hands before and after touching her baby
III. She should wear a mask (preferably N95)
IV. She should avoid coughing or sneezing while breastfeeding
V. All surfaces should be kept clean and disinfection should be done.
VI. If a mother does not wish to feed the child directly, she can express her breast
milk by hand or by a pump. If a pump is used, it should be kept separate and
instructions on keeping it clean should be followed. The mother should follow
hand hygiene.
VII. The expressed milk should be fed to the baby by another individual who is
not infected.
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6. Post-natal Care
The various aspects of post-natal care that need to be addressed including counselling
about nutrition, perineal, breast, hand hygiene, counselling about birth spacing and
family planning and advice on early mobilization and gentle exercise. Iron and folic
acid, calcium supplementation should be provided for at least 6 months after delivery.
Tab Vit C, Multi vitamin with Zinc for 6 weeks.
A suspected/confirmed COVID-19 mother should be kept in a separate room with a
strict watch for respiratory status and symptoms. Standard practices of routine postnatal
care and hygiene maintenance should be practiced.
i. Postnatal care of the mother infected with COVID -19 should include
continued medical evaluation for respiratory status and symptoms and
standard practices of routine postnatal care.
ii. 3 months post COVID-positive and delivery, all women in the post-
partum period must be evaluated for multi-organ functioning.
iii. She should be encouraged to maintain the good practices of hygiene
related to the puerperium and hand hygiene.
iv. Advice should include management of engorged breasts when feeding has
not been established and measures to enhance breastfeeding after the
isolation period is completed.
v. She should consume a healthy, nutritious diet to recover from the
infection and build immunity.
vi. The discharge card from the maternity unit should have advice about
COVID- 19 infection in addition to the usual post-delivery instructions.
It should emphasize social distancing and need for evaluation if
symptoms of acute respiratory illness (SARI) arise after delivery.
vii. The mother who is recovering from an acute illness and/or is isolated from
the infant may be at risk for developing anxiety, postpartum depression
and other mental health issues. She should be offered counselling and
psychological support.
viii. Some women may need a psychiatrist's consultations. These interventions
can be safely provided by tele-consultation 104 Call Centre or E-
Sanjeevani. After an individual (and especially a pregnant woman)
recovers, they may face stigma of the disease. There should be widespread
community awareness of recovery and de-stigmatization campaigns.
ix. Further into the puerperium, the couple should follow contraceptive
practices as per their informed choice.
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7. Referral Protocols
I. Birth preparedness and complication readiness especially for PW in last month of
EDD and for SOS calls is the key.
II. Map referral and referring facilities
III. One person responsible for referral (preferably Nursing in-charge of the LR/OT).
IV. Ensure that complete of case records are sent with the patient and mention the
reason for referral
V. Prior to referring, the facility should telephonically contact the referral facility and
confirm the availability of resources for the management of PW with Covid-19.
Mapping of Health Facility
Name of Nodal
Person and
Contact
Number
Nearest Non
COVID health
facility
Dedicated
COVID health
centre
Dedicated
COVID
Hospital
Private Hospital
with CEmONC
facilities