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Ask the patient about signs and symptoms of coronavirus disease 2019 (COVID-19) or a COVID variant upon arrival to the facility. Obtain this history from a distance of 1.8 meters (6 ft) or more if possible.undefined#ref9">9,19
Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Consider the risk versus the benefit of administering magnesium sulfate for neuroprotection, preeclampsia, or seizure prophylaxis due to the increased risk of respiratory depression with magnesium sulfate administration in a patient with increasing oxygen requirements.19
To reduce the risk of transmission, it is recommended that visitors be limited in the inpatient obstetric setting for patients diagnosed with, or suspected of having, COVID-19.7 Depending on current community status, the decision may be made to limit visitors to one consistent person throughout the patient’s inpatient stay.7
COVID-19 (Figure 1) is an infectious disease affecting the respiratory tract, which can progress to severe pneumonia and death. COVID-19 is caused by a strain of novel coronavirus (SARS-CoV-2). Due to the extent of the infection, COVID-19 was declared a pandemic by the World Health Organization as of March 11, 2020.14,18
The virus has been found to change over time.11 New strains of COVID-19 include Alpha, Beta, Gamma, Delta, and Omicron. The Delta variant has been associated with more severe disease and more hospital admissions in pregnant and postnatal persons than the Alpha variant. The Omicron variant has been associated with less severe disease but is more infectious and still associated with adverse maternal and neonatal outcomes, especially in unvaccinated pregnant patients.13,16
Although pregnant patients are no more likely to contract SARS-CoV-2 than the general population, the evidence suggests that pregnant patients are at an increased risk of severe illness from COVID-19 compared to patients who are not pregnant, especially in the third trimester.7,10,16 Recent data also suggest COVID-19 in pregnancy is associated with an increased risk for mechanical ventilation, admission to the intensive care unit, and death.2,7,16
There is no reported increased risk of congenital anomalies with COVID-19 infection. It has been shown that in pregnant patients with COVID-19, especially symptomatic COVID-19, there is an increased risk of preterm birth. An increased risk of newborns who are small for gestational age has also been noted.1,16
Transmission of COVID-19 is spread person to person, although it likely initially emerged from an animal source. It can be spread by two routes, either directly by respiratory secretions entering the eyes, mouth, nose, or airways after close contact with an infected person, or indirectly by touching an object, surface, or an infected person that is contaminated with respiratory secretions and then touching the mouth, nose, or eyes.11,16,18 The COVID-19 virus can survive on dry, inanimate surfaces for 48 to 96 hours.15
Pregnancy changes that can also increase the risk of more severe symptoms in patients positive for COVID-19 include increased oxygen consumption and decreased lung capacity.6 Vertical transmission to the fetus antenatally is possible, but no strong data exist.16 Some newborns have tested positive for COVID-19, but it is unknown if they were exposed before, during, or after delivery.8
The incubation period of COVID-19 is 3 to 12 days11 postexposure, with viral shedding up to 20 days. The infected person may spread the infection before onset of symptoms.11 Most pregnant patients who are infected with SARS-CoV-2 do not have symptoms. Pregnant patients with increased age and comorbidities such as gestational diabetes on insulin, preexisting diabetes, cardiovascular disease, and obesity have a much greater risk of contracting SARS-CoV-2 than pregnant patients without these comorbidities.2,16
Common symptoms of COVID-19 in pregnancy include:7,11,16
If possible, patients with COVID-19 and persons under investigation (PUIs) due to their symptoms should be isolated into a restricted area of the facility. If aerosolizing procedures are anticipated, an airborne infection negative pressure isolation room with at least six air exchanges per hour is best.19 If this is not possible, an isolation room with droplet and contact precautions is recommended.19
There is no evidence of an increased risk of COVID-19 infection with internal fetal monitors, amniotomy, or operative delivery; however, the data are limited. The use of nitrous oxide in labor may increase the risk of aerosolization of bodily fluids and should be avoided, if possible, to decrease the risk of transmitting COVID-19.1,4,19 The routine use of high-flow nasal cannula or face mask oxygen for fetal intolerance of labor should be suspended because it may be an aerosolizing procedure, which could increase the risk of COVID-19 transmission.3,4,19 Oxygen, using the safest, most effective method, should be administered to treat maternal oxygen desaturation.4
Newborns born to mothers who are COVID-19 positive have a low risk of contracting the disease, especially when the parent or caregiver wears a mask and washes their hands.5,8,20 The Centers for Disease Control and Prevention (CDC) recognizes that, ideally, mother and newborn should remain together following birth, while taking precautions to avoid further newborn exposure.8 Temporary separation should take into consideration the mother’s wishes, breastfeeding, and bonding.8 The World Health Organization recommends that mothers and infants remain in isolation together.21
Mothers infected with COVID-19 may breastfeed their newborn if their illness does not prevent them from caring for their newborn. If unable to breastfeed, the mother can safely express milk to be given to the newborn.5,8,21 Before breastfeeding or expressing milk, the mother should perform hand hygiene with soap and water or use an alcohol-based hand sanitizer, wear a medical mask, and clean and disinfect any surfaces the mother comes in contact with. To date, no evidence of COVID-19 has been found in breastmilk.5,8 Caution should be used during handling and storage of breastmilk (e.g., sanitizing the outside of the container, double bagging).
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The majority of pregnant patients with SARS-CoV-2 are asymptomatic.16
Reserve negative pressure isolation rooms for patients undergoing aerosol-generating procedures.
Use contact and droplet precautions for most encounters with a newborn born to a mother with COVID-19.11
PPE is required and includes a gown, gloves, an N95 mask, and eye protection (i.e., goggles). An air-purifying respirator that also provides eye protection may also be used. This equipment provides protection from both maternal and newborn aerosols that may be generated during resuscitation measures. These measures include bag and mask ventilation, intubation, suctioning and oxygen therapy, as well as positive pressure ventilation.9,11
Rationale: This prevents contamination of the outside of the biohazard bag.
Rationale: Magnesium sulfate can contribute to the mother’s respiratory depression.19
If visitors are allowed, the organization may consider limiting visitors to one essential support person and having that person be the same individual throughout the mother’s stay.7
Ensure that any permitted visitor is screened for symptoms of acute respiratory illness and not allowed entry if fever or respiratory symptoms are present.7
Rationale: Clinical guidance is driven by the results of a COVID-19 diagnosis.19
Transporting the specimen across the unit increases the risk of exposure and should be avoided.
Rationale: Consolidation of procedures may help to limit exposure.
There is some evidence that infection with COVID-19 can lead to preterm labor and birth.16
Rationale: Decreased maternal oxygen saturation levels and increased oxygen therapy requirements can signal worsening condition and the need for more intensive care measures, including delivery considerations.
Rationale: The need for continuous fetal monitoring in low-risk pregnant patients who have tested positive for SARS-CoV-2 but are asymptomatic is still an area of uncertainty due to lack of evidence. Therefore, the risks and benefits of continuous fetal monitoring should be discussed with low-risk, asymptotic SARS-CoV-2 positive pregnant patients.16
The use of a high-flow nasal cannula or face mask oxygen may be an aerosolizing procedure which could increase the risk of COVID-19 transmission.3,4,19
Rationale: Maternal oxygen saturation should be maintained at greater than or equal to 95%.4,16
An N95 mask should be worn if available due to the length of patient contact, and because of repeated and prolonged exhalations, there is an increased risk of exposure to aerosolized bodily fluids in the second stage of labor.19
The use of nitrous oxide should be discussed on individual labor and delivery units and avoided, if possible, to decrease the risk of transmitting COVID-19.4,19
Rationale: Newborn aerosols may be generated along with maternal aerosols during intubation, airway suctioning, and initiating positive pressure ventilation.1
This practice can increase the risk of COVID-19 transmission.19
Ensure that the mother wears a mask when within 6 feet of the newborn.8
Ensure that the breast pump is dedicated to the mother in isolation and left in the room.
Rationale: Disinfecting equipment after use decreases the risk of infection transmission. Using equipment that is dedicated for use only with the patient on isolation precautions further minimizes this risk.17
The door to the isolation room and the anteroom should never be open at the same time.
Rationale: During a pandemic with restricted visiting and possibly having to give birth without a support person, depression can be severe.
Rationale: Limiting trips in and out of the room reduces the exposure of the health care team members to airborne pathogens.
Andrikopoulou, M. and others. (2020). Symptoms and critical illness among obstetric patients with coronavirus disease 2019 (COVID-19) infection. Obstetrics & Gynecology, 136(2), 291-299. doi:10.1097/AOG.0000000000003996 Retrieved September 22, 2022, from https://journals.lww.com/greenjournal/Abstract/9000/Symptoms_and_Critical_Illness_Among_Obstetric.97341.aspx
California Perinatal Quality Care Collaborative (CPQCC), California Maternal Quality Care Collaborative (CMQCC). (2022). COVID-19 resources for maternal and infant health. Retrieved September 22, 2022, from https://caperinatalprograms.org
Fan, C. and others. (2020). Perinatal transmission of 2019 coronavirus disease–associated severe acute respiratory syndrome coronavirus 2: Should we worry? Clinical Infectious Diseases, 72(5), 862-864. doi:10.1093/cid/ciaa226
Savasi, V.M. and others. (2020). Clinical findings and disease severity in hospitalized pregnant women with coronavirus disease 2019 (COVID-19). Obstetrics & Gynecology, 136(2), 252-258. doi:10.1097/AOG.0000000000003979
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