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Ask the patient about signs and symptoms of coronavirus disease 2019 (COVID-19) upon arrival to the facility. Obtain this history from a distance of 1.8 m (6 ft) or more if possible.undefined#ref20">20
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.20
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-19.6 Depending on current community status, the decision may be made to limit visitors to one consistent person throughout the patient’s inpatient stay.6
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 new 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, 2020.6,9,11,16,17
Transmission of COVID-19 is spread person to person, although it likely initially emerged from an animal source.9 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 (within 2 m [6.5 ft]16), 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.16,19 The COVID-19 virus can survive on dry, inanimate surfaces for 48 to 96 hours.15 It is easily isolated from respiratory secretions, fomites, and feces.16
Pregnant people may have an increased risk of developing more severe illness due to COVID-19.6 Recent data also suggest an increased risk for mechanical ventilation and serious pregnancy complications, including preterm labor and birth.3,8,16
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.17 Vertical transmission to the fetus antenatally is possible, but no strong data exist.16 Some newborns have been born and 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 14 days11 postexposure, with viral shedding up to 20 days. The infected person may spread the infection before onset of symptoms.11
Common symptoms include:9,14
Worsening symptoms include:9,14
Other symptoms that have been reported include:9,14
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.20 If this is not possible, an isolation room with droplet and contact precautions is recommended.20
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-19.4,20 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.4,20 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 should be considered PUIs. The Centers for Disease Control and Prevention (CDC) recognizes that, ideally, mother and newborn should remain together following birth.8 Temporary separation may be considered to avoid exposure to COVID-19. Temporary separation should take into consideration the mother’s wishes. If temporary separation is not implemented, the mother should take precautions to avoid further newborn exposure.8 The World Health Organization recommends that mothers and infants remain in isolation together.21,22,23 The organization’s practice regarding mother and newborn should be followed. The determination of whether or not to separate a mother with known or suspected COVID-19 from the newborn should be made on a case-by-case basis using shared decision-making between the mother and the health care team and should consider factors such as the mother’s and newborn’s clinical condition and COVID-19 testing results, the mother’s desire to breastfeed, and the facility’s capacity to accommodate separation.6
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 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.1,7,10,19,21,23 To date, no evidence of COVID-19 has been found in breastmilk.3,7,15 Caution should be used during handling and storage of breastmilk (e.g., sanitizing the outside of the container, double bagging).
Face masks are an acceptable alternative when the supply chain of respirators or N95 masks cannot meet the demand.
Available respirators should be prioritized for procedures that generate respiratory aerosols.
Rationale: Some patients may present without a fever. A lack of fever may be noted in the immunosuppressed or in patients taking certain medications (e.g., steroids).
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.
Personal eyeglasses are not adequate protection for the eyes.
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.
Rationale: This prevents contamination of the outside of the biohazard bag.
Rationale: Magnesium sulfate can contribute to the mother’s respiratory depression.
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.
Ensure that any permitted visitor is screened for symptoms of acute respiratory illness and not allowed entry if fever or respiratory symptoms are present.
Rationale: Clinical guidance is driven by the results of a COVID-19 diagnosis.
Transporting the specimen across the unit increases the risk of exposure and should be avoided.
Rationale: Consolidating of procedures may help to limit exposure.
There is some evidence that infection with COVID-19 can lead to preterm labor and birth.
Rationale: Decreased maternal oxygen saturation levels and increased oxygen therapy requirements can signal worsening condition and need for more intensive care measures, including delivery considerations.
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.
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.
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.
Rationale: Newborn aerosols may be generated along with maternal aerosols during intubation, airway suctioning, and initiating positive pressure ventilation.
This practice can increase the risk of COVID-19 transmission.
If separate rooms are not used, other methods to reduce the risk of transmission include the use of engineering controls like physical barriers (e.g., incubator) and keeping the newborn 1.8 m (6 ft) or further away from the mother unless breastfeeding.
Rationale: Bathing the newborn as soon as possible after birth removes any virus potentially present on skin surfaces and decreases the risk of transmission.
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.
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 July 30, 2020, 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). (2020). COVID-19 resources for maternal and infant health. Retrieved July 30, 2020, from https://caperinatalprograms.org
Fan, C. and others. (2020). Perinatal transmission of COVID-19 associated SARS-CoV-2: Should we worry? Clinical Infectious Diseases. Epub ahead of print. doi:10.1093/cid/ciaa226 Retrieved July 30, 2020, from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa226/5809260
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 Retrieved July 30, 2020, from https://journals.lww.com/greenjournal/Abstract/9000/Clinical_Findings_and_Disease_Severity_in.97347.aspx
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