Coronavirus: Novel Coronavirus (COVID-19) and COVID Variant Infection Management (Maternal-Newborn) - CE/NCPD - INACTIVE

ALERT

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

OVERVIEW

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

• Fever
• Cough (either productive or nonproductive)
• Dyspnea
• Loss of sense of taste
• Myalgia
• Sore throat
• Diarrhea
• Fatigue
• Nausea and vomiting
• Headache

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).

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the purpose of the isolation to the mother and support person and any precautions that the support person should take when entering an isolation room.
• Demonstrate and assist the mother with donning and proper wearing of a mask.
• Inform the mother and support person of the organization’s visitation restrictions so that the mother can make arrangements for virtual contact options if applicable.
• Provide the mother and support person information on the signs and symptoms of COVID-19.
• Educate the mother and support person about modes of COVID-19 transmission.
• Explain to the mother and support person about testing for COVID-19 if the mother is a PUI.
• Explain to the mother and support person the methods of infection prevention, including hand hygiene, respiratory hygiene, and cough etiquette (Box 1).
• Demonstrate to the support person how to put on and take off PPE (Figure 2) (Figure 3) (Figure 4).
• Educate the mother and support person about the possible exposure of individuals in contact with the mother before the diagnosis. Discuss the need for these individuals to be tested.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the mother and support person.
3. Verify the correct patient using two identifiers.
4. Assess the mother’s vital signs, including oxygen saturation.
5. Assess the mother for signs and symptoms of COVID-19 (Figure 1).

   The majority of pregnant patients with SARS-CoV-2 are asymptomatic.¹⁶

6. Ensure that the mother with COVID-19 or the PUI wears a mask during assessment.¹¹
7. Assess the mother for signs and symptoms of pneumonia and auscultate the mother’s lungs.
8. Test for COVID-19 as indicated and per the organization’s practice.

Preparation

1. Place the mother in a single person room with the door closed.

   Reserve negative pressure isolation rooms for patients undergoing aerosol-generating procedures.

2. Choose isolation precautions that are appropriate for the mother’s signs and symptoms or diagnosis.
   1. Contact precautions: Standard precautions plus gloves and gown
   2. Droplet precautions: Standard precautions plus a mask and eye protection

      Use contact and droplet precautions for most encounters with a newborn born to a mother with COVID-19.¹¹

   3. Airborne precautions: Standard precautions plus an N95 respirator or powered air-purifying respirator (PAPR) and eye protection

      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

3. Provide proper PPE access and signage as needed.
4. Limit trips in and out of the room; gather all equipment and supplies needed before entering the room. If the mother is a PUI and COVID-19 testing is to be done, include a test kit.
5. Dedicate medical equipment (e.g., stethoscope, blood pressure cuff, thermometer, oxygen saturation monitor) to be used only by the mother.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids (Figure 2).
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
4. Ensure that the mother has had the opportunity to discuss health problems, course of treatment, or other important topics while in the isolation room.
5. Remind the mother to cover the mouth when coughing, if not wearing a mask, or to wear a mask if leaving the room for any reason (Box 1).
6. Provide designated care to the mother while maintaining precautions.
   1. Keep hands away from own face.
   2. Limit touching surfaces in the room.
   3. Remove gloves when torn or heavily contaminated, perform hand hygiene, and don clean gloves.
7. Collect any ordered specimens, such as COVID-19 testing for a PUI, per the instructions on the COVID-19 test kit.
8. In the presence of the patient, label the specimen(s) per the organization’s practice.¹²
9. Place the labeled specimen(s) in a biohazard bag.
10. At the door, have another health care team member hold another biohazard bag into which the bagged specimen(s) is placed.

    Rationale: This prevents contamination of the outside of the biohazard bag.

11. Ensure that the specimen(s) is transported to the laboratory.

General Considerations

1. Consider the risk versus the benefit of administering magnesium sulfate for neuroprotection or preeclampsia and seizure prophylaxis.

   Rationale: Magnesium sulfate can contribute to the mother’s respiratory depression.¹⁹

2. Restrict or disallow visitors for a mother who tests positive for COVID-19 or is a PUI to reduce the risk of transmission.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

3. Ensure that a laboring mother with COVID-19 or a PUI is not allowed to leave the isolation room.
4. Ensure that a pregnant and breastfeeding patient is a priority in screening algorithms for COVID-19.¹⁹

   Rationale: Clinical guidance is driven by the results of a COVID-19 diagnosis.¹⁹

5. Follow the organization’s practice for obtaining and transporting specimen collection (e.g., fern specimens) for patients positive for COVID-19 and PUI.

Triage

1. Avoid transporting specimens across the unit when using ferning and microscopy evaluation for rupture of membranes. Use alternative methods for ruling out rupture of membranes such as pooling, nitrazine, and commercially available tests.¹⁹

   Transporting the specimen across the unit increases the risk of exposure and should be avoided.

Antepartum

1. Implement antenatal fetal surveillance procedures, as ordered, for obstetric indications; consolidate if possible.¹⁸

   Rationale: Consolidation of procedures may help to limit exposure.

2. Monitor the mother for signs and symptoms of preterm labor (Figure 1).

   There is some evidence that infection with COVID-19 can lead to preterm labor and birth.¹⁶

3. Monitor maternal oxygen saturation and oxygen therapy requirements closely.¹⁸

   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.

Intrapartum

1. Implement continuous fetal monitoring for a mother in labor.¹⁶

   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

2. Refrain from the routine use of high-flow nasal cannula or face mask oxygen for fetal distress.

   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

3. Administer oxygen as needed for maternal oxygen desaturation.^4,16

   Rationale: Maternal oxygen saturation should be maintained at greater than or equal to 95%.^4,16

4. Don an N95 mask, if available, when the mother is pushing.¹⁹

   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

5. Limit the use of nitrous oxide in labor due to the potential for aerosolization of bodily fluids.

   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

6. Ensure that health care team members use airborne, droplet, and contact precautions-level PPE during delivery and when newborn resuscitation or stabilization is needed at delivery.¹

   Rationale: Newborn aerosols may be generated along with maternal aerosols during intubation, airway suctioning, and initiating positive pressure ventilation.¹

7. Delay cord clamping and practice skin-to-skin care at delivery per the organization’s practice and as appropriate.¹
8. Ensure that a mother who tested positive for COVID-19 wears a mask when holding the newborn.¹

Cesarean Birth

1. Avoid the practice of having open surgical equipment in operating rooms, as is sometimes done on labor and delivery units for possible emergency cesarean birth.

   This practice can increase the risk of COVID-19 transmission.¹⁹

2. Facilitate the use of a negative pressure operating room, if possible, for a patient with SARS-CoV-2 or a PUI. If this is not possible, with proper PPE (Figure 2) and transportation guidelines, a cesarean birth can still be performed in a positive flow operating room safely.¹⁹

Postpartum and Breastfeeding

1. Facilitate rooming in and care for mothers and newborns per the organization’s practice.¹ Newborns needing intensive care unit (ICU) care should have a separate room with negative pressure capabilities.¹
2. Ensure that the mother remains a reasonable distance from the infant. During hands-on care of the newborn, ensure that the mother wears a mask and performs hand hygiene.¹

   Ensure that the mother wears a mask when within 6 feet of the newborn.⁸

3. Ensure that healthcare team members don appropriate PPE when caring for infants born to mothers with COVID-19: gowns, gloves, N95 masks, and eye protection. Standard procedural masks can be used if supplies indicate.¹
4. If another healthy family member is present to provide care such as diapering, bathing, and feeding for the newborn, ensure that this person wears a mask and uses hand hygiene when providing hands-on care of the newborn.¹
5. Assist the mother with breastfeeding, as needed, after delivery.
6. Before breastfeeding or expressing milk, ensure that the mother performs hand hygiene with soap and water or uses an alcohol-based hand sanitizer and wears a mask. Disinfect any surfaces with which the mother comes into contact.^5,8,21
7. If the mother is unable to breastfeed, assist with expressing breastmilk and ensure that the breast pump and all of its parts are cleaned.

   Ensure that the breast pump is dedicated to the mother in isolation and left in the room.

8. If the mother is expressing breastmilk, collect a specimen of breast milk.
9. In the presence of the patient, label the breastmilk per the organization’s practice.¹²
10. Place the breastmilk in a biohazard bag.
11. At the door, have another health care team member hold another biohazard bag into which the bagged breastmilk is placed.

    Rationale: This prevents contamination of the outside of the biohazard bag.

12. Ensure that the breastmilk is transported to the appropriate refrigerator.
13. Discard linen, trash, and disposable items.
    1. Use single bags that are sturdy and impervious to moisture to contain soiled articles. Double bag heavily soiled linen or heavy, wet trash if necessary.
    2. Tie the bags securely at the top with a knot.
14. Remove all reusable pieces of equipment and thoroughly disinfect reusable equipment brought into the room. Ensure that equipment is disinfected with an organization-approved disinfectant when it is removed from the room and before it is used on another patient.

    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

15. Remove PPE and perform hand hygiene (Figure 3) (Figure 4).
16. Exit the isolation room and close the door.
17. If using a negative-pressure room, enter the anteroom, close the door to the isolation room, remove PPE, exit the anteroom, and close the door to the anteroom.

    The door to the isolation room and the anteroom should never be open at the same time.

18. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Assess the mother’s laboratory test results, if tests were ordered, including the COVID-19 test if the mother is a PUI.
2. Ensure that the mother with COVID-19 or the PUI wears a mask during assessment and when transported out of the isolation room.¹¹
3. Assess, treat, and reassess pain.
4. Discontinue isolation precautions, per the organization’s practice, when:
   1. COVID-19 is ruled out.
   2. The mother is no longer contagious.
      1. If the patient had symptoms, the isolation period ends after all these conditions are met:⁸
         1. 5 days since symptoms first appeared
         2. 24 hours with no fever, without fever-reducing medicine
         3. Other symptoms of COVID-19 are improving.
      2. If the patient never had symptoms, the isolation period ends 5 days after testing positive for COVID-19.⁸
5. Answer questions and assist the mother as needed during the antepartum, intrapartum, and postpartum period.
6. Monitor the mother for depression related to isolation.

   Rationale: During a pandemic with restricted visiting and possibly having to give birth without a support person, depression can be severe.

7. Resupply the room as needed. Have another health care team member hand in new supplies, if needed.

   Rationale: Limiting trips in and out of the room reduces the exposure of the health care team members to airborne pathogens.

EXPECTED OUTCOMES

• Respirator mask fits properly.
• Health care team members are free from airborne-transmitted infectious illness.
• Mother asks for information about disease transmission.
• Mother explains purpose of isolation and cooperates with precautions.
• Mother able to care for newborn if illness allows.
• Mother able to breastfeed newborn if illness allows.
• Mother asks questions about newborn care and breastfeeding if illness allows.

UNEXPECTED OUTCOMES

• Respiratory mask is not donned properly.
• Health care team members contract COVID-19.
• Mother does not cooperate with precautions.
• Mother is unable to care for newborn.
• Mother is unable to breastfeed.
• Mother does not ask questions about newborn care and breastfeeding.

DOCUMENTATION

• Education
• Procedures performed
• Mother’s response to social isolation
• Depression screening
• Mother’s response to newborn care and breastfeeding
• Evidence or suspected breach of isolation precautions
• Unexpected outcomes and related interventions

REFERENCES

1. American Academy of Pediatrics (AAP). (2022) FAQs: Management of infants born to mothers with suspected or confirmed COVID-19. Retrieved September 22, 2022, from https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/ (Level VII)
2. American College of Obstetricians and Gynecologists (ACOG). (2022). COVID-19 vaccines and pregnancy: Key recommendations and messaging for clinicians. Retrieved September 22, 2022, from https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/clinical-guidance/practice-advisory/covid19vaccine-conversationguide-121520-v2.pdf?la=en&hash=439FFEC1991B7DD3925352A5308C7C42 (Level VII)
3. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2021) AWHONN COVID-19 practice guidance: AWHONN’s update on oxygen use for fetal resuscitation during the COVID-19 pandemic. Retrieved September 22, 2022, from https://www.awhonn.org/novel-coronavirus-covid-19/covid19-practice-guidance/ (Level VII)
4. Aubey, J., Zork, N., Sheen, J. (2020). Inpatient obstetric management of COVID-19. Seminars in Perinatology, 44(7), 151280. doi:10.1016/j.semperi.2020.151280 (Level VII)
5. Australian Breastfeeding Association (ABA). (2022). Breastfeeding and COVID. Retrieved September 22, 2022, from https://www.breastfeeding.asn.au/bfinfo/covid-19 (Level VII)
6. Cashion, K. (2020). Chapter 16: Labor and birth processes. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 319-332). St. Louis: Elsevier.
7. Centers for Disease Control and Prevention (CDC). (2021). COVID-19: Considerations for inpatient obstetric healthcare settings. Retrieved September 22, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html (Level VII)
8. Centers for Disease Control and Prevention (CDC). (2022). COVID-19: Breastfeeding and caring for newborns if you have COVID-19. Retrieved September 22, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fpregnancy-breastfeeding.html (Level VII)
9. Centers for Disease Control and Prevention (CDC). (2022). COVID-19: Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Retrieved September 22, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html (Level VII)
10. Centers for Disease Control and Prevention. (CDC). (2022). COVID-19: Pregnant and recently pregnant people: At increased risk for severe illness from COVID-19. Retrieved September 22, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant-people.html (Level VII)
11. Jamil, S. and others. (2020). Diagnosis and management of COVID-19 disease. American Journal of Respiratory and Critical Care Medicine, 201(10), 19-20. doi:10.1164/rccm.2020C1 (Level VII)
12. Joint Commission, The. (2022). National Patient Safety Goals for the hospital program. Retrieved September 22, 2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf (Level VII)
13. Katella, K. (2022). Omicron, Delta, Alpha, and more: What to know about the coronavirus variants. Retrieved September 22, 2022, from https://www.yalemedicine.org/news/covid-19-variants-of-concern-omicron (Level VII)
14. Patrick, N.A., Johnson, T.S. (2021). Maintaining maternal-newborn safety during the COVID-19 pandemic. Nursing for Women’s Health, 25(3), 212-220. doi:10.1016/j.nwh.2021.03.003 (Level VII)
15. Poon, L.C. and others. (2020). ISUOG Safety Committee position statement on safe performance of obstetric and gynecological scans and equipment cleaning in the context of COVID-19. Ultrasound in Obstetrics & Gynecology, 55(5), 709-712. doi:10.1002/uog.22027 Retrieved September 22, 2022, from https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1002/uog.22027 (Level VII)
16. Royal College of Obstetricians and Gynecologists (RCOG), Royal College of Midwives. (2022). Coronavirus (COVID-19) in pregnancy: Information for healthcare professionals. Retrieved September 22, 2022, from https://www.rcog.org.uk/media/xsubnsma/2022-03-07-coronavirus-covid-19-infection-in-pregnancy-v15.pdf (Level VII)
17. Siegel, J.D. and others. (2007, updated 2022). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved September 22, 2022, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level VII)
18. Society for Maternal Fetal Medicine (SMFM). (2022). COVID-19 and pregnancy: What maternal-fetal medicine subspecialists need to know. Retrieved September 22, 2022, from https://s3.amazonaws.com/cdn.smfm.org/media/3402/COVID19-What_MFMs_need_to_know_revision_3-1-22_%28final%29.pdf (Level VII)
19. Society for Maternal Fetal Medicine (SMFM), Society for Obstetric Anesthesia and Perinatology (SOAP). (2020). Labor and delivery COVID-19 considerations. Retrieved September 22, 2022, from https://s3.amazonaws.com/cdn.smfm.org/media/2319/SMFM-SOAP_COVID_LD_Considerations_-_revision_4-14-20_PDF_(003).pdf (Level VII)
20. World Health Organization (WHO). (2022). Coronavirus disease (COVID-19): Pregnancy, childbirth and the postnatal period: Q&A. Retrieved September 22, 2022, from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-pregnancy-and-childbirth (Level VII)
21. World Health Organization (WHO) Regional Office for the Eastern Mediterranean. (n.d.). Breastfeeding advice during the COVID-19 outbreak. Retrieved September 22, 2022, from http://www.emro.who.int/nutrition/nutrition-infocus/breastfeeding-advice-during-covid-19-outbreak.html (Level VII)

ADDITIONAL READINGS

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

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports