Postnatal care for COVID-19 positive/suspect patients involves rooming-in of neonates with frequent feeding while maintaining infection prevention protocols, monitoring maternal vital signs and symptoms in isolation wards, and referring symptomatic or sick patients to critical care or COVID red zones as needed based on consultation with internists.

1. FRONTIERS PRESENTATION
Mentor:
Prof Shahanara
Chowdhury(HOD,Gynae,CMC)
Dr Fahmida Rashid(AP,Gynae,CMC)

2. Coronavirus Disease
2019 (COVID-19)
Statistics in CMCH
Dr. Dina Sharmin
Assistant Registrar
Gynae Unit-I, CMCH

3. COVID-19, A Worldwide Pandemic
Coronavirus Disease 2019 (COVID-19) outbreak started in
Wuhan, China in December, 2019.
WHO has officially declared the outbreak of COVID-19 a
pandemic on 11th March, 2020.
Bangladesh reported first case on 8th March, 2020.
CMCH declared as COVID-19 dedicated hospital on 20th
May, 2020.

4. COVID-19, A Worldwide Pandemic
•Utilization of
ANC has ↓by
19% in January
– March 2020,
since reporting
of the first case.
According to
National Guideline
for providing
essential Maternal,
Newborn, Child
health Services in
context of COVID-
19(Updated on 18th
May 2020):

5. COVID-19, A Worldwide Pandemic
Facility based birth ↓ by
12%.
SCANU utilization has ↓
by 2/3rd
IMCI utilization has ↓ by
1/5th

6. COVID-19, A Worldwide Pandemic
Most pregnant with COVID-19 developed only mild
or uncomplicated illness.
Approximately 14% developed severe disease that
requires hospitalization and O2 support.
5% require admission to ICU.

7. COVID-19, A Worldwide Pandemic
Pregnant are at an ↑ risk of
acquiring COVID-19 as pregnancy
itself is a immuno compromised
state.
• Maternal age > 35
yrs.
• Pregnancy > 28
weeks .
• With Co-morbidity
like, DM, HTN,
Asthma, Obesity,
Heart Disease.
Risk factors for
hospital admission
in pregnant women
with COVID-19 :

8. COVID-19 Statistics in CMCH
Category
(21st May-20th July)
Number of Patients
COVID-19 positive in CMCH 2635
COVID-19 positive in Gynae & Obs . 22
Confirm on admission 16
Suspect on Admission 33
Confirmed after admission 06
Reference : Director office and Gynae & Obs Dept, CMCH

9. ANC
Pregnancy with COVID-19 (for ANC)
8
Early pregnancy : 4
(On going Rx)
Late pregnancy : 4
• Recovered :3
• On going Rx :1

10. Maternal outcome
Mode of
Delivery
Number &
Percentage
Vaginal
delivery
5 (35.71%)
LSCS 9 (64.29%)
0%
LSCS
64%
0%
Vaginal
delivery
36%

11. Maternal Morbidity
Complete
recovery
14 (63.63%)
Complication
3(13.64%)
•ARDS – Died in COVID
ICU.
•ARDS – Improved with
HFNC in ICU.
•ARDS – Recovered with
oxygen with
non
rebreather
mask.
Ongoing Rx
5(22.72%)

12. Recovery
64%
Ongoing Rx
23%
Complication
13%
Maternal Morbidity

13. • All babies are referred to
NICU, among them one baby
was positive with COVID-19.
• Cause of death :
• Still born due to
obstructed labour.
• IUD due to severe PE(IVF
pregnancy).
Neonatal Outcome
Outcome Number
Alive 12
Dead 2

14. •Totaldeath:1(4.54%)Maternal Death with COVID-19
Recovery &
ongoing
treatment
95%
Death
5%

15. Mother we lost
26 years, physician, hypertensive, pregnant
(G2 P0 Ab1).
C- section due to 2nd gravida with 34 weeks of
pregnancy with IUGR with AGN with superimposed PE.
Discharged on 3rd POD from Clinic

16. Continue…….
On 8th POD-
Respiratory distress, low grade fever,PO2 -80%
,hospitalized into COVID ICU.
Treatment –
O2 inhalation by HFNC, Inj. Ceftriaxone, inj.
Methylprednisolone, inj. LMWH, Tab.
Favipiravir, Tab Fixocard,Plasma.

17. Continue…..
PO2not maintained & renal function
deteriorated expired on 21st POD due to ARDS
with MOD.
Investigation :
↑ D- dimer, S. creatinine, massive
proteinuria, bilateral consolidation on CXR P/A view.

18. Gynae & Obs frontiers positive with COVID-19
Category Number
Total teaching stuff 29
Total trainee 36
Total COVID-19
positive doctors-
17
(26.15%)
Consultant and
above
5
(7.69%)
Trainee 12
(18.46%)
Complete recovery 16
Still in rehabilitation 1
On isolation (as suspected case) 1
Reference : Gynae & Obs Dept, CMCH

19. SSN & MLSS positive with COVID-19
Category Number
SSN 4
MLSS 3
Complete recovery 6
Still in rehabilitation 1
Reference : Gynae & Obs Dept, CMCH

20. THANK YOU

21. Intrapartum Management
of Suspected /Confirmed
COVID-19 Patient
(Vaginal Delivery)
Dr. Marjan Sultana
MS Resident (Phase B)
Department of Obstetric and Gynaecology
Chittagong Medical College

23. Time of Delivery:
Should not be influenced by presence of
COVID-19.
Mode of Delivery –
Dictated by obstetric indication

24. All Patient in Labour Unit
With labour pain Without labour pain
Send patient to Fetomaternal assessment
COVID dedicated labour unit
If no problem-
shifted Red/Yellow Zone- COVID
Send sample for RT-
PCR test
Suspected/ confirmed
COVID-19
Negative
Triage at receiving
Obstetric Triage

25. Triage at Receiving
Triage Form

26. Mrs. Rahima Akter, 26 years old, para 1(NVD+0) from a red
alert area, at her 39 weeks of pregnancy with LP 6 hours with
H/O fever and dry cough for last 10 days.
All Findings were favourable for vaginal delivery
Planned for vaginal delivery
Augmentation of labour was done.
Case Scenario…..

27. Following are the ways we care
suspected/confirmed COVID-19 patients
in our department

28. Management of Labour
Confirmation of the onset of
labour.
Feto-maternal assessment in Obs.
isolation room with level II PPE
Assessment of severity of
COVID-19 symptoms.
On admission
Isolation Room

29. First Stage of Labour
Management same as normal patient
Intervention with oxytocin and amniotomy,
When labour progression is slow
Higher oxytocin doses can be considered

30. Monitoring of Labour
By -partograph
By- dedicated BP machine, pulse
oxymeter,thermal scanner .
Hourly SPO2 is monitored (>94%.)
Foetal monitoring- Intermittent
auscultation by handheld Doppler.

31. Preparation For
Delivery
Ideally delivery should
be conducted in isolated
negative pressure room
(but not available in our
facility )
We use a dedicated labour
room

32. AEROSOL BOX

33. We inform consultant
obstetrician, anaesthetist,
neonatologist, Obstetric
nurse in charge, Neonatal
nurse in-charge
A family member is allowed as a
birth companion with full PPE
Wear level III PPE to conduct
delivery
Preparation For Delivery

34. Preparation For Delivery Cont...
Logistics need
for vaginal
delivery and
new born
resuscitation

35. Second Stage of Labour
Cut short of second stage
via forceps or ventouse
in maternal distress.
Discourage bear down, As it is
an aerosol generating
procedure
Patient wear a mask /aerosol box
We wear level III PPE

36. Vaginal delivery with episiotomy was done
A healthy male baby was delivered weighing 3 kg,
APGAR score 8 at 5 minutes
In our case

37. Third Stage of Labour
Early cord
clamping.
AMTSL
Prophylactic tranexamic acid and
misoprostol

38. Placenta & used instruments disposed in
chlorine solution
Among two pairs of gloves, outer pair is
disposed in chlorine solution
Chlorine Solution
After Delivery Precaution

39. IPC
Every person (patient/ healthcare worker)is considered
infectious.
Minimum staff in the isolation labor unit.
Donning and Doffing- before and after attending
birth.
Every patient wear/provide Surgical mask (regardless
of respiratory symptoms.)

40. General
Patient
Surgical mask
Surgical Cap
Work uniform (apron/ OT dress)
Gloves
Suspected/
confirmed
History
taking
Examination
Surgical cap
N-95/FFP2 mask
Work uniform (apron/ OT
dress)
Gown (Disposable/
autoclaved linen)
Gloves,Goggles
Delivery
Surgical cap
N-95/FFP2 mask
PPE-Gown (Full)
Gloves
Face shield/powered air purifying
respirator
Level I
LevelII
Level III
Precaution for Transmission
Prevention

41. • We do donning and
doffing in donning
and doffing room.
Precaution for Transmission
Prevention cont...

42. Take Home Message
Vaginal delivery is not contraindicated in
suspect/confirm COVID-19 patient
Delivery should ideally be conducted in a negative
pressure isolation room
Limit visitors & staff
Continuous CTG monitoring
Cut short the second stage of labour
Donning & doffing should be done in specified area in
proper way .

43. Thank you!

44. Suspect/confirm COVID-19
pregnancy:
Care & safety during caesarean
delivery
DR. ISHRAT JABIN
MS Resident, Phase B
Department of Obstetrics & Gynaecology
Chittagong Medical College & Hospital

45. Timing of Delivery
In suspect/confirm COVID pregnancy,
personalized assessment –
• To determine if delay elective C-section is
beneficial/not .
• Urgency of birth and risk of infection prevention
taken into account.

46. Indication of C-section
COVID 19
alone -not
an
indication
for
suspect/co
nfirm
COVID
patient.
Here
indication
were –
-Fetal Distress
-Poor
progression of
labor
-Deterioration of
maternal
condition(SPO2<
95%)
-Respiratory
Distress
(>30breath/Min)

47. Case summary
Mrs. Amena, 28 yrs ,P-1(CS), admitted at 34 wks
pg with fever for 5 days, respiratory distress for 1
day in yellow zone as suspect of COVID-19.
Developed LP ,
Referred to Ob-gyn and
Dx as 2nd gr with 34 wk pg with LP with H/O 1 CS
with Suspected COVID.
Decision for emergency LSCS was taken.

48. Patient transfer
We transfer the patient directly to the
dedicated COVID operating room.

49. Patient transfer
Separate pathway should be
used.
Transit of patient is as quick as possible
Dedicated trolley or wheelchair is used.
All the staff (Doctors, sisters, MLSS)
handling the suspect/confirm COVID , wear Level 3 PPE.

50. Patient transfer

51. Dedicated COVID Operation room
Ideally negative pressure room - recommended for OT of
suspect /confirm COVID (we do not have)

52. Donning before operation

53. Level of PPE
Level 3 PPE used by all the staff
(surgeons, anesthetist, sisters, MLSS) in OT are-
• Long-sleeved disposable fluid repellent gowns/
disposable fluid repellent coveralls.
• N95/FFP2/FFP3 facial mask.
• Protective goggles/face shield.
• 2 pairs of gloves.
• Disposable head cap.
• Disposable shoe cover.

54. Operation room management
Spinal or epidural
anesthesia is the
preferred
method of
anesthesia, but
here spinal
anesthesia
mostly preferred.

55. Operation room management
General anesthesia is usually avoided as it is
an aerosol generating procedure.
We enter the room after anesthesia and
positioning of patient.

56. Safety measures during operation
 Surgery Safely and minimum
period of time.
 Avoid - electro cautery and
minimum sucker.
 Minimum number of staff.
 Door remains closed until
entire procedure completed.
 Patient wear surgical mask
during OT.
OT Room

57. Baby and patient Mx
• AMTSL
• Early cord Clamping.
• All neonate referred to Neonatal ward for
further assessment.
• Patient transferred to Immediate PO isolation
ward by dedicated trolley with minimum
personnel involved.

58. Postoperative room for COVID-19

59. Postoperative IPC
 All the staff should be
doffed properly in
designated area
followed by shower.
 The PPE is discarded in
a closed container
labeled as bio-
hazardous material.

60. Postoperative IPC
Operation waste like
placenta, blood and
blood products are
immediately
discarded in 1%
hypocholrite solution.
Surgical scrub, surgical
gloves are discarded
in chlorine solution.
Chlorine Solution

61. Postoperative IPC
 After Completion of operation spilled blood in floor
and OT table cleaned by 1% Hypochlorite solution for
a contact time of 30 minute .
 Later Floor of OT is swabbed by 1% hypochlorite
solution .
 As per advice by OGSB, After one operation we keep
close OT for 4 hours after disinfection.

62. Postoperative IPC
• Reusable
instruments are
treated with 1%
hypochlorite
solution for 30
minute, followed
by autoclave.

63. Postoperative IPC
• The disposable waste of OT
discarded in dedicated
container for hazardous
material and transmitted in
a closed container.
• The staff transporting the
waste for final incineration
wear level 2 PPE.

64. Take home messages
Surgery of suspect/ confirm COVID pregnancy must
be carried out with utmost safety measures to
prevent transmission.
Dedicated OT & logistics needs to be used.
All staff should use PPE with proper donning and
doffing.
Standard operating procedure (SOP) and IPC should
be maintained to prevent transmission of disease.

66. DR Zenifar Sharmin
MS resident , phase B
CMCH
Postnatal Care of COVID
positive/suspect at
hospital

67. Postnatal care in COVID positive/
suspect
At CMCH we follow WHO triage.
suspect confirm
Mild Moderate/Severe Case
Kept in Ob-gyn
Isolation Ward
Shifted to
COVID red Zone

68. COVID ZONE
RED ZONE YELLOW ZONE

69. red zone,CMCH

70. COVID
Suspect Confirm
VD/LSCS VD/LSCS
RT-PCR
Isolation ward(Suspect) Isolation ward(Confirm)
Positive
Negative
Normal PN ward
VD-
Discharge next day
LSCS-
Discharge 2nd POD
Follow Up 10th POD(if possible Video call)

71. Isolation ward,CMCH

72. • Immediate care:
• Neonate- Rooming In.
• Initiation of breast feeding
within 1 hr
• Frequent feeding(8-10 times)
• Counseling about IPC.

73. cont.
• BCG immunization just after birth before
discharge.
• All neonate of Positive/suspect mother tested
RT-PCR for COVID on 48 hour.
• Regular routine cleaning of all surfaces of PN
ward with disinfectant.
• Referral of symptomatic or sick newborn with
COVID 19 infections to the SCANU.

74. Immediate follow up after VD and cesarean
section(suspected/Confirmed)
• VD and CS pt. shifted to
immediate postnatal ward
• Close F/U for first 6 hr to check
PPH & vital parameters
• If patient is settled she is
transferred to isolation ward
having central O2 supply.

75. • In isolation ward following parameters:
• pulse
• BP
• SPO2
• respiratory rate
• Monitoring of Wound-
• If there is any wound infection(as immuno-
suppressed)—
Daily dressing and debridement by level ll PPE.
using pulse oxymeter and
automated BP machine

76. Postnatal
examination
• Patient wearing
surgical mask.
• Proper hand
washing before and
after examination.

77. • Investigations(if necessary)
• RT-PCR of nasopharyngeal
swab & oropharyngeal swab
• CBC,CRP,X ray chest P/A view, if
required HRCT chest.
• serum ferritin ,APTT
• D-dimer
• Liver function test
• Renal function test
After Consultation with Internist

78. When to refer to
critical care or
red zone
Critically ill postpartum patient shifted to ICU and
jointly by obstetrician ,anesthesiologist and
intensivist.
Danger sign:
severe respiratory distress or falling SPO2,
Signs of thromboembolism ,chest pain ,limb pain
redness,septicaemia,persistent diarrhea, electrolyte
imbalance, unconsciousness,

79. Postnatal follow up
• First postnatal checkup is given before
discharge from hospital.
• First follow up call in 48 hrs after discharge.
• Subsequent over telephone by video calling if
required.
• Final visit on 6th week postpartum period
• Follow up phone calls 3 and 6 months after
discharge.

80. Postnatal advice
components
Breast feeding encouraged irrespective of
COVID 19 status of mother and baby.
Counseling about Contraceptive
Counseling about IPC.

81. Precautions During Breast Feeding
Mothers should maintain proper personal hygiene.
Mother should wear surgical mask during feeding.
She should wash her hands for 20 secs with soap
water/60 % alcohol solution before touching the
baby.
She should maintain coughing and sneezing
etiquette( On elbow or tissue and tissue should be
discarded on bin and hand wash later on).

82. Breastfeeding cont….
If the mother have moderate respiratory distress
then she can take help from a caregiver and
breastfed her baby by expressed milk.
-In critically ill patient breastfeeding stopped
temporarily keeping in mind for relactation when
patient improves.
-For time being-we can also think about wet nursing
and donor milk

83. Contraceptive counselling
• All modern methods suitable for COVID
suspect/confirm.
• Promoting immediate LARC (PPIUD,PP IMPLANT)
• Telehealth contraceptive counselling should be
given .

84. Thromboprophylaxis
• All pregnant confirmed cases of COVID 19
who have delivered in Hospital should
receive thromboprophylaxis for 10 days
following discharge.
• For women with persistent morbidity
consider a longer duration of
thromboprophylaxis.

85. Thromboprophylaxis in postnatal
period
• We also advice frequent drinking of water and
activity.
• We usually stop using prophylactic enoxaparin 12
hours before delivery, but it should be started 6 to
12 hrs after delivery.
• In severe or critical cases it is must to give
enoxaparin.
• Oral Rivaroxaban can be given
post partum.

86. Advice during discharge
• Advices for home isolation .
• Stay in a separate room .
• Don't go outside.
• Avoid symptomatic members of family.
• Maintain social distance.
• Ensure personal hygiene and self care

87. • Body temperature normal for 3 days.
• Respiratory symptoms significantly improved.
• Lung imaging shows obvious improvement in
lesion.
• No comorbidities or complications which
require hospitalization with SPO2>93%
without O2.
• Discharge should be approved by
multidisciplinary team approach.
Discharge criteria

88. If the mother has no symptoms for 3 days or
10 days passed since positive in
asymptomatic case- she is cured.
When Mother is Cured:

89. Take home message
• Categorization of COVID 19 cases according to
triage .
• Transfer of critical postnatal patient to Red zone
and uncomplicated cases to isolation ward .
• Discharge in 2nd PN day in VD and 3rd POD in
cesarean uncomplicated cases.
• Important investigations, follow up, contraceptive
counselling,Breastfeeding..
• Prevention of thromboprophylaxis in postnatal
period