COVID management in pregnancy and safe delivery

1. 1
COVID MANAGEMENT IN PREGNANCY AND SAFE
DELIVERY
MODULE FOR THIRD COVID WAVE CAPACITY BUILDING FOR MEDICAL OFFICERS
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

2. 2
EFFECT ON FOETUS
 There are currently no data suggesting an increased risk of miscarriage or
early pregnancy loss in relation to COVID
 There is no evidence currently that the virus is teratogenic.
 Long term data is awaited.
 COVID infection is currently not an indication for Medical termination of
pregnancy.
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

3. 3
EFFECT ON HEALTH OF THE PREGNANT WOMAN
 Most (>90 percent) infected pregnant women recover without need for
hospitalization.
 Compared with pregnant women without COVID-19, those with symptomatic
COVID-19 are at increased risk of adverse pregnancy outcomes, including
admission to the ICU, iatrogenic preterm birth, pre-eclampsia-like symptoms,
Caesarean section and death.

4. 4
EFFECT ON NEWBORNS OF
COVID-19 POSITIVE MOTHERS
 Most (over 95 percent) of newborns of COVID-19 positive mothers have been
in good condition at birth.
 However, Covid-19 in pregnancy increases the chances of preterm birth,
increasing the possibility of hospitalization for the neonate

5. 5
ANTE-NATAL CARE FOR NON-COVID PREGNANT
WOMEN IN CURRENT PANDEMIC
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

6. 6
ANC FOR NON-COVID PREGNANT WOMEN
 Reduce antenatal contact for ANC visits to minimum needed. Postpone unnecessary visits
and utilize telemedicine.
 Advice
 Vaccination (TT and COVID)
 Diet
 Quarantine
 Avoid travel
 Limit visitors
 Hygiene: Infection Prevention (masks, social distancing, handwashing) and Shielding
 Antenatal Advice to Pregnant HCP
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

7. 7
MINIMIZE ANTENATAL CONTACT
 WHO prescribed minimum visits at 12, 20, 28 and 36 weeks to be followed in
uncomplicated cases
 Reduce/Postpone/increase interval between follow up visits/scans
 Shorten Duration of consultation
 Limit Visitors in hospital
 Individualize patients who require frequent review
 Continue to provide ANC as per established protocol to High Risk Pregnancy
 Telemedicine/Videoconferencing when direct observation is not required
 Virtual/Online Consultation with Counselors/Fetal Medicine/Mental Health
Experts
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

8. 8
HOME CARE/MONITORING
 Blood Pressure
 Maternal weight
 Daily fetal movement count
 Urine Checks for Albumin/Sugar
 Home blood glucose monitoring if feasible and required for the mother
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

9. 9
HYGIENE
 Wash hands frequently
 Social distancing and avoid direct physical contact as much as possible
 Avoid touching nose/mouth/face
 Cough/Sneeze into elbows
 Stay Home and void visiting crowded places
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

10. 10
TRAVEL & QUARANTINE
 Avoid non essential travel
 Home quarantine as per national protocol
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

11. 11
WARNING SYMPTOMS
 Cough
 Fever, weakness,bodyache
 Headache
 Worsening shortness of breath
 Inability to tolerate oral hydration or needed medications
 Persistent pleuritic chest pain
 New-onset confusion or lethargy
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

12. 12
WARNING SYMPTOMS (CONTD.)
 Obstetrical complaints, such as preterm contractions, vaginal bleeding, or
decreased fetal movement
 Tachypnea
 Unremitting fever (greater than 39 °C) despite antipyretics
 Oxygen saturation less than 95% either at rest or on exertion
 Cyanotic lips, face, or fingertips
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

13. 13
SHIELDING
 To protect clinically vulnerable women like mothers with heart disease,
immuno-compromised status
 How?
 Minimize interaction with others and avoid non essential contact
 Stay at home at least for 12 weeks
 Remote medical assistance
 Family members role in shielding
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

14. 14
ANTENATAL ADVICE FOR PREGNANT HCP
 Vaccination, if not yet vaccinated
 Work from home when possible
 Choice should be offered to pregnant HCPs: whether to work in direct patient
contact or otherwise,
 For less than 28 weeks pregnant
 Practice social distancing and use precautions appropriately while facing
direct patient contact
 For more than 28 weeks pregnant
 Should avoid direct patient contact and work from home
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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ANC FOR SUSPECTED / CONFIRMED PATIENTS
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16. 16
PREGNANCY WITH SUSPECT COVID INFECTION
 Avoid panicking under all circumstances
 Immediately contact care giver if severe symptoms develop
 Do not attend routine clinic but special clinic area for triage and screening
area with minimum number of attendants in private transport with a view to
minimize contact with others and reduce risk of transmission
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

17. 17
ALGORITHM FOR MANAGEMENT OF PREGNANT WOMEN
Antenatal contact categories:
0. Asymptomatic from hotspot
1. With suspected COVID infection
2. With confirmed COVID infection
 Asymptomatic
 Symptomatic
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

18. 18
ASYMPTOMATIC
 Pregnant women residing in cluster/containment area or from hotspot districts
presenting in labor or likely to deliver in next 5 days should be tested even if
asymptomatic.
 All such asymptomatic pregnant women should be tested in the health facility
where they are expected to deliver, hence testing facilities to be made in all
such centers or arrangements should be in place for safe & appropriate
transfer of samples to testing facilities.
 No patient should be sent to testing center for lack of testing (swab) facility at
the center they are supposed to deliver
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

19. 19
ASSESSMENT IN TRIAGE
 Fever > 380 C (100.40 f)
 Cough
 Shortness of breath
 Diarrhea
 History of travel in affected country in last 14 days
 Close contact with lab confirmed COVID positive case ( <1 m for more than
15 min, living together, direct contact with body fluids)
 Give the woman a face mask and keep a distance of at least 1 meter
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

20. 20
ASSESSMENT
Infection risk by ID
specialist or physician
Obstetric issue
(labor/emergency)
High Yes Need admission
Low No • Isolation at home for 14
days
• Clinical self monitoring
• If symptoms persist test
for COVID infection
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

21. 21
ADMISSION (SUSPECTED, NOT IN LABOUR)
 IPC practices to be followed
 Transfer the patient to isolation room
 Donning appropriate PPE by HCP
 Testing
 Do not delay Obstetric Care if testing is pending, need to do both on
urgent basis
 NP/OP Swab samples to be taken
 Till Results awaited treat all as COVID positive
 Multidisciplinary approach
(Obstetrician/Neonatologist/Anesthesiologist/physician)
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

22. 22
ASYMPTOMATIC (CONFIRMED)
 COVID positive pregnant woman
 Asymptomatic
 No co-morbidities
 No obstetric emergency/labour
 Should be kept on home isolation with for 2 weeks with telemedicine follow-up
at 1 week and then fetal monitoring for growth and well being to be done after
the period of isolation
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

23. 23
ANC FOR SUSPECTED OR CONFIRMED COVID
 Routine ANC appointments, OGTT, growth scans are to be delayed until the
period of isolation prescribed.
 No additional tests to be performed and if pregnant woman has any concern
for fetal well being, she should contact obstetric team
 COVID care as per protocol
 Additional care if any complication arise during the period of isolation whether
medical or obstetric
 Counseling for potential risk or adverse pregnancy outcomes can be
discussed
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

24. 24
MANAGEMENT OF CONFIRMED SYMPTOMATIC CASES
 Hospitalize in dedicated area based on severity of symptoms and need for labor & delivery (ward/labor
room/OB-OT/ICU)
 Continue maternal surveillance
 ICU admission criteria
 Systolic BP<90 or >160 mmHg
 Diastolic BP>100 mmHg
 HR<50 or >120/min
 RR<10 or >30/min
 Room air spo2<94%
 Oliguria urine output <35ml/hr for 2 hours
 Confusion/agitation/unresponsive
 Poor QSOFA score
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

25. 25
MANAGEMENT OF CONFIRMED SYMPTOMATIC CASES (CONTD.)
 Severe failure criteria:
 Consider C section delivery in consultation with treating physician
 Septic shock
 Acute organ failure
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

26. 26
MATERNAL SURVEILLANCE: CONFIRMED SYMPTOMATIC
 Temperature, pulse, BP, respiratory rate (3-4 times a day)
 Chest imaging (x-ray) (Only if clinically needed with abdomen shield after
consent)
 Oxygen therapy to maintain spo2 > 94%
 Encourage oral hydration and restrict IV fluids especially in cardiac conditions
 Antipyretic therapy (for maternal comfort, to mitigate fetal effects of maternal
hyperthermia)
 Screen for other viral/bacterial infection/s
 Consider IV antiviral/antibacterial/antiviral treatment
 Consider thromboprophylaxis
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

27. 27
FETAL SURVEILLANCE: CONFIRMED SYMPTOMATIC
 FHR, daily FM count
 Women at risk of preterm birth (24-34 weeks) can be considered for AN
corticosteroids provided there is no clinical evidence of infection (maybe of
benefit in mild COVID infection)
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

28. 28
ANC: SUSPECTED /CONFIRMED COVID INFECTION
 Recovery
 Little is known about natural history of COVID in pregnant women
 If patient recovers in first trimester: consider mid trimester anatomical
ultrasound
 If patient recovers in later half of pregnancy: consider USG growth
assessment 2 weeks after infection
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

29. 29
TAKE HOME MESSAGE
 Pregnant women should follow the same recommendation for avoiding
exposure to coinfection as the nonpregnant population.
 Teleconferencing/videoconferencing is key for quality care in a pandemic
 Triage based on symptom severity and need for obstetric emergency
 Multidisciplinary approach to management of COVID-suspected/confirmed
pregnant women
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

30. 30
MANAGEMENT DURING INTRANATAL CARE FOR
PREGNANT WOMEN WITH COVID-19
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

31. 31
OBJECTIVES
 Preparation of isolation LR and OT
 Labour triage
 Management in labour
 Management of neonate
 Postpartum care
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

32. 32
PRINCIPLES OF MANAGEMENT OF PATIENT IN LABOUR
 Provide client-centred, respectful skilled care and support
 Inform MDT: consultant obstetrician, consultant anaesthetist, paediatrician,
nurse in charge and infection control team.
 Manage in designated COVID Area
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

33. 33
COVID LABOUR ROOM COMPLEX
TRIAGE AND DELIVERY
ROOM
RECOVERY ROOM
OPERATION
THEATRE
ISOLATION AREA IN NICU
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34. 34
ISOLATION LABOUR ROOM
 Separate delivery room of adequate size where triage and labour can be
managed
 Donning and doffing area
 Labour table, portable light, emergency drugs tray, EFM, delivery tray, baby
tray, oxygen, disposables tray
 Keep the room free from any unnecessary items which could act as infected
fomites
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

35. 35
ISOLATION LABOUR ROOM
 Personnel: obstetrician, nurse, paediatrician, cleaning staff
 Keep anaesthetist on stand by
 Baby corner 2 mtr away from labour table
 PPE for 4
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

36. 36
ISOLATION OT
 Equipment: OT table, light,
anaesthesia trolley cum ventilator,
multipara monitor, gases
 Drugs, surgical instruments,
disposables, electrocautery
 OT personnel: obstetrician,
assistant, staff sister, circulating
nurse, anaesthetist, paediatrician,
cleaning staff
 PPE for 6-7 persons
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

37. 37
ISOLATION RECOVERY AREA
 Equipment for monitoring:
 Oxygen
 Multipara monitor
 Ventilator
 Drugs
 Staff: obstetrician, nursing staff, anaesthetist, cleaning staff
 Drugs and disposables
 PPE for 4
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

38. 38
LABOUR TRIAGE: RECEIVING THE PATIENT
 Prehospital notification i.e. call in advance
 Private transport or ambulance
 Receiving staff in PPE
 Give mask to patient
 Reception and triage in the same room as labour and delivery.
 General and obstetric assessment
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

39. 39
LABOUR TRIAGE: GENERAL ASSESSMENT
 Asymptomatic or pre-symptomatic infection – positive test for sars-cov-2
but no symptoms.
 Mild illness – Signs and symptoms (eg. fever, cough, sore throat, malaise, headache, muscle
pain) without shortness of breath, dyspnoea, or abnormal chest imaging.
 Moderate illness – evidence of lower respiratory disease by clinical assessment or imaging
and a saturation of oxygen (SaO2) >93 percent on room air at sea level.
ICU ADMISSION
 Severe illness – RR>30/minute, SaO2 ≤93 percent on room air at sea level, ratio of arterial
partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung infiltrates
>50 percent
 Critical illness – Respiratory failure, septic shock, and/or multiple organ dysfunction.
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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OBSTETRIC ASSESSMENT AND DECISION MAKING
 Is she in labour?
 Check fetal status
 Assess for high risk factors
 Induction of labor: only for obstetric indications using standard
interventions or medical reasons as per physician
 Mode of delivery:
 Should not be influenced by the presence of COVID-19, unless the
woman’s respiratory condition demands urgent intervention for birth as
guided by the physician.
Patients with severe or critical illness have
high chance of preterm birth and CS
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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MANAGEMENT IN LABOUR
 Monitor vital signs, spO2: aim to keep oxygen saturation more than 94%,
titrating oxygen therapy accordingly
 Restrict IV fluids:
 Labour management as per routine protocol.
 Delayed cord clamping
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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BIRTH COMPANION
 Preferably should not be allowed in COVID LR
 Video call with companion may be arranged for
 If entry is allowed, companion should be screened for fever and other
symptoms before entering the premises
 Wear a cloth face cover or face mask
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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CESAREAN SECTION
 Regional anesthesia preferred
 Experienced obstetrician to perform the operation
 Electrocoagulation is an aerosol generating procedure. Use minimum settings
and suction out smoke
 Surgical difficulties: due to face shield and multiple layers, visibility and tactile
sensation compromised.
 The risk of COVID transmission by blood products has not been documented
and is unclear at present
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

44. 44
POSTPARTUM CARE
 For patients who are asymptomatic, postpartum maternal monitoring is similar
to that in non-COVID patients
 Patients who are symptomatic covid - treat them as per protocol
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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NEONATAL ASSESSMENT
 The infants of mothers with COVID are considered COVID suspects, and they
should be tested and isolated from other healthy infants
 When to test: 2 samples, one at birth & second after 48 hrs
 Transport neonate to isolation NICU in a closed chamber
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

46. 46
CO-LOCATION OF MOTHER AND BABY
 If both mother and neonate test positive, rooming in can be permitted
 Healthy neonates should preferably be cared for by family member not in
contact with mother or other suspected/proven case
 Mother can express milk after washing hands and breasts, and while wearing
mask. This expressed milk can be fed to her own baby without pasteurization.
 Sick neonates should be managed in an isolation area in NICU
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

47. 47
BREAST FEEDING
 No evidence of viral shedding in breast milk
 Risk of transmission through close contact with mother is present
 Risks and benefits must be explained to the mother
 Frequent handwashing, respiratory hygiene, cleaning of all surfaces,
minimum touching of the neonate
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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NEONATAL VACCINATION
 Follow routine immunization policy in healthy neonates born to mothers with
suspected/proven COVID infection.
 In neonates with suspected/proven infection, vaccination should be completed
before discharge from the hospital as per existing policy.
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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PERMANENT AND REVERSIBLE CONTRACEPTION
 Temporary: LARC (long-acting reversible contraceptive) post-placental and
post partum IUCD preferred
 After a vaginal birth sterilization is being elective procedure, should be
deferred.
 Progesterone only pills also an option for bridging
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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DISCHARGE
 Early discharge in postpartum period
 24 hours for VD, 48-72 hrs for CS
 Postpartum assessments including wound and blood pressure checks with
telehealth
 Visit may be planned at 12 weeks
 Psychological support
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat

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SUMMARY
 Management of labour is not altered in women giving birth during in women
with confirmed COVID
 Infected women, especially those who develop pneumonia, appear to have an
increased frequency of preterm birth and caesarean delivery.
 Infants born to mothers with known COVID-19 are COVID-19 suspects and
should be tested, isolated from other healthy infants,
 To minimize direct contact, ideally, the infant is fed expressed breast milk by
another caregiver until the mother has recovered or proven uninfected
 Recommended ICP should be followed
www.gujhealth.gujarat.gov.in Health and Family Welfare Dept., Govt. of Gujarat