This document provides guidelines for nursing care of pregnant women during the COVID-19 pandemic. It discusses that pregnant women do not appear more likely to contract COVID-19 but are at higher risk of severe symptoms. It recommends screening all pregnant women for COVID-19 risk factors and symptoms. For positive cases, it outlines protocols for monitoring, delivery, and neonatal care that minimize transmission while ensuring maternal and fetal well-being. The guidelines aim to provide safe care during pregnancy, childbirth and the postpartum period during the pandemic.

1. NURSING CARE IN
PREGNANCY DURING
PANDEMIC
Presented by:-
KHUSHBOO SINGH
M.SC NURSING Ist year

3. Effect of COVID-19 on Pregnancy
❑ Pregnant women do not appear more likely
to contact the infection than the general
population.
❑ Pregnancy itself alters the body’s immune
system and response to viral infections in
general, which can occasionally be related to
more severe symptoms and this will be the
same for COVID-19.
❑ Reported cases of COVID-19 pneumonia
in pregnancy are milder and with good
recovery.

4. ❑ In other types of coronavirus infection (SARS,
MERS), the risks to the mother appear to
increase in particular during the last trimester of
pregnancy.
❑ There are case reports of preterm birth in
women with COVID-19 but it is unclear whether
the preterm birth was always iatrogenic, or
whether some were spontaneous.
❑ Pregnant women with heart disease are at
highest risk (congenital or acquired).

5. ❑Risk of spread via respiratory droplets
❑ On account of lockdown situation an
isolation, perinatal anxiety and
depression/ Domestic Violence may
increase, and pregnant women may
require additional mental health
support

6. ❑Certain other Conditions like:
• Heart Disease
• Diabetes
• Hypertension
• Asthma
• Immuno-compromised conditions like
HIV, SLE
Increases risk of complications

7. Transmission
Vertical transmission (transmission from
mother to baby antenatally or
intrapartum),
Emerging evidence now suggests that
vertical transmission is probable, although
the proportion of pregnancies affected and
the significance to the neonate has yet to
be determined.

8. At present, there are no recorded cases
of vaginal secretions being tested
positive for COVID-19.
At present, there are no recorded cases
of breast milk being tested positive for
COVID-19.

9. Effect on Foetus
There are currently no data suggesting an
increased risk of miscarriage or early
pregnancy loss in relation to COVID-19.
There is no evidence currently that the virus
is teratogenic. Long term data is awaited.
At present, COVID-19 infection is currently
not an indication for Medical Termination of
Pregnancy

10. General Guidelines for Obstetric
Health Care Providers
✔ Nurse/ Ob-gyns/Midwives and other health care
practitioners should contact their local and/or
state health department for guidance on testing
persons under investigation and should follow
the national protocol.
✔ Health care practitioners should immediately
notify infection control personnel at their
health care facility and their local or state health
department in the event of a PUI for COVID-19

11. ✔ A registry for all women admitted to with confirmed
COVID-19 infection in pregnancy should be
maintained.
✔ Maternal and neonatal records including outcome
should be completed in detail and preserved for
analysis in future.
✔ Health care providers should create a plan to
address the possibility of a decreased health care
workforce, potential shortage of personal protective
equipment, limited isolation rooms
✔ Maximize the use of Tele-health across as many
aspects of prenatal care as possible

12. ✔ Each facility should consider their appropriate
space and staffing needs to prevent
transmission of the virus that causes COVID-19.
✔ Pregnant women should be advised to increase
their social distancing to reduce the risk of
infection and practice hand hygiene.
✔ Health care practitioners should notify infection
control personnel at their Hospital for the
arrival of a pregnant patient who has
confirmed COVID-19 or is a PUI so that infection
control measures can be kept in place.

13. ✔ Intrapartum services should be provided in a
way that is safe, with reference to minimum
staffing requirements and the ability to provide
emergency obstetric, anaesthetic and neonatal
care where indicated.
✔ A single, asymptomatic birth partner should
be permitted to stay with the woman, at a
minimum, through pregnancy and birth.
✔ Visitors should be instructed to wear appropriate
PPE, including gown, gloves, face mask, and eye
protection.

14. ✔Women should be met at the maternity unit
entrance by staff wearing appropriate
PPE, surgical face mask. The face mask
should not be removed until the woman is
isolated in a suitable room.
✔ Staff providing care should take Personal
Protective Equipment (PPE) precautions
as per national guidance

15. Specific Obstetric Management
Considerations
Medical History
For all pregnant women obtain the following
information
⮚A detailed travel history
⮚ History of exposure to people with symptoms
of COVID-19
⮚ Symptoms of COVID-19
⮚ Coming from hot spot area
⮚Immunocompromised conditions

16. INFORMATION TO BE SHARED WITH
PREGNANT WOMEN
•If infected with COVID-19 have no symptoms or a mild
illness, they will make a full recovery.
•If develop more severe symptoms or recovery is delayed,
they should contact their maternity care team immediately.
•There may be a need to reduce the number of antenatal
visits they have. However, do not reduce number of visits
without agreeing first with your maternity team.

17. Do’s & DonT’s for Obstetricians/Nurses
during pandemic
• A woman meeting criteria for testing should be
tested. until test results are available, she
should be treated as confirmed COVID-19.
• Do not delay obstetric management in order
to test for COVID-19.
• Elective procedures like induction of labour ,
routine growth scans ,that are not strictly
necessary,and routine investigations should be
reduced to minimum

18. Antenatal Care Service delivery
1st visit: Within 12 weeks—preferably as soon
as pregnancy is suspected
➢2nd visit: Between 14 and 26 weeks
•➢3rd visit: Between 28 and 34 weeks
•➢4th visit: Between 36 weeks and term

19. ANTENATAL CARE
❑Additional ANC visit may be planned at the
discretion of the maternal care provider, if
there are any specific symptoms or danger signs
related to pregnancy,with all self-isolation
criteria.
❑ For women who have/had symptoms,
appointments can be deferred until 7 days
after the start of symptoms, unless symptoms
(aside from persistent cough)
❑Foetal Kick count to be maintained.

20. ❑ If needed to visit health centre, should
take own transport or call 108, informing
the ambulance staff about her status.
❑ For women who are self-quarantined
because someone in their household has
possible symptoms of COVID-19,
appointments should be deferred for 14
days.

21. ❑ Any woman who has a routine appointment delayed
for more than 3 weeks should be contacted. (In
rural areas ANMs/ASHAs can contact by telephone/ if
routine household visits go with PPE)
❑ Even if a woman has previously tested negative for
COVID-19, if she presents with symptoms again,
COVID-19 should be suspected.
❑ Referral to antenatal ultrasound services for foetal
growth surveillance is recommended after 14 days
following the resolution of acute illness.

22. Note: if positive mother
❖ The service providers can
assess the isolation criteria
for the patient at home,
especially if in slums/small
households, else she could be
admitted in hospital or
quarantine facility.
❖self-quarantine for close
contacts of pregnant covid
patient for 14 days.

23. ❖Whether she has attended ANC
clinic in the last 14 days before
testing, if so self quarantine of
the service providers.
❖If a woman tests positive, she
should be advised to deliver at
least at an FRU (Rural/Sub
district)
❖preferably a tertiary facility
anticipate the complications
during delivery.

24. Advisory for Antenatal Women
• Disinfection of surfaces to reduce
fomites related spread.
• For women working outside the house, it
is preferable to take Work from Home.
• Keeping a distance of at least one metre
in various necessary interactions and
activities

26. ➢ Avoid non-essential travel. If travel is
undertaken,it is preferable to use a private
vehicle
➢ Avoid gatherings and functions
➢ Minimize visitors from coming to meet
the mother and newborn after delivery

28. Follow-Up of Pregnant Women after
COVID-19
• Resolution After hospital discharge
of pregnant women with COVID-19
infection, telehealth follow-up is
recommended to ensure maternal
well-being
• Due to the limited evidence on the
effects of COVID-19 infection during
pregnancy, follow-up appointment
will be scheduled after the end of
the infective period (at least 4
weeks after the onset of symptoms
or after a negative test).

29. • Assessment of pregnancy risks,
fetal growth, and well-being will
be recommended throughout
pregnancy.
• Due to concerns on fetal growth,
serial ultrasounds in the third
trimester (28, 32, and 37 weeks)
may be indicated.
• If follow-up assessment is
required within the
contagiousness period, it will be
carried out with the necessary
protection measures.

30. Intrapartum Care Services
➢ Ensure safe institutional delivery
➢ Maintaining due list of all pregnant
women with Expected Date of Delivery
(EDD) in next three months (last trimester)
at HC level for active follow up.
➢ Each pregnant woman to be linked to
appropriate health facility for delivery
by the ANM / CHO or PHC MO.

31. • Assessment of the severity of COVID-
19 symptoms if positive, which should
follow by a multi disciplinary team
approach medical specialist.
• Maternal observations including
temperature, respiratory rate & oxygen
saturations

32. • Confirmation of the onset of labour,
as per standard care.
• Electronic foetal monitoring
• Hourly oxygen saturation during
labour.

33. General Guidance
“All women despite the pandemic
have a right to have
safe and positive
childbirth experience”

35. ❑Minimise the number of people involved
in any procedure
❑A single, asymptomatic birth partner can be
permitted to stay with the woman, at a
minimum, through pregnancy and birth.
❑Standard universal precautions to
prevent contact with body fluids need to be
followed & BMW managed as per protocols

36. Care in Labour
• Aim to keep oxygen saturation >94%
• If the woman has signs of sepsis,
investigate and treat as per guidance
on sepsis in pregnancy, but also
consider active COVID-19 as a cause of
sepsis and investigate according to
guidance.

37. • Continuous electronic foetal monitoring
in labour is recommended.
WHICH MODE OF DELIVERY IS BEST
• There is currently no evidence to favour one
mode of birth over another.
• Mode of birth should not be influenced by
the presence of COVID-19, unless the
woman’s respiratory condition demands
urgent delivery.

38. • There is no evidence that epidural or
spinal analgesia or anaesthesia is
contraindicated in the presence of
coronaviruses.
• Epidural analgesia should therefore be
recommended in labour to women with
suspected/confirmed COVID19 to minimise
the need for general anaesthesia if urgent
delivery is needed

39. An individualised decision should be
made regarding shortening the length
of the second stage of labour with
elective instrumental birth in a
symptomatic woman who is becoming
exhausted or hypoxic

40. In case of deterioration in the woman’s
symptoms, make an individual
assessment regarding the risks and
benefits of continuing the labour,
versus emergency caesarean birth if
this is likely to assist efforts to
resuscitate the mother.

41. • When caesarean birth or other operative
procedure is advised, it should be done
after wearing PPE.

42. Intrapartum Monitoring
Besides strict monitoring maternal and fetal
well being with partograph
❑ Periodic evaluation of respiratory status
❑ Symptoms of difficulty or shortness of breath
❑ Oxygen saturation using pulse oximeter hourly oxygen
saturation needs to be examined and should be >94%
❑ Prolonged labour should be avoided- early decision for c section
should be taken in case of prolonged labour.

43. Mode of delivery for COVID-19
suspected or confirmed case
• Mode of birth should not be influenced by the
presence of COVID19, unless the woman’s
respiratory condition demands urgent delivery
• C- Section Indication? – COVID 19 is NOT an
indication for c -section Decision based on
obstetric (fetal or maternal) indications and not
COVID-19 status alone
Scheduled inductions of labor or cesarean
deliveries: Inductions of labor and cesarean
deliveries should continue to be performed as
indicated.
Mode of birth should not be influenced by the presence of
COVID19, unless the woman’s respiratory condition demands
urgent delivery
C- Section Indication? – COVID 19 is NOT an indication for c -
section Decision based on obstetric (fetal or maternal)
indications and not COVID-19 status alone
Scheduled inductions of labor or cesarean deliveries:
Inductions of labor and cesarean deliveries should continue to
be performed as indicated.

44. ❑Amniotomy: Given the reassuring (but limited)
data to date pertaining to maternal-to-child
transmission, amniotomy may still be utilized
for labor management as clinically indicated.
❑Delayed cord clamping: According to WHO,
delayed umbilical cord clamping is highly
unlikely to increase the risk of transmitting
pathogens from the mother to the fetus even in
the case of maternal infection.
❑Delayed cord clamping: According to WHO, delayed
umbilical cord clamping is NOT AT ALL going to
increase the risk of transmitting pathogens from the
mother to the fetus even in the case of maternal
infection.
❑Amniotomy: Given the reassuring (but
limited) amniotomy may still be utilized for
labor management as clinically indicated.

45. Nursing care during Vaginal
Delivery
• Continuous CTG monitoring is advised due to
possible increased risk of fetal distress in case
mother is covid positive
• Although there is no evidence on the presence
of SARS-CoV-2 in vaginal secretions so we can
avoid fetal scalp pH testing or internal fetal
heart rate monitoring.
• If fetal well-being loss is suspected, immediate
delivery of pregnancy should be done by the
most appropriate mode of delivery.

46. • Monitor temperature, respiratory rate, and
SO2 hourly.
• Under normal labor progression, vaginal
examinations should be minimized (i.e., every 2–
4 h). Ideally,
• A minimal number of professionals should be
involved in labour management
• Neuraxial analgesia is not contraindicated, and
by providing good analgesia, it may reduce
cardiopulmonary stress from pain and anxiety.
• Consider shortening the second stage of labour
(forceps or vacuum) according to obstetric
criteria

47. • •
Unless indicated for avoid routine umbilical cord gas
analysis in neonate
• In any case, the support person should be screened for
symptoms before admission to the delivery room,
wearing appropriate protective equipment (at least a
surgical mask) and keeping droplet and contact
isolation measures.
• Any generated material during labour should be treated
as contaminated.

48. Nursing care during Caesarean
Delivery
The potential risk of vertical transmission
is not an indication for caesarean
section
Maternal indication:
❖ women with respiratory compromise,and
maternal hypoxia also has fetal risks.Under this
rationale, a caesarean section could be
considered after 32–34 weeks in women with
severe illness,

49. Medical Management
➢ Supportive therapy include rest, oxygen
supplementation and nutritional care
➢ Hydroxychloroquine in a dose of 600 mg (200 mg
TDS with meals) and Azithromycin (500 mg OD) for
10 days
➢ Anti-viral Therapy Lopinavi ritonavir, Remdesivir
➢ Antibiotics: If there is a suspicion of secondary
bacterial infection
➢ Oxygen: If there is difficulty in breathing, oxygen
supplementation by nasal prongs or mask may be
added.

50. Indications for ICU Admission
❖ Respiratory rate > 30 breaths/min
❖ Oxygen saturation < 93% at a rest
❖ Arterial partial pressure of oxygen
(PaO2)/oxygen concentration (FiO2) < 300
mm Hg
❖ Patients with > 50% lesions progression
within 24 to 48 hours in lung imaging
❖ Quick Sequential Organ Failure Assessment
Score (qSOFA) score can be a useful adjunct
to decision making for ICU management

52. Neonatal Issues
✔ Neonates from COVID-19-positive women should
be tested, isolated, and cared following droplet
and contact preventive measures
✔The WHO recommends for mothers with COVID-
19 infection to be able to room in with their
babies
✔ The mother should wear a surgical mask and
practice hand hygiene when in close contact with
her infant, particularly when feeding.

53. ✔Alternatively, if another healthy adult is in
the room, they can care for the newborn.
✔ Asymptomatic newborns could be
discharged after delivery and cared by an
asymptomatic family member with the
adequate isolation measures.
✔ If they are symptomatic or have other
hospitalization criteria (prematurity, etc.),
they will be admitted to an isolated area
defined in the neonatal care unit.

54. ✔ Newborn care should be carried out in the
same operating/labour room unless
resuscitation measures are required that can
not be provided in-room
✔ Although evidence of mother-to-child
transmission is lacking, The patient could
informally decide skin-to-skin contact with the
newborn
✔ This can only be offered if a good mother-
child placement can be ensured, and in
asymptomatic newborns >34 weeks, ensuring
precautions for respiratory droplets with the
use of a mask as well as hand and skin
hygiene.

55. Management of Patients with COVID-19
Admitted to Critical Care
Hourly observations
oxygen to keep saturations >94%.
Hourly respiratory rate
Deterioration in respiratory function should
be managed by starting or increasing oxygen.

56. Do not assume all pyrexia is due to COVID-19 and
also perform full sepsis screening (lymphocytes
usually normal or low with COVID-19)
Apply caution with IV fluid management.
Try boluses in volumes of 250-500mls and then
assess for fluid overload before proceeding with
further fluid resuscitation.
Foetal heart rate monitoring

57. Postpartum Care
Immediate postpartum surveillance until
transfer to the hospitalization room
Paracetamol is the analgesic of choice
due to some reports of rapid disease
progression in young adults under non-
steroidal anti-inflammatory drugs
(ibuprofen)

58. Postpartum prophylactic low-molecular-
weight heparin (if maternal weight <80 kg:
enoxaparin 40 mg every 24 h or equivalent;
if maternal weight >80 kg: 60 mg every 24
h) is indicated during hospitalization and 6
weeks thereafter
In women with infection more than 4 weeks
before delivery, thromboprophylaxis should
be followed

59. Ensure availability of IFA and
calcium tablets during PNC
period
➢ Consider temporary
separation of mother and
baby

60. Mother/Baby Contact
If separate room is not the option:permit Room-in
Newborn with ill mother:
• Use physical barriers (e.g., a curtain between the
mother and newborn)
• Keep newborn ≥6 feet away from the ill mother If
no other healthy adult is present for caregiving:
• Mother should put on a facemask and practice
hand hygiene before each feeding or other close
contact with her newborn.
• Facemask should remain in place during contact
with the newborn.

61. BREST FEEDING

65. The final decision on the type and mode of
lactation must be agreed between the
patient and the neonatologists based on
current scientific knowledge as well as and
maternal and neonatal health status. If
artificial feeding is decided, milk production
can be maintained through extraction and
discard until the mother tests negative

66. Mental Health
Issues

67. Addressing Mental Health Issues
among Pregnant and Postpartum
Women during COVID-19
Symptoms of anxiety and psychological
distress during the perinatal period
related to COVID-19 is more
❖Excessive worry about getting the
infection even when all precautions are
being taken and even after reassurance is
found in pregnant women

68. Anxiety about the COVID-19 infection is normal at this time of pandemic
and lockdown. But
your mental health is important for the growth and development of your
baby
❑ Lack of sleep because of anxiety
❑ Focusing excessively on social
media messages about COVID-19
❑ Getting anxious about infection
control procedures in family
members
❑ Excessive worrying about missing
work
❑ Feeling sad and angry because of
isolation and not being able to meet
family and friends
❑ Feeling nervous, anxious, or on
edge
❑ Not being able to stop or control
worrying
❑ Addressing Mental Health Issues
❑ among Pregnant and Postpartum
❑ Trouble relaxing
❑ Being so restless that it's hard to
sit still
❑ Becoming easily annoyed or
irritable
❑ Feeling afraid as if something awful
might happen General
recommendation forpregnant
women
❑ Remember that your mental health
is as important as physical health
for the adequate growth and
❑ development of your baby.
❑ Minimize watching, reading or
listening to news about COVID-19
that causes you to feel
❑ anxious or distressed.

69. NURSES ADVICE PREGNANT
MOTHERS

70.  Who have recovered or who have supported a
loved one and are willing to share their
experience.
✔ Practice hand hygiene techniques frequently at
home
✔Exposure to COVID-19 can be prevented by
following your doctor's advice.
✔ Physical health during pregnancy can be
sustained by maintaining an adequate diet
which includes green leafy vegetables, protein,
and carbohydrates.

71. ✔Continue take Iron and Folic acid tablets
prescribed by your doctor.
✔Keep your contact only with persons near
to you and who practice infection control.
✔ It is good to stay at your home and
involve in pleasurable activities.

72. ✔ Ask doctor regarding sanitation practices at
home.
✔ Contact ASHA or ANM or obstetrician over
the phone.
✔If delivery is near, then tell to keep
“Mother Card”, emergency ambulance
number ready.
✔ Tell to follow the instructions provided by
doctor regarding hospital visits.
✔ In case doctor advises pregnant women to
visit the hospital, then explain not to touch
any surface in the hospital.

73. Discharge
counselling

74. Discharge counselling
• Basic Strategy is to reduce the Physical
visits to healthcare facility of mother and
her newborn unless URGENT.
• Inform how she can communicate with
their obstetric/ pediatric care team,
especially in the case of an emergency
• Inform woman to return to facility in case
of Fever, Respiratory symptoms, or any
danger sign

75. • For patients who express
interest in postpartum
contraception, Suggest all
family planning options
within the limitations of
decreased postpartum in
person visits.
• Those experiencing anxiety
regarding the COVID-19
pandemic or are at an
increased risk of intimate
partner violence, offer
mental health or social work
services or referrals to
provide additional resources
• Discharge for postpartum
women should follow
recommendations for
discharge of Hospitalized
Patients with COVID-19 i.e.
when Tests are negative and
maternal and neonatal
condition should be stable.
• Stable neonates exposed to
COVID19 and being roomed-
in with their mothers may be
discharged together at time
of mothers’ discharge