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COVID-19: Pregnancy
CMECNE

Labor and Delivery During COVID-19: Management Highlights

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the suggested labor and delivery screening protocol during the COVID-19 pandemic
2. Describe changes to labor floor practice that may be considered during the COVID-19 pandemic

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date

SUMMARY:

This expert review provides some suggestions regarding best practices on labor and delivery during the COVID-19 pandemic. The following are highlights of interest to obstetric healthcare professionals (both staff and administration). The full document can be found in ‘Learn More – Primary Sources’

Triage Management

Screening Questions: Ask About the Following

  • Symptoms
    • Presence of fever and/or respiratory symptoms
  • Exposure Risk
    • Contact with person(s) suspected or known to be positive for COVID-19

If Patient is Symptomatic

  • Severe (chest pain and/or shortness of breath)
    • Transfer to L&D for further evaluation
    • Use proper provider PPE
    • Flu and COVID-19 testing
  • Mild (afebrile and new onset cough) or Moderate (New fever and new onset cough)
    • Acute OB concern: Transfer to L&D
    • No acute OB concern (e.g., anesthesia consult): Drive through testing | home quarantine | 24 follow up by phone

If Patient at Risk of Exposure

  • Acute OB concern
    • Transfer to L&D
  • No acute OB concern
    • Telehealth
    • Home quarantine

Admission Location

  • Limit movement between units (i.e. triage and labor rooms)
  • Women who are stable and are to be admitted for antepartum monitoring
    • If possible, keep patient in triage until transfer to antepartum floor

Respiratory Protection

  • The authors recommend that the following should be the goal of L&D units due to asymptomatic transmission

…every patient wear a surgical mask and every provider have a surgical mask for each patient encounter

  • Patient
    • Surgical mask (regardless of respiratory symptoms)
  • Provider
    • During routine patient encounter: Surgical mask
    • Patient with upper respiratory tract symptoms: Droplet PPE (gown, gloves, surgical mask/face shield)
    • Patient who is suspected or confirmed COVID-19: Droplet PPE and N-95 mask
    • In presence of indispensable aerosolizing procedure: Droplet PPE and N-95 mask

Note: Second stage of labor is included in the “indispensable aerosolizing procedures” category

KEY POINTS:

Labor induction

  • In keeping with professional recommendations, medical inductions should not be delayed
    • Authors include 39 week induction after counseling
  • COVID-19 specific recommendations (authors stress importance of local circumstances)
    • Surge situation (extreme healthcare burden): “May be appropriate” to postpone or reschedule
    • Early COVID-19 phase: “May be prudent to get patients delivered prior to high COVID-19 burden”
    • Consider outpatient cervical ripening (e.g., Foley) for patients at low risk

First stage

  • COVID-19 specific recommendations
    • Avoid peanut ball: Not shown to be effective | May transmit infection
    • Early intervention with oxytocin and amniotomy may be considered for women making slow progress | Higher oxytocin doses “can be considered”
    • Do not proceed to cesarean for first stage arrest unless
      • Arrest ≥4 hours with adequate uterine activity or
      • ROM: 6 hours with inadequate uterine activity, adequate oxytocin and cervical dilation ≥6 cm

Oxygen Therapy

  • Authors recommend against use of oxygen for fetal resuscitation
    • No proven benefit
    • Potential risk for transmission via respiratory assist devices, including ventilatory masks

Nitrous Oxide

  • Recommend eliminating use
    • Risk of transmission

Learn More – Primary Sources:

Expert Review: Labor and Delivery Guidance for COVID-19

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Related ObG Topics:

Managing an Obstetric Office Practice During COVID-19
Coronavirus and Pregnancy: CDC Guidance and Professional Recommendations
ACOG COVID-19 FAQs for Obstetrical Care
COVID-19: The SMFM/SOAP Guidelines for Labor and Delivery

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OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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