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

SUMMARY:

SMFM and Society for Obstetric and Anesthesia and Perinatology (SOAP) have released COVID-19 guidelines for obstetric professionals, including anesthesiologists. The following are highlights. The complete document link can be found in ‘Learn More – Primary Sources’. The guideline is not proscriptive with an understanding that they “may not apply in your clinical setting”

• Initial Assessment and Intake
• Patient Rooms
• PPE for Health Care Workers
• Preterm Medications
• Labor and Delivery
• Postpartum Care

Initial Assessment and Intake

• Initial assessment performed upon patient arrival
  • Personnel should maintain distance (>6 feet if possible)
  • Limit duration of encounter
  • Limit number of support persons
    • Develop policies locally | There may be state restrictions as well
    • Screen visitors for symptoms of respiratory illness before entering the healthcare facility
    • Provide exceptions for bereavement
• Log staff entering and leaving cohorted rooms
• Consider staggering staff schedule to limit exposure
  • Example: Rotate telehealth team with in-person team every 2 weeks
• Testing of women admitted to labor and delivery
  • Prioritize pregnant women with exposure to or symptoms of COVID-19
  • Universal testing “may be considered due to the potential for asymptomatic patients to present, particularly in areas of high community prevalence”

Patient Rooms

• Confirmed COVID-19 and PUI: “Ideally” should be placed in isolation room
• Airborne infection isolation rooms
  • In general
    • Droplet and contact precautions
  • If aerosol-generating procedure is anticipated
    • Single-patient negative-pressure rooms | Minimum of 6 air changes per hour
• “Crash Rooms”
  • Negative-pressure ORs should not have open surgical equipment

PPE for Health Care Workers

Women with Confirmed Covid-19 Or PUI

• Should wear a surgical mask

Health Care Workers Caring for Women Who are Positive for SARS-CoV2 or PUIs

• Use droplet and contact precautions with eye protection: Gown | Gloves | Surgical mask | Face shield or goggles
• High-risk obstetrical scenarios
  • Use respirators (e.g., N95 masks) in any room where there is performance or anticipation of aerosol generating procedure (e.g., intubation)
  • Obstetrical examples include
    • Cesarean deliveries
    • Twin vaginal deliveries
    • Women brought to OR for management of PPH
    • Intubation (actual or anticipated)
• Second stage of labor and deep respiratory effort
  • SMFM/SOAP states that healthcare workers

…should use N95 (or facemasks if N95 is not available), eye protection, gloves, and gowns during the second stage of labor, in addition to other personal protective equipment that may be typically indicated for labor and delivery

Surgical drapes could be used as an additional physical respiratory droplet barrier during the second stage and at delivery

KEY POINTS:

Preterm Medications

• Antenatal corticosteroids
  • Use with caution in ICU/acute care setting
  • Balance risks and benefits and adjust protocols accordingly (e.g., >34 weeks and repeat courses)
• Magnesium for fetal neuroprotection
  • Concern regarding maternal respiratory depression | Adjust accordingly based on clinical scenario, including gestational age and increasing maternal oxygen demands
  • Assess renal function | If mild respiratory distress, single 4 g bolus “may serve as an alternative”
• NSAIDs restriction
  • Document considers restricting NSAIDs to be controversial because data lacking to support this practice
• Prenatal ultrasonography
  • Use in settings where sonography would likely impact care

Labor and Delivery

• Follow standard guidelines for the following practices (based on availability, which may change over time)
  • Amniotomy
  • Internal monitoring (may change with more data but currently no evidence that there is an increased risk for transmission)
  • Operative vaginal deliveries
  • Magnesium for preeclampsia/seizure prophylaxis
    • In absence of severe features of preeclampsia, “avoidance of magnesium seems prudent”
    • Be cognizant of potential renal dysfunction and adjusts dosing accordingly
  • Epidural
    • Consider early epidural to mitigate risks of general anesthesia including increased risk of aerosol-generating procedures such as intubation
• Nitrous Oxide
  • Currently, limited data regarding use of nitrous oxide in patients with COVID-19
  • Patients with confirmed COVID-19 | Suspected COVID-19 | Unconfirmed COVID-19 negative status
    • “…may consider suspending use of nitrous oxide”
  • Patients with COVID-19 confirmed negative result
    • Nitrous oxide remains an option
• Oxygen for fetal indications
  • While considered controversial, “suspend” use of high flow nasal cannula or face mask | Consider oxygen in the setting of maternal hypoxia
• Worsening maternal respiratory status
  • Uterine decompression to improve maternal respiratory status
    • Data are unclear
  • Risk for fetal hypoxemia
    • Must be balanced against risks of preterm birth and maternal compromise

Postpartum Care

• CDC recommendation regarding mother/infant separation has been updated since SMFM/SOAP Statement posted
  • CDC guideline now recommends that separation be based on ‘shared decision making’ | For those mothers who wish to room in, use mask/gloves and maintaining bassinet distance
  • Use expedited testing to determine COVID-19 status
• Breastfeeding
  • Breastfeeding (with appropriate precautions) or pumping for women for confirmed COVID-19 or PUI is recommended
  • The document notes there may be risk to infant associated with direct breast feeding
• NSAIDs
  • Increased risk with opioids vs NSAIDs
  • The document states “For women who are asymptomatic, mildly symptomatic, or moderately symptomatic who require analgesic medication beyond acetaminophen, nonsteroid anti-inflammatory drugs (NSAIDs) should be used if there are no other contraindications because systemic opioids likely pose more clinical risks”
• Postpone postpartum tubal ligations if alternatives available
• Circumcisions
  • Infants are considered PUIs
  • Decision “should be made in communication with the pediatric team, and appropriate PPE must be worn”

Learn More – Primary Sources

Society for Maternal-Fetal Medicine and Society for Obstetric and Anesthesia and Perinatology – Labor and Delivery COVID-19 Considerations

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