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. Describe the PPE requirements for obstetrical healthcare worker
2. Discuss medication use in threatened preterm labor

Estimated time to complete activity: 0.5 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 04/09/2020 through 04/09/2021, 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 0.5 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 0.5 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

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:

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

Related ObG Topics:

U.S. COVID-19 PRIORITY Pregnancy Registry Now Open

ACOG COVID-19 FAQs for Obstetrical Care

COVID-19 Guidance: Key Highlights for Healthcare Professionals

ARDS, Critical Care and COVID-19: ‘Surviving Sepsis Campaign’ Guidelines and Key Points