NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date. This entry has been updated with additional information on counseling patients working in a non-healthcare setting.

SUMMARY:

ACOG has released FAQs that address common questions faced by obstetrical care professionals. The recommendations in this document reinforce CDC guidance and clarify some issues specific to obstetrics. Below are highlighted FAQs from the document (please see ‘Learn More – Primary Sources’ below for link to complete document)

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• Pregnant Healthcare Workers
• Pregnant Women in Non-Healthcare Settings 
• Masks
• NSAIDs
• Antenatal Corticosteroids for Lung Maturity
• Postpartum Contraception
• Expedited Discharge Planning
• Postpartum Visits
• Clinical Guidelines that Remain Unchanged
• PPH: Use of TXA and Hemabate 
• Visitation Policies During COVID-19

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Pregnant Healthcare Workers

• A CDC study found that pregnant women with COVID-19 may be at higher risk for adverse outcomes and pregnancy is now listed in the ‘increased risk’ category
  • However, the study had significant limitations (e.g. a substantial amount of missing data) and detailed stratification by gestational or medical comorbidities is not currently available
• ACOG recommends that for pregnant healthcare personnel
  • “Health care facilities may consider limiting exposure of pregnant health care personnel to patients with confirmed or suspected COVID-19 infection, especially during higher risks procedures (CDC)”
  • Women can continue to work up until delivery if they so choose and appropriate, recommended PPE is available
  • Any recommendations related to comorbidities for nonpregnant individuals should be applied to pregnant individuals as well
• If recommended PPE is not available
  • Avoid exposure to high-risk procedures
  • Healthcare personnel are not “ethically obligated” to engage in high-risk procedures in the absence of recommended PPE

Pregnant Women in Non-Healthcare Settings

• With the addition of pregnancy to the CDC ‘increased risk’ category, pregnant women
  • Should “be provided the ability to occupy roles” with less risk of exposure
  • Can opt to work until delivery
• Employers should
  • Follow current CDC guidance
  • Assess potential hazards and ensure workers “use controls to prevent exposure (Department of Labor)”
• In the event that a pregnant woman requests a letter to support a COVID-19 specific work accommodation, aside from advocating for infection protection, ACOG states that

…maternal health care professionals can respond to the request in the context of the risk to the pregnant individual considering the particular patient’s circumstances

Masks

For Pregnant Women

• Should be worn in setting of COVID-19 symptoms or confirmed COVID-19 when in public or around others
•  For other individuals, especially those in areas of significant community-based spread, cloth face coverings are recommended in public settings where other social distancing measures are difficult to maintain (eg, grocery stores and pharmacies | CDC specifies cloth vs surgical masks or respirators as these PPE items, currently in short supply, should be reserved for healthcare personnel

Obstetrical Healthcare Workers

• ACOG
  • Healthcare providers should use PPE, including respirators or face masks, goggles, gowns and gloves | N95 respirators should be used for aerosol-generating procedures
  • ACOG states that “COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care”
  • In addition to wearing appropriate PPE, respirators (e.g., N95 masks) should be worn by “All medical staff caring for potential or confirmed COVID-19 patients” when available
  • In the setting of limited infection protections “physicians are not ethically obligated to provide care to high-risk patients without protections in place”

• PPE: ACOG reviews CDC guidance
  • Respirators (e.g., N95 respirators) should be used when caring for patients with confirmed or suspected COVID-19
  • Aerosol-generating procedures should be prioritized during shortages
  • ACOG restates the CDC opinion that second stage is not considered an aerosol-generating procedure and adds the following

ACOG continues to review questions and data regarding the potential for aerosolization in the context of forceful exhalation during the second stage of labor 

• ‘Expert Review’ (Berghella. AJOG MFM, 2020)
  • Healthcare workers including ObGyns and other obstetric care professionals “are one of the populations at highest risk of contracting the disease and dying from it”
  • All obstetrical healthcare workers coming into contact with patients – both inpatient (L&D) and outpatient setting – should wear PPE
  • COVID-19 testing: All patients should be tested for COVID-19 on admission to hospital at least once and more often if symptomatic or there is concern over exposure
    • If patient positive for COVID-19: Obstetrical healthcare workers should wear N-95 mask or equivalent
• ‘Expert Review’ (Boelig et al. AJOG MFM, 2020)
  • The authors acknowledge that there may be logistical issues but state the goal should be that

N95 mask should be worn in addition to droplet precaution PPE for any patients with suspected or confirmed COVID, and for any patient, regardless of respiratory symptoms, during indispensable aerosolizing procedures, including second stage of labor

NSAIDs

• No evidence of association between NSAIDs, such as ibuprofen, and COVID-19 exacerbation
• Preeclampsia prophylaxis

…low-dose aspirin should continue to be offered to pregnant and postpartum women as medically indicated

For patients with suspected or confirmed COVID-19 for whom low-dose aspirin would be indicated, modifications to care may be individualized

Antenatal Corticosteroids for Lung Maturity

• Data indicates that corticosteroids may play a beneficial role in the treatment of severely ill patients with COVID-19 (see ‘NIH COVID-19 Treatment Guidelines’ in ‘Related ObG Topics’ below)
• Based on the above

ACOG now recommends offering antenatal corticosteroids, as indicated, for fetal benefit

Postpartum Contraception

• Discuss benefits of immediate postpartum LARC
• Tubal sterilization
  • Unless the patient is at high risk, “it may be appropriate to temporarily consider tubal sterilization only when performing cesarean birth”

Expedited Discharge Planning

• “May be considered”
  • Uncomplicated vaginal delivery: Day 1
  • Cesarean delivery: Day 2
• Dependent on mother and infant health
• Follow-up planning
  • Coordinate with pediatric team
  • Telehealth for outpatient visits

Postpartum Visits

• Frequency and timing may be modified to prevent exposures
  • Should be determined at local level
• Modification examples include
  • Telehealth for the following
    • Initial 3 week assessment (or sooner) | Wound checks | Blood Pressure checks
  • In-person visit for comprehensive postpartum visit | Delay to 12 weeks | Consider earlier visit if the patient may lose insurance prior to 12 weeks

KEY POINTS:

Clinical Guidelines that Remain Unchanged

Continue to Manage According to Current Clinical Guidance

• GBS screening between 36w0d to 37w6d
  • Option: Patient may self-collect specimen if infrastructure available
• Timing of delivery
  • COVID-19 should generally not impact timing of delivery
  • Exception: If a woman is infected in the third trimester and there are no medical indications to the contrary, “it is reasonable” to try and postpone delivery until there is a negative test result or quarantine lifted
• Induction of labor
• Operative delivery
• Mode of delivery
• Delayed cord clamping
• Cord blood banking management
• Home birth counseling
• Antenatal and fetal surveillance
  • Try to limit to situations where testing will provide “an expected answer to a relevant clinical question or otherwise provide medical benefit to the patient”
  • There may be circumstances where delaying or cancelling tests or encounters may be warranted if harm is greater than benefit
  • Decisions to delay or alter scheduling should be made at the local level

PPH: Use of TXA and Hemabate

TXA

• COVID-19 appears to be a hypercoagulable state
• TXA can be considered for the treatment of PPH in keeping with guidance for non-COVID-19 patients
• However, the document states

Because of the possible additive effect of the increased risk of thrombosis from COVID-19 infection and the hypercoagulative state of pregnancy, it may be prudent to consider this increased likelihood of clotting before adminisitering TXA for postpartum hemorrhage

Hemabate

• While Hemabate is not used in asthma due to risk for bronchospasm, patients with COVID-19 have respiratory symptoms consistent with viral pneumonia
• While there is no data specific to COVID-19 and this medication, “Hemabate is not generally withheld” in patients with viral pneumonia

Visitation Policies During COVID-19

• Visitation policy decisions are ultimately guided by
  • Local facilities and capabilities (e.g., physical space, equipment)
  • Community spread and prevalence
  • Governmental regulations and recommendations at multiple levels
• ACOG recommends that for both inpatient and outpatient
  • Reduce number of visitors to minimum necessary
  • Limit to those individuals “essential for the pregnant individual’s well-being (emotional support persons)”
  • Screen all visitors for symptoms of respiratory illness
    • Patient should be attended to by an asymptomatic visitor
    • A visitor with fever or respiratory symptoms should not accompany the patient
• Additional support persons
  • Encourage the use of alternative forms of interaction (e.g., video-call apps)
• Counseling patients and families regarding restrictive visitation policies
  • Acknowledge value of support persons
  • Explain the temporary nature of the policies and that they are in place to protect everyone’s safety, including the patient, baby and community at large
• Special considerations for underserved communities
  • Support systems including support persons are especially important throughout the delivery journey, including postpartum care
  • ACOG states that

…institutions should be mindful of how restrictions might differentially and negatively affect these communities, which in many areas are also disproportionately affected by COVID-19

Learn More – Primary Sources:

COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

NOW!: Protection for Obstetrical providers and Patients (Berghella. AJOG MFM, 2020)

Labor and Delivery Guidance for COVID-19 (Boelig et al. AJOG MFM, 2020)

ACOG & SMFM: Joint Statement: Recent Developments Regarding COVID-19 and Pregnant Women

Related ObG Topics: