Abstract
Background
The spread of the novel coronavirus (COVID-19) was declared a pandemic by the World Health Organization on 11th March 2020. Since then there has been a rapid rise in development of maternal and perinatal health guidelines related to COVID-19. The aim of this project was to develop a database of Australian and international recommendations relating to antenatal, intrapartum and postpartum care of women during the COVID-19 pandemic, in order to identify inconsistencies in clinical guidance.
Methods
We conducted weekly web searches from 30th March to 15th May 2020 to identify recommendations pertaining to the care of women during pregnancy, labour and postpartum period from national or international professional societies, specialist colleges, Ministries of Health, Australian state and territory governments, and international guideline development organisations. Individual recommendations were extracted and classified according to intervention type, time period, and patient population. Findings were reported using descriptive analysis, with areas of consensus and non-consensus identified.
Results
We identified 81 guidelines from 48 different organisations. Generally, there was high consensus across guidelines for specific interventions. However, variable guidance was identified on the use of nitrous oxide during labour, administration of antenatal corticosteroids, neonatal isolation after birth, labour and birth companions, and the use of disease modifying agents for treating COVID-19.
Conclusion
Discrepancies between different guideline development organisations creates challenges for maternity care clinicians during the COVID-19 pandemic. Collating recommendations and keeping up-to-date with the latest guidance can help clinicians provide the best possible care to pregnant women and their babies.
Abbreviations:
SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), USA (the United States of America), UK (United Kingdom), PPE (personal protective equipment)Keywords
Statement of significance
Problem or issue
In response to the COVID-9 pandemic, a large number of maternal health guidelines have been rapidly produced. Disagreements between guidelines can create uncertainties for clinicians and health services.
What is already known
COVID-19 was declared a pandemic on 11th March 2020. While there is limited evidence on the effects of COVID-19 on pregnant women and newborns, guideline development organisations have rapidly produced antenatal, intrapartum and postpartum care guidelines to assist clinicians.
What this paper adds
This paper summarises the available maternal healthcare guidelines released since the start of the COVID-19 pandemic and identifies interventions where there is high and low consensus between guideline organisations.
1. Introduction
In December 2019 a pneumonia of unknown cause was detected in Wuhan, China and reported to the World Health Organization []. The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was found to be the causative agent, and the disease subsequently named COVID-19 [
[2]
]. The World Health Organization declared the outbreak a pandemic on 11th March 2020. As of 9th July 2020, there have been over 11 million confirmed cases of COVID-19 globally, and over 540,000 deaths []. Available data on the effect of COVID-19 on pregnancy, pregnant women, and newborns is limited [[4]
]. Current information suggests pregnant women are not at higher risk of severe illness than the general population [[4]
]. A systematic review identified 33 studies which reported on the outcomes of 385 pregnant women with COVID-19, of whom 368 (95.6%) were considered to have mild disease [[5]
]. Amongst 256 newborns the prevalence of preterm birth was 15.2% and low birth weight was 7.8%. Eight (3.1%) newborns required admission to neonatal intensive care and 3 deaths occurred. The extent to which maternal COVID-19 infection contributed to these perinatal outcomes is unclear.In the case of COVID-19 – a novel disease where new evidence is emerging daily – up-to-date clinical guidelines are vital in providing clinicians and other stakeholders with recommendations based on the latest available evidence. A considerable volume of guidance relating to care of pregnant women with COVID-19 has been rapidly developed and published. In some instances, clinical recommendations from different organisations are in conflict, which can create confusion for healthcare providers. We aimed to develop a database of national and international guidelines related to the antenatal, intrapartum and postpartum care of women during the COVID-19 pandemic and identify those interventions where there was high and low consensus across recommendations.
2. Methods
2.1 Literature search and eligibility assessment
We developed a study protocol to guide literature searching and data extraction. We aimed to identify and include any guidance that provided clinical recommendations or normative statements related to the clinical care of women during pregnancy, labour, childbirth or the postpartum period in the context of the COVID-19 pandemic. Guidelines of interest were those developed specifically in response to COVID-19, or where the recommendations pertained to changes to routine care in the context of treating COVID-19. We included guidelines produced either at international, national or Australian state or territory levels. Guidelines produced from reputable guideline development organisations such as national or international professional societies or specialty colleges, Governmental departments or Ministries of Health or international agencies were included. Guidelines published prior to 2020 pertaining to other respiratory illnesses or infections were not eligible.
First, we developed a list of relevant guideline development organisations and searched their institutional websites directly. This was supplemented with structured searches for clinical guidelines via the Trip database, using the ‘guideline’ filter and search terms pregnancy, childbirth, postpartum (and related terms) and COVID-19 [].We also contacted international collaborative networks to identify further eligible resources. For the period of 30th March to 15th May 2020, weekly searches of all identified websites and Trip were conducted to identify new guidelines or updates of existing guidelines. On 17th April 2020, we published a list of included guidelines on the Burnet website [
[7]
]. Web visitors were invited to suggest additional guidelines or resources for consideration via an online form.2.2 Data extraction and management
All identified guidelines were initially screened by one reviewer to assess eligibility. For eligible guidelines, each recommendation pertaining to management of pregnancy, labour, childbirth and the immediate postpartum period for women in the context of the COVID-19 pandemic were extracted. Each guideline was reviewed by two independent reviewers. Individual recommendations were extracted and classified them according to intervention type, period (preconception, antenatal, intrapartum, postpartum, all periods, unspecified) and population (e.g. women, healthcare providers or newborns). Recommendations for women and newborns were classified differently depending on whether they were regarding care of the general population, or specifically those with suspected or confirmed COVID-19. Where one recommendation included the use of two (or more) interventions, it was extracted twice (or more) and classified accordingly. Disagreements between reviewers were resolved through discussion or consultation with a third reviewer. If a guideline was updated, we updated the data extraction accordingly, with superseded or outdated recommendations removed from the database.
While standardised guideline quality assessment tools (such as the AGREE II tool) exist, the majority of guidelines identified in our searches were produced rapidly without the customary documentation of the evidence synthesis and guideline development process. This lack of information makes it difficult to properly (and consistently) assess guideline quality. We therefore decided against a formal quality assessment of individual guidelines. For two guidelines that were not in English (French and Italian) we used a combination of colleagues familiar with these languages plus Google Translate to translate relevant recommendations into English for analysis.
2.3 Data analysis
From the data we identified a list of 91 specific interventions, grouped under 18 intervention types, for which at least one recommendation was available. A full list of this interventions can be found on the Burnet website (www.burnet.edu.au/projects/435_). This list was reviewed and discussed by the review team, in consultation with three specialists in obstetrics, gynaecology and midwifery, in order to identify a shortlist of priority topics (Box 1). Priority topics were those considered most important from a clinical care perspective and/or where lower consensus was anticipated. We then prepared a detailed table of all recommendations relating to this shortlist of priority topics. A narrative summary of each priority topic was prepared by the review team based on these findings, in order to qualitatively assess the degree of consensus.
Box 1
Priority topics.
Tabled
1
| Provision of maternal health care during the COVID-19 pandemic |
|---|
| 1. Models of care |
| 2. Policies on visitors and support persons |
| 3. Antenatal corticosteroids for preterm birth |
| 4. Mode of birth |
| 5. Pain management during labour |
| 6. Cord clamping |
| Essential newborn care for COVID-19 positive mothers |
| 7. Skin-to-skin |
| 8. Rooming in |
| 9. Breastfeeding |
| Managing COVID-19 in pregnant women |
| 10. Monitoring COVID-19 progression |
| 11. Antibiotic treatment |
| 12. Antivirals and other disease modifying agents |
| 13. Anticoagulants |
| 14. Prone ventilation |
| 15. Intubation |
3. Results
As of 15th May 2020, 81 unique guidelines pertaining to pregnancy, labour, childbirth and postpartum care from 48 different organisations were identified (Table 1), all of which are publicly available via the Burnet Institute website [
[7]
]. Most of these (55/81) were state or national guidelines from Australia (21 guidelines) [8
, 9
, 10
, 11
, 12
, 13
, 14
, , 16
, 17
, 18
, , , 21
, 22
, 23
, 24
, 25
, 26
, 27
, - The Australiasian Diabetes in Pregnancy Society (ADIPS)
- The Australian Diabetes Society (ADS)
- The Australian Diabetes Educators Association (ADEA) and Diabetes Australia (DA)
Diagnostic Testing for Gestational Diabetes Mellitus (GDM) During the COVID-19 Pandemic: Antenatal and Postnatal Testing Advice.
The Australiasian Diabetes in Pregnancy Society (ADIPS), the Australian Diabetes Society (ADS), the Australian Diabetes Educators Association (ADEA) and Diabetes Australia (DA),
2020
28
], New Zealand (five guidelines) [29
, 30
, 31
, 32
, 33
] the United States of America (USA) (11 guidelines) [34
, 35
, 36
, 37
, 38
, 39
, 40
, 41
, 42
, - The American College of Obstetricians and Gynaecologists (ACOG)
- American Academy of Family Physicians (AAFP)
- Society for Maternal-Fetal Medicine (SMFM)
- American College of Nurse-Midwives (ACNM)
Patient-Centered Care for Pregnant Patients During the COVID-19 Pandemic.
The American College of Obstetricians and Gynaecologists (ACOG), American Academy of Family Physicians (AAFP) Society for Maternal-Fetal Medicine (SMFM). American College of Nurse-Midwives (ACNM),
2020
43
, 44
], United Kingdom (UK) (eight guidelines) [45
, 46
, 47
, 48
, 49
, 50
, 51
, 52
], Canada (three guidelines) [53
, 54
, 55
], Sri Lanka (two guidelines) [[56]
,[57]
], and one guideline from Ireland [[58]
], Belgium [[59]
], Malaysia [[60]
], the Philippines [[61]
], India [- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[62]
], Italy [[63]
], France [[64]
] and Spain [[65]
]. There were 14 international guidelines from eight different international organisations or societies [- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
66
, 67
, 68
, 69
, 70
, 71
, 72
, 73
, 74
, 75
, 76
, 77
, 78
, 79
] and nine guidelines from peer-reviewed journals [[80]
,- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[81]
,[82]
,[83]
,[84]
,[85]
,[86]
,[87]
,[88]
]. Guidelines were issued by state or national governments (21 guidelines), national speciality societies (obstetric, anaesthetic, infectious disease or paediatric; 37 guidelines), international societies (eight guidelines) and United Nations organisations (five guidelines). In total, 71 guidelines were published on websites and ten were published in peer-reviewed journals. All guidelines were published between 2nd March and 13th May. In total, 81 guidelines had 2205 recommendations for interventions regarding pregnancy, childbirth and postpartum care (though some recommendations were counted twice, where they pertained to two different interventions). The number of recommendations per guideline ranged from two [[42]
] to 180 [- The American College of Obstetricians and Gynaecologists (ACOG)
- American Academy of Family Physicians (AAFP)
- Society for Maternal-Fetal Medicine (SMFM)
- American College of Nurse-Midwives (ACNM)
Patient-Centered Care for Pregnant Patients During the COVID-19 Pandemic.
The American College of Obstetricians and Gynaecologists (ACOG), American Academy of Family Physicians (AAFP) Society for Maternal-Fetal Medicine (SMFM). American College of Nurse-Midwives (ACNM),
2020
[58]
].Table 1Organisations and guidelines.
| Number of guidelines | Number of recommendations | |
|---|---|---|
| Australia | ||
| The Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) | 6 | 119 |
| Queensland Clinical Guidelines | 2 | 71 |
| New South Wales Health | 2 | 46 |
| Department of Health (Western Australia) | 3 | 254 |
| Australian Capital Territory Health | 2 | 12 |
| South Australia Health | 1 | 15 |
| Australian and New Zealand College of Anaesthetists (ANZCA) | 1 | 6 |
| Victorian Department of Health and Human Services | 1 | 77 |
| Department of Health Tasmania | 2 | 18 |
| Australasian Diabetes in Pregnancy Society (ADIPS), Australian Diabetes Society (ADS), Australian Diabetes Educators Association (ADEA), Diabetes Australia (DA) | 1 | 17 |
| New Zealand | ||
| Ministry of Health New Zealand | 5 | 89 |
| USA | ||
| Centers for Disease Control and Prevention (CDC) | 2 | 23 |
| The American College of Obstetricians and Gynecologists (ACOG) | 4 | 109 |
| Society for Obstetric Anesthesia and Perinatology (SOAP) | 1 | 17 |
| Society for Obstetric Anesthesia and Perinatology (SOAP); Society for Maternal-Fetal Medicine (SMFM) | 1 | 41 |
| Society for Maternal-Fetal Medicine (SMFM) | 2 | 35 |
| Society for Maternal-Fetal Medicine (SMFM), The American College of Obstetricians and Gynecologists (ACOG), American Academy of Family Physicians (AAFP), American College of Nurse-Midwives (ACNM) | 1 | 2 |
| UK | ||
| Royal College of Obstetricians and Gynaecologists (RCOG) | 6 | 227 |
| Obstetric Anaesthetists’ Association (OAA) | 1 | 14 |
| Royal College of Paediatrics and Child Health (RCPCH) | 1 | 28 |
| Ireland | ||
| Institute of Obstetricians and Gynaecologists — Royal College of Physicians of Ireland (RCPI) | 1 | 180 |
| Canada | ||
| The Society of Obstetricians and Gynaecologists of Canada (SOGC) | 1 | 26 |
| Canadian Paediatric Society (CPS) | 2 | 9 |
| India | ||
| Federation of Obstetric and Gynaecological Societies of India (FOGSI) | 1 | 70 |
| The Phillipines | ||
| Philippine Obstetrical and Gynecological Society (POGS); Philippine Society of Maternal Fetal Medicine (PSMFM) | 1 | 40 |
| Malaysia | ||
| Ministry of Health | 1 | 12 |
| Sri Lanka | ||
| Ministry of Health and Indigenous Medical Services | 2 | 41 |
| Italy | ||
| Società Italiana di Neonatologia (SIN) | 1 | 21 |
| France | ||
| Collège National des Gynécologues et Obstétriciens Français (CNGOF) | 1 | 33 |
| Spain | ||
| Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain | 1 | 45 |
| Belgium | ||
| Taskforce (ScienSano et al.) | 1 | 9 |
| International | ||
| World Health Organization (WHO) | 1 | 19 |
| The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) | 1 | 43 |
| International Federation of Gynecology and Obstetrics (FIGO) | 5 | 29 |
| United Nations Population Fund (UNFPA) | 3 | 114 |
| Jhpiego | 1 | 16 |
| Inter-Agency Working Group on Reproductive Health in Crises (IAWG) | 1 | 37 |
| International Planned Parenthood Federation (IPPF) | 1 | 6 |
| Peer-reviewed journals | ||
| Dashraath et al. (Singapore) [ [83] ] | 1 | 25 |
| Chen et al. (China) [ [81] ] | 1 | 37 |
| Qi et al. (International) [ [82] ] | 1 | 24 |
| Chawla et al. (India) [ [80] ]
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP). Indian Pediatr. 2020; 57: 536-548 | 1 | 44 |
| Baud et al. (International) [ [85] ] | 1 | 9 |
| Schmid et al. (International) [ [84] ] | 1 | 5 |
| Favre et al. (International) [ [86] ] | 1 | 26 |
| McIntosh (USA) [ [88] ] | 1 | 7 |
| Capanna et al. (Italy) [ [87] ] | 1 | 46 |
| International Federation of Gynecology and Obstetrics & allied partners | 1 | 91 |
4. Provision of maternal healthcare during the COVID-19 pandemic
4.1 Models of care
There were 239 recommendations from 43 guidelines (originating from 29 organisations) regarding models of care for all women during the COVID-19 pandemic. These included recommendations pertaining to attending or postponing appointments (63 recommendations), face-to-face visits (57 recommendations), and the use of telehealth (88 recommendations). There was general consensus that face-to-face visits should be minimised in favour of telehealth and home visits where possible. Several guidelines recommended the number of face-to-face visits be reduced, such as by grouping components of care together [
[4]
,[10]
,[30]
,[31]
,[37]
,[46]
,[49]
,[66]
,[71]
,[75]
], and both antenatal and postnatal care should be redirected to telehealth or home visits where possible [[4]
,[10]
,[16]
,[17]
,[21]
,[23]
,[25]
,[30]
,[31]
,[37]
,[41]
,[45]
,[48]
,[58]
,[61]
,- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[66]
,[71]
,[75]
,[76]
].Additionally, there was consensus that women who are well should attend appointments which require a face-to-face visit and should not be deterred from presenting to hospital if concerned about their pregnancy [
[23]
,[45]
,[46]
,[48]
,[58]
,[78]
]. One guideline from Sri Lanka [[56]
] suggested that routine antenatal and postnatal care should only be conducted for specific groups of women and newborns with complications. Some guidelines stated the time taken for these appointments and for physical examination should be limited to minimise the risk of infection transmission [[4]
,[17]
,23
, 24
, 25
,[30]
,[31]
,[66]
]. There was general consensus that face-to-face visits should be delayed for women in self-isolation or with respiratory symptoms [[13]
,[17]
,[21]
,[23]
,[31]
,[37]
,[45]
,[48]
,[53]
,[58]
,[61]
,- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[66]
,[74]
,[75]
] and that screening should occur prior to all visits to identify women who are unwell [[17]
,[23]
,[37]
,[38]
,[46]
,[75]
].4.2 Policies on visitors and support persons during antenatal visits and childbirth
There were 87 recommendations across 40 guidelines (from 28 organisations) regarding the presence of a support person and birth and appointments for all pregnant women, and infection control policies for these visitors. There was general consensus that the number of visitors for women in hospital should be restricted, with some guidelines suggesting a limit of one visitor per day [
[4]
,[8]
,[10]
,[13]
,[16]
,[17]
,, , 21
,23
, 24
, 25
,[30]
,[34]
,[40]
,[45]
,[56]
,[65]
,- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
[66]
,[71]
,[81]
]. Four guidelines – Western Australia [[18]
], India [[62]
], Italy (Capanna et al. [[87]
]) and the USA [[35]
] – suggested that women with suspected or confirmed COVID-19 should not be allowed visitors.Other recommendations for minimising the risk of infection transmission included preventing young children from visiting their mothers in hospital [
[10]
,,[66]
], encouraging women to have one regular support person rather than rotating through numerous visitors [[13]
,[23]
], and enforcing regular hand hygiene and appropriate Personal Protective Equipment (PPE) for all visitors and patients [[10]
,[17]
,[23]
,[40]
,[45]
,[65]
,- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
[66]
,[80]
].- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
There was no consensus between guidelines regarding birth companions. Eight guidelines indicated that women – irrespective of COVID-19 status – should be allowed and encouraged to have a companion present, provided the companion is asymptomatic [
[13]
,[18]
,[45]
,[50]
,[58]
,[62]
,[66]
]. However, three guidelines from Sri Lanka [[57]
], Italy (Capanna et al. [[87]
]) and FIGO and allied partners [[75]
] advised that no birth partners should be allowed for women with suspected or confirmed COVID-19. There was consensus that individuals who are symptomatic or confirmed to have COVID-19 should not be allowed to visit a hospital [[4]
,[10]
,[13]
,[23]
,[54]
,[66]
,[80]
] and that all support persons should be screened prior to presenting to a facility [- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[34]
,[40]
,[45]
,[66]
,[80]
]. Regarding appointments, some guidelines stated it is preferable that women attend alone, however if necessary for support or care then a maximum of one visitor may be allowed [- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[18]
,[25]
,[47]
,[48]
,[61]
,- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[66]
].4.3 Antenatal corticosteroids for preterm birth
There were 29 guidelines from 27 organisations which provided 37 recommendations regarding the use of antenatal corticosteroids (both betamethasone and dexamethasone) for preterm birth in women with COVID-19 infection. There was disagreement between guidelines as to whether corticosteroids should be given when usually recommended. While some guidelines recommended that steroids should be given where usually indicated [
[8]
,[13]
,[23]
,[45]
,[52]
,[53]
,[57]
,[65]
,- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
[66]
,[81]
], others suggested there should be more careful assessment of the balance between maternal risks and neonatal benefit, and that it should be discussed with maternal-fetal, neonatal and infectious disease specialists in light of evidence suggesting harm to the patient with severe COVID-19 [[35]
,[61]
,- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[62]
,[64]
,73
, 74
, 75
,[77]
,[83]
,[85]
,[87]
,[88]
]. Three guidelines from Western Australia [[17]
], Queensland [[13]
] and Ireland [[58]
] recommended that while COVID-19 infection itself is not an indication to alter the provision of antenatal corticosteroids, in those with moderate to severe disease the administration of antenatal corticosteroids should be discussed with specialists in light of the maternal risks. Two guidelines from the USA [[37]
,[44]
] suggested that antenatal corticosteroids could be given up until 34 weeks’ gestation, as at later gestations the benefits may not outweigh the potential risks to a COVID-19 positive patient with moderate to severe disease.4.4 Mode of birth
There were 115 recommendations from 38 guidelines (32 organisations) regarding the mode of birth for women with COVID-19. The majority of these were regarding the decision between a caesarean or vaginal birth (53 recommendations). Others pertained to instrumental birth, induction of labour, the timing of birth and guidelines for performing a caesarean section such as PPE and the number of theatre staff.
There was general consensus that the mode of birth should not be influenced by maternal COVID19, unless urgent birth is required due to the mother’s respiratory condition [
[4]
,[8]
,[10]
,[13]
,[17]
,[21]
,[23]
,[37]
,[44]
,[45]
,57
, 58
, 59
,[61]
,- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[62]
,[64]
,73
, 74
, 75
, 76
, 77
, 78
, 79
, 80
, - Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
81
]. In the case of rapid maternal deterioration, guidelines advise an individual assessment and treatment of the patient [[17]
,[45]
,[87]
] and caesarean section may be required [[10]
,[75]
,[83]
,[86]
]. Alternatively, if the woman delivers vaginally and is short of breath, some guidelines suggest instrumental birth may be required to shorten the length of the second stage of labour [[8]
,[74]
,[75]
,[86]
]. However, two guidelines suggested that there may be a greater need for caesarean section in COVID-19 positive women — Qi et al. [[82]
] suggested that the threshold for a caesarean should be lower. A Malaysian guideline [[60]
] suggested that infected women should be offered caesarean section until there is further information on the safety of vaginal birth, however this guideline had not been updated since 24 March 2020.There was general consensus that maternal COVID-19 infection alone is not a reason to expedite birth [
[13]
,[44]
,[58]
,[65]
,- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
[74]
,[75]
,[81]
,[82]
], however delaying elective caesarean section and induction of labour could be considered [[8]
,[53]
,[61]
]. Despite suggesting that COVID-19 infection alone is not a reason to expedite birth, Qi et al. [- Philippine Obstetrical and Gynecological Society (POGS), Philippine Society of Maternal Fetal Medicine (PSMFM)
COVID-19 and Pregnancy: a Guide to MFM Specialists and General Obstetric Practitioners. Philippine Obstetrical and Gynecological Society (POGS).
Philippine Society of Maternal Fetal Medicine (PSMFM),
2020
[82]
] recommended that if COVID-19 infection is not improved by treatment, early birth should be considered even in absence of obstetric indications (no justification was provided for this).4.5 Pain management
There were 26 guidelines from 23 different organisations which offered 80 recommendations regarding labour analgesia for all women including regional and general anaesthesia (45 recommendations), water immersion/birthing pools (10 recommendations) and nitrous oxide (23 recommendations).
There was disagreement between guidelines as to whether to use nitrous oxide. Several guidelines suggested that given the insufficient information as to whether or not nitrous oxide is an aerosol generating procedure it should be avoided in women with suspected or confirmed COVID-19 [
[4]
,[12]
,[13]
,[17]
,[22]
,[33]
,[60]
]. Others suggested that nitrous oxide was safe to give all pregnant women, provided it was used with a single-patient microbiological filter [[10]
,[23]
,[45]
,[51]
,[58]
]. One guideline from the UK indicated that nitrous oxide use was not an aerosol-generating procedure, however it did not provide a recommendation as to its safety in COVID-19-positive women [[52]
]. Other guidelines from the USA indicated that its use and potential suspension should be discussed within individual labour and delivery units [[34]
,[35]
,[37]
], or that it may be a source of cross-infection, and that it is important staff are aware of the appropriate decontamination guidelines [[83]
].There was consensus that regional anaesthesia should continue to be used normally [
[4]
,[8]
,[12]
,[22]
,[34]
,[45]
,[51]
,[62]
]. Although both regional and general anaesthesia may be considered [[74]
,[75]
,[81]
,[82]
], regional anaesthesia is preferred to general anaesthesia, unless it is unavoidable [[22]
,[51]
,[57]
,[58]
,[60]
,[75]
]. Several guidelines indicated that early epidural anaesthesia in labour should be considered to minimise need for general anaesthesia [[12]
,[13]
,[17]
,[23]
,[35]
,[45]
,[51]
,[58]
], and also as an alternative to nitrous oxide in women who are COVID-19 positive [[12]
]. Three guidelines indicated that in women with COVID-19 the platelet count should be checked prior to spinal/epidural, considering that thrombocytopenia is a common finding in people with COVID-19 [[22]
,[51]
,[58]
]. When general anaesthesia is used, guidelines recommend it should be done under negative pressure [[45]
], by experienced anaesthetists with adequate PPE [[57]
,[58]
].There was general consensus that birthing pools (i.e. giving birth while immersed in water) should be avoided in women with COVID-19 due to the risk of infection to the newborn and healthcare workers [
[13]
,[17]
,[23]
,[45]
,[58]
,[74]
,[75]
]. However, RANZCOG [[4]
,[12]
] has indicated that water immersion may continue to be used in the normal manner. It is unclear as to whether this recommendation also includes women who are COVID-19 positive.4.6 Delayed umbilical cord clamping
There were 20 guidelines from 18 organisations which gave 23 recommendations regarding cord clamping. There was no consensus between guidelines surrounding whether delayed cord clamping is appropriate in women with COVID-19. While many guidelines suggest that delayed cord clamping safe to continue given the lack of evidence to suggest otherwise [
[8]
,[12]
,[13]
,[17]
,[23]
,[37]
,[45]
,[52]
,[53]
,[85]
], others recommended it may be best avoided [[58]
,[65]
,- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
[74]
,[75]
,[80]
,- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[81]
,[83]
,[87]
]. One guideline from Ireland [[58]
] suggested that delayed cord clamping might be appropriate for preterm neonates less than 32 weeks’ gestation, but should not be routinely done for babies born at a later gestation. Favre et al. [[86]
] suggested that for women with septic shock, acute organ failure or fetal distress, there should be early clamping of the umbilical cord. However, Schmid et al. [[84]
] suggested this recommendation was harmful when applied to the general population, stating that vertical transmission of SARS-CoV-2 is uncommon.5. Essential newborn care for babies born to women with COVID-19
5.1 Skin-to-skin contact for the newborn
There were 21 recommendations in 17 guidelines (from 16 organisations) regarding skin-to-skin contact between mothers and newborns after birth. There was consensus that skin-to-skin should continue regardless of maternal COVID-19 infection, provided appropriate PPE is worn [
[12]
,,[17]
,[23]
,[31]
,52
, 53
, 54
,[66]
,[73]
,[76]
]. However, guidelines from Spain [[65]
], Singapore (Dashraath et al. [- Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO)
Recomendaciones para la prevención de la infección y el control de la enfermedad por coronavirus 2019 (COVID-19) en la paciente obstétrica.
Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain (SEGO),
2020
[83]
]), Ireland [[58]
], India (Chawla et al. [[80]
]) and Italy (Capanna et al. [- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[87]
]) recommended that early skin-to-skin contact be avoided in mothers with COVID-19, although they did not provide evidence that skin-to-skin transmission of COVID-19 occurs.5.2 Rooming in for mother and baby
In total, 32 guidelines (27 organisations) gave 67 recommendations on this topic. There was lower consensus regarding whether or not, in the presence of maternal COVID-19, rooming in should be used. Most indicated that the newborn should not be separated from the mother, regardless of maternal COVID-19 status, unless in the case of severe maternal or newborn illness [
[8]
,[10]
,[13]
,,[17]
,[23]
,[45]
,[53]
,[54]
,[58]
,[63]
,[66]
,[74]
,[75]
,[78]
]. However, some guidelines from the USA, as well as China (Chen et al.) and Favre et al. recommended separation to prevent maternal-infant transmission [[34]
,[35]
,[81]
,[86]
]. Others from the USA, FIGO and Baud et al. suggested separation should be considered on a case-by-case basis, with full involvement of the mother [[38]
,[40]
,[41]
,[71]
,[85]
]. One guideline from India (Chawla et al. [[80]
]) suggested that rooming-in be undertaken for stable neonates, but if there are available resources for isolation then separation should be favoured. It was suggested that in the event of rooming-in, when a mother has COVID-19, measures should be taken to reduce transmission, for example using PPE or a curtain between mother and newborn and attention to strict hand hygiene measures [- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[35]
,[40]
,[58]
,[71]
,[74]
,[75]
].5.3 Breastfeeding
In total, 52 guidelines from 41 different organisations had 121 recommendations related to breastfeeding. There was consensus that breastfeeding is safe and important to continue, regardless of the woman’s COVID-19 status, and if a woman was well enough to breastfeed she should be encouraged to do so [
[8]
,[10]
,12
, 13
, 14
, ,[17]
,,[21]
,[23]
,[29]
,[31]
,[41]
,[45]
,[53]
,[54]
,[56]
,[58]
,62
, 63
, 64
,[66]
,[67]
,[71]
,[73]
,[76]
,78
, 79
, 80
]. However, three guidelines from Malaysia [- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[60]
], China (Chen et al. [[81]
]) and Favre et al. [[86]
] advised against direct breastfeeding in mothers with COVID-19, however no evidence was provided to support these recommendations.Several guidelines indicated that while there is currently no evidence that the virus can be transmitted through breastmilk, there is a risk of transmission from mother to baby during breastfeeding via respiratory droplets. Guidelines consequently emphasised the need for mothers with suspected or confirmed COVID-19 to wear a face mask and to practice hand hygiene while breastfeeding [
[8]
,[9]
,[16]
,[17]
,[23]
,[29]
,[31]
,[35]
,[38]
,[40]
,[41]
,[45]
,[46]
,[53]
,[54]
,[56]
,[58]
,[59]
,[62]
,[63]
,[66]
,[67]
,[71]
,73
, 74
, 75
,79
, 80
, - Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
81
,[83]
,[85]
].Additionally, there was consensus that if women are not well enough to breastfeed, or if temporary separation is undertaken due to maternal COVID-19 infection, they should still be encouraged to express milk which can safely be provided to their newborn [
[10]
,,[17]
,[23]
,[29]
,[39]
,[54]
,[58]
,[62]
,[63]
,[66]
,[67]
,[71]
,73
, 74
, 75
, 76
,[80]
]. One guideline from the UK [- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[52]
] suggested that given the overwhelming benefits of breast milk to the infant, unwell COVID-19 positive women who are required to withhold breastfeeding are encouraged to express their breastmilk and discard it in order to maintain lactation until she is no longer infectious.6. Managing pregnant women with COVID-19 disease
6.1 Monitoring COVID-19 progression
There were 28 guidelines (from 26 different organisations) which gave 93 recommendations regarding caring for pregnant women with COVID-19. These pertained to hospital admission (22 recommendations), fluid balance monitoring (21 recommendations) and target oxygen saturation (29 recommendations). There was consensus that pregnant women who had COVID-19 infection with moderate or severe disease or respiratory complications or compromise should be admitted to hospital for management [
[43]
,[44]
,[64]
,[71]
,[86]
]. Two guidelines specified that criteria should be in place for transferring women to a centre with Intensive Care Unit facilities [[62]
,[86]
] and one guideline indicated there should be a lower threshold for transferring vulnerable groups of patients to such facilities [[10]
].There was general consensus that given the association of fluid overload and Acute Respiratory Distress Syndrome, women with moderate and severe disease require close fluid balance monitoring [
[8]
,[13]
,[17]
,[45]
,[58]
,[66]
,[75]
]. Several noted critically ill pregnant patients without shock should be managed with conservative fluid management [[74]
,[81]
]. Additionally, there was consensus that oxygen saturations should be monitored closely [[17]
,[45]
,[74]
,[75]
,[80]
,- Chawla D.
- Chirla D.
- Dalwai S.
- Deorari A.K.
- Ganatra A.
- Gandhi A.
- et al.
Perinatal-neonatal management of COVID-19 infection — guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP).
Indian Pediatr. 2020; 57: 536-548
[81]
] and hypoxia should be avoided, with the aim of maintaining target oxygen saturation >92% [[8]
,[13]
,[44]
,[45]
,[57]
- Ministry of Health and Indigenous Medical Service
Interim Guidelines for Maternal and Newborn Care Service