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Clinical guidelines for caring for women with COVID-19 during pregnancy, childbirth and the immediate postpartum period

Published:November 03, 2020DOI:https://doi.org/10.1016/j.wombi.2020.10.015

      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 [
      • World Health Organization
      Rolling Updates on Coronavirus Disease (COVID-19).
      ]. 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 []. 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 [
      • World Health Organization
      Coronavirus Disease (COVID-19) Situation Report — 171.
      ]. Available data on the effect of COVID-19 on pregnancy, pregnant women, and newborns is limited [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ]. Current information suggests pregnant women are not at higher risk of severe illness than the general population [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ]. 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 [
      • Elshafeey F.
      • Magdi R.
      • Hindi N.
      • Elshebiny M.
      • Farrag N.
      • Mahdy S.
      • et al.
      A systematic scoping review of COVID-19 during pregnancy and childbirth.
      ]. 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 [
      • Burnet Institute
      Rapid Review of Maternal Health Recommendations Related to the COVID-19 Pandemic.
      ]. 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.
      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 [
      • Burnet Institute
      Rapid Review of Maternal Health Recommendations Related to the COVID-19 Pandemic.
      ]. Most of these (55/81) were state or national guidelines from Australia (21 guidelines) [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus (COVID-19) Statement.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Outpatient Services; Office Consultations and Procedures.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • New South Wales Health
      ,
      • New South Wales Health
      Guidance for Neonatal Services.
      ,
      • Western Australian Department of Health
      COVID-19 Guidance for Neonatal Services Statewide.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Western Australia Department of Health
      COVID-19 Public Hospital Visitor Guidelines.
      ,
      • Canberra Health Services
      COVID-19: Advice for Pregnant Women.
      ,
      • Australian Capital Territory Government
      Health Service Update.
      ,
      • South Australia Department of Health
      COVID-19 Frequently Asked Questions Maternity Patients.
      ,
      • Australian and New Zealand College of Anaesthetists (ANZCA)
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      , , ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19 and Gestational Diabetes Screening, Diagnosis and Management.
      ,
      • 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.
      ,
      • Queensland Clinical Guidelines
      Gestational Diabetes Mellitis.
      ], New Zealand (five guidelines) [
      • Ministry of Health New Zealand
      COVID-19 — Breastfeeding Advice for Pregnant Women, or Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      COVID-19 — Information for Pregnant Women, and Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • Ministry of Health New Zealand
      Information for Radiologists on Community Based Maternity Ultrasounds.
      ,
      • Ministry of Health New Zealand
      Recommendations for the Use of Nitrous Oxide/entonox for Labour Analgesia During the COVID-19 Pandemic.
      ] the United States of America (USA) (11 guidelines) [
      • Society for Obstetric Anesthesia and Perinatology (SOAP)
      Interim Considerations for Obstetric Anesthesia Care Related to COVID19.
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      COVID-19 FAQs for obstetrician-gynecologists.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      Novel Coronavirus 2019 (COVID-19).
      ,
      • Centers for Disease Control and Prevention (CDC)
      Pregnancy & Breastfeeding | Information about Coronavirus Disease 2019.
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      COVID-19: Changes in Pregnancy and Maternity Care Advice for Women and Their Families.
      ,
      • 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.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      Outpatient Assessment and Management for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID-19).
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      Management Considerations for Pregnant Patients with COVID-19.
      ], United Kingdom (UK) (eight guidelines) [
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal and Postnatal Services in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal Screening and Ultrasound in Pregnancy in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Fetal Medicine Units (FMUS) in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Maternal Medicine in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Provision of Midwife-led Settings and Home Birth in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Obsetric Anaesthatists’ Association (OAA)
      Management of Pregnant Women with Known or Suspected COVID-19.
      ,
      • Royal College of Paediatrics and Child Health (RCPCH)
      COVID-19 — Guidance for Neonatal Settings.
      ], Canada (three guidelines) [
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • Canadian Paediatric Society (CPS)
      NICU Care for Infants Born to Mothers with Suspected or Proven COVID-19.
      ], Sri Lanka (two guidelines) [
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Field Maternal and Child Care Services During the Outbreak of COVID-19 Infection.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Services in Hospitals During the Outbreak of COVID-19 Infection.
      ], and one guideline from Ireland [
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ], Belgium [
      • Ierssel S.V.
      • Dauby N.
      • Bottieau E.
      • Huits R.
      • Wyndham-Thomas C.
      • Loock R.V.
      Interim Clinical Guidance for Patients Suspected of/confirmed with COVID-19 in Belgium.
      ], Malaysia [
      • Ministry of Health Malaysia
      Guideline on Management of Coronavirus Disease 2019 (COVID-19) in Pregnancy.
      ], the Philippines [
      • 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).
      ], India [
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ], Italy [
      • Società Italiana di Neonatologia (SIN)
      Allattamento E Infezione da SARS-CoV-2 (Coronavirus Disease 2019 — COVID-19).
      ], France [
      • Collège National des Gynécologues et Obstétriciens Français (CNGOF)
      Prise en charge aux urgences maternite d’une Patiente enceinte suspectee ou infectee par le coronavirus (COVID 19).
      ] and Spain [
      • 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.
      ]. There were 14 international guidelines from eight different international organisations or societies [
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • United Nations Population Fund
      UNFPA Statement on Novel Coronavirus (COVID-19) and Pregnancy.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Abortion Access and Safety with COVID-19.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Elective Surgery and COVID-19.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Non-Communicable Diseases and COVID-19.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      SRH in Humanitarian Settings During COVID-19.
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Inter-Agency Working Group (IAWG)
      Programmatic Guidance for Sexual and Reproductive Health in Humanitarian and Fragile Settings During COVID-19 Pandemic.
      ,
      • JHPIEGO
      Initial Assessment of Clients Presenting for Intrapartum Care: Summary of Key Considerations in the Context of COVID-19.
      ,
      • United Nations Population Fund
      Sexual and Reproductive Health and Rights, Maternal and Newborn Health & COVID-19.
      ,
      • International Planned Parenthood Federation (IPPF)
      COVID-19 Impact.
      ] and nine guidelines from peer-reviewed journals [
      • 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).
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ,
      • Qi H.
      • Luo X.
      • Zheng Y.
      • Zhang H.
      • Li J.
      • Zou L.
      • et al.
      Safe delivery for pregnancies affected by COVID-19.
      ,
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ,
      • Schmid M.B.
      • Fontijn J.
      • Ochsenbein-Kolble N.
      • Berger C.
      • Bassler D.
      COVID-19 in pregnant women.
      ,
      • Baud D.
      • Giannoni E.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • et al.
      COVID-19 in pregnant women — authors’ reply.
      ,
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ,
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ,
      • McIntosh J.J.
      Corticosteroid guidance for pregnancy during COVID-19 pandemic.
      ]. 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 [
      • 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.
      ] to 180 [
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ].
      Table 1Organisations and guidelines.
      Number of guidelinesNumber of recommendations
      Australia
      The Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG)6119
      Queensland Clinical Guidelines271
      New South Wales Health246
      Department of Health (Western Australia)3254
      Australian Capital Territory Health212
      South Australia Health115
      Australian and New Zealand College of Anaesthetists (ANZCA)16
      Victorian Department of Health and Human Services177
      Department of Health Tasmania218
      Australasian Diabetes in Pregnancy Society (ADIPS), Australian Diabetes Society (ADS), Australian Diabetes Educators Association (ADEA), Diabetes Australia (DA)117
      New Zealand
      Ministry of Health New Zealand589
      USA
      Centers for Disease Control and Prevention (CDC)223
      The American College of Obstetricians and Gynecologists (ACOG)4109
      Society for Obstetric Anesthesia and Perinatology (SOAP)117
      Society for Obstetric Anesthesia and Perinatology (SOAP); Society for Maternal-Fetal Medicine (SMFM)141
      Society for Maternal-Fetal Medicine (SMFM)235
      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)12
      UK
      Royal College of Obstetricians and Gynaecologists (RCOG)6227
      Obstetric Anaesthetists’ Association (OAA)114
      Royal College of Paediatrics and Child Health (RCPCH)128
      Ireland
      Institute of Obstetricians and Gynaecologists — Royal College of Physicians of Ireland (RCPI)1180
      Canada
      The Society of Obstetricians and Gynaecologists of Canada (SOGC)126
      Canadian Paediatric Society (CPS)29
      India
      Federation of Obstetric and Gynaecological Societies of India (FOGSI)170
      The Phillipines
      Philippine Obstetrical and Gynecological Society (POGS); Philippine Society of Maternal Fetal Medicine (PSMFM)140
      Malaysia
      Ministry of Health112
      Sri Lanka
      Ministry of Health and Indigenous Medical Services241
      Italy
      Società Italiana di Neonatologia (SIN)121
      France
      Collège National des Gynécologues et Obstétriciens Français (CNGOF)133
      Spain
      Federation of the Societies of Gynaecology and Obstetrics of the Autonomous Communities of Spain145
      Belgium
      Taskforce (ScienSano et al.)19
      International
      World Health Organization (WHO)119
      The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)143
      International Federation of Gynecology and Obstetrics (FIGO)529
      United Nations Population Fund (UNFPA)3114
      Jhpiego116
      Inter-Agency Working Group on Reproductive Health in Crises (IAWG)137
      International Planned Parenthood Federation (IPPF)16
      Peer-reviewed journals
      Dashraath et al. (Singapore) [
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ]
      125
      Chen et al. (China) [
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ]
      137
      Qi et al. (International) [
      • Qi H.
      • Luo X.
      • Zheng Y.
      • Zhang H.
      • Li J.
      • Zou L.
      • et al.
      Safe delivery for pregnancies affected by COVID-19.
      ]
      124
      Chawla et al. (India) [
      • 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).
      ]
      144
      Baud et al. (International) [
      • Baud D.
      • Giannoni E.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • et al.
      COVID-19 in pregnant women — authors’ reply.
      ]
      19
      Schmid et al. (International) [
      • Schmid M.B.
      • Fontijn J.
      • Ochsenbein-Kolble N.
      • Berger C.
      • Bassler D.
      COVID-19 in pregnant women.
      ]
      15
      Favre et al. (International) [
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ]
      126
      McIntosh (USA) [
      • McIntosh J.J.
      Corticosteroid guidance for pregnancy during COVID-19 pandemic.
      ]
      17
      Capanna et al. (Italy) [
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ]
      146
      International Federation of Gynecology and Obstetrics & allied partners191

      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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Ministry of Health New Zealand
      COVID-19 — Information for Pregnant Women, and Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal and Postnatal Services in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Maternal Medicine in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ], and both antenatal and postnatal care should be redirected to telehealth or home visits where possible [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Western Australian Department of Health
      COVID-19 Guidance for Neonatal Services Statewide.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • South Australia Department of Health
      COVID-19 Frequently Asked Questions Maternity Patients.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,,
      • Ministry of Health New Zealand
      COVID-19 — Information for Pregnant Women, and Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      COVID-19: Changes in Pregnancy and Maternity Care Advice for Women and Their Families.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Fetal Medicine Units (FMUS) in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • 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).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Inter-Agency Working Group (IAWG)
      Programmatic Guidance for Sexual and Reproductive Health in Humanitarian and Fragile Settings During COVID-19 Pandemic.
      ].
      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 [
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal and Postnatal Services in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Fetal Medicine Units (FMUS) in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • United Nations Population Fund
      Sexual and Reproductive Health and Rights, Maternal and Newborn Health & COVID-19.
      ]. One guideline from Sri Lanka [
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Field Maternal and Child Care Services During the Outbreak of COVID-19 Infection.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      , , ,
      • Ministry of Health New Zealand
      COVID-19 — Information for Pregnant Women, and Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ]. There was general consensus that face-to-face visits should be delayed for women in self-isolation or with respiratory symptoms [
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • South Australia Department of Health
      COVID-19 Frequently Asked Questions Maternity Patients.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Fetal Medicine Units (FMUS) in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • 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).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ] and that screening should occur prior to all visits to identify women who are unwell [
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      Novel Coronavirus 2019 (COVID-19).
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal and Postnatal Services in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ].

      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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      COVID-19 Guidance for Neonatal Services Statewide.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Canberra Health Services
      COVID-19: Advice for Pregnant Women.
      ,
      • Australian Capital Territory Government
      Health Service Update.
      ,
      • South Australia Department of Health
      COVID-19 Frequently Asked Questions Maternity Patients.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      , , ,
      • Ministry of Health New Zealand
      COVID-19 — Information for Pregnant Women, and Those Who Have Recently Given Birth.
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP)
      Interim Considerations for Obstetric Anesthesia Care Related to COVID19.
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Field Maternal and Child Care Services During the Outbreak of COVID-19 Infection.
      ,
      • 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.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ]. Four guidelines – Western Australia [
      • Western Australia Department of Health
      COVID-19 Public Hospital Visitor Guidelines.
      ], India [
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ], Italy (Capanna et al. [
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ]) and the USA [
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ] – 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Australian Capital Territory Government
      Health Service Update.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ], encouraging women to have one regular support person rather than rotating through numerous visitors [
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ], and enforcing regular hand hygiene and appropriate Personal Protective Equipment (PPE) for all visitors and patients [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • 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.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • 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).
      ].
      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 [
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australia Department of Health
      COVID-19 Public Hospital Visitor Guidelines.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Provision of Midwife-led Settings and Home Birth in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ]. However, three guidelines from Sri Lanka [
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Services in Hospitals During the Outbreak of COVID-19 Infection.
      ], Italy (Capanna et al. [
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ]) and FIGO and allied partners [
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • 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).
      ] and that all support persons should be screened prior to presenting to a facility [
      • Society for Obstetric Anesthesia and Perinatology (SOAP)
      Interim Considerations for Obstetric Anesthesia Care Related to COVID19.
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • 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).
      ]. 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 [
      • Western Australia Department of Health
      COVID-19 Public Hospital Visitor Guidelines.
      ,,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal Screening and Ultrasound in Pregnancy in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Fetal Medicine Units (FMUS) in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • 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).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ].

      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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Paediatrics and Child Health (RCPCH)
      COVID-19 — Guidance for Neonatal Settings.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Services in Hospitals During the Outbreak of COVID-19 Infection.
      ,
      • 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.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ], 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 [
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • 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).
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • Collège National des Gynécologues et Obstétriciens Français (CNGOF)
      Prise en charge aux urgences maternite d’une Patiente enceinte suspectee ou infectee par le coronavirus (COVID 19).
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • JHPIEGO
      Initial Assessment of Clients Presenting for Intrapartum Care: Summary of Key Considerations in the Context of COVID-19.
      ,
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ,
      • Baud D.
      • Giannoni E.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • et al.
      COVID-19 in pregnant women — authors’ reply.
      ,
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ,
      • McIntosh J.J.
      Corticosteroid guidance for pregnancy during COVID-19 pandemic.
      ]. Three guidelines from Western Australia [
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ], Queensland [
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ] and Ireland [
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ] 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 [
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      Management Considerations for Pregnant Patients with COVID-19.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • South Australia Department of Health
      COVID-19 Frequently Asked Questions Maternity Patients.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      Management Considerations for Pregnant Patients with COVID-19.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Services in Hospitals During the Outbreak of COVID-19 Infection.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • Ierssel S.V.
      • Dauby N.
      • Bottieau E.
      • Huits R.
      • Wyndham-Thomas C.
      • Loock R.V.
      Interim Clinical Guidance for Patients Suspected of/confirmed with COVID-19 in Belgium.
      ,
      • 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).
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • Collège National des Gynécologues et Obstétriciens Français (CNGOF)
      Prise en charge aux urgences maternite d’une Patiente enceinte suspectee ou infectee par le coronavirus (COVID 19).
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Inter-Agency Working Group (IAWG)
      Programmatic Guidance for Sexual and Reproductive Health in Humanitarian and Fragile Settings During COVID-19 Pandemic.
      ,
      • JHPIEGO
      Initial Assessment of Clients Presenting for Intrapartum Care: Summary of Key Considerations in the Context of COVID-19.
      ,
      • United Nations Population Fund
      Sexual and Reproductive Health and Rights, Maternal and Newborn Health & COVID-19.
      ,
      • International Planned Parenthood Federation (IPPF)
      COVID-19 Impact.
      ,
      • 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).
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ]. In the case of rapid maternal deterioration, guidelines advise an individual assessment and treatment of the patient [
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ] and caesarean section may be required [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ,
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ]. 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ]. However, two guidelines suggested that there may be a greater need for caesarean section in COVID-19 positive women — Qi et al. [
      • Qi H.
      • Luo X.
      • Zheng Y.
      • Zhang H.
      • Li J.
      • Zou L.
      • et al.
      Safe delivery for pregnancies affected by COVID-19.
      ] suggested that the threshold for a caesarean should be lower. A Malaysian guideline [
      • Ministry of Health Malaysia
      Guideline on Management of Coronavirus Disease 2019 (COVID-19) in Pregnancy.
      ] 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 [
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      Management Considerations for Pregnant Patients with COVID-19.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • 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.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ,
      • Qi H.
      • Luo X.
      • Zheng Y.
      • Zhang H.
      • Li J.
      • Zou L.
      • et al.
      Safe delivery for pregnancies affected by COVID-19.
      ], however delaying elective caesarean section and induction of labour could be considered [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • 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).
      ]. Despite suggesting that COVID-19 infection alone is not a reason to expedite birth, Qi et al. [
      • Qi H.
      • Luo X.
      • Zheng Y.
      • Zhang H.
      • Li J.
      • Zou L.
      • et al.
      Safe delivery for pregnancies affected by COVID-19.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Australian and New Zealand College of Anaesthetists (ANZCA)
      ,
      • Ministry of Health New Zealand
      Recommendations for the Use of Nitrous Oxide/entonox for Labour Analgesia During the COVID-19 Pandemic.
      ,
      • Ministry of Health Malaysia
      Guideline on Management of Coronavirus Disease 2019 (COVID-19) in Pregnancy.
      ]. Others suggested that nitrous oxide was safe to give all pregnant women, provided it was used with a single-patient microbiological filter [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Obsetric Anaesthatists’ Association (OAA)
      Management of Pregnant Women with Known or Suspected COVID-19.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ]. 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 [
      • Royal College of Paediatrics and Child Health (RCPCH)
      COVID-19 — Guidance for Neonatal Settings.
      ]. Other guidelines from the USA indicated that its use and potential suspension should be discussed within individual labour and delivery units [
      • Society for Obstetric Anesthesia and Perinatology (SOAP)
      Interim Considerations for Obstetric Anesthesia Care Related to COVID19.
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ], or that it may be a source of cross-infection, and that it is important staff are aware of the appropriate decontamination guidelines [
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ].
      There was consensus that regional anaesthesia should continue to be used normally [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • Australian and New Zealand College of Anaesthetists (ANZCA)
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP)
      Interim Considerations for Obstetric Anesthesia Care Related to COVID19.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Obsetric Anaesthatists’ Association (OAA)
      Management of Pregnant Women with Known or Suspected COVID-19.
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ]. Although both regional and general anaesthesia may be considered [
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ,
      • Qi H.
      • Luo X.
      • Zheng Y.
      • Zhang H.
      • Li J.
      • Zou L.
      • et al.
      Safe delivery for pregnancies affected by COVID-19.
      ], regional anaesthesia is preferred to general anaesthesia, unless it is unavoidable [
      • Australian and New Zealand College of Anaesthetists (ANZCA)
      ,
      • Obsetric Anaesthatists’ Association (OAA)
      Management of Pregnant Women with Known or Suspected COVID-19.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Services in Hospitals During the Outbreak of COVID-19 Infection.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • Ministry of Health Malaysia
      Guideline on Management of Coronavirus Disease 2019 (COVID-19) in Pregnancy.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ]. Several guidelines indicated that early epidural anaesthesia in labour should be considered to minimise need for general anaesthesia [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Obsetric Anaesthatists’ Association (OAA)
      Management of Pregnant Women with Known or Suspected COVID-19.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ], and also as an alternative to nitrous oxide in women who are COVID-19 positive [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ]. 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 [
      • Australian and New Zealand College of Anaesthetists (ANZCA)
      ,
      • Obsetric Anaesthatists’ Association (OAA)
      Management of Pregnant Women with Known or Suspected COVID-19.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ]. When general anaesthesia is used, guidelines recommend it should be done under negative pressure [
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ], by experienced anaesthetists with adequate PPE [
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Services in Hospitals During the Outbreak of COVID-19 Infection.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ].
      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 [
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ]. However, RANZCOG [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      A Message for Pregnant Women and Their Families.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Paediatrics and Child Health (RCPCH)
      COVID-19 — Guidance for Neonatal Settings.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Baud D.
      • Giannoni E.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • et al.
      COVID-19 in pregnant women — authors’ reply.
      ], others recommended it may be best avoided [
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • 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.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • 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).
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ,
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ,
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ]. One guideline from Ireland [
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ] 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. [
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ] 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. [
      • Schmid M.B.
      • Fontijn J.
      • Ochsenbein-Kolble N.
      • Berger C.
      • Bassler D.
      COVID-19 in pregnant women.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • New South Wales Health
      Guidance for Neonatal Services.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • Royal College of Paediatrics and Child Health (RCPCH)
      COVID-19 — Guidance for Neonatal Settings.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • Inter-Agency Working Group (IAWG)
      Programmatic Guidance for Sexual and Reproductive Health in Humanitarian and Fragile Settings During COVID-19 Pandemic.
      ]. However, guidelines from Spain [
      • 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.
      ], Singapore (Dashraath et al. [
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ]), Ireland [
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ], India (Chawla 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).
      ]) and Italy (Capanna et al. [
      • Capanna F.
      • Haydar A.
      • McCarey C.
      • Bernini Carri E.
      • Bartha Rasero J.
      • Tsibizova V.
      • et al.
      Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips.
      ]) 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • New South Wales Health
      Guidance for Neonatal Services.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • Società Italiana di Neonatologia (SIN)
      Allattamento E Infezione da SARS-CoV-2 (Coronavirus Disease 2019 — COVID-19).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • United Nations Population Fund
      Sexual and Reproductive Health and Rights, Maternal and Newborn Health & COVID-19.
      ]. However, some guidelines from the USA, as well as China (Chen et al.) and Favre et al. recommended separation to prevent maternal-infant transmission [
      • Society for Obstetric Anesthesia and Perinatology (SOAP)
      Interim Considerations for Obstetric Anesthesia Care Related to COVID19.
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ,
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ]. 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 [
      • American College of Obstetricians and Gynaecologists (ACOG)
      Novel Coronavirus 2019 (COVID-19).
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      COVID-19: Changes in Pregnancy and Maternity Care Advice for Women and Their Families.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • Baud D.
      • Giannoni E.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • et al.
      COVID-19 in pregnant women — authors’ reply.
      ]. One guideline from India (Chawla 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).
      ]) 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 [
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ].

      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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID-19: Protection of Midwives and Doctors in the Birth Unit.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • New South Wales Health
      ,
      • New South Wales Health
      Guidance for Neonatal Services.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Canberra Health Services
      COVID-19: Advice for Pregnant Women.
      ,
      • South Australia Department of Health
      COVID-19 Frequently Asked Questions Maternity Patients.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Ministry of Health New Zealand
      COVID-19 — Breastfeeding Advice for Pregnant Women, or Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      COVID-19: Changes in Pregnancy and Maternity Care Advice for Women and Their Families.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Field Maternal and Child Care Services During the Outbreak of COVID-19 Infection.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • Società Italiana di Neonatologia (SIN)
      Allattamento E Infezione da SARS-CoV-2 (Coronavirus Disease 2019 — COVID-19).
      ,
      • Collège National des Gynécologues et Obstétriciens Français (CNGOF)
      Prise en charge aux urgences maternite d’une Patiente enceinte suspectee ou infectee par le coronavirus (COVID 19).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • United Nations Population Fund
      UNFPA Statement on Novel Coronavirus (COVID-19) and Pregnancy.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • Inter-Agency Working Group (IAWG)
      Programmatic Guidance for Sexual and Reproductive Health in Humanitarian and Fragile Settings During COVID-19 Pandemic.
      ,
      • United Nations Population Fund
      Sexual and Reproductive Health and Rights, Maternal and Newborn Health & COVID-19.
      ,
      • International Planned Parenthood Federation (IPPF)
      COVID-19 Impact.
      ,
      • 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).
      ]. However, three guidelines from Malaysia [
      • Ministry of Health Malaysia
      Guideline on Management of Coronavirus Disease 2019 (COVID-19) in Pregnancy.
      ], China (Chen et al. [
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ]) and Favre et al. [
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ] 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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus (COVID-19) Statement.
      ,
      • Western Australian Department of Health
      COVID-19 Guidance for Neonatal Services Statewide.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Ministry of Health New Zealand
      COVID-19 — Breastfeeding Advice for Pregnant Women, or Those Who Have Recently Given Birth.
      ,
      • Ministry of Health New Zealand
      Information for Community-based Midwives.
      ,
      • Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal Fetal Medicine (SMFM)
      Labor and Delivery COVID-19 Considerations.
      ,
      • American College of Obstetricians and Gynaecologists (ACOG)
      Novel Coronavirus 2019 (COVID-19).
      ,
      • Centers for Disease Control and Prevention (CDC)
      Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      COVID-19: Changes in Pregnancy and Maternity Care Advice for Women and Their Families.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Guidance for Antenatal and Postnatal Services in the Evolving Coronavirus (COVID-19) Pandemic.
      ,
      • The Society of Obstetricians and Gynaecologists of Canada (SOGC)
      Updated SOGC Committe Opinion — COVID-19 in Pregnancy.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Field Maternal and Child Care Services During the Outbreak of COVID-19 Infection.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • Ierssel S.V.
      • Dauby N.
      • Bottieau E.
      • Huits R.
      • Wyndham-Thomas C.
      • Loock R.V.
      Interim Clinical Guidance for Patients Suspected of/confirmed with COVID-19 in Belgium.
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • Società Italiana di Neonatologia (SIN)
      Allattamento E Infezione da SARS-CoV-2 (Coronavirus Disease 2019 — COVID-19).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • United Nations Population Fund
      UNFPA Statement on Novel Coronavirus (COVID-19) and Pregnancy.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • International Planned Parenthood Federation (IPPF)
      COVID-19 Impact.
      ,
      • 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).
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ,
      • Dashraath P.
      • Wong J.L.J.
      • Lim M.X.K.
      • Lim L.M.
      • Li S.
      • Biswas A.
      • et al.
      Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.
      ,
      • Baud D.
      • Giannoni E.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • et al.
      COVID-19 in pregnant women — authors’ reply.
      ].
      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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ,
      • New South Wales Health
      Guidance for Neonatal Services.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Department of Health and Human Services Victoria
      Coronavirus Disease (COVID-19): Maternity and Newborn Care Guidance for Clinicians.
      ,
      • Ministry of Health New Zealand
      COVID-19 — Breastfeeding Advice for Pregnant Women, or Those Who Have Recently Given Birth.
      ,
      • Centers for Disease Control and Prevention (CDC)
      Pregnancy & Breastfeeding | Information about Coronavirus Disease 2019.
      ,
      • Canadian Paediatric Society
      Breastfeeding When Mothers Have Suspected or Proven COVID-19.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • Società Italiana di Neonatologia (SIN)
      Allattamento E Infezione da SARS-CoV-2 (Coronavirus Disease 2019 — COVID-19).
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • United Nations Population Fund
      UNFPA Statement on Novel Coronavirus (COVID-19) and Pregnancy.
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • World Health Organization
      Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease is Suspected.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • Inter-Agency Working Group (IAWG)
      Programmatic Guidance for Sexual and Reproductive Health in Humanitarian and Fragile Settings During COVID-19 Pandemic.
      ,
      • 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).
      ]. One guideline from the UK [
      • Royal College of Paediatrics and Child Health (RCPCH)
      COVID-19 — Guidance for Neonatal Settings.
      ] 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 [
      • American College of Obstetricians and Gynaecologists (ACOG)
      Outpatient Assessment and Management for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID-19).
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      Management Considerations for Pregnant Patients with COVID-19.
      ,
      • Collège National des Gynécologues et Obstétriciens Français (CNGOF)
      Prise en charge aux urgences maternite d’une Patiente enceinte suspectee ou infectee par le coronavirus (COVID 19).
      ,
      • International Federation of Gynecology and Obstetrics (FIGO)
      Safe Motherhood and COVID-19.
      ,
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ]. Two guidelines specified that criteria should be in place for transferring women to a centre with Intensive Care Unit facilities [
      • FOGSI
      Good Clinical Practice Recommendation on Pregnancy with COVID-19 Infection.
      ,
      • Favre G.
      • Pomar L.
      • Qi X.
      • Nielsen-Saines K.
      • Musso D.
      • Baud D.
      Guidelines for pregnant women with suspected SARS-CoV-2 infection.
      ] and one guideline indicated there should be a lower threshold for transferring vulnerable groups of patients to such facilities [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      COVID 19: Advice for GP Obstetricians and Regional Fellows.
      ].
      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 [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • RCPI IoOaG
      COVID-19 Infection — Guidance for Maternity Services.
      ,
      • United Nations Population Fund
      COVID-19 Technical Brief for Maternity Services.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ]. Several noted critically ill pregnant patients without shock should be managed with conservative fluid management [
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ]. Additionally, there was consensus that oxygen saturations should be monitored closely [
      • Western Australian Department of Health
      Management of COVID-19 Infection in Pregnant Women.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • International Society of Ultrasound in Obstetrics & Gynecology (ISUOG)
      ISUOG Interim Guidance on 2019 Novel Coronavirus Infection During Pregnancy and Puerperium: Information for Healthcare Professionals.
      ,
      • Poon L.C.
      • Yang H.
      • Kapur A.
      • Melamed N.
      • Dao B.
      • Divakar H.
      • et al.
      Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals.
      ,
      • 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).
      ,
      • Chen D.
      • Yang H.
      • Cao Y.
      • Cheng W.
      • Duan T.
      • Fan C.
      • et al.
      Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection.
      ] and hypoxia should be avoided, with the aim of maintaining target oxygen saturation >92% [
      • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
      Coronavirus Disease (COVID-19) in Pregnancy. A Guide for Resource-limited Environments.
      ,
      • Queensland Clinical Guidelines
      Maternity Care for Mothers and Babies During the COVID-19 Pandemic.
      ,
      • Society for Maternal Fetal Medicine (SMFM)
      Management Considerations for Pregnant Patients with COVID-19.
      ,
      • Royal College of Obstetricians and Gynaecologists (RCOG)
      Coronavirus (COVID-19) Infection in Pregnancy.
      ,
      • Ministry of Health and Indigenous Medical Service
      Interim Guidelines for Maternal and Newborn Care Service