Covid 19 - information for pregnant women and their families
This weeks blog is written for My Expert Midwife by Dr Emma Ferriman, MBChB, FRCOG, who is a consultant in Obstetrics and Fetal Medicine, Sheffield Teaching Hospitals NHS Trust.
The blog covers:-
- General information about about Covid-19 and pregnant women, and newborns
- The symptoms to look out for
- The effects of the virus on the fetus at different gestations
- Antenatal care and appointments
- Labour and delivery
- Care of the baby in the neonatal period
Please note that the following information is a general guide only. For those women with specific complications or conditions in pregnancy they should seek an individual care plan from their health care provider.
For the majority of pregnant women, they will be either asymptomatic or have mild symptoms only and most will make a full recovery.
The virus is a new strain of Corona virus causing Covid 19. It is related to other Coronavirus infections such as the common cold, middle east respiratory (MERS) virus and severe acute respiratory (SARS) virus. The virus originated in Hubei Province, China towards the end of 2019. Pregnant women do not appear more likely to contact the virus above the general population. Pregnancy does however alter the body's immune system and its response to viral infection and because of this Covid 19 may produce more severe symptoms in some women. There is very limited information on whether there is a risk that the virus can be transmitted from Mother to Baby (vertical transmission). The limited data available from case reports in China suggests that this does not occur. Studies testing pregnant women for the virus found that samples taken from placental tissue, amniotic fluid, umbilical cord blood, neonatal throat swabs and breastmilk were all negative for the virus.
There is increasing evidence that a population of individuals with COVID-9 will be asymptomatic for the virus or demonstrate only mild symptoms. Most women will exhibit mild or moderate cold/flu-like symptoms. Cough, fever and shortness of breath are symptoms to be aware of. For pregnant women, although they are not necessarily more prone to a viral infection, changes in their immunity in pregnancy may be associated with more severe symptoms especially in the latter part of pregnancy (third trimester). This is also potentially the case for COVID-19. More severe symptoms such as pneumonia are more likely to occur in older patients or in patients with other health issues such as diabetes, cancer, chronic lung disease or any condition where immunity is suppressed. Because the virus is new there is limited data available, but when looking at previous related viral infections and how they affect pregnant women the risks appear to increase in the third trimester. There is a potential increase in women who will need preterm delivery for medical reasons in pregnancy.
The current advice for pregnant women is that if you are infected with COVID-19 you are most likely to be asymptomatic or have mild symptoms and will make a full recovery. For the small proportion of women who develop more severe symptoms or show a delayed recovery this could be a sign of a significant chest infection (pneumonia). If this is the case, you should contact your maternity health team or dial 111 for advice.
What is known about the effects of the virus on the fetus at different gestations
Currently there is no evidence suggesting that pregnancy with COVID-19 carries an increased risk of early or late miscarriage. There is also NO evidence of congenital intrauterine fetal infection with COVID-19 and because of this there are unlikely to be effects on the developing fetus. There appears to be an association between preterm birth, but in these few cases delivery was usually indicated for maternal health reasons. There are isolated reports of preterm rupture of membranes and fetal distress.
For women who have had confirmed COVID-19 infection in pregnancy further antenatal care should be arranged following the period of self-isolation. It is currently recommended that these women should have a scan to check baby's growth fourteen days following resolution of the acute illness. There is still no evidence that COVID-19 affects fetal growth but this recommendation follows on from the data obtained in the SARS outbreak where 2/3 of pregnancies affected by SARS were found to have small babies (fetal growth restriction)
The UK Chief Medical Officer has recommended that pregnant women should increase their social distancing to reduce the risk of infection. This recommendation has been made given there is limited information on the effect of the virus and pregnant women. Social distancing includes the following recommendations:
- Avoiding contact with individuals who have symptoms of COVID-19 including high temperature and/or a new and continuous cough
- Avoiding non-essential use of public transport
- Avoiding large and small gatherings in public places (e.g. pubs, restaurants, cafes)
- Avoiding gatherings with friends and family
- The use telephone or online services to contact health providers
Handwashing and respiratory hygiene
- Wash your hands more often with soap and water for at least twenty seconds or use a hand sanitiser when you get home or in to work, if you blow your nose, cough, sneeze, eat or handle food.
- Avoid contact with your eyes, nose and mouth with unwashed hands.
- Avoid close contact with anyone who has symptoms
- Cover your cough or sneeze with a tissue and then discard and wash hands
- Clean and disinfect frequently touched objects and surfaces
Antenatal care and appointments
All women should attend routine antenatal care unless they meet the current social isolation guidance for individuals and households of individuals with symptoms of a new continuous cough or fever. For women who have had symptoms, appointments can be delayed until seven days after the start of their symptoms if this has been deemed safe by their healthcare professional. The exception to this is when symptoms other than cough are persistent and may indicate a more severe form of the infection.
For women who are self-isolating because someone in their household has possible symptoms of COVID-19, appointments should be delayed for fourteen days, if this has been deemed safe by their healthcare professional.
Please be aware that there may be a limitation in some service being provided. Staff shortages may affect routine appointments and ultrasound examinations and some visits may be conducted via telephone consultation.
For pregnant women who are currently well:
- If you have a routine ultrasound scan or visit in the coming days contact your maternity unit and agree a plan. You may still need to attend for an appointment, but the visit may change due to staffing alterations
- For women between appointments, await contact from your maternity care team
- For women requiring more regular attendances such as those requiring serial scans or who have had previous pregnancy complications, wait for your health provider to contact you and agree a plan of care
For all pregnant women consider the following:
- For any concerns contact the maternity team by telephone - be aware that this may take longer than usual due to the current workload caused by the virus.
- For urgent problems unrelated to COVID-19 contact your maternity care team in the usual way.
- If you are symptomatic of COVID-19 contact your maternity care team who will arranged the correct place and time for your visit. Please do NOT attend a routine clinic or scan.
- Please keep the number of people attending with you to a minimum and do not bring children to maternity appointments (Children are more likely to be asymptomatic and thus may spread the infection).
- You may find that your appointments are reduced or may occur as a telephone consultation (e.g. booking induction of labour or elective caesarean section). Do not reduce your maternity visits unless this is agreed with your maternity team.
- If you have a visit cancelled or delayed contact your maternity team via your usual telephone route of contact for further information and advice.
Admission in labour
Women with suspected or confirmed COVID-19 for whom hospital attendance is necessary
- Attend via private transport. If an ambulance is required inform the call handler that you are currently in self isolation for COVID-19.
- Alert a member of staff prior to entering the hospital.
- Staff providing care will use personal protective equipment (PPE) and pregnant women will be provided with a surgical face mask and escorted to an isolation room.
- Only essential staff will be admitted, and visitors should be kept to a minimum.
Women with suspected or confirmed COVID-19 for unscheduled/urgent antenatal care
- Where possible you will be provided with advice via telephone.
- If you in in early labour you will be given advice by telephone. Women with mild symptoms should stay at home in the early stages of labour if all other parameters are normal.
- If you are booked for a homebirth or delivery at a birthing unit there should be a discussion regarding the risks of fetal distress in women infected with COVID-19. You should be advised to give birth on an obstetric unit with continuous fetal monitoring.
- If your birth partner is asymptomatic they will be treated as possibly infected and advised to wear a mask and wash hands frequently during labour.
- If your birth partner is symptomatic they will be advised to stay at home in self isolation. You should identify an alternative birth partner should this situation occur.
Labour and delivery
- Currently there is no evidence that either vaginal birth or caesarean section are a safer method of delivery. Mode of delivery should not be influenced by COVID-19.
- Birthing pools should be avoided in suspected or confirmed cases due to the inability to ensure adequate protection for healthcare staff.
- Epidural and spinal anesthesia are not contraindicated. If you have suspected/confirmed COVID- 19 infection you may be offered an epidural earlier in labour to reduce the need for a general anaesthetic should you need urgent delivery.
- Entonox is safe in labour.
- If you require urgent delivery by caesarean section within thirty minutes (category 1 delivery) you will be informed that the wearing of PPE for healthcare professionals is time consuming and may lead to a delay in the decision to delivery interval for you and your baby.
- There is no evidence to suggest that delayed cord clamping has an adverse outcome and this practice is still recommended.
Care of the baby in the neonatal period
- There is limited information to guide the postnatal management of babies whose Mothers have been diagnosed with COVID-19.
- There is no evidence currently of transmission from Mother to baby (vertical transmission)
- There is no evidence to isolate mothers from their babies. Women with healthy babies should be kept together with their babies.
- There is no contraindication to breast feeding in terms of transmission of the virus from Mother to baby in breast milk, however there is the risk of transmission via the close contact which will inevitably occur during breast feeding. Women who are breastfeeding will be advised to employ strict hand washing, avoid coughing or sneezing, may be asked to consider wearing a face mask while feeding, advised to follow recommendations for pump and bottle cleaning and also may be asked to consider whether someone who is well could feed baby expressed breast milk.
Please remember to keep yourself and your families safe at this worrying time. Prevention and spread of the infection are essential to reduce the number of cases and fatalities.