COVID 19: Advice for GP Obstetricians and Regional Fellows

23 March 2020

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the risk posed to the community, healthcare workers, and all patients, due to the COVID-19 pandemic. Particularly in rural and remote communities, much of the burden of women’s healthcare falls to Regional Fellows and GP Obstetricians. The College expresses our admiration and gratitude to those working in non-metropolitan settings without the benefit of services and facilities that are readily available in larger centres and cities. As the impact of the pandemic increases, the support and expertise of Regional Fellows and GP Obstetricians in Australia and New Zealand will be paramount.

The College encourages all GP Obstetricians and Regional Fellows to connect with their local health jurisdictions and to follow the general advice of hospitals, the Ministry of Health in New Zealand and State and Territory Departments of Health in Australia and government authorities. The following advice is a general summary for clinicians to assist in the care of pregnant patients infected, or at risk of infection, with COVID-19.

1.    Personal health and safety. Your personal health and safety and that of your family is of primary importance. Members with confirmed infection or who are symptomatic. Those who are unwell and pregnant health workers should not be under pressure to keep services going.
a.    Ensure that you get enough rest, eat a good diet and exercise regularly.
b.    Seek help if you are physically or mentally unwell.
c.    Minimise your exposure to potentially infected patients.

2.    Minimise your contact with potential COVID-19 patients and take measures to reduce the risk of viral spread within your clinic and hospital.
a.    Patients with a possible COVID-19 infection should be directed to a specialised testing clinic where this is available.
b.    Your clinic/hospital should have a dedicated room in which to assess and test potential COVID-19 patients with appropriate personal protective equipment (PPE) provided.
c.    Patients entering your clinic/hospital should be encouraged to wear a face mask if they have a fever or respiratory symptoms, diarrhoea, anorexia and vomiting, or if they are elderly or suffer from chronic disease. All patients should be encouraged to use a hand sanitiser as they enter your clinic/hospital.
d.    Use telephone or video consultations wherever this is an appropriate alternative to a face to face consultation.
e.    Provide timed appointments, where possible, to avoid crowding within your clinic.
f.    Encourage patients to wait outside in their vehicles or in designated outdoor seating areas with appropriate spacing until the doctor or nurse is ready to see them.
g.    Have a policy in your hospital to restrict visitors.

3.    Antenatal Care
a.    Telephone and video conferencing should be considered, especially in early pregnancy, when counselling forms a large component of the antenatal visit.
b.    A reduced frequency of antenatal visits may be appropriate especially in uncomplicated multiparous women.
c.    Specific precautions regarding COVID-19 for pregnant women remain the same as for the general population.
d.    Pregnant women presenting with COVID-19 infection have the same clinical features, pathology and imaging findings as non-pregnant patients (fever, dry cough, respiratory distress, normal WBC, lymphopenia, possible LFT abnormalities and a typical appearance on chest CT). They do not seem to be more susceptible to severe disease compared to the general population, allowing for the awareness that respiratory disease e.g. pneumonia can manifest more severely in pregnancy.
e.    The risk of maternal complications are not yet definitely known but there is no current evidence of teratogenicity, increased miscarriage or vertical transmission. There has been an associated increased rate of premature birth (in part iatrogenic), PROM and fetal distress in sick women with a COVID-19 infection. There has been one stillbirth reported in a pregnant woman with multiorgan failure on ECMO.
f.    COVID-19 has not been found in amniotic fluid, cord blood, neonatal swabs or breastmilk in women who were COVID-19 positive.
g.    Pregnant women living in remote and rural Indigenous Australian and Māori communities will be at particular risk of COVID-19 infection due to a high incidence of smoking, chronic disease, overcrowded housing and malnutrition. You should have a low threshold for transferring vulnerable women who are pregnant and unwell from a COVID-19 infection to a centre with ICU capabilities.
h.    You should be alert to the increased risk of antenatal anxiety and depression and domestic violence due to the financial and social impacts of the COVID-19 pandemic adding to the normal stresses of pregnancy.
i.    It is imperative that all pregnant women be encouraged to have their flu vaccination as soon as it is available and pertussis vaccination after 20 weeks gestation.
j.    Consider the use of on-line resources or video conferencing to deliver antenatal and lactation classes.

4.    Intrapartum care
a.    Women with a known COVID-19 infection should be nursed in a single room, using PPE, with minimal interaction with non-essential staff and visitors. If an infected woman needs a caesarean section all personnel in theatre should wear PPE.
b.    The timing of delivery and mode of delivery will usually be determined based on the usual obstetric indications. Caesarean section may be indicated in a woman with significant symptoms of COVID-19 infection, and it would be preferable to defer induction of labour or elective caesarean section for non-essential reasons until a woman has completed her isolation period, if that is possible.
c.    Continuous electronic fetal monitoring is recommended in any woman in labour with a known COVID-19 infection.
d.     The greatest risk to staff during CS relates to intubation during which time the virus load from aerosolisation is highest.
e.    RANZCOG recognises that there is limited information regarding the use of nitrous oxide in labour. Concerns relate to cleaning, filtering, and potential aerosolisation in the setting of Covid-19.  Given these considerations, RANZCOG advises a cautious approach i.e. that nitrous oxide should not be routinely provided to women who are defined as suspected, probable or confirmed for Covid-19 infection. If nitrous oxide is used in this setting then all exposed staff should wear appropriate PPE, as determined by the local health jurisdiction. Nitrous oxide may still be offered to women at low risk of Covid-19, as deemed appropriate by the midwife.

5.    Post partum care in infected mothers
a.    There is currently no evidence that a woman with a known COVID-19 infection who has recently given birth should be separated from her baby. She should avoid contact with other mothers and infants, appropriate precautions with hand washing and facial contact and consider wearing a mask when feeding.
b.    Breastmilk from infected mothers has been shown to be negative for COVID-19 so breastfeeding is not contra-indicated. Where a woman is unwell, expressed breastmilk can still be fed to her infant.
c.    The few neonatal infections that have been reported were acquired postnatally and the infants were not significantly unwell. Fetal distress and early neonatal complications when present were considered due to maternal illness or prematurity.

6.    Post natal care in non-infected mothers
a.    Visitors should be limited while the pandemic is current. Any visitor with a possible COVID-19 infection or contact should be excluded from the maternity ward and advised against meeting with new mothers and their infants outside the ward. It is best to also exclude children that are not immediate family. All visitors should use hand sanitiser on entering and leaving the maternity ward and offered face masks to wear during the visit. There should be no prolonged visits from anyone who is not immediate family.
b.    Breastfeeding should be encouraged.
c.    Early discharge from hospital should be considered where appropriate with ongoing home based and/or telephone support.
d.    Postnatal anxiety and depression is common and may be compounded by the social isolation and financial stresses imposed on the community by the COVID-19 pandemic. New mothers should be encouraged to interact with friends and family and other new mothers using online resources if necessary. They should also be given appropriate advice and contact information to access if they are not coping. It is important to remember that many new fathers/partners may also suffer from anxiety and depression which again may be compounded by the pandemic.
e.    Consider telephone and video consultations in the postnatal period. (temporary MBS item numbers are available for all pregnant women and parents with new babies).



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