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COVID-19: Protection of midwives and doctors in the birth unit

30 March 2020

Updated on 18 August 2020

Key points
 
  • Droplets are particles that are heavier, travel a short distance, and are contained/deflected by a surgical mask. Aerosol refers to smaller particles that can disseminate throughout a room and can pass through a surgical mask
 
  • Labour and birth are primarily associated with surface and droplet exposure but they are potentially aerosol-generating behaviours (AGB).
 
  • Caesarean section under general anaesthetic should be considered an aerosol-generating procedure (AGP). A caesarean section planned under a regional anaesthetic could be converted to a general anaesthetic
 
  • Updated advice is that N95 masks are required for healthcare workers caring for women with suspected or proven COVID-19 infection in labour, birth and caesarean section
 
  • The College recognises concerns regarding PPE supplies and recommends that information available to Government and Health Departments is shared in a transparent manner with healthcare workers
 
  •  Medical personnel should observe their local health organisation’s protocols, engage with their Infection Control Practitioner (if available).
 
 
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the risk posed to the community, health workers, and all patients, due to the COVID-19 pandemic. RANZCOG also recognises our responsibility to respond to this situation as a large organisation and also as a medical college and health leader.
 
The College respects the role of governments, health departments and health administrators in coordinating national responses. We continue to communicate regularly with the Chief Medical Officer and other authorities in both Australia and New Zealand. The purpose of this communiqué is to address the issue of protection of midwives and doctors in the birth unit. Availability and use of healthcare resources, the welfare of healthcare workers and patients and local hospital protocols are all considerations.
 
Midwives, doctors and other personnel caring for pregnant women, have a right to be fully informed about potential risks, and to have access to protective equipment. Health services should accept that all healthcare workers will feel vulnerable at this time, and ensure that appropriate supports are in place. RANZCOG accepts that guidance regarding PPE is not consistent across all jurisdictions and clinicians should follow the advice and protocols of their local authority.

RANZCOG is a bi-national College and it is important to note that advice may differ between Australia and New Zealand. The guidance from the New Zealand MoH is reproduced, with permission, in the chart below. The chart can also be found here.

* Please note: this statement continues after this chart

 

Currently, women are screened for exposure, symptoms or diagnosis prior to admission to the birth unit.  The current definition for suspected cases is available for Australia from the Communicable Diseases Network Australia COVID 19 Series of National Guidelines and for New Zealand from the Ministry of Health. At the start of the pandemic, the rate of community exposure was low and the relative risk of a screen-negative pregnant woman being an asymptomatic carrier was considered low.
 
However, the situation in Victoria has now changed with an increasing rate of community transmission.
 
Aerosol generating behaviour (AGB)= screaming, shouting, crying out, vomiting
 
Aerosol-generating procedures (AGP). Examples include: bronchoscopy, tracheal intubation, non-invasive ventilation (e.g. BiPAP, CPAP), high flow nasal oxygen therapy, manual ventilation before intubation, intubation, cardiopulmonary resuscitation, suctioning, sputum induction, nebuliser use
 
The chart here and below is reproduced from the Victorian Department of Health and Human Services (DHHS)

* Please note: this statement continues after this chart


 
 
 
 
 

 


 

General recommendations
 
  • Usual hygiene protocols should be followed, particularly hand washing and social distancing
 
  • All multi-use medical equipment and surfaces should be cleaned between patients, including antenatal assessment e.g. ultrasound or CTG 
 
  • Restrict support persons to one
 
  • Healthcare workers should minimise time in the room, allowing for provision of usual care, including CTG and abdominal palpation
  
  • Mobilisation and epidural anaesthesia may be used in the usual manner. Active mobilisation, use of water immersion in labour, and epidural analgesia are not affected. However, in the setting of increased community transmission of coronavirus (COVID-19), services are advised to suspend the use of water immersion for labour and birth for all women. The protection of our maternity and neonatal health care workforce is essential. PPE is not effective when wet and consequently, the use of water immersion during this period presents an unacceptable risk.
 
  • 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.
 
  • Consideration should be given to early epidural in labour as an option for analgesia e.g. as an alternative to nitrous oxide
 
  • Particularly during the pushing phase, the woman’s expulsive exhalation presents an increased risk of contact, faecal contamination, aerosol and droplet exposure to the doctor and midwife in the room.
 
  • All healthcare workers should wear protective apparel, fluid-repellant surgical mask and eye protection during the pushing phase, for all patients and N95 for suspected or proven COVID-19 patients
 
  • The patient who has proven or is suspected to be at high-risk for COVID-19 infection should be encouraged to wear an appropriate mask, recognizing that this may not be tolerable.
 
  • During the third stage, retain protective equipment and follow usual practice, including, where appropriate delayed cord clamping, controlled cord traction, skin to skin contact and initiation of breastfeeding
 
 
 



 



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