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

30 March 2020

Updated on 30 April 2020

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.
 
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. Because the current rate of community exposure is still low, the relative risk of a screen-negative pregnant woman being an asymptomatic carrier is considered low at this point in time.
 
The chart here and below is reproduced with the permission of the New Zealand Ministry of Health

(this statement continues below)


 

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 associated with surface and droplet exposure but are not aerosol-generating processes. That is why full PPE e.g. N95 masks are not required
      
  • All multi-use medical equipment and surfaces should be cleaned between patients, including antenatal assessment e.g. ultrasound or CTG
 
  • Strategies to minimise the quantity of PPE usage must be implemented.  For example, during the first stage, traffic in and out of the room should be minimised and the same PPE can be worn by the midwife for the duration. During the second and third stage, the attending medical and midwifery staff should stay in the room, as far as practicable, with the same PPE on.  Staff members may enter the room without PPE providing that they do not approach the patient. 
 
  • The College recognises concerns regarding PPE supplies and recommends that areas with no, or very minimal, community transmission limit use of PPE in consultation with their jurisdictional public health unit or in line with DHB policies.
 
  •  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. Medical personnel should observe their local health organisation’s protocols, engage with their Infection Control Practitioner (if available) and use airborne contact precautions.
 
 
General recommendations
 
  • Usual hygiene protocols should be followed, particularly hand washing and social distancing
 
  • Restrict support persons to one
 
  • Healthcare workers should minimise time in the room, allowing for provision of usual care, including CTG and abdominal palpation
 
  • Healthcare workers should use gloves and wear an apron but do not need to use additional protective equipment during patient care in the first stage of labour, including performing a vaginal examination
 
  • Mobilisation, use of water (shower and immersion) and epidural anaesthesia may be used in the usual manner
 
  • 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
     
  • The second stage of labour should be considered higher-risk for exposure
     Particularly during the pushing phase, the woman’s expulsive exhalation presents an increased risk of contact, faecal contamination and droplet exposure to the doctor and midwife in the room.
 
  • All medical personnel should wear protective apparel, fluid-repellant surgical mask and eye protection during the pushing phase, for all patients
 
  • 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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