Adapting obstetric and neonatal services during the COVID-19 pandemic: a scoping review

Options for staff scheduling changes, based on the phase of the pandemic, local prevalence of cases, and resource availability, include: (1) no change, (2) a formal back-up system (across hospitals, if feasible), in the event of a surge in admissions or reduced staffing from HCPs requiring self-isolation [11, 12], (3) creating HCPs teams always working together and caring for all patients [13], or (4) designating ‘COVID-19 teams’, solely responsible for the care of COVID-19 positive or suspected persons [9, 12, 14‐18]. High prevalence areas may benefit from designated care teams/cohorting [19]. HCPs with health or other concerns, should be offered the option of working in lower-risk areas or taking temporary leave [20, 21].

Perinatology services that are critically necessary at all times should exempt HCPs from redeployment to intensive care units (ICU)s and infectious disease wards [22]. Cancellation of elective gynaecologic procedures allows increased inpatient capacity [23], and staff availability.

Current evidence supports the view that the SARS-CoV-2 virus primarily spreads via droplets, but may be transmitted during aerosol-generating medical procedures (AGMPs) [24]. Training on appropriate donning and doffing of PPE is essential, and most effective through simulation [9, 25]. With adequate PPE and infection control measures, the risk of acquiring an infection within the healthcare setting is low [26].

Depending on the phase of the pandemic and the ability of healthcare systems to safely cope with increased volumes of extremely high-risk patients, it was suggested that medical students should be removed from clinical care ADDIN EN.CITE [27‐29]. This also helped prevent unnecessary exposure of medical students to COVID-19 and conserve PPE. In order to to minimize impact on their education, medical students in several jurisdictions were provided access to print materials and virtual learning tools [27‐29]. It may be necessary to suspend subspecialty rotations and deploy trainees to cover emergency perinatology [30], or other emergency services. Reducing trainee work hours could facilitate the creation of a backup pool supporting trainees who are ill or self-isolating. In-person educational activities and non-essential clinical activities should be cancelled [30, 31] or moved online [32, 33]. Fellowship training programs that recruit post-residency trainees could continue with minimal changes, with fellows providing virtual and in-person clinics, in-house team call, and clinical service on the wards.

Universal screening of HCPs at the hospital/clinic entrance should be considered; those screening positive should be tested and self-isolate until results are available or for 14-days. Monitoring symptoms of COVID-19 [34] include measuring temperatures twice daily, having a dedicated clinic to assess HCPs with symptoms [35], and ensuring 14-days of self-isolation for those exposed to COVID-19 without adequate PPE [34, 36, 37]. HCPs are also at increased risk for psychological distress and mental health problems during pandemics [38]. Recommendations for promoting psychosocial wellness include recognition of efforts, creating back-up schedules to avoid fatigue [9], providing discussion forums to raise concerns [38], and the availability of dedicated psychiatrists and counsellors to provide resilience coaching and support.

Universal screening via telephone, for symptoms and risk factors the day prior to appointments, and again upon entry into a clinical setting, is an effective risk-reduction method [4, 9, 28, 29, 34, 39‐42]. If deferral of appointments for screen-positive persons is not possible, protocols as described in Supplementary Data 5 should be implemented. Testing policies could vary from universal testing of all HSUs to testing only those that are screen-positive, depending on community prevalence of COVID-19, testing capacity, turnaround time for test results and the availability of PPE for all HSUs and HCPs under investigation while awaiting results [43‐46].

Centres should have systems that limit physical exposure between and among HSUs and HCPs. Telephone and videoconferencing can effectively limit the number of in-person visits, and can be scheduled to coincide with routine blood or ultrasound tests [4, 28, 36, 42, 47‐54]. Any modifications to care, as illustrated in Fig. 2, should consider limitations of virtual care, which include barriers to access, language skills, and impaired HSU-HCP relationships [53]. A summary of COVID-specific considerations at in-person antenatal visits for low-risk pregnancies is presented in Table 1. Basic principles for the management of high-risk pregnancies include individualization of care plans and 24-h access to a telephone line in case of emergencies and specific considerations are discussed in Table 2. Specialized Ambulatory Units such as obstetrical day units, which provide non-urgent in-person services including administration of antenatal corticosteroids, blood pressure assessments, blood work and non-stress tests; and obstetrical triage may continue to offer services, and possibly expand their scope to limit hospitalization, with strict protocols/algorithms (Fig. 3) and designated rooms for screen-positive persons. Risk-reduction strategies during in-person visits include diligent hand and surface hygiene and wearing of surgical masks by HCPs [34, 36, 39, 55] and symptomatic [9, 20, 28, 34, 40] or all HSUs [28, 39, 53, 55, 56]. Screen-positive HSUs should wear a mask, wait in a designated area prior to assessment [9, 40], and enter an assessment room along a designated route guided by a HCP in full droplet- and contact PPE [53]. Paper charts should be avoided in the assessment room, and there should be clear signage describing the necessary cleaning protocols. Strategies to minimize contact between and among HSUs and HCPs include assessment of vital signs by physicians in physician-led units to avoid additional contact with a nurse at each visit [40], creation of distanced waiting areas [50], and increasing time between appointments [29]. Physical space modifications include ensuring that triage/screening areas are separate and well-ventilated, incorporating plexiglass barriers to triage settings, placing chairs in waiting rooms six feet apart, and providing hand hygiene stations [9, 28, 29, 40, 55]. Special clinics/ hospitals could be designated for providing antenatal care to COVID-19-positive or suspected persons in high-prevalence areas [11, 39, 50, 57]. Centres should have contingency plans if case numbers increase (Supplementary data 6). Decisions regarding the presence of partners/ support persons during antepartum appointments should be based on the patient volume at each centre, the ability to follow physical distancing protocols, while safely providing in-person care to the birthing parent and emerging evidence on the impact of restrictions on maternal physical and mental health, preterm birth and stillbirths [58‐61]. Pregnancy and parenting education classes could be conducted online, if possible. While making these decisions, the human impact of these restrictions need to be considered.

A positive COVID-19 result is not an indication for hospital admission or transfer to a higher centre; inpatient management should only be considered when medically indicated [21, 42, 71]. Those admitted for COVID-unrelated concerns, should be monitored daily for development of COVID-19 symptoms, and those admitted with suspected or confirmed COVID-19 should be systematically assessed for disease progression using algorithms such as the one presented in Fig. 4. In high-prevalence areas, sequestration of HSUs with suspected and confirmed COVID-19 in isolated wards [11, 28, 34, 37, 39, 72], management by specific HCPs [9], or redirection to designated hospitals may be considered [39, 57]. These policies need regional cooperation. In addition to structural modifications to inpatient units, measures to limit HSU-HCP contact include limiting blood-draws and avoidable assessments, care by the senior-most and fewest numbers of HCPs, and using virtual platforms for handovers. An evidence-based approach to the use of routine and experimental medications is described elsewhere [73, 74].

COVID-19 is not an indication for inducing labour or performing a caesarean [4, 6, 13‐15, 21, 34, 36, 39, 41, 42, 50, 75‐77]. Scheduled births may be delayed in COVID-19 positive and suspected HSUs to enable confirmatory testing [15], allow time for recovery, optimize one’s respiratory status [78] and reduce the risk to themselves, HCPs and neonates [4, 6, 41]. Timing of birth must consider the HSU’s clinical status, gestational age and fetal condition [4, 6, 34, 41, 42]. While medically-indicated labour inductions should continue uninterrupted [15, 36, 78], decisions on non-urgent indications must be based on a risk-benefit assessment that includes duration of hospitalization, contact with HCPs, resource utilization and the perceived risk of continuing the pregnancy. Outpatient cervical ripening is safe and effective [79], and has the advantage of reducing the length of hospital stay [15]. Telephone-screening for symptoms the day before scheduled inductions or planned caesareans, as well as upon arrival, is recommended. While hospital-births are considered safest for those with confirmed or suspected COVID-19, decisions regarding homebirths for non-infected individuals, to minimize contact with HCPs should depend on locally-available infrastructure and regional/cultural acceptance [53]. Suggested modifications to protocols for hospital births including visitor policies are presented in Table 3. Decisions around labour analgesia are often personal, with considerable regional variation. Regional (epidural) analgesia has been recommended early in labour to avoid exacerbation of respiratory symptoms secondary to labour pain [15, 17, 25, 34‐36, 76, 80, 81], and the need for general anaesthesia in case of an emergency caesarean. Neuraxial anaesthesia (spinal or epidural) is the preferred modality for caesareans [11, 15, 25, 34, 35]. Widespread use of epidurals could increase the incidence and severity of intrapartum pyrexia, which could result in designating a HSU as a suspected case of COVID-19, requiring increased use of PPE [80]. Some organizations have advocated for suspending the use of nitrous oxide for labour analgesia, because of possible aerosolization [15, 36, 56, 81], while others suggest its use may be acceptable with precautions such as a single-use microbiological filter [13, 25, 35]. Hydrotherapy (water births) was disallowed by certain groups due to possible presence of SARS-Cov-2 in feces [34, 42, 53].

Multiple transfers between birthing and recovery units should be avoided and the duration of postpartum hospitalization should be reduced where possible [15, 50, 78, 81].

Although not ideal, depending on a local risk-benefit assessment, group breastfeeding and discharge classes may be replaced by instructive videos. One-on-one care should be provided for those that require additional breastfeeding support prior to discharge. For those that meet pre-specified criteria (Supplementary data 7), early discharge and screening at home within 24–36 h of birth by midwives should be considered [9, 15, 57]. Those requiring blood draws or wound care could be assessed in Postnatal Ambulatory Care clinics and the scheduled six-week postpartum visit may be conducted virtually.

Pregnant persons with COVID-19 are at risk of life-threatening complications, particularly acute respiratory failure, shock and thromboembolic disease, requiring review by a critical care rapid response team and sometimes ICU admission [91]. Early warning scores can indicate escalation through detection of worsening oxygen saturation, increasing respiratory rate, and decreased level of alertness [92]. The ICU should have equipment and drugs for vaginal or caesarean birth and for neonatal resuscitation. A nearby location should be identified for potential neonatal resuscitation, allowing airborne precautions. Although ICU management is not different in the pregnant person, and there are no data to suggest an alteration to usual ventilatory approaches, airway management requires a higher degree of skill and prone positioning may be more difficult [93]. Although delivery may not always result in significant improvement of respiratory distress [94, 95], this may improve maternal oxygenation when conservative measures have failed [13, 14, 21, 34, 36, 50, 75, 76].

There has been a considerable increase in self-reported depression and anxiety during the pandemic [96], possibly due to isolation, job and financial insecurity, intimate partner violence and reduction in support systems [42, 53, 88]. HCPs should ask about HSU’s mental health during every encounter [4, 53]. At our centre, referral to a perinatal mental health team, composed of social workers and perinatal psychiatrists, can be made for any mental health concerns in pregnancy. Our obstetric and psychiatry teams developed weekly interactive pregnancy-specific webinars to discuss adaptations to care and mental health topics.

Pregnant women were initially excluded from vaccine trials and safety data was therefore limited. Therefore, the UK had initially recommended against vaccination in pregnant persons or those planning to conceive within 3 months, but did not describe vaccination as an indication for termination [5]. The US and Canada, cautiously supported vaccination, particularly for those at high risk of infection and/or morbidity [7, 97]. Now, it is universally recommended by all national organizations for all pregnant persons to be vaccinated by COVID-19 during pregnant women [4‐7]. Although vaccine-elicited SARS-CoV-2 antibodies have been isolated in neonatal cord blood and in breast milk, however, the degree of passive immunity is not confirmed [53].