Guidelines for Antenatal, Intranatal and Postnatal and New-born Management of COVID-19
The unprecedented scale of coronavirus infections or COVID-19 pandemic has affected the lives of millions of people across the globe. This has put tremendous strain on the health-care facilities and doctors, who are facing the direct brunt of this crisis and face numerous challenges in diagnosing and treating the affected people.
The central and state governments have been actively working with medical bodies such as ICMR and health-care facilities to formulate management guidelines for effectively tackling the growing number of COVID-19 infections.
Some of the most vulnerable population groups in this COVID-19 pandemic are pregnant mothers, mothers who have recently delivered a child and new-born babies. The National Neonatology Forum’s (NNF) Karnataka State Chapter has taken the initiative to draft and issue the “Guidelines for Antenatal, Intranatal and Postnatal and New-born Management of COVID-19”.
The NNF Karnataka State Chapter has prepared a comprehensive and evidence-based set of guidelines for the diagnosis and management of COVID-19 during pregnancy and delivery. It has been prepared by leading and eminent Neonatologists, Gynaecologists and Obstetricians from Karnataka.
This guideline prescribing standard operating procedures (SOPs) for the management of pregnant mothers and new-borns was released on 24th July 2020. The guideline has been duly endorsed by the Honourable Chief Minister of Karnataka, Shri BS Yediyurappa, Deputy Chief Minister, Dr. Ashwath Narayan CN, Honourable Health Minister of Karnataka, Shri B. Sreeramulu and Honourable Medical Education Minister, Dr. K. Sudhakar.
Brief Background of COVID-19
Towards the end of 2019, a coronavirus was identified to be the cause of a cluster of pneumonia cases in the city of Wuhan in China. The virus rapidly reached an epidemic scale across China and subsequently throughout the world. In February 2020, the World Health Organization (WHO) designated the disease caused by the coronavirus as COVID-19.
Recent studies have reported a variation in the viral genome of the coronavirus which has improved its ability to infect human cells. It has now become the dominant strain responsible for most COVID-19 cases. Common symptoms include fever, cough, sore throat, breathing issues, headache, and abdominal pain.
The coronavirus is primarily transmitted through close-range person-to-person contact mainly via respiratory droplets from an infected individual. Other modes of transmission are airborne, fomite, faecal-oral, blood born, and mother to child. Globally there are now close to 24 million confirmed COVID-19 cases and 3.2 million cases in India alone as of August 2020.
Management of COVID-19 and Pregnancy
Pregnant women undergo physiological and immunological changes. In the case of COVID-19 infection, most pregnant women experience mild or moderate symptoms. With the existing data, there is no evidence of an increased risk of miscarriage in COVID-19 positive mothers. The risk of vertical transmission or transmission from mother to foetus is also very low. Transmission of COVID-19 from breast milk to baby is extremely rare.
Highlights of Guidelines for Obstetric Health Care
- All pregnant women will be treated as COVID-19 suspects and all precautionary measures will be followed.
- The pregnant patient will be placed in a separate ward, negative pressure will be maintained in the Operation theatres (OT), the patients will wear a triple-layer mask.
- All healthcare professionals must wear Personal Protection Equipment (PPE).
- The Department of health and family welfare should be immediately notified for suspected COVID-19 cases and testing should be done at Government accredited labs.
- The healthcare centres must maintain a registry of confirmed COVID-19 cases.
- Healthcare centres will follow universal mask policy i.e. all visitors, patients, doctors, medical and non-medical staff will wear masks.
- Sanitization of diagnostic equipment such as ultrasound machines will be done after each use.
Criteria for testing for COVID-19
Under certain circumstances, the pregnant patient will be needed to undergo testing for COVID-19. The following criteria will be used to prescribe the COVID-19 test:
- Symptomatic persons will travel history in the past 14 days.
- Patients with severe respiratory illness.
- An asymptomatic person who has had direct contact with confirmed COVID-19 case.
- In addition, ICMR has announced mandatory testing of patients living in COVID-19 hotspots or containment zones even if they are asymptomatic.
Management of pregnant patients with COVID 19
Most COVID-19 positive pregnant patients exhibit only mild symptoms. Severe symptoms are observed among immunosuppressed patients and patients with chronic conditions such as diabetes, lung disease, etc. Nevertheless, apart from the general precautions, particular considerations will be given to pregnant patients with COVID-19. Some of these include:
- Maintaining high oxygen levels and keep saturations > 94%.
- Conduct radiographic investigations such as chest X-ray using abdominal shielding.
- Periodic blood analysis to monitor white blood cell count and prescribe antibiotics when necessary.
- Current guidelines however do not recommend the use of Hydroxychloroquine or antiviral drugs in pregnant women.
Postnatal care for mothers with COVID-19
Limited information is available on the severity of COVID-19 symptoms exhibited in new-born babies born to mothers with COVID-19. However, the risk of transmission from mother to child after birth exists. Individualized care is recommended on a case-to-case basis after a thorough risk and benefit analysis with neonatologists and the concerned families.
Breastfeeding guidelines for mothers with COVID-19
It is extremely rare for transmission of COVID-19 from mother to baby through breast milk. It is strongly recommended to initiate breastfeeding within 1 hour of birth and that the baby is exclusively breastfed for the first 6 months.
- Mothers confirmed with COVID-19 should breastfeed the baby with facemask and practice hand hygiene.
- Face-mask should be worn during all events of contact with new-born.
- If the baby and mother are required to be separated temporarily, expressed breast milk is strongly recommended to be given to the new-born by a healthy caregiver.
- Gloves must be worn by the caregiver when receiving bottles of expressed breast milk. After securing the cap, the bottles should be wiped with viricidal wipes and air-dried on a clean surface.
In addition, the NNF Karnataka State Chapter also provides general guidelines for Basic Hospital Management, Visitor Policy, Managing Biomedical Waste, Mental Health and Wellness support for Patients and Healthcare Professionals and District Wise Government Helpline numbers in Karnataka.
Acknowledgements: We would like to acknowledge the Dr. Prashnath and Dr. Jyothi Bandi from LittleBaby Clinic for kindly permitting us to disseminate this information for the benefit of all.