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Care of the Maternity Patient on OB Unit – Update

***KHN PPE Preservation Guidelines Must be Followed*****

Visitor and Patient Screening Process

All maternity patients and visitors will be screened at front entrance.

If maternity patient has a positive screen, (fever, cough, and/or SOB) staff is to place regular mask on the patient, if not already present.

  • The patient should be transferred to a private room (if available, place in negative pressure room) and placed on Droplet & Contact Precautions.
  • PPE used by the health care worker should be donned prior to going into the patient room and includes the following: N95, goggles, gown, gloves 
  • Notify Infection Control that a PUI has been admitted to L&D
  • Admitting obstetrician should be notified for further orders and to order COVID-19 testing
  • Visitor will be screened at front entrance. Any visitor with a positive screen (fever, cough, and/or SOB) will be asked to leave

Labor & Delivery- Stage 1 and 2

Non-Covid or Non-PUI 

  • First stage of labor: PPE is Standard Precautions
  • Second stage of labor:  PPE is Standard Precautions
    • PPE used by the health care worker should be donned prior to going into the patient room and includes the following: Gloves, gown, surgical mask, eye protection (face shield or goggles) 

COVID-19 Positive or PUI at Any Stage of Labor

  • Patient would be placed in applicable isolation (Droplet/Airborne & Contact) all health care workers should wear the PPE as follows: Gloves, gown, N95 mask, eye protection (face shield or goggles)
  • Visitor guidelines: any visitor with patient to wear applicable PPE (gloves, gown, N95 mask, eye protection)

Supply Change

  • Nitrous oxide is temporarily discontinued 

C-Section Delivery-Patient with Covid-19 or PUI

PPE 

  • The patient should wear a surgical mask during transport if not intubated
  • Staff should follow Droplet & Contact precautions during transport donning PPE including:
    • Isolation gown 
    • Surgical mask with face shield or goggles 
    • Gloves 
  • There should be a separate individual who clears the transport path and opens all doors. 

Transport Guidelines Based on Location

  • From L & D to OB OR: If intubation needed, it should take place in designated L & D negative pressure room prior to being transported to OB OR 
    • PPE changes to Airborne with Contact: N95 mask, isolation gown, goggle/face shield, and gloves
  • From a non-OB unit (i.e., ICU): Intubated maternity patient with Covid-19 or PUI hospitalized on a non-OB unit requiring C-Section will go directly to OB OR
  • Anesthesia to determine extubation.
  • Staff turning over the room after extubation will wear droplet and contact precautions.
  • After delivery, patient will return to designated room for post-operative care.

OR Traffic

  • No visitors in OR
  • Limit staff in OR [Neonatal respiratory therapist (NRT) if needed or available at the door]
  • Any specimen collected should be hand carried to the lab. 
  • Call to inform the lab prior to transporting the specimen.
  • Gloves should be worn to transport the specimen.   

Vaginal Delivery Patient with COVID-19 or PUI

Continue to maintain Droplet & Contact Precautions and PPE as follows: gown, gloves, N95, eye protection (face shield or goggles)

Recommended

  • Staff in room should be limited to RN & attending physician only (NRT if needed or available at the door) 
  • No skin to skin recommended
  • No delayed cord clamping if >32 weeks
  • Infant to be bathed as soon as he/she is stable after delivery – not at 12 hours.
  • The determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should be made on a case-by-case basis using shared decision making between the mother and the clinical team. Considerations in this decision include:
    • The clinical condition of the mother (symptomatic vs. asymptomatic) and of the infant.
    • COVID-19 test results of mother (confirmed vs. suspected) and infant (a positive infant test would negate the need to separate).
    • Desire to breastfeed.
    • Facility capacity to accommodate separation or co-location.
    • The ability to maintain separation upon discharge.
    • Other risks and benefits of temporary separation of a mother with known or suspected COVID-19 and her infant
  • If the decision is for co-location, measures to reduce the risk of transmission from mother to infant should be performed using shared decision-making including the following:
    • Keep the newborn ≥6 feet away from the mother, and also using controls like physical barriers (e.g., a curtain between the mother and newborn) if possible.
    • Mothers who choose to breastfeed should put on a face mask, their breasts with antimicrobial soap and water, and practice hand hygiene before each feeding. Breast pumping may also be offered as an option.  These measures should be utilized for bottle feeding as well.
    • The face mask should remain in place during contact with the newborn and staff members. 
  • If the decision is for separation
    • Infants with suspected COVID-19 should be isolated from other healthy infants. 
    • If another healthy caregiver or staff member is present to provide care such as diapering, bathing and feeding for the newborn, they should use droplet and contact precautions (gown, gloves, face mask, and eye protection). Currently, we recommend avoiding admitting asymptomatic, otherwise healthy infants to the NICU due to concerns of transmission to fragile preterm neonates.  

Postpartum Care of Patient COVID-19 or PUI and Stable Infant PUI

  • The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team.
  • A separate isolation room should be available for the infant while they remain a PUI using Droplet and Contact Precautions: gown, gloves, surgical mask and eye protection. 
  • If another healthy family or staff member is present to provide care (e.g., diapering, bathing) and feeding for the newborn, they should use appropriate PPE including gown, gloves, surgical mask, and eye protection. 
  • The decision to discontinue temporary separation of the mother from her baby should be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. The decision should take into account disease severity, illness signs and symptoms, and results of laboratory testing for the virus that causes COVID-19.
  • If co-location (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19. 
    • Consider using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the ill mother.
    • If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed COVID-19 or is a PUI should put on a face mask, practice hand hygiene, and clean the breast before each feeding or other close contact with her newborn. The face mask should remain in place during contact with the newborn. These practices should continue while the mother is on transmission-based precautions in a healthcare facility.
  • Circumcision is permitted
  • Hearing screening only done if maternal COVID-19 results negative. 
    • If positive or unknown prior to discharge, infant may have OAE (not ABR) and referred to outpatient testing for follow up. 

Breastfeeding

  • During temporary separation, mothers who intend to breastfeed should be encouraged to express their breast milk to establish and maintain milk supply. If possible, a dedicated breast pump should be provided. 
  • Prior to expressing breast milk, mothers should practice hand hygiene, and clean breasts. 
  • After each pumping session, all parts that come into contact with breast milk should be thoroughly washed and the entire pump should be appropriately disinfected with purple top SaniCloths. 
  • This expressed breast milk should be fed to the newborn by a healthy caregiver.
  •  If a mother and newborn do co-locate and the mother wishes to feed at the breast, she should put on a face mask, practice hand hygiene, and clean the breasts before each feeding.

SCN/NICU PUI /COVID-19 Positive

  • Infants to be admitted to SCN/NICU based on the clinical criteria.  
  • Neonatologist to determine the need for negative pressure room.  
  • Droplet and Contact Precautions: Gown, Gloves, Surgical Mask and Eye Protection.  
  • If intubated, using CPAP or nebulizer treatment, change to Airborne and Contact precautions: Gown, Gloves, N95 Mask and Eye Protection

No visitor with confirmed or suspected COVID-19, nor possible exposure to confirmed or suspected COVID-19 infected person, shall be permitted to enter the NICU.  

Asymptomatic partner may visit after 14 days of last exposure to the positive mother, or after 2 negative tests 24 hours apart.  

For a COVID-19 positive or PUI mother, she will be encouraged to identify a non-household, non-PUI, healthy individual to be the well caregiver for her infant. 

Encourage use of telemedicine for those parents not allowed to visit.

If the newborn is uninfected but requires prolonged hospital care for any reason, the mother will not be allowed to visit the infant until she meets the CDC recommendations for suspending precautions.

Discharge COVID-19 Pending Patients 

For patients that are clinically improved and can be safely discharged, please proceed with discharge even though the COVID-19 test may be pending. The patient will need to maintain self-isolation precautions until the test results become available. Infection Prevention Control (IPC) must be notified at discharge so they may contact the local health department if the test returns as POSITIVE. Negative results will be routed to the physician’s in basket.

Please note there are specific AVS instructions for these patients.

Discharge Education

  • Use SmartPhrase .covid available for Designated Unit discharge documentation
  • Provide and explain the “What to do if you are sick with coronavirus disease 2019” educational sheet to patient and family/support persons. Click here to access that resource.

Infant Discharge

  • Infant shall be discharged when otherwise deemed medically ready.  
  • A healthy individual designated to care for the infant shall be identified when possible.Both infant and mother shall remain in droplet and contact isolation while leaving the building: Infant shall be placed in an infant carrier and a loose blanket placed over the seat while in the hallway (to be removed once in the vehicle). 
  • Direct physician to (follow up) physician contact should occur prior to discharge so appropriate precautions can be taken upon patient’s arrival.
  • Consider telehealth if necessary, for discharge instructions with the mother and the designated care giver if the mother is positive.
  • Symptomatic mothers who were separated from their infants in the hospital should continue separation until (a) she has been afebrile for 72 hours without use of antipyretics, and (b) she has improvement in respiratory symptoms, and (c) at least 10 days have passed since symptoms first appeared; OR she has negative results of a molecular assay for detection of COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart.
  • Symptomatic mothers and infants who co-located in the hospital should continue protective measures including limited contact (>6 ft away) and continue to wear masks until (a) she has been afebrile for 72 hours without use of antipyretics, and (b) she has improvement in respiratory symptoms, and (c) at least 10 days have passed since symptoms first appeared; OR she has negative results of a molecular assay for detection of COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart. 
  • Asymptomatic mothers who tested positive COVID-19 who were separated from her infant in the hospital, should continue separation for 7 days since the date of her first positive COVID-19 diagnostic test and has had no subsequent illness. She should continue to limit contact (>6ft away) and wear a facemask for an additional 3 days. 
  • Asymptomatic mothers who tested positive for COVID-19 who co-located with her infant in the hospital should continue protective measures including limited contact >6ft away and wearing a face mask for a total of 10 days from the date of her first positive diagnostic test.

Infant Readmission

  • Infants born to mothers with confirmed COVID-19 infections or infants that remain under investigation for COVID-19 at the time of discharge and remain asymptomatic (afebrile without respiratory symptoms) may be considered for readmission.  
  • If needed, the same precautions should be exercised as in the initial stay (droplet isolation in private room). 
  • If infants have fever or respiratory symptoms, they should be admitted to the NICU
  • Infants without known or suspected exposure to COVID-19 that do not have respiratory symptoms or fever may be readmitted as typically indicated (hyperbilirubinemia, poor feeding, etc.).

Click here for resources from the CDC.

Cincinnati Wide Guidance for the Newborn Care of Infants Born to COVID-19 Positive or Suspected Mothers (5/5/20)

Cincinnati Children’s: Care of Infants Born to Pregnant Women with Suspected or Confirmed Covid-19 Infection

May 21, 2020