Considerations for Inpatient Obstetric Healthcare Settings

Summary of Recent Changes

Revisions were made on April 4, 2020, to reflect the following:
Guidance has been updated to clarify the following:

Considerations related to visitors and essential support persons to pregnant women who have known or suspected COVID-19 infection
Prioritized testing of pregnant women with suspected COVID-19 at admission or who develop symptoms of COVID-19 during admission
Testing of infants with suspected COVID-19 and isolation from other healthy infants
Determination of whether to keep a mother with known or suspected COVID-19 and her infant together or separated after birth on a case-by-case basis, using shared decision-making between the mother and the clinical team

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These infection prevention and control considerations are for healthcare facilities providing obstetric care for pregnant patients with confirmed coronavirus disease (COVID-19) or pregnant persons under investigation (PUI) in inpatient obstetric healthcare settings including obstetrical triage, labor and delivery, recovery and inpatient postpartum settings.

This information is intended to aid hospitals and clinicians in applying broader CDC interim guidance on infection control (Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings).

Since maternity and newborn care units vary in physical configuration, each facility should consider their appropriate space and staffing needs to prevent transmission of the virus that causes COVID-19. These considerations include appropriate isolation of pregnant patients who have confirmed COVID-19 or are PUIs; basic and refresher training for all healthcare personnel on those units to include correct adherence to infection control practices and personal protective equipment (PPE) use and handling; sufficient and appropriate PPE supplies positioned at all points of care; and processes to protect newborns from risk of COVID-19.

These considerations are based upon the limited evidence available to date about transmission of the virus that causes COVID-19, and knowledge of other viruses that cause severe respiratory illness including influenza, severe acute respiratory syndrome coronavirus (SARS-CoV), and Middle East Respiratory Syndrome coronavirus (MERS-CoV). The approaches outlined below are intentionally cautious until additional data become available to refine recommendations for prevention of person-to-person transmission in inpatient obstetric care settings.

Prehospital Considerations

Pregnant patients with known or suspected COVID-19 should notify the obstetric unit prior to arrival so the facility can make appropriate infection control preparations such as identifying the most appropriate room for labor and delivery, ensuring infection prevention and control supplies and PPE are correctly positioned, and informing and training all healthcare personnel who will be involved in the patient’s care of infection control expectations before the patient’s arrival.
If a pregnant patient who has confirmed COVID-19 or is a PUI is arriving via transport by emergency medical services, the driver should contact the receiving emergency department or healthcare facility and follow previously agreed-upon local or regional transport protocols. For more information refer to the Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
Healthcare providers should promptly notify infection control personnel at their facility of the anticipated arrival of a pregnant patient who has confirmed COVID-19 or is a PUI.

During Hospitalization

Healthcare facilities should ensure recommended infection control practices for hospitalized pregnant patients who have confirmed COVID-19 or are PUIs are consistent with Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.

All healthcare facilities that provide obstetric care must ensure that their personnel are correctly trained and capable of implementing recommended infection control interventions. Individual healthcare personnel should ensure they understand and can adhere to infection control requirements.
Healthcare facilities providing inpatient obstetrical care should limit visitors to pregnant women who have known or suspected COVID-19 infections.
- Visitors should be limited to those essential for the pregnant woman’s well-being and care (emotional support persons).
  - Depending upon the extent of community-transmission, institutions may consider limiting visitors to one essential support person and having that person be the same individual throughout the hospitalization.
  - Use of alternative mechanisms for patient and visitor interactions, such as video-call applications, can be encouraged for any additional support persons.
- Any visitors permitted to labor and delivery should be screened for symptoms of acute respiratory illness and should not be allowed entry if fever or respiratory symptoms are present.
- Visitors should be informed about use of masks (including cloth masks) for any person entering the healthcare facility and about appropriate use of personal protective equipment according to current facility visitor policy. Additionally, visitors should be instructed to only visit the patient room and should not go to other locations within the facility, including any newborn nursery.
Pregnant women admitted with suspected COVID-19 or who develop symptoms concerning for suspected COVID-19 during admission should be prioritized for testing.
Infants born to a pregnant woman with suspected COVID-19 for whom testing is unknown (either pending results or not tested) are NOT considered to be infants with suspected COVID-19.
Infants born to mothers with known COVID-19 at the time of delivery should be considered infants with suspected COVID-19. As such, infants with suspected COVID-19 should be isolated from other healthy infants, and cared for according to the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19.

Mother/Baby Contact

The many benefits of mother/infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels, and maintaining infant body temperature and though transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern, the risk of transmission and the clinical severity of SARS-CoV-2 infection in infants are not clear.

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 and of the infant
SARS-CoV-2 testing results of mother (confirmed vs. suspected) and infant (a positive infant test would negate the need to separate)
Desire to feed at the breast
Facility capacity to accommodate separation or colocation
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 separation is not undertaken, other measures to reduce the risk of transmission from mother to infant could include the following, again, utilizing shared decision-making:

Using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the mother.
Mothers who choose to feed at the breast should put on a face mask and practice hand hygiene before each feeding.
If the mother is not breastfeeding and no other healthy adult is present in the room to care for the newborn, a mother with known or suspected COVID-19 should put on a face mask and practice hand hygiene1 before each feeding or other close contact with her newborn.
The facemask 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.

If the decision is made to temporarily put the mother with known or suspected COVID-19 and her infant to reduce the risk of transmission in separate rooms, the following should be considered:

Infants with suspected COVID-19 should be isolated from other healthy infants and cared for according to the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
If another healthy family or staff member is present to provide care such as diapering, bathing and feeding for the newborn, they should use appropriate PPE. For healthy family members, appropriate PPE includes gown, gloves, face mask, and eye protection.
For healthcare personnel, recommendations for appropriate PPE are outlined in the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
Considerations to discontinue temporary separation in the healthcare setting are the same as those to discontinue transmission-based precautions, as described in the Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance).
Patients who have clinically recovered and are able to be discharged from the hospital but who have not met criteria to discontinue temporary separation and who wish to reduce the risk of transmission to the newborn should continue separation at their place of residence until cleared as described in the Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance).
- For more information regarding implementation of care at home, please see Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19), and Preventing the Spread of Coronavirus Disease 2019 in Homes and Residential Communities

Breastfeeding

If temporary separation is undertaken, 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.1 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 per the manufacturer’s instructions. This expressed breast milk should be fed to the newborn by a healthy caregiver.
If a mother with known or suspected COVID-19 and her infant do room-in and the mother wishes to feed at the breast, she should put on a face mask and practice hand hygiene before each feeding.

Footnote:

1 Hand hygiene includes use of alcohol-based hand sanitizer that contains 60% to 95% alcohol before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Hand hygiene can also be performed by washing with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to alcohol-based hand sanitizer.