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Pregnancy, birth and the postnatal period during the pandemic -what do you need to know?

Updated 24/03/20 in line with new RCOG guidelines

If you are pregnant right now, I can imagine that the unpredictability of the pandemic situation might make you feel anxious.

I am writing this to try and help allay fears, as well as suggest of list of ways you can get support for yourself.

We haven’t got a lot of data as Covid-19 is a new virus, which was identified for the first time in China in November 2019. We’re mid March 2020 as I write this which means that we only have about 4 month’s worth of data. But there is some data, and it has been evaluated thoroughly to issue guidelines. These guidelines are likely to change as we get more data.

You might be worried about the recent government report on the news saying that all pregnant women need to self-isolate. I’d like to reassure you that this was just a precaution blanket statement, in fact the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives and the Royal College of Paediatrics and Child Health issued a joint statement to reassure women after the government announced these measures:

“We welcome this precautionary approach as COVID-19 is a new virus, but would like to reassure pregnant women that, as things stand, no new evidence has come to light suggesting they are at higher risk of becoming seriously unwell compared with other healthy individuals. Research and data are key to monitoring the ongoing situation and the UK Obstetric Surveillance System – UKOSS – will monitor all cases of pregnant women who have a diagnosis of coronavirus.”

You can find the RCOG new updates here , and there is also a Q&A for pregnant women and their families here

The RCOG guidance  (published 21st March) states that:

  • Pregnant women do not appear more likely to contract the infection than the general population. 
  • There is also no evidence that the virus can pass to your baby while you are pregnant or during birth.
  • As a precautionary approach, pregnant women with suspected or confirmed coronavirus when they go into labour are being advised to attend an obstetric unit for birth but their birth plan should be followed as closely as possible.
  • At the moment there is no evidence that the virus can be carried in breastmilk, so it is felt the benefits of breastfeeding outweigh any potential risks of transmission of coronavirus through breastmilk.

The RCOG has also published a Q&A section for pregnant women and their families.

Two papers (Chen et al; Zhu et al)and have been published from retrospectively studying 2 sets of 9 and 10 women in China who tested positive for Covid-19 in pregnancy. The authors found no evidence of the virus being transmitted to the baby during pregnancy, found no trace of the virus in amniotic fluid, cord blood, placenta, and also importantly none in breastmilk, which is very reassuring.

There has been however, a couple of cases reported of babies born from COVID-19 positive mothers who tested positive for the virus soon after birth. We do not yet know whether transmission occurred during the pregnancy or after the birth.

In the RCOG guidance to pregnant women, it is suggested all women positive for COVID should be admitted to an obstetric unit rather than giving birth at home or in a birth centre, so that their baby’s heart rate could be monitored continuously during labour.

“If birth at home or in a midwifery-led unit is planned, a discussion should be initiated with the woman regarding the potentially increased risk of fetal compromise in women infected with COVID-19 (as was noted in the Chinese case series of nine women). The woman should be advised to attend an obstetric unit for birth, where the baby can be monitored using continuous electronic fetal monitoring.”

The guideline is based on the fact that two Chinese publications showed some level of fetal distress in women who were positive for the virus. However, when you review the evidence on this, this suggestion is open to interpretation. Obstetrician Dr Kirsten Small’s blog explains that the evidence is based on the only 2 papers published so far (papers about pregnant women positive for COVID-19 who gave birth in China):

The first paper (Chen, et al., 2020) included 9 women, 8 of whom had viral pneumonia, and the remaining woman had fever and a cough, having experienced prelabour membrane rupture at 36 weeks of gestation. The abstract stated that “fetal distress was monitored in two cases” but provided no further information about how this was determined. All infants had normal Apgar scores.

It is difficult to ascertain whether the 10 women whose outcomes were reported in the second paper (Zhu, et al., 2020) include some of the women reported in the previous paper. All ten women were symptomatic with signs of viral pneumonia. The findings stated that six fetuses exhibited “intra-uterine distress” without expanding on how this was determined. Two women out of the ten had vaginal births, with both these fetuses being classified as having “distress”. All infants had normal Apgar scores.

The small number of women (19) used to generate a recommendation which might be carried out on thousands of women worldwide is concerning. The Cochrane review on CTG monitoring included over 37,000 women and it is often argued that the research still has not included enough women to generate reliable answers. These papers do not offer any useful information about the risk of intrapartum fetal hypoxia in women who have tested positive, but who have no, or mild symptoms secondary to CoVid19, as all the women in the papers were hospitalised with significant symptoms. Therefore using these findings as the basis of a recommendation for CTG monitoring is not consistent with how evidence-based care is conducted.

Dr Small goes on to explain the pros and cons of continuous fetal monitoring, which is something that is known to increase obstetrics interventions such as cesarean. To date, continous fetal monitoring has not been shown to improve outcomes for babies. Dr Sara Wickham has written several blogs reviewing the evidence for CTG monitoring.

How to protect yourself

The WHO has issued a set of guidelines for the public, which includes basis protective measures.

Be especially mindful to wash your hands after you touch objects such as door handles or petrol station’s pump handles etc.

What are your rights regarding maternity care?

The charity birthrights has published a useful guidance on your rights to maternity care during the pandemic. You still have the same rights to maternity care during the pandemic, however availability of services (for example homebirth or birth centre availability) might change as the level of available staff.

Labour and birth

This is my local trust’s guidelines. Check your local trust, as  it is possible that there may be slight differences from one trust to another (I have seen divergence in the number of birth partners allowed, ie some hospitals still say two, some only one), in doubt call the hospital to ask what the current rules are (as they are likely to change)

Guidance for women during labour:

  • If you are in early labour you should call the maternity unit for advice.
  • If your intended birth partner has symptoms, or has been in contact with a confirmed case, they will not be able to visit in any area of the maternity unit.
  • If you have mild coronavirus/ COVID-19 symptoms you should remain at home in early labour as per standard practice but call the maternity unit first for advice.
  • You should come to the hospital in private transport (your own car or someone else giving you a lift) where possible or call 111/999 for advice as appropriate. If an ambulance is required, the call handler should be informed that you are currently in self-isolation for possible coronavirus/COVID-19.
  • You should alert a member of maternity staff that you have arrived at the hospital, remain in your car and phone the labour ward for instructions before you enter the hospital. You can do this by phoning the labour ward.

Guidance for women who are pregnant for antenatal appointments:

  • If you have no symptoms of coronavirus please attend your antenatal appointments as usual unless you are contacted directly by your community midwife.
  • Please contact your community midwives directly for all queries regarding appointments and where they are taking place as circumstances will be changing daily
  • Please note that GP surgeries and Children’s Centres are likely to be reviewing access to them over the coming weeks and months so location of appointments may change over this period
  • Please note If your partner has symptoms they should self-isolate and not attend any appointments/visits  with you.

One thing you may want to think about ahead of time would be to have a backup birth partner in case your partner develops symptoms.

The RCOG guideline also says that if you have suspected or confirmed COVID-19 you will not be able to use a birthing pool.

Bliss, the charity for premature and sick babies, has published guidance on neonatal care and COVID-19 

Where to get information and support?

NHS If you have any concerns (Covid or otherwise) about your health during pregnancy, your midwife and your GP should be your first port of call. As I write this as far as I’m aware pregnant women are still receiving normal antenatal care from midwifes. The majority of GP surgeries have switched to screening people via phone appointments. My understanding at the moment is that pregnant women who have symptoms are being told to self isolate. It can take some time to get through the phone to your doctor, or to get through 111 for advice but you should still get support.

If you are (understandably) worried or concerned, consider enlisting the support of people who are used to supporting pregnant women navigate the maternity services, such as antenatal teachers and doulas.

Many antenatal educators and birth professionals have moved to offering their services online. All around the UK, doulas, antenatal teachers, pregnancy and postnatal exercise classes (yoga, pilates, babywearing exercises classes etc), are offering online instead of face to face support.

One major advantage is that you are no longer constrained by distance, so you can lookup antenatal and postnatal classes nationally and pick the ones that suit you best.

Here is a list of organisations you can get support from:

Find a doula at Doula UK, the non profit associations for doulas in the UK. Having a doula will help you navigate your birth and postnatal options whilst things change in the maternity services right now, and also guarantee that you have someone to talk to when you need to. I have blogged several times about what doulas do, both to support birth and the postnatal period, feel free to scroll through my previous blog posts to read these.

Independent midwives

Antenatal and postnatal support and education

  • The positive birth movement  is a network of pregnancy and birth support groups, linked up by social media, therefore a way to connect with other mums during pregnancy
  • Find someone to help you carry your baby in a sling at Slingpages .
  • The NCT charity runs antenatal and postnatal classes
  • The motherside provides a support networks and a g global community and support network for all mums and mums-to-be
  • Calmfamily is an education CIC that provides consultations and classes to educate and support parents
  • The daisy foundation offer antenatal and postnatal classes
  • Netmums
  • Gingerbread is a charity that support single parent families

Mental health support

  • Traumatic birth recovery offers a listing of practitioners trained in a fast birth trauma release technique called the Rewind technique
  • Make birth better is a collective of parents and professionals working together to end suffering from birth trauma.
  • Mind is a mental health charity, they have a section on postnatal depression
  • Mia Scotland is a perinatal psychologist
  • The Pandas foundation for perinatal mental health
  • SHaRON is a peer support based ehealth system, available via a mobile phone app and associated website.

Breastfeeding support

The current RCOG guidelines state that :

” It is reassuring that in six Chinese cases tested, breastmilk was negative for COVID-19;2 however, given the small number of cases, this evidence should be interpreted with caution. The main risk for infants of breastfeeding is the close contact with the mother, who is likely to share infective airborne droplets. In the light of the current evidence, we advise that the benefits of breastfeeding outweigh any potential risks of transmission of the virus through breastmilk. The risks and benefits of breastfeeding, including the risk of holding the baby in close proximity to the mother, should be discussed with her.”

This is a welcome recommendation. Despite this, it is possible that if a COVID-19 positive mother might be encouraged to be separated from her baby and formula feed. This needs to be balanced against the possible distress for both mother and baby, and the fact that breastmilk has antiviral properties, and that it allows the transfer of antibodies to the baby, as well as supporting the development of the immune system (Prameela 2011, Newman 2018).

The Unicef baby friendly initiative also states that:

“There is a wealth of evidence that breastfeeding reduces the risk of babies developing infectious diseases. There are numerous live constituents in human milk, including immunoglobulins, antiviral factors, cytokines and leucocytes, that help to destroy harmful pathogens and boost the baby’s immune system. Considering the protection that human milk and breastfeeding offers the baby and the minimal role it plays in the transmission of other respiratory viruses, it seems sensible to do all we can to continue to promote, protect and support breastfeeding”

La Leche League has published some guidance on breastfeeding during the pandemic and so has Baby milk action.

Should you require breastfeeding support, it is now possible to access the support from breastfeeding clinics, breastfeeding counsellors and lactation consultants online.

The list of organisations include

 

I will aim to regularly update this blog as new information becomes available

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