Practitioners welcome guidelines on childbirth under COVID-19
New provincial directive to allow doctors, midwives to offer uniform guidance
Ontario obstetricians and midwives grappling with the uncertainties of COVID-19 are welcoming new provincial guidelines that aim to keep mothers and newborns safe during the pandemic.
Released Friday by a provincial task force, the guidelines address many aspects of labour, delivery and postpartum care, and include screening protocols for birthing mothers, the proper use of personal protective equipment (PPE) by health-care staff and patients and — crucially for worried families — the recommendation for a single support person during labour and birth.
They also provide guidance on caring for pregnant women and new mothers with a suspected or confirmed case of COVID-19. This includes the advice that mothers with the virus can, with proper precautions, safely breastfeed their babies.
The goal is to reduce conflicting messages to health-care practitioners and provide them with uniform guidance on childbirth and newborn care during the pandemic, said Dr. Mark Walker, co-chair of the provincial Maternal-Neonatal COVID-19 Task Force and chief of obstetrics, gynecology and newborn care at the Ottawa Hospital. As well, he added, the guidelines should reassure pregnant women and their families that care decisions are being made with the best-available evidence.
“The biggest challenge for all of us is there is no playbook for this virus,” said Walker, professor and chair of the department of obstetrics and gynecology at the University of Ottawa. “In everything else we’re trained to do, we have evidence, textbooks and published articles. For the first time in our lives, we are facing a situation where the answers aren’t always known.”
In the absence of provincial guidelines, individual hospitals and midwifery practices have been determining their own protocols for childbirth and newborn care based on a variety of sources, ranging from the Southern Ontario Obstetrical Network to the World Health Organization. This has created conflicting messages for health-care practitioners and, in some cases, increased anxiety for mothers and families, said Dr. Jon Barrett, co-chair of the task force and head of maternal fetal medicine at Toronto’s Sunnybrook Health Sciences Centre.
In the Toronto area, for example, some hospitals have had a different set of birthing guidelines than a neighbouring hospital, thereby creating confusion for families and care providers, said Barrett, a professor of obstetrics and gynecology at the University of Toronto.
There have also been reports of families “shopping around” for a hospital with the fewest restrictions on support partners, which means they may be delivering their baby at a hospital that doesn’t have their medical records on hand, leading to an increased health risk for mother and baby, Barrett said.
The guidelines state a birthing mother may have a single support partner throughout her stay as long as that partner has screened negative for COVID-19, the hospital’s infrastructure allows adequate physical distancing between patients and has enough PPE for the support person.
Dr. Karen Gronau, site chief of obstetrics and gynecology at Brampton Civic Hospital, welcomes the guidelines and said they will bring consistency across institutions, a big help for both providers and patients.
“Patients were hearing a lot of rumours and saying, ‘Oh, this hospital is doing this and that hospital is doing that,’ and it’s pretty difficult as a provider to know what to tell people,” she said. “I only knew what we were doing at our institution.
“It’s great to reassure patients that we have these evidencebased guidelines based on several weeks of local experience and several months of international research and observations during the pandemic.”
Gronau said the guidelines for newborn care will be particularly reassuring for mothers because the best-available evidence suggests there is a low risk of vertical transmission of the virus between mom and baby. “Everyone is anxious about getting COVID-19, but pregnant women must be additionally anxious about it — before they have their baby and postpartum, worrying they may pass it (the virus) on to their baby.”
Jasmin Tecson, a registered midwife with the Torontobased Seventh Generation Midwives and president-elect of the Association of Ontario Midwives, also welcomed the guidelines, and said in an email they take into account two key priorities: “To keep healthy patients out of hospital who have chosen to receive care in the community with their midwife, and to protect the well-being of health-care workers on the front lines.”
Remi Ejiwunmi, a registered midwife at Midwives of Mississauga, with privileges at Trillium Health Partners, said the guidelines are patient-centred and ensure decisions of where a mother will deliver her baby is based on her clinical picture, rather than on rigid rules.
For example, a COVID-positive mother who is in distress will need to be in hospital, said Ejiwunmi, who is on the Maternal-Neonatal COVID-19 Task Force. But a mother who had the virus early in her pregnancy but is clear of COVID-19 when she will deliver and has a low-risk pregnancy can safely opt for a home birth — if that is what she wishes, she said.
The guidelines also make it clear midwives who care for patients at home and in the community require proper PPE, something that midwives have been advocating for, but hasn’t happened consistently across the province, with some midwives having to use homemade masks and gowns, she said.
“Our hope is that this document shows PPE should be available to everyone in every setting,” Ejiwunmi said. “That will be the expectation.”
The Maternal-Neonatal COVID-19 Task Force is made up of more than a dozen experts, including obstetricians, midwives, infectious disease physicians and family doctors, and includes perspectives from rural, community and academic hospitals and midwifery practices.
The guidelines are made up of 13 recommendations, and include, among others:
Mothers who are COVIDpositive, have symptoms of the virus or have been in close contact with a COVID-positive person will wear a surgical mask during all stages of labour.
Infants who are born to COVID-positive mothers should be tested for the virus within the first 24 hours of delivery, even if they don’t have symptoms.
Mothers who are COVIDpositive can safely do skin-toskin with their newborn and breastfeed their baby using proper precautions, which include wearing a surgical mask and washing their breasts, chest and hands before breastfeeding or pumping breast-milk.
“The biggest challenge for all of us is there is no playbook for this virus.”
MARK WALKER PROFESSOR, DEPARTMENT CHAIR OF OBSTETRICS AND GYNECOLOGY AT UNIVERSITY OF OTTAWA