Last updated May 19, 2020
The American College of Obstetricians and Gynecologists (ACOG) is closely monitoring the COVID-19 pandemic. Different parts of the country are seeing different levels of COVID-19 activity. The United States nationally is in the acceleration phase of the pandemic. The Centers for Disease Control and Prevention (CDC) has released Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) and guidance for Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19).
This Practice Advisory has been developed to aid clinicians providing care during the rapidly evolving COVID-19 pandemic. As the situation evolves, this document may be updated or supplemented to incorporate new data and relevant information. ACOG has developed COVID-19 FAQs for Obstetrician–Gynecologists to supplement this Practice Advisory and provide additional information for clinicians on the front lines of the COVID-19 pandemic.
Summary of Key Updates (May 19, 2020)
Below is a summary of recent critical updates to this Practice Advisory.
- ACOG’s testing section has been revised to strengthen the recommendation regarding testing on labor and delivery units.
- ACOG has revised its section on personal protective equipment to clarify and emphasize the recommendation for obstetrician–gynecologists and other health care professionals.
Testing is critical for risk mitigation, data collection, and directing critical resources, including PPE. CDC has published guidance for who should be tested, but decisions about testing are at the discretion of state and local health departments and individual clinicians. Clinicians should work with their state and local health departments to coordinate testing through public health laboratories, or to work with clinical or commercial laboratories.
Pregnant women admitted with suspected COVID-19 or who develop symptoms suggestive of COVID-19 during admission should be prioritized for testing. In addition, facilities may consider additional molecular (eg, PCR by nasopharyngeal swab) testing strategies, such as universal testing as the potential for asymptomatic patients presenting to labor and delivery units exists, particularly in high prevalence areas.
General Information Regarding Pregnant Individuals and COVID-19
The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (SMFM) have developed an algorithm to aid practitioners in assessing and managing pregnant women with suspected or confirmed COVID-19. View the algorithm (Spanish version).
Historically, respiratory infections in pregnant individuals have been thought to increase their risk for severe morbidity and mortality. With regard to COVID-19, the limited data currently available do not indicate that pregnant individuals are at an increased risk of infection or severe morbidity (eg, need for ICU admission or mortality) compared with nonpregnant individuals in the general population. Pregnant patients with comorbidities may be at increased risk for severe illness consistent with the general population with similar comorbidities. To date, there is no conclusive evidence of vertical transmission of COVID-19. ACOG will continue to diligently monitor the literature for any COVID-19 risk signals in pregnancy.
All individuals, including pregnant individuals, are encouraged to take precautions to avoid exposure to COVID-19 as the pandemic evolves. We understand that many pregnant individuals are experiencing increased stress and anxiety due to COVID-19. When counseling pregnant individuals about COVID-19, it is important to acknowledge that these are unsettling times. Clinicians are encouraged to share ACOG’s patient resources as appropriate.
ACOG is working to address the concerns that have been raised about the effect of COVID-19 in pregnant individuals and encourages our members and all clinicians who care for pregnant patients with known or suspected COVID-19 to submit information to an appropriate COVID-19 registry such as PRIORITY to augment the collective knowledge about the effect of COVID-19 during pregnancy.
Obstetrician–gynecologists and other health care professionals should be vigilant in screening for exposure as well as symptoms of COVID-19 for all patients, including pregnant patients. This can be done via phone or telehealth before a visit to allow facilities to appropriately prepare and optimize care coordination needs. For any patient with fever or acute respiratory illness, clinicians should follow the CDC’s Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) and guidance for Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19). Of note, health care professionals should follow their health care facility’s policies and their local and state health department policies for notification of a person under investigation for COVID-19.
Community Mitigation Efforts
Community mitigation efforts to control the spread of COVID-19 have been implemented across the United States. Although these efforts are important, ob-gyns and other health care professionals should be aware of the unintended effect they may have, including limiting access to routine prenatal care. Ob-gyns and other obstetric care professionals should continue to provide medically necessary prenatal care, referrals, and consultations, although modifications to health care delivery approaches may be necessary. Ob-gyns and other prenatal care professionals also should consider creating a plan to address the possibility of a decreased health care workforce, potential shortage of personal protective equipment, and limited isolation rooms, and should maximize the use of telehealth across as many aspects of prenatal care as possible.
Addressing Inequities in Racial and Ethnic Minority Populations
Obstetrician–gynecologists and other women’s health care professionals can work toward addressing inequities in the health care system by confronting individual and structural biases. Emerging data indicate disproportionate rates of COVID-19 infection, severe morbidity, and mortality in some communities of color, particularly among Black, Latinx, and Native American people. Social determinants of health, current and historic inequities in access to health care and other resources, and structural racism contribute to these disparate outcomes. These inequities also contribute to disproportionate rates of comorbidities in these communities that place individuals at higher risk of severe illness from COVID-19. Access to COVID-19 testing and health care resources for those testing positive or who would be considered as persons under investigation also may be limited in these communities. Additional data are needed to understand the full extent of these disparities and to guide equitable allocation of health care resources and other public health interventions.
Infection Prevention and Control in Inpatient Obstetric Care Settings
The CDC has published Considerations for Inpatient Obstetric Healthcare Settings. These considerations apply to health care facilities providing obstetric care for pregnant individuals with confirmed COVID-19 or pregnant persons under investigation in inpatient obstetric health care settings including obstetric triage, labor and delivery, recovery, and inpatient postpartum settings.
ACOG encourages physicians and other obstetric care professionals to read and familiarize themselves with the complete list of recommendations.
Key highlights from the recommendations include:
- Health care professionals should follow their health care facility’s policies and their local and state health department policies for notification of a person under investigation for COVID-19. Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms may be reserved for patients undergoing aerosol-generating procedures.
- Infants born to patients 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 tested, 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).
- Infants born to a pregnant individual 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.
- To reduce the risk of transmission of the virus that causes COVID-19 from the patient to the newborn, facilities may consider temporarily separating (eg, separate rooms) patients who have confirmed COVID-19 or are persons under investigation from their newborns until the patient’s transmission-based precautions are discontinued. ACOG recognizes that separation of patients from their newborns may be linked to additional risks including, but not limited to, undue stress on the patient and disruption of breastfeeding. The determination of whether to keep patients with known or suspected COVID-19 and their infants together or separated after birth should be made on a case-by-case basis, using shared decision-making between the patient and the clinical team.
- Discharge for postpartum individuals with suspected or confirmed COVID-19 should follow recommendations described in CDC’s Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) in conjunction with guidance from the local and state health department and health system.
Precautions for Health Care Personnel: Personal Protective Equipment
COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care. All medical staff caring for potential or confirmed COVID-19 patients should use personal protective equipment (PPE) listed below, including respirators (eg. N95 respirators). In areas where universal testing is not employed and adequate PPE is available, universal PPE, including respirators (eg. N95 respirators) is recommended until the patient’s status is known. Importantly, all medical staff should be trained in and adhere to proper donning and doffing of personal protective equipment. Personal protective equipment (PPE) recommended by the CDC is listed below, and the CDC provides strategies for how to optimize the supply of PPE. ACOG and the Society for Maternal–Fetal Medicine (SMFM) also have made statements regarding the urgent need for personal protective equipment in obstetrics.
CDC Recommended Personal Protective Equipment:
- Respirator or Face Mask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted)
- Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area.
- N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure. Disposable respirators and facemasks should be removed and discarded after exiting the patient’s room or care area and closing the door. Perform hand hygiene after discarding the respirator or facemask.
- If reusable respirators (eg, powered air purifying respirators [PAPRs]) are used, they must be cleaned and disinfected according to manufacturer’s reprocessing instructions before re-use.
- When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19.
- Eye Protection
- Put on eye protection (ie, goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
- Remove eye protection before leaving the patient room or care area.
- Reusable eye protection (eg, goggles) must be cleaned and disinfected according to manufacturer’s reprocessing instructions before re-use.
- Disposable eye protection should be discarded after use.
- Put on clean, nonsterile gloves upon entry into the patient room or care area.
- Change gloves if they become torn or heavily contaminated.
- Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene.
- Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.
- If there are shortages of gowns, they should be prioritized for:
- Aerosol-generating procedures
- Care activities where splashes and sprays are anticipated
- High-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of health care practitioner. Examples include:
- Providing hygiene
- Changing linens
- Changing briefs or assisting with toileting
- Device care or use
- Wound care
During N95 respirator shortages, facilities might need to prioritize N95 respirator use for aerosol-generating procedures*, and use face masks for other types of health care. Even during a shortage, it is important that medical staff use appropriate forms of personal protective equipment, including surgical masks. During shortages, facilities are encouraged to take steps that facilitate the protection of medical staff and enable personnel to protect themselves. Although there has been an understandable emphasis on facial protection, data from the SARS outbreak suggest that the comprehensive array of recommended personal protective equipment (listed above) used alongside hand hygiene and environmental cleaning leads to the optimal decreased risk of transmission of respiratory viruses, and this is likely true for COVID-19. Finally, although individual physicians, after careful consideration, may opt to provide care without adequate personal protective equipment, physicians are not ethically obligated to provide care to high-risk patients without protections in place.
*ACOG continues to review questions and data regarding the potential for aerosolization in the context of forceful exhalation during the second stage of labor. According to CDC, based on limited data, forceful exhalation during the second stage of labor would not be expected to generate aerosols to the same extent as procedures more commonly considered to be aerosol-generating (such as bronchoscopy, intubation, and open suctioning). See CDC’s Obstetrical FAQs for more information about the second stage of labor and aerosol-generating procedures.
For more information on Staffing, Personnel, and Hospital Resources, see ACOG’s COVID-19 Physician FAQs webpage.
The CDC has developed information on Pregnancy and Breastfeeding. There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and health care professionals. Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding. A mother with confirmed COVID-19 or who is a symptomatic persons under investigation should take all possible precautions to avoid spreading the virus to her infant, including breast and hand hygiene and wearing a face mask, if possible, while breastfeeding. If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is not sick feed the expressed breast milk to the infant.
In limited case series reported to date, no evidence of virus has been found in the breast milk of individuals infected with COVID-19; however, it is not yet known with a high level of confidence if COVID-19 can be transmitted through breast milk (ie, infectious virus in the breast milk).
The American College of Obstetricians and Gynecologists will continue to closely monitor the evolution of the 2019 novel coronavirus (COVID-19) in collaboration with the CDC. New and updated information will be shared as it becomes available. Obstetrician-gynecologists and other health care practitioners are encouraged to check ACOG’s COVID-19 webpage and CDC’s COVID-19 webpage regularly for updated information.
This Practice Advisory was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group in collaboration with Laura E. Riley, MD; Richard Beigi, MD; Denise J. Jamieson, MD, and Brenna L. Hughes MD.