Last updated August 12, 2020
Summary of Key Updates (August 12, 2020)
Below is a summary of recent critical updates to this Practice Advisory.
- The section, "Location of the Mother-Infant Dyad" has been updated to reflect new data and recommendations.
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, early available data did not indicate that pregnant individuals were at an increased risk of infection or severe morbidity compared with nonpregnant individuals in the general population. However, a recent data analysis from the Centers for Disease Control and Prevention (CDC) COVID-19 surveillance suggest that in women with COVID-19, pregnant women (n = 8,207) appear to be at increased risk for certain manifestations of severe illness compared to non-pregnant peers (n = 83,205). Specifically, these data indicate an increased risk of ICU admissions (1 in 68 of pregnant versus 1 in 110 non-pregnant women, crude risk ratio 1.6, 95% CI 1.3-1.9) and mechanical ventilation (1 in 195 of pregnant versus 1 in 370 non-pregnant women, crude risk ratio 1.9, 95% CI 1.4-2.6). Yet no increase was noted in the rate of mortality (1 in 513 of pregnant versus 1 in 400 of non-pregnant women, crude risk ratio 0.8, 95% CI 0.5-1.3). Consistent with previously reported data regarding non-pregnant individuals, this analysis suggests that pregnant patients who are Black or Hispanic may be disproportionately affected by SARS-CoV-2 infection. Of note, when stratified by race/ethnicity, ICU admission was more common among non-Hispanic Asians (3.5%) than among all pregnant women (1.5%). Further, while this report suggests an increase in risk of severe outcomes in pregnant women with SARS-CoV-2 infection, it is important to highlight that the overall risk to pregnant women is still low, and consider this risk compared to risks from other upper respiratory illnesses, especially while counseling patients. For example, based on data currently available, the absolute risk is still substantially lower than that of pandemic H1N1 influenza infection during pregnancy. During the H1N1 influenza pandemic, pregnant women made up 5% of deaths, despite only making up 1% of the population and pregnancy risk of ICU admission was reported as high as a 7-fold increase (Rasmussen et al 2012; Mosby et al 2011). ACOG recognizes the need for further data, analysis, and peer review literature on SARS-CoV-2 infection during pregnancy.
Importantly, these new data have several key limitations including missing pregnancy status for 72% of women included in the surveillance. Moreover, among COVID-19 cases in female patients with known pregnancy status, data was unavailable for race/ethnicity in 20%, symptoms in 35%, and underlying medical conditions in 77%. Information on gestational age at the time of infection and whether the hospitalization, ICU admission, or mechanical ventilation was related to delivery or other pregnancy conditions rather than for COVID-19 illness are not available, which limits the interpretation (CDC).
Pregnant patients with comorbidities such as obesity are likely at increased risk for severe illness consistent with the general population with similar comorbidities. However, given that pregnancy itself is now identified as a risk factor for certain outcomes, the magnitude of further increase from such comorbidities will need to be further delineated. Although there are cases of reported vertical transmission of SARS-CoV-2, the data are reassuring that vertical transmission appears to be uncommon. Finally, the surveillance data analyzed in this report do not capture pregnancy or birth outcomes. ACOG continues to monitor the emerging literature on these topics.
Clinicians should counsel pregnant women and those contemplating pregnancy about the potential risk for severe illness from COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for pregnant women and their families. Pregnant individuals in particular are encouraged to take all available precautions to optimize health and avoid exposure to COVID-19 including:
- maintaining prenatal care appointments
- wearing a mask and other recommended PPE, if applicable, at work and in public
- washing hands frequently
- maintaining physical distancing
- limiting contact with other individuals as much as practicable
- maintain an adequate supply of preparedness resources including medications
The findings in this report underscore the need to advocate for protection measures such as appropriate PPE for individuals with increased risk of exposure and infection due to occupation or other circumstances.
ACOG understands that many pregnant individuals are experiencing increased stress due to COVID-19. When counseling pregnant individuals about COVID-19, it is important to acknowledge that these are unsettling times (see How can I help my pregnant and postpartum patients manage stress, anxiety, and depression?) and to encourage patients to communicate regularly with the health care team. 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. While this data analysis from CDC increases our knowledge of the impact of COVID-19 on pregnant women, more robust and complete data, including data on race/ethnicity, are needed to truly understand the impact of COVID-19 on pregnancy. ACOG 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 to augment the collective knowledge about the effect of COVID-19 during pregnancy.
Obstetrician–gynecologists and other health care professionals should be vigilant in counseling pregnant women and in screening for exposure as well as symptoms of COVID-19 for 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 Overview of Testing for SARS-CoV-2. 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.
ACOG will continue to work with CDC and diligently monitor the literature for any COVID-19 risk signals in pregnancy.
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.
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.
- 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. Personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) is listed below, and CDC provides strategies for how to optimize the supply of PPE. ACOG and SMFM have also made statements regarding the urgent need for PPE in obstetrics.
- To protect patients and coworkers, all healthcare personnel should wear a facemask at all times while they are in a healthcare facility, regardless if patients are wearing a face covering or facemask (CDC FAQs). Recent data suggests that universal masking, appropriate use of N95 respirators, and close evaluation of extended use or reuse of N-95 respirators in the healthcare setting can play a crucial role in decreasing healthcare-related COVID-19 infections (Degesys 2020, Seidelam 2020, Chu 2020).
- In areas with moderate to substantial community transmission, healthcare personnel should also wear eye protection in addition to their facemask (CDC).
- 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 PPE.
- Although there is understandable emphasis on facial protection, data from the SARS outbreak suggest that the comprehensive array of recommended PPE (listed below) 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.
- During a possible N95 shortage, extended use or limited reuse of N95 masks may be implemented or necessary. If extended use or limited reuse is being implemented, polices regarding extended use or limited reuse should be in accordance with CDC/NIOSH recommendations, taking into account the actual masks being used. These policies should also be developed in coordination with local occupational health and infection control departments.
- Although limited data have noted subtle physiologic changes (with no known clinical impact) associated with extended wear of N95 masks (Kim 2015, Tong 2015), the reduction of infectious risk outweighs any theoretical physiologic concern.
Caring for individuals with potential or confirmed COVID-19:
All medical staff caring for potential or confirmed COVID-19 patients should use PPE listed below, including respirators (eg, N95 respirators).
CDC Recommended Personal Protective Equipment:
- Respirator or Facemask (cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or in 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’s 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’s room or care area. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
- Remove eye protection before leaving the patient’s 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’s room or care area.
- Change gloves if they become torn or heavily contaminated.
- Remove and discard gloves when leaving the patient’s room or care area, and immediately perform hand hygiene.
- Put on a clean isolation gown upon entry into the patient’s 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’s 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 the 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* or surgical procedures that involve anatomic regions where viral loads might be higher (e.g., nose and throat, oropharynx, respiratory tract). Even during a shortage, it is important that medical staff use appropriate forms of PPE, including surgical masks. During shortages, facilities are encouraged to take steps that facilitate the protection of medical staff and enable personnel to protect themselves. Finally, although individual physicians, after careful consideration, may opt to provide care without adequate PPE, physicians are not ethically obligated to provide care to high-risk patients without protections in place. ACOG continues to advocate for congressional and regulatory action to increase access to PPE for obstetrician–gynecologists, particularly in labor and delivery units. We are working to address the PPE shortage through conversations with the White House Coronavirus Response Coordinator, the Surgeon General, colleagues at the Food and Drug Administration, and others.
*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 the 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.
Location of the Mother-Infant Dyad
Early and close contact between the mother and neonate has many well-established benefits including increased success with breastfeeding, facilitation of mother-infant bonding, and promotion of family-centered care. Given the available evidence on this topic, mother-infant dyads where the mother has suspected or confirmed SARS-CoV-2 infection should ideally room-in according to usual facility policy. Although data is still emerging and long-term effects are not yet fully understood, data suggests that there is no difference in risk of SARS-CoV-2 infection to the neonate whether a neonate is cared for in a separate room or remains in the mother’s room (CDC).
Importantly, any determination of whether to keep individuals with known or suspected SARS-CoV-2 infection and their infants together or separate after birth should include a process of shared decision-making with the patient, their family, and the clinical team. This issue should be raised during prenatal care and continue through the intrapartum period. Healthcare providers should respect maternal autonomy in the medical decision-making process. Decision-making around rooming-in or separation should be free of any coercion, and facilities should implement policies that protect an individual’s informed decision.
For mothers with suspected or confirmed COVID-19, rooming-in should be combined with safety measures to minimize the risk of transmission, including:
- Mother using a mask or cloth face covering and practicing hand hygiene prior to and during all contact with the neonate. Masks or cloth face coverings should not be placed on neonates or children younger than 2 years of age.
- Engineering controls such as using physical barriers (eg, placing the neonate in a temperature-controlled isolette) and keeping the neonate 6 feet or more away from the mother as often as possible.
- If it is possible to have a non-health care professional caregiver provide care for the neonate while in the hospital, it should be an individual who is not at increased risk for severe illness and uses appropriate infection prevention precautions (e.g., wearing a mask, practicing hand hygiene).
While enabling rooming-in is a key practice to encourage and support breastfeeding, there may be circumstances (related to COVID-19 or otherwise) where temporary separation is appropriate for the well-being of the mother and neonate. Decisions about temporary separation should be made in accordance with the mother’s wishes.
Considerations for counseling patients considering temporary separation include:
- Mothers with suspected or confirmed SARS-CoV-2 infection do not pose a potential risk of virus transmission to their neonates if they have met the criteria for discontinuing isolation and precautions:
- At least 10 days have passed since their symptoms first appeared (up to 20 days if they have more severe to critical illness or are severely immunocompromised), and
- At least 24 hours have passed since their last fever without the use of antipyretics, and
- Their other symptoms have improved.
- Mothers who have not met these criteria may choose to temporarily separate from their neonates in an effort to reduce the risk of virus transmission. However, if after discharge they will not be able to maintain separation from their neonate until they meet the criteria, it is unclear whether temporary separation while in the hospital would ultimately prevent SARS-CoV-2 transmission to the neonate, given the potential for exposure from the mother after discharge.
- Separation may be necessary for mothers who are too ill to care for their infants or who need higher levels of care.
- Separation may be necessary for neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care).
- Consideration for separation as an approach to reduce the risk of transmission from a mother with suspected or confirmed SARS-CoV-2 to her neonate is not necessary if the neonate tests positive for SARS-CoV-2.
If temporary separation is undertaken, mothers who intend to breastfeed should be supported and encouraged to express their breastmilk to establish and maintain the milk supply. If possible, a dedicated breast pump should be provided.
Infant Feeding with Breastmilk
Breastmilk provides protection against many illnesses and there are few contraindications to breastfeeding (Committee Opinion 756, CDC's Pregnancy and Breastfeeding). It is not known whether COVID-19 can be transmitted through breastmilk, or if any potential viral components, if transmitted, are infectious. Although a recent case report detected SARS-CoV-2 RNA in the breastmilk (Lancet Groß 2020), the majority of the data has not demonstrated the presence of SARS-CoV-2 virus in breastmilk. Therefore, suspected or confirmed maternal COVID-19 is not considered a contraindication to infant feeding with breastmilk at this time.
However, individuals with suspected or confirmed COVID-19 can transmit the virus through respiratory droplets while in close contact with the infant, including while breastfeeding. Therefore, obstetrician-gynecologists and other maternal care practitioners should counsel women with suspected or confirmed COVID-19 who intend to infant feed with breastmilk on how to minimize the risk of transmission, including:
- Breastmilk expression with a manual or electric breast pump. This includes the importance of proper hand hygiene before touching any pump or bottle parts and following recommendations for proper pump cleaning after each use. If possible, individuals should consider having someone who does not have suspected or confirmed COVID-19 infection and is not sick feed the expressed breastmilk to the infant. Additionally, individuals should be counseled on whether the facility is able to provide a dedicated breast pump.
- Safety measures if breastfeeding. A mother with suspected or confirmed COVID-19 who wishes to breastfeed her infant directly should take all possible precautions to avoid spreading the virus to her infant, including hand hygiene and wearing a mask or cloth face covering, if possible, while breastfeeding.
Even in the setting of the COVID-19 pandemic, obstetrician–gynecologists and other maternal care practitioners should support each woman's informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant (Committee Opinion 756).
ACOG will continue to review emerging literature on this topic.
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.