COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

 Staffing, Personnel, and Hospital Resources

• When can an obstetric care professional with SARS-CoV-2 infection or exposure return to work? When they return to work, what personal protective equipment (PPE) do they need to wear on a regular basis? REVISED

  Last updated January 14, 2022 at 10:06 a.m. EST.

  The Centers for Disease Control and Prevention (CDC) has developed guidance outlining work restrictions for health care personnel (HCP) with SARS-CoV-2 exposures based on the risk level of the exposure, the PPE used at the time of exposure, and the vaccination status of the individual. Furthermore, the CDC provides recommended work restrictions for HCP with SARS-CoV-2 infection and exposures based on a facility's level of need to mitigate HCP and staffing shortages. Clinicians are encouraged to review these work restrictions and recommendations from the CDC regularly, as they are updated frequently. Additionally, clinicians are encouraged to work with their facilities, as situations may vary based on local circumstances.

  After adhering to any applicable restrictions and returning to work, HCP should do the following:

  • Always wear a face mask for source control (to contain respiratory secretions) while in the health care facility until all symptoms are completely resolved or at baseline. After this time period, HCP should revert to their facility's policy regarding universal source control during the pandemic.
    • As with other respiratory illnesses, a residual nonproductive cough may persist for weeks after the illness has otherwise resolved. This is also the case for SARS-CoV-2 infection. Therefore, it is possible that an individual will meet the criteria for returning to work despite having lingering symptoms.
    • A face mask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated (read What personal protective equipment (PPE) should clinicians and patients wear for potential or confirmed COVID-19 cases?).
  • Self-monitor for symptoms and seek reevaluation from an occupational health specialist if respiratory symptoms recur or worsen.
• Q: Should pregnant health care personnel be transferred to roles where they are not providing in-person patient care to help reduce their risk? REVISED

  Last updated July 1, 2021 at 11:53 a.m. EST.

  Available data suggest that symptomatic pregnant and recently pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Khan 2021).

  Currently, there are insufficient data in pregnant health care personnel that stratify risk by either gestational age, medical comorbidities, the availability of recommended personal protective equipment (PPE), capacity to screen for SARS-CoV-2 infection, vaccination status, or the effect of the level of community prevalence of SARS-CoV-2 infection.

  However, the correct and comprehensive use of recommended PPE, alongside vaccination, hand hygiene and environmental cleaning, leads to the optimal decreased risk of transmission of COVID-19, making it unnecessary, in most cases, to transfer pregnant health care personnel to roles where they are not providing in-person patient care. 

• Q: What personal protective equipment (PPE) should health care professionals wear to reduce their risk of COVID-19 infection? REVISED

  Last update July 1, 2021 at 7:00 a.m. EST

  COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care. Recommendations for personal protective equipment (PPE) from the Centers for Disease Control and Prevention (CDC) can be found on the CDC's website. CDC also provides strategies for how to optimize the supply of PPE.

  As vaccination rates increase, it is still critical to maintain general infection control strategies in health care settings. Regardless of vaccinations status, obstetric care clinicians should still wear adequate and appropriate PPE when caring for patients with suspected or confirmed COVID-19.

• Q: What is the best approach to cleaning surfaces and ultrasound equipment?

  Last updated November 4, 2020 at 1:49 p.m. EST.

  Clinicians should follow CDC guidance in regards to properly cleaning surfaces.

  AIUM has published guidelines for cleaning and preparing external- and internal-use ultrasound transducers and equipment that include specific recommendations during the COVID-19 pandemic. For external and interventional procedures, low-level disinfection is effective when used according to CDC guidelines. EPA-approved disinfectants for use against COVID-19 (SARS-CoV-2) can be found online. If low-level disinfectant agents are depleted, then soap and water should be used per CDC guidelines. If indicated but no transducer covers are available, medical gloves or other physical barriers should be used. Along with the ultrasound transducer, it is important to clean all ancillary equipment involved in the procedure. In addition to low-level disinfectant cleaning, a cover sheet may be used as a physical barrier between the keyboard/console and the operator. If possible, use a dedicated system (scanner and transducers) for COVID-19, positive or suspected, patients. In instances where a patient who is COVID-19 positive and requires an aerosolizing procedure, a transducer cover should be used and all equipment requires low-level disinfection both inside and outside of the exam room. In addition to following manufacturer usage guidelines, health care professionals should follow their health care facility’s infection control policies. 

General Considerations

• Q: Should oral SARS-CoV-2 protease inhibitor therapy be used as a treatment option for pregnant patients? (REVISED)

  Last updated January 10, 2022 at 12:44 p.m. EST.

  Recently, an oral severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) protease inhibitor, PAXLOVID (which includes nirmatrelvir, a SARS-CoV-2 main protease inhibitor, and ritonavir, an HIV-1 protease inhibitor and CYP3A inhibitor) became available only under emergency use authorization (EUA) (EUA, EUA Fact Sheet). It is recommended for the treatment of outpatients with mild to moderate COVID-19 infection with a positive result of a SARS-CoV-2 viral test and who are at high risk of clinical progression as defined by the EUA criteria. Pregnancy is included among the conditions that put individuals at high risk for clinical progression. This makes pregnant patients, including those with pregnancy as their only risk factor, eligible to receive outpatient oral SARS-CoV-2 protease inhibitor therapy, according to the EUA. Obstetric care clinicians may consider the use of the oral SARS-CoV-2 protease inhibitor for the treatment of non-hospitalized COVID-19 positive pregnant individuals with mild to moderate symptoms, particularly if one or more additional risk factors are present (eg body mass index >25, chronic kidney disease, diabetes mellitus, cardiovascular disease). Clinicians should weigh the available data against the individual risks of COVID-19 in pregnancy in each situation.

  There are no available human data on the use of nirmatrelvir during pregnancy to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. In an embryo-fetal development study with nirmatrelvir, reduced fetal body weights following oral administration of nirmatrelvir to pregnant rabbits were observed at systemic exposures approximately 10 times higher than exposure at the authorized human dose of PAXLOVID. Published observational studies on ritonavir use in pregnant women have not identified an increased risk of birth defects. Ritonavir has been used extensively during pregnancy in people living with HIV, which suggests that it has an acceptable safety profile during pregnancy. No other adverse developmental outcomes were observed in animal reproduction studies with nirmatrelvir or ritonavir at systemic exposures greater than or equal to 3 times higher than clinical exposure at the authorized human dose of PAXLOVID (EUA Fact Sheet). The short-term exposure to these medications must be balanced against the maternal and fetal risks associated with untreated COVID-19 in pregnancy.

  If utilizing protease inhibitor (PAXLOVID) treatment, this treatment should be initiated orally as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset. PAXLOVID should be administered orally with or without food. The recommended dosage is 300 mg of nirmatrelvir (two 150 mg tablets) with 100 mg of ritonavir (one 100 mg tablet), with all three tablets taken together twice daily for 5 days. 

  Obstetric care clinicians should be aware that the concomitant use of PAXLOVID and certain other drugs (including medications used in obstetric settings such as nifedipine, methylergonovine, fentanyl, midazolam, or betamethasone) may result in potentially significant drug interactions. Prescribing clinicians should consult the full prescribing information prior to and during treatment for potential drug interactions (EUA Fact Sheet).

  Lactation is not a contraindication for the use of this oral SARS-CoV-2 protease inhibitor (EUA Fact Sheet). Lactating individuals with one or more risk factors for severe COVID-19 illness may receive SARS-CoV-2 protease inhibitor for treatment. There are no available data on the presence of nirmatrelvir in human or animal milk, the effects on the breastfed infant, or the effects on milk production. A transient decrease in body weight was observed in the nursing offspring of rats administered nirmatrelvir. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for PAXLOVID and any potential adverse effects on the breastfed infant from PAXLOVID or from the underlying maternal condition (EUA Fact Sheet).

  Efforts should be made to ensure that communities most affected by SARS-CoV-2 have equitable access to these treatments.

• Q: What is the impact of the Delta variant strain of the SARS-CoV-2 virus on pregnant people? (NEW)

  Last updated December 9, 2021 at 5:56 p.m. EST

  In late July 2021, the CDC began reporting a significant increase in new cases of COVID-19 infection which appeared more like past rates seen before the vaccine was widely available. Data began to emerge that this was secondary to a new variant of the SARS-CoV-2 virus, called Delta, which has subsequently become the predominate virus strain in the U.S. The Delta variant is noted to be more contagious, with higher rates of increased transmissibility when compared with other variants, even in some vaccinated individuals. Some data suggest the Delta variant might cause more severe illness than previous variants in unvaccinated people. As of November 20, 2021, only 35% of pregnant people ages 18 to 49 are fully vaccinated with COVID-19 vaccine prior to or during pregnancy.

  Pregnant individuals with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Khan 2021). Emerging data suggest that the risk of severe illness to pregnant people is further increased during the Delta period (July 2021-present) of the pandemic, when compared to pregnant women in the pre-Delta time period. Specifically, a recent CDC analysis suggests an increased risk of stillbirth in individuals with COVID-19 diagnosis documented at the time of delivery hospitalization, with the association stronger during the Delta period (DeSisto 2021). Another study found that for pregnant women with COVID-19 during the Delta period, the risk of ICU admission was 66% higher, the risk of needing a ventilator or special equipment to breathe was 63% higher, and the risk of death was more than 2 times higher than it was for pregnant women in the pre-Delta period. The risk for severe illness also increased for non-pregnant women of reproductive age (15─44 years) with COVID-19 during the Delta period, compared with the pre-Delta period (Strid 2021). Finally, an increased risk of death in pregnant individuals has been reported during the Delta period compared to the pre-Delta period (Kasehagen 2021, Strid 2021).

  As the pandemic continues, new variants have and will continue to emerge. As new variants are identified, they are classified by the U.S. government SARS-CoV-2 Interagency Group as “variants of concern” when they are more transmissible, cause more severe disease, or are less susceptible to mitigation measures. Delta was the predominate variant in the last peak and as described above, data now illustrate that in pregnant persons, Delta caused more severe disease when compared to earlier strains. The Omicron variant is a recently identified variant of concern and may have increased risk of transmissibility. It is currently unknown whether it will portend a difference in severity of disease. Future surges in COVID-19 infections caused by variants may occur with unknown potential impact. The studies highlighted above and the unknowns surrounding future variants underscore the critical importance of COVID-19 vaccination for people who are pregnant, recently pregnant, trying to become pregnant, or may get pregnant in the future. COVID-19 vaccines are safe and effective during pregnancy. Health care professionals should routinely discuss, recommended, and offer COVID-19 vaccination to these patients.

  For more information on ACOG’s COVID-19 vaccination recommendations, see COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care.

• Q: What are the criteria to discontinue transmission-based precautions for previously COVID-19 positive patients?

  Last updated September 2, 2020 at 10:13 a.m. EST.

  According to CDC’s guidance, discontinuation of transmission-based precautions in the health care setting for an individual with confirmed COVID-19 should be made using a symptom-based strategy, as described below (CDC). The time period used depends on the patient’s severity of illness and if they are severely immunocompromised. Meeting criteria for discontinuation of transmission-based precautions is not a prerequisite for discharge from a healthcare facility. Patients who are discharged home for required isolation or who are treated as outpatients with a diagnosis of COVID-19 should follow discontinuation of isolation precautions guidance from the CDC.  

  A test-based strategy is no longer recommended (except as noted below) because, in the majority of cases, it results in prolonged isolation of patients who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.

  Symptom-based strategy:

  Patients with mild to moderate illness who are not severely immunocompromised:

  • At least 10 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (eg, cough, shortness of breath) have improved

  Note: For patients who are not severely immunocompromised and were asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test. 

  Patients with severe to critical illness or who are severely immunocompromised:

  • At least 10 days and up to 20 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved; and
  • Consider consultation with infection control experts.

  Note: For severely immunocompromised patients who were asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 10 days and up to 20 days have passed since the date of their first positive viral diagnostic test.

  Test-based strategy:

  In some instances, a test-based strategy could be considered for discontinuing transmission-based precautions earlier than if the symptom-based strategy was used. However, many individuals will have prolonged viral shedding, limiting the usefulness of this approach. A test-based strategy could also be considered for some patients (eg, those who are severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the patient being infectious for more than 20 days.

  The criteria for the test-based strategy are:

  Patients who are symptomatic:

  • Resolution of fever without the use of fever-reducing medications and
  • Improvement in symptoms (e.g., cough, shortness of breath), and
  • Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular viral assay to detect SARS-CoV-2 RNA. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).

  Patients who are not symptomatic:

  • Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular viral assay to detect SARS-CoV-2 RNA. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).
• Q: Does pregnancy increase the need for critical care in the setting of COVID-19 infection? REVISED

  Last updated December 14, 2020 at 1:58 p.m. EST.

  Available data suggest that symptomatic pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Panagiotakopoulos MMWR 2020, Zambrano MMWR 2020), however the data have limitations (see FAQ “Does COVID-19 present an increased risk of severe morbidity and mortality for pregnant women compared with non-pregnant women?”). Although the absolute risk for severe COVID-19 is low, these data indicate an increased risk of ICU admission, need for mechanical ventilation and ventilatory support (ECMO), and death reported in pregnant women with symptomatic COVID-19 infection, when compared with symptomatic non-pregnant women (Zambrano MMWR 2020). Information on whether ICU admission or mechanical ventilation were related to pregnancy complications rather than for COVID-19 illness are not available, which limits the interpretation.  Pregnant patients with comorbidities may be at increased risk for severe illness consistent with the general population with similar comorbidities. Clinical management of COVID-19 pregnant patients includes prompt implementation of recommended infection prevention and control measures and supportive management of complications; in some cases, this may include critical care if indicated.
  
  If a pregnancy is complicated by critical illness, the woman should ideally be cared for at a Level III or IV hospital with obstetric services and an adult ICU (Obstetric Care Consensus No. 9, “Levels of Maternal Care”). COVID-19 status alone is not necessarily a reason to transfer non-critically ill pregnant women with suspected or confirmed COVID-19, but care location planning should be based on the levels of maternal and neonatal care (Obstetric Care Consensus No 9 “Levels of Maternal Care”, AAP’s Levels of Neonatal Care).
  
  Facility-level factors may influence the decision to transfer a patient to a higher level of care. These factors include lack of adequate staff to care for a critically ill patient, need for frequent assessments, special equipment, and access to trials for novel treatments. When a request is made to transfer a patient to a higher level of care for facility-level factors, a discussion between the transferring health care practitioner and the intensive care practitioners regarding the current limitations of care on the obstetric unit may help facilitate rapid transfer (Practice Bulletin 211, “Critical Care in Pregnancy”).
  
  The Society for Maternal-Fetal Medicine offers a COVID-19 response bundle at no cost addressing: Pulmonary Hypertension, Pulmonary Embolism, Hemodynamic Monitoring and Mechanical Ventilation, Sepsis, and ARDS/Respiratory Failure. The society also offers a Critical Care Basics webinar. The Society of Critical Care Medicine also offers a series of resources in response to COVID-19.

• Q: Does COVID-19 present an increased risk of severe morbidity and mortality for pregnant and recently pregnant individuals? REVISED

  Last updated February 17, 2022 at 9:16 a.m. EST

  Compared to Pregnant and Recently Pregnant Individuals Without COVID

  Available data suggest that, compared to pregnant individuals without SARS-CoV-2 infection,  SARS-CoV-2 infection during pregnancy (particularly moderate or severe infection) is associated with increased risk of a composite outcome of maternal mortality or serious morbidity from obstetric complications such as hypertensive disorders of pregnancy, postpartum hemorrhage, or infection other than SARS-CoV-2 (Metz 2022).

  Compared to Nonpregnant Individuals with COVID-19

  Available data suggest that symptomatic pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Khan 2021). CDC includes pregnant and recently pregnant individuals in its “increased risk” category for severe COVID-19 illness. Although the absolute risk for severe COVID-19 is low, available data indicate an increased risk of ICU admission, need for mechanical ventilation and ventilatory support (ECMO), and death reported in pregnant women with symptomatic COVID-19 infection, when compared with symptomatic non-pregnant women (Zambrano MMWR 2020, Kahn 2021). Compared to asymptomatic pregnant patients, severe–critical COVID-19 illness has been associated with adverse perinatal outcomes such as increased risk of cesarean birth and hypertensive disorders of pregnancy, while mild-to-moderate illness has not been associated with adverse perinatal outcomes (Metz 2021). Some emerging data have suggested an association between COVID-19 infection and preeclampsia (Papageroghiou 2021, Conde-Agudelo 2021). However, COVID-19 can cause similar clinical findings to some forms of preeclampsia. As such, data regarding COVID-19 and preeclampsia are mixed and to date, there is not a clear relationship between COVID-19 infection and preeclampsia.

  While data indicate an increased risk of severe illness and maternal death, data also indicate that the majority of pregnant individuals diagnosed with COVID-19 experience relatively mild symptoms; however, symptoms lasting up to 8 weeks have been reported (Yee 2020).

  Special Populations

  Pregnant and recently pregnant patients with comorbidities such as obesity, diabetes, hypertension, and lung disease may be at an even higher risk of severe illness consistent with the general population with similar comorbidities (Ellington MMWR 2020, Panagiotakopoulos MMWR 2020, Knight 2020, Zambrano MMWR 2020, Galang 2021). Further, the risk of moderate-to-severe or critical illness during pregnancy appears to increase with increasing maternal age (Metz 2021, Galang 2021). Black and Hispanic individuals who are pregnant appear to have disproportionate SARS CoV-2 infection and death rates (Ellington MMWR 2020, Moore MMWR 2020, Zambrano MMWR 2020).

  Counseling and Prevention

  Clinicians should counsel pregnant individuals and those contemplating pregnancy about the potential risk of COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for these individuals and their families. Pregnant individuals are encouraged to take all available precautions to avoid exposure to COVID-19 and optimize health including:

  • Getting a COVID-19 vaccine during pregnancy or postpartum, if not already vaccinated
  • Follow routine hygiene practices including washing hands often
  • Continue following safety measures to prevent COVID-19 infection, especially if not fully vaccinated, including wearing a mask, maintaining physical distancing, and limiting contact with other individuals as much as practical

  The increased risk of severe illness for pregnant and recently pregnant people highlights the critical importance of vaccination for family members and clinicians caring for these individuals. ACOG recommends that pregnant and recently pregnant people receive a COVID-19 vaccine, if not already vaccinated, to protect themselves. Information on vaccination is available in the ACOG Practice Advisory “COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care.”

• Q: What is the effect of COVID-19 on fetal and neonatal outcomes? REVISED

  Last updated March 21, 2022, at 11:10 a.m. EST

  Although there are cases of reported vertical transmission of SARS-CoV-2, currently available data indicate that vertical transmission appears to be uncommon (Dumitriu 2020). Pregnant people with COVID-19 are at increased risk for preterm birth and some data suggest an increased risk for other adverse pregnancy complications and outcomes, such as preeclampsia, coagulopathy, and stillbirth, compared with pregnant people without COVID-19 (Allotey 2020, Jering 2021, Ko 2021, Villar 2021, DeSisto 2021). Data now indicate that neonates born to people with COVID-19 are also at increased risk for admission to the neonatal intensive care unit (Allotey 2020, Villar 2021). ACOG is aware of case series reporting uncommon but severe placentitis in pregnant individuals with SARS-CoV-2 (Fitzgerald 2022, Hecht 2020). However, these reports have several limitations, including lack of a control group and selection bias. More data regarding placentitis frequency in pregnant individuals with SARS-CoV-2 infection, timing of onset, and severity of SARS-CoV-2 infection are needed to confirm any association between SARS-CoV-2 and placentitis and to guide any potential changes in clinical management. Until then, see the “Do patients with suspected or confirmed COVID-19 need additional antenatal fetal surveillance?” FAQ. In addition to more data regarding placental function and pathology, more data are needed to understand the possible association between SARS-CoV-2 infection and delivery timing, and SARS-CoV-2 and neonatal outcomes.

  Population level changes in preterm birth and stillbirth rates have also been noted when comparing periods of COVID-19 lockdown to a time period prior to COVID. In Europe, decreases in rates of preterm delivery have been reported along with increased number of stillbirths, but initial evidence in the United States suggests preterm delivery and stillbirth rates are unchanged (Handley 2020, Hedermann 2020, Kahlil 2020, Yang 2022).

  ACOG continues to monitor the emerging literature on these topics.

  Clinicians should counsel pregnant individuals and those contemplating pregnancy about the potential risk of COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for those who are pregnant and their families. Pregnant individuals are encouraged to take all available precautions to avoid exposure to COVID-19 and optimize health including:

  • Getting a COVID-19 vaccine during pregnancy or postpartum, if not already vaccinated
  • Follow routine hygiene practices including washing hands often
  • Continue following safety measures to prevent COVID-19 infection, especially if not fully vaccinated, including wearing a mask, maintaining physical distancing, and limiting contact with other individuals as much as practical
• Q: Should pregnant patients wear a mask? REVISED

  Last updated March 10, 2022 at 10:06 a.m. EST.

  With regard to wearing a mask, pregnant patients should follow the same recommendations as the general population as outlined by the CDC. The CDC now provides recommendations for prevention strategies, including mask wearing, based on COVID-19 community levels (low, medium, and high). The COVID-19 community level is determined by a combination of three metrics: new COVID-19 cases, new COVID-19 hospital admissions in the past week, and the percentage of hospital beds occupied by COVID-19 patients. The use of these new COVID-19 community levels can help communities and individuals determine the appropriate prevention measures, including mask wearing, based on local context and unique needs.

  Pregnant individuals are at increased risk for severe disease; therefore, it is extremely important that pregnant individuals in high COVID-19 community level areas continue to use masks. Even in low COVID-19 community level areas, pregnant individuals may wish to continue wearing masks and should be supported if they decide to do so. There are currently no known risks related to mask use during pregnancy.

  Regardless of vaccination status or COVID-19 community level, masks should continue to be worn in health care settings. Patients should wear a mask for the duration of their health care setting visit and adhere to respiratory hygiene, cough etiquette, and hand hygiene, and follow triage procedures. Masks also should continue to be worn while utilizing public transportation, during travel, and while in travel hubs such as airports (CDC, IDSA). Patients who are sick with COVID-19 and their caregivers also should wear a mask or respirator.

  Emerging data demonstrate that while all masks and respirators provide some level of protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), properly fitting respirators provide the highest level of protection. It is most important for individuals to wear a well-fitting mask or respirator correctly so that it is comfortable and provides good protection (CDC). Importantly, masks with exhalation valves or vents should NOT be worn to help prevent the person wearing the mask from spreading COVID-19 to others (source control) (CDC).

  Clinicians and patients should be aware that CDC recommendations regarding mask wearing may change frequently and CDC and/or state officials may reinstate mask mandates, as needed.

• Q: How should screening for intimate partner violence and domestic violence proceed during the COVID-19 pandemic? REVISED

  Last updated July 1, 2021 at 7:22 a.m. EST.

  There have been reports of the exacerbation of intimate partner violence during the COVID-19 pandemic. The severity of intimate partner violence may escalate during pregnancy or the postpartum period. ACOG recommends screening all patients for intimate partner violence at periodic intervals throughout obstetric care (at the first prenatal visit, at least once per trimester, and at the postpartum checkup) (Guidelines for Perinatal Care, 8th edition; Committee Opinion 518). Screening all patients multiple times is important because some individuals do not or cannot disclose abuse each time they are asked. During the COVID-19 pandemic, screening may need to be provided by telehealth, but this may not allow individuals the privacy or safety needed to disclose abuse. In addition to possibly screening during prenatal telehealth appointments, screening is important to perform during in-person appointments and at hospital admission in a private and safe setting with the patient alone and not in the presence of a partner, friends, family, or caregiver. Obstetrician–gynecologists and other obstetric care professionals should proactively identify local resources and be prepared to offer or provide referrals for social work services, mental health care, or additional resources for patients who disclose intimate partner violence. It may be necessary to provide these services or other enhanced resources by phone, electronically, or by telehealth where possible.
  
  For additional information, see ACOG Committee Opinion 518, Intimate Partner Violence.
  
  Additional key resources include:

  • National Domestic Violence Hotline (24-hour, toll-free): call 800-799-SAFE (7233) and 800-787-3224 (TTY), text LOVEIS to 22522, or use the live chat option at www.thehotline.org
  • National Health Resource Center on Domestic Violence
  • Futures Without Violence

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists.)

• Q: How can I help my pregnant and postpartum patients manage stress, anxiety, and depression? REVISED

  Last updated July 1, 2021 at 11:53 a.m. EST.

  Perinatal mood and anxiety disorders are among the most common complications that occur in pregnancy or in the first 12 months after delivery. Data suggest that the prevalence of depression and anxiety among pregnant individuals has increased during the COVID-19 pandemic (Racine 2021, Vigod 2021). Obstetrician–gynecologists and other maternal health care professionals should continue to screen all pregnant individuals at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool (Committee Opinion 757). Even if an individual is screened during pregnancy, additional screening also should occur during the postpartum period (Committee Opinion 757). Pregnant and recently pregnant individuals may still be experiencing increased stress due to COVID-19. Obstetrician–gynecologists and other maternal health care professionals should reassure patients that there continue to be effective treatment and support options for stress, anxiety, and depression. If physical activity is possible, patients may find it beneficial for mental health. When counseling pregnant and recently pregnant individuals, it is important to acknowledge that COVID-19 has presented patients with new and challenging situations and encourage patients to communicate regularly with their health care team. If you are concerned that your patient may be at imminent risk of harm to self or others, refer them to emergency services for further evaluation.

  Clinicians are encouraged to share ACOG’s patient resources as appropriate.

  Additional key resources include:

  • The Lifeline4Moms Perinatal Mental Health Toolkit: provides information and algorithms for screening, assessment, and treatment of perinatal mental health conditions. 
  • Lifeline4Moms Network of Perinatal Psychiatry Access Programs: if you are in CA, FL,  LA, MA, MI, NC, RI, VT, WA, or WI, visit the program’s website for contact information. Clinicians can call with questions regarding the diagnosis and management of perinatal mood and anxiety disorders. Some programs also provide mental health resources and referrals.
  • Postpartum Support International’s Perinatal Psychiatric Consult Line: available to all clinicians throughout the U.S. Call 877-499-4773 or visit the website to schedule a 1:1 consultation by phone with a perinatal psychiatry expert. 
  • Postpartum Support International’s online facilitated support group meetings: for your patients to connect with other pregnant and postpartum women. Patients can call 1-800-944-4773 (#1 Español or #2 English) or text 503-894-9453 (English) or 971-420-0294 (Español).
  • My Perinatal Network provides a free, virtual course on trauma-informed care for frontline maternity clinicians during the COVID pandemic.
  • Massachusetts Child Psychiatry Access Program for MOMS. Taking Care of Yourself During COVID-19. Resources for Pregnant and Postpartum Women.
  • Lifeline4Moms Promoting Optimal Mental Health for Pregnant and Postpartum Women during COVID-19.

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists.)

• Q: How should visitation rules be modified in the setting of the COVID-19 pandemic? REVISED

  Last updated March 25, 2021 at 10:36 a.m. EST.

  Modifications to visitation policies should be made on an individual facility level and based on community spread, local and state recommendations or regulations, and infection control and space considerations (eg, whether postpartum recovery rooms are individual or shared, while adhering to appropriate social distancing). Although it is recommended that the number of visitors be reduced to those essential for the pregnant individual’s well-being (emotional support persons) (CDC), ACOG encourages facilities to consider innovative solutions and localized, collaborative approaches that ensure patients have the support and stability they need while pregnant, during labor, and postpartum if in-person support must be limited. The visitor policy should not be a barrier to an individual receiving medically-indicated in-person care. Visitors should be screened for symptoms of acute respiratory illness and should not be allowed entry if fever or respiratory symptoms are present; in those instances, a different, asymptomatic visitor can be allowed to provide support. Hospitals may consider routinely evaluating visitors for symptoms. Use of alternative mechanisms for patient and visitor interactions, such as video-call applications, can be encouraged for any additional support persons. The Centers for Disease Control and Prevention (CDC) provides additional suggested guidance for managing visitors in inpatient obstetric health care settings.

  When counseling patients about any modified visitation policies, obstetrician–gynecologists and other obstetric care professionals should acknowledge the importance of support persons and also communicate that any policies that temporarily limit visitors or support persons are being implemented for the safety of the patient, her newborn, and the community.

  Labor, delivery, and postpartum support may be especially important to improve outcomes for individuals from communities traditionally underserved or mistreated within the health care system. In considering visitation policies, institutions should be mindful of how restrictions might differentially and negatively affect these communities, which in many areas are also disproportionately affected by COVID-19.

   

• Q: Should routine screening testing continue to occur in labor and delivery units? REVISED

  Last updated July 1, 2021 at 7:16 a.m. EST.

  Pregnant women admitted for labor and delivery with suspected COVID-19 or who develop symptoms suggestive of COVID-19 during admission should be tested (CDC, ACOG Practice Advisory, AMA statement). Performance of SARS-CoV-2 viral testing upon admission to labor and delivery is at the discretion of the facility. Key factors in considering the use of diagnostic (PCR) screening testing in labor and delivery units include:

  • Vaccination status. CDC now suggests that fully vaccinated people can refrain from routine screening testing if feasible. Some facilities may decide that testing does not need to be performed for patients with documentation of vaccination. The yield of testing for identifying asymptomatic infection might be lower among vaccinated patients because a growing body of evidence suggests that fully vaccinated people are less likely to have asymptomatic infection. However, testing vaccinated individuals might continue to be useful in some situations to inform the type of infection control precautions used (e.g., room assignment/cohorting, or personal protective equipment used).
  • Prevalence of COVID-19. Routine testing has the potential to identify unvaccinated asymptomatic COVID-19 positive patients presenting to labor and delivery units. As such, this approach is likely most beneficial in areas where there is wide community spread or low vaccination rates with the potential for many asymptomatic individuals.

  Regardless of vaccination status, individuals may decline testing for a variety of reasons including stigma, mistrust, and fear of possible mother–baby separation. Facilities that continue to practice routine screening testing in labor and delivery should have a plan for the care of individuals who decline COVID-19 testing.

• Q: How should thromboprophylaxis be managed for pregnant and postpartum patients with suspected or confirmed COVID-19 infection? REVISED

  Last updated July 1, 2021 at 7:22 a.m. EST

  Pregnancy is a hypercoagulable state, and women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (Practice Bulletin 196, Thromboembolism in Pregnancy). Data indicate that COVID-19 infection may lead to increased coagulopathy. Although not yet known, it is possible that pregnancy and COVID-19 infection may be additive for risk of thrombosis. The National Institutes of Health COVID-19 Treatment Guidelines recommends that pregnant patients hospitalized for severe COVID-19 receive prophylactic dose anticoagulation unless contraindicated. 
  
  Additional resources:

  • American Society of Hematology. COVID-19 and VTE/Anticoagulation: Frequently Asked Questions
  • National Institutes of Health. COVID-19 Treatment Guidelines. Antithrombotic Therapy in Patients with COVID-19
  • COVID-19 resources on coagulation and anticoagulation (International Society on Thrombosis and Haemostasis)

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists.)

• Q: Should monoclonal antibodies be used as a treatment option for pregnant patients? REVISED

  Last updated February 17, 2022 at 9:16 a.m. EST

  Various monoclonal antibody treatments are available only under emergency use authorization (EUA). They are recommended for the treatment of outpatients with mild to moderate COVID-19 infection who are at high risk of clinical progression as defined by the EUA criteria. Recently, the Omicron variant of SARS-CoV-2 has rapidly become the dominant COVID-19 viral strain worldwide. Most approved anti-SARS-CoV-2 monoclonal antibodies have a diminished potency or are ineffective against the Omicron variant.

  Pregnancy is included among the conditions that put individuals at high risk for clinical progression. This makes patients with pregnancy as their only risk factor eligible to receive outpatient monoclonal antibodies, according to the EUA (NIH). Obstetric care clinicians may consider the use of monoclonal antibodies for the treatment of non-hospitalized COVID-19 positive pregnant individuals with mild to moderate symptoms, particularly if one or more additional risk factors are present (eg BMI >25, chronic kidney disease, diabetes mellitus, cardiovascular disease).

  Post-exposure prophylaxis should be considered for inadequately vaccinated individuals who have been exposed to SARS-CoV-2 (NIH). These individuals include those who have had a recent exposure to an individual with SARS-CoV-2 for a cumulative total of 15 minutes or more over a 24-hour period or there is a recent occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting AND are 1) not fully vaccinated or 2) fully vaccinated but may not mount an adequate immune response.

  Lactation is not a contraindication for the use of monoclonal antibodies. Lactating individuals with one or more risk factors for severe COVID-19 illness may receive monoclonal antibodies for treatment or post-exposure prophylaxis. There is no need to temporarily discontinue breastfeeding when receiving monoclonal antibodies.

  People who previously received monoclonal antibodies as part of COVID-19 treatment, post-exposure prophylaxis, or pre-exposure prophylaxis can be vaccinated at any time; COVID-19 vaccination no longer needs to be delayed following receipt of monoclonal antibodies.

  Due to current reduced effectiveness of some monoclonal antibodies against the Omicron variant, physicians should consult their facilities as to which monoclonal antibody therapies against SARS-CoV-2 infection are available for treatment options.

  A recent analysis of data from 41 health care systems found that White and non-Hispanic patients received monoclonal antibody treatment more often than Black, Asian, and Other race [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multiple or Other races] patients with positive SARS-CoV-2 test results (Wiltz 2022). As with other COVID-19 treatments, vaccines, and prevention practices, efforts (e.g., considering measures of social vulnerability in patient triage, engaging trusted messengers in outreach, and directly addressing structural barriers to access) should be made to ensure that communities most affected by SARS-CoV-2 have equitable access to these treatments.

Prenatal Care

• Q: What key considerations and modifications to prenatal and postpartum care should continue as the COVID-19 pandemic declines? REVISED

  Last updated March 16, 2022 at 9:00 a.m. EST.

  In addition to standard components of prenatal and postpartum care, obstetrician-gynecologists and other obstetric care clinicians should continue to provide the following COVID-19-specific counseling to all pregnant individuals:

  • Counsel patients that although the absolute risk for severe COVID-19 is low, available data indicate an increased risk of ICU admission, need for mechanical ventilation and ventilatory support (ECMO), and death reported in pregnant and recently pregnant individuals with symptomatic COVID-19 infection.
  • Emphasize the importance of taking all available precautions to avoid exposure to COVID-19 and to prevent infection including:
    • Recommending and offering COVID-19 vaccination during pregnancy or postpartum, if not already vaccinated.
    • Counseling regarding the importance of routine hygiene practices such as washing hands often to help decrease the spread of COVID-19 and other infectious diseases, particularly when there may be breakthrough COVID-19 cases and during flu season.
    • Counseling regarding ongoing safety measures to prevent COVID-19 infection, especially if not fully vaccinated, including wearing a mask, maintaining physical distancing, and limiting contact with other individuals as much as practical.

  • Offer mental health or social work services or referrals to provide additional resources, particularly for patients who are experiencing difficulties related to the COVID-19 pandemic. For example, individuals who are experiencing housing or food insecurity, intimate partner violence, or mental health disorders may benefit from additional resources.
  • Provide anticipatory guidance to patients encouraging them to check with their pediatric clinician or family physician regarding newborn visits because pediatric clinicians or family physicians also may have altered their procedures and routine appointments (American Academy of Pediatrics, COVID-19 Healthychildren.org Resources).

  It may still be necessary or preferred to provide prenatal and postpartum services by phone or electronically. ACOG fully supports the use of telehealth in obstetrics and gynecology and encourages physicians to become familiar and adept in this new technology (ACOG CO 798, DeNicola 2020). If telehealth visits are anticipated, patients should be provided with any necessary equipment (e.g., blood pressure cuff) if available and as appropriate. Furthermore, although many institutions may no longer need to employ alternative care and staffing strategies in response to the COVID-19 pandemic, some institutions may decide to continue to implement a modified prenatal care schedule (see ACOG’s Redesigning Prenatal Care Initiative). Plans for modified care schedules are best made at the local level with consideration of patient populations and available resources. Clinicians and institutions should engage with patients in shared decision making to understand their preferences for modifications to their prenatal care schedule.

• Q: Can telehealth strategies help assist obstetric care? REVISED

  Last updated March 30, 2021 at 3:45 p.m. EST.

  Yes, and the American College of Obstetricians and Gynecologists (ACOG) encourages practices and facilities that do not yet have the infrastructure to offer telehealth to begin strategizing how telehealth could be integrated into their services as appropriate. The ability to access telemedicine may vary by patient resources and some assessment of this—although often challenging in times of crisis—is necessary to ensure equitable care. Some patients may not be able to access technology appropriate for telehealth services; practices and facilities are encouraged to explore ways to ensure those patients still have access to care.

  As part of the COVID-19 emergency response, several new federal telehealth allowances have been made. These may be subject to ongoing changes. Please see ACOG’s Managing Patients Remotely: Billing for Digital and Telehealth Services for the latest information on federal policy changes and coding advice.

  The Department of Health and Human Services Office for Civil Rights has announced that it will exercise enforcement discretion and waive penalties for HIPAA violations against health care personnel (HCP) who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. See HHS.gov for more information on the Department of Health and Human Services response to COVID-19 and HIPAA.

  For obstetrician–gynecologists, maintaining confidentiality when meeting with a patient by phone or virtual visit is essential. Confidentiality is a vital component of the patient–physician relationship; it may be especially important for adolescent patients or adult patients at high risk of intimate partner violence.

  The Drug Enforcement Administration has released guidance allowing HCP registered by the administration to issue prescriptions for controlled substances without an in-person medical evaluation for the duration of the public health emergency (see specific guidelines here).

  The ability to use telehealth for purposes of obtaining informed consent is affected by state rules and regulations; members are encouraged to become familiar with local, regional, and state rules, regulations, and polices regarding the use of telehealth and informed consent. The Department of Health and Human Services offers information on obtaining informed consent for care provided via telehealth.

  For more information on telehealth, see COVID-19 FAQs for Obstetrician–Gynecologists, Telehealth.

  Additional Resources on COVID-19 From Other Organizations

  (These links are for resource purposes only and should not be considered to be developed or endorsed by ACOG):

  • Current State Laws & Reimbursement Policies (The National Telehealth Policy Resource Center)
  • Obtaining Informed Consent (The Agency for Healthcare Research and Quality)
  • Easy-to-Understand Telehealth Consent Form (The Agency for Healthcare Research and Quality)
• Q: Should I screen patients before they come in for in-person appointments?

  Last updated March 23, 2020 at 11:30 p.m. EST.

  Health care clinicians can also consider an approach (eg. phone, telehealth) to implement routine screening of patients, and their guests if permitted, for potential exposure or COVID-19 symptoms (cough, sore throat, fever) before their in-person appointment to prevent any potential persons under investigation from entering the facility. Patients should be instructed to call ahead and discuss the need to reschedule their appointment if they develop symptoms of a respiratory infection (eg, cough, sore throat, fever) on the day they are scheduled to be seen. This can be done through phone calls before appointments asking about recent travel, potential exposure, and symptoms. Proactive communication to all patients (ie, via email, text, recorded phone calls) advising individuals with possible exposure to or symptoms of COVID-19 to call the office first also may be considered. Additionally, health care clinicians should confirm whether a person is currently undergoing testing for COVID-19.

  If, after screening, the patient reports symptoms of or exposure to a person with COVID-19, that patient should be instructed not to come to the health care facility for their appointment and health care clinicians should contact the local or state health department to report the patient as a possible person under investigation (PUI).

• Q: Do patients with suspected or confirmed COVID-19 need additional antenatal fetal surveillance?

  Last updated November 4, 2020 at 1:54 p.m. EST.

  During acute illness, fetal management should be similar to that provided to any critically ill pregnant person. Continuous fetal monitoring in the setting of severe illness should be considered only after fetal viability, when delivery would not compromise maternal health or as another noninvasive measure of maternal status.

  Very little is known about the natural history of pregnancy after a patient recovers from COVID-19. In the setting of a mild infection, management similar to that for a patient recovering from influenza is reasonable. It should be emphasized that patients can decompensate after several days of apparently mild illness, and thus should be instructed to call or be seen for care if symptoms, particularly shortness of breath, worsen. Given how little is known about this infection, a detailed mid-trimester anatomy ultrasound examination may be considered following pre-pregnancy or first-trimester maternal infection. Interval growth assessments could be considered depending on the timing and severity of infection, with the timing and frequency informed by other maternal risk factors. Antenatal testing is reserved for routine obstetrical indications (SMFM Coronavirus COVID-19 and Pregnancy).

  ACOG will continue to carefully monitor the literature to provide our members with the best available and most current guidance. Should new literature indicate any need for additional antenatal fetal surveillance for pregnant patients with suspected or confirmed COVID-19, ACOG will update our recommendations accordingly.

• Q: Should pregnant women continue to receive maternal immunizations during the COVID-19 pandemic? REVISED

  Last updated May 26, 2021 at 2:09 p.m. EST.

  Yes. Maternal immunizations continue to be an essential component of prenatal care during the COVID-19 pandemic. Additionally, COVID-19 vaccines can be given with other routine maternal immunizations and there is no need to withhold routine maternal immunizations for any time period before or after receiving COVID-19 vaccination. Adhering to the recommended timing of maternal immunization as much as possible is encouraged to maximize maternal and fetal benefits. If a practice decides to modify or reduce the number of prenatal care visits, clinicians are encouraged to include recommended maternal immunizations (influenza and Tdap) during remaining in-person appointments, even if that means immunizations will be administered outside of the typically recommended weeks of gestation. Modified prenatal care schedules during COVID-19 may make it disproportionately more difficult for some to receive preventive care such as maternal immunizations. This reality underscores the importance of clinicians integrating social determinants of health screening into practice, and maximizing and facilitating referrals to social services (Committee Opinion 729).

  Importantly, there is no evidence that vaccination with either the influenza vaccine or Tdap vaccine increases a pregnant woman’s or fetus’ risk of infection with or complications from the virus that causes COVID-19.

  Similar to other infectious diseases, if a postpartum individual has suspected or confirmed COVID-19 and did not receive indicated immunizations prior to (e.g. MMR) or during (influenza & Tdap) pregnancy, those immunizations should be delayed until the patient has fully recovered from illness. 

• Q: Is there any benefit associated with the use of corticosteroid treatment for pregnant patients with moderate to severe COVID-19 illness?

  Last updated July 27, 2020 at 5:24 p.m. EST.

  A preliminary published analysis from a large, multicenter, randomized, open-label trial for hospitalized patients in the United Kingdom demonstrated that patients who were randomized to receive dexamethasone (6mg once daily; oral or IV) had a reduced rate of mortality compared to those who received standard of care (NEJM 2020). In the dexamethasone group, the incidence of death was lower than that in the standard care group among patients requiring mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving supplemental oxygen at enrollment (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55).  Therefore, for the general population, the NIH now recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated. The NIH recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen. Although these recommendations are not specific to pregnant individuals, ACOG recommends that dexamethasone be used for pregnant women with COVID-19 who are receiving supplemental oxygen or are mechanically ventilated, and that dexamethasone should not be withheld for treatment of COVID-19 due to pregnancy status.  
  
  ACOG will continue to diligently monitor the literature on the use of corticosteroids for patients with suspected or confirmed COVID-19.

   

• Q: Is timing of delivery affected by COVID-19?

  Last updated March 23, 2020 at 11:30 p.m. EST.

  Timing of delivery, in most cases, should not be dictated by maternal COVID-19 infection. For women with suspected or confirmed COVID-19 early in pregnancy who recover, no alteration to the usual timing of delivery is indicated. For women with suspected or confirmed COVID-19 in the third trimester who recover, it is reasonable to attempt to postpone delivery (if no other medical indications arise) until a negative testing result is obtained or quarantine status is lifted in an attempt to avoid transmission to the neonate. In general, COVID-19 infection itself is not an indication for delivery.

• Q: Is COVID-19 considered an indication for cesarean delivery for patients with suspected or confirmed COVID-19 infection? REVISED

  Last updated February 11, 2022 at 2:35 p.m. EST.

  No. While there are cases of reported vertical transmission of SARS-CoV-2, currently available data indicate that vertical transmission appears to be uncommon (Dumitriu 2020). There is growing evidence suggesting increased risk of ICU admission, mechanical ventilation, and death for symptomatic pregnant patients with COVID-19 (Ellington MMWR 2020, Zambrano, 2020), but these findings are not an indication for cesarean delivery. Cesarean delivery should therefore be based on obstetric (fetal or maternal) indications and not COVID-19 status alone (Omar 2022).

  In the event that an individual should request a cesarean delivery because of COVID-19 concerns, obstetrician–gynecologists and other obstetric care clinicians should follow ACOG’s guidance provided in Committee Opinion 761, Cesarean Delivery on Maternal Request.

• Q: Is operative vaginal delivery indicated in a patient with suspected or confirmed COVID-19?

  Last update March 26, 2020 at 8:00 a.m. EST.

  No, operative vaginal delivery is not indicated for suspected or confirmed COVID-19 alone. Practitioners should follow usual clinical indications for operative vaginal delivery, in the setting of appropriate personal protective equipment (Practice Bulletin 154 on Operative Vaginal Delivery).

• Q: Is delayed cord clamping still appropriate in a patient who has suspected or confirmed COVID-19?

  Last updated March 23, 2020 at 11:30 p.m. EST.

  Yes, delayed cord clamping is still appropriate in the setting of appropriate clinician personal protective equipment. Although some experts have recommended against delayed cord clamping, the evidence is based on opinion; a single report later confirmed COVID-19 transmission most likely occurred from the obstetric care clinician to the neonate. Current evidence-based guidelines for delayed cord clamping should continue to be followed until emerging evidence suggests a change in practice. See Committee Opinion 684, Delayed Umbilical Clamping After Birth, for more information.

• Q: How can doulas support maternal care and delivery during the COVID-19 pandemic?

  Last updated May 1, 2020 at 8:50 a.m. EST.

  Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor (Committee Opinion No. 766). The presence of doulas during the COVID-19 pandemic should be considered in the context of the institutional visitor policy. If doulas are considered by the facility to be health care personnel, they should adhere to infection prevention and control recommendations, including the correct and consistent use of proper personal protective equipment. If doulas are not designated as health care personnel by the facility, they would be considered visitors and included in that facility’s visitor count for the patient.

  Labor, delivery, and postpartum support may be especially important to improve outcomes for individuals from communities traditionally underserved or mistreated or harmed within the health care system. In considering visitation policies, institutions should be mindful of how restrictions might differentially and negatively affect these communities, which in many areas are also disproportionately affected by COVID-19.

• Q: Should nitrous oxide continue to be used during labor?

  Last updated May 20, 2020 at 12:30 p.m. EST.

  With insufficient information currently available regarding the physiologic safety of inhaled nitrous oxide in individuals with suspected or confirmed COVID-19, labor and delivery units may consider suspending use of nitrous oxide for individuals with suspected or confirmed COVID-19 or individuals with unconfirmed COVID-19 negative status.

  For patients with a diagnostic test for COVID-19 confirmed negative, nitrous oxide may continue to be offered as an option for analgesia.

• Q: Is it reasonable to use tranexamic acid (TXA) or Hemabate for treatment of postpartum hemorrhage in pregnant individuals with suspected or confirmed COVID-19 infection?

  Last updated July 27, 2020 at 11:23 a.m. EST.

  Because of pulmonary and pro-thrombotic manifestations of COVID-19 infection, the question as to whether TXA or hemabate can be used has arisen. Hemabate is associated with bronchospasm, such that its use is contraindicated in women with asthma (Practice Bulletin 183, Postpartum Hemorrhage). While there are no data specific to COVID-19 infection, the pulmonary manifestations of COVID-19 include a viral pneumonia, and Hemabate is not generally withheld in that setting. Similar to individuals without COVID-19 infection, TXA may be considered for individuals with suspected or confirmed COVID-19 infection experiencing postpartum hemorrhage when all other initial medical therapy fails (Practice Bulletin 183, Postpartum Hemorrhage). Because of the possible additive effect of the increased risk of thrombosis from COVID-19 infection and the hypercoagulative state of pregnancy, it may be prudent to consider this increased likelihood of clotting before administering TXA for postpartum hemorrhage.

  Additional resource:

  American Society of Hematology. COVID-19 and VTE/Anticoagulation: Frequently Asked Questions

Postpartum Care

• Q: How should lactating individuals be counseled about special considerations for infant feeding with breastmilk in the setting of suspected or confirmed maternal COVID-19 infection? REVISED

  Last updated February 11, 2022 at 3:15 p.m. EST.

  Breastmilk provides protection against many illnesses and there are few contraindications to breastfeeding (Committee Opinion 756, CDC's Pregnancy and Breastfeeding). Current evidence suggests that breastmilk is not a source of COVID-19 infection (Walker 2020, CDC). A recent cohort of 110 lactating women found no SARS-CoV-2 infectious material in breastmilk samples (Krogstad 2022). Therefore, suspected or confirmed maternal COVID-19 is not considered a contraindication to infant feeding with breastmilk.

  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 patients 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 birthing 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 patient's informed decision about whether to initiate or continue breastfeeding, recognizing that the patient is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal (Committee Opinion 756).

  A child being breastfed by someone with suspected or confirmed COVID-19 should be considered as a close contact of a person with COVID-19, and should be quarantined for the duration of the lactating parent’s recommended period of isolation and during their own quarantine thereafter (CDC).

  ACOG will continue to review emerging literature on this topic.

• Q: How should a mother-infant dyad be located in the hospital when the mother has suspected or confirmed SARS-CoV-2 infection?

  Last updated August 11, 2020 at 1:31 p.m. EST.

  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 (see How should women be counseled about special considerations for infant feeding with breastmilk in the setting of suspected or confirmed maternal COVID-19 infection?). 

   

Special Populations

• Q: Are there special considerations for incarcerated pregnant people? REVISED

  Last updated July 1, 2021 at 7:16 a.m. EST.

  Prisons, jails, and detention facilities are high-risk environments for COVID-19 transmission, and ACOG has provided recommendations for addressing the needs of pregnant and postpartum individuals who are incarcerated during the pandemic. For pregnant people who must remain in custody, prisons, jails, and detention facilities should implement measures for social distancing, hygiene, screening, testing, medical care including COVID-19 vaccination, safe housing arrangements, and other interventions as outlined by the CDC’s Interim Guidance on Management of COVID-19 in Correctional and Detention Facilities and as recommended by guidance from the National Commission on Correctional Health Care. As institutions of incarceration adapt operations in response to the pandemic, they must ensure that pregnant people continue to have access to comprehensive health care, including prenatal care, abortion care, postpartum care and breastmilk expression, and timely assessment of pregnancy-related or COVID-19 symptoms, in accordance with ACOG guidance.

COVID-19 FAQs

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