COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

 Staffing, Personnel, and Hospital Resources

• Q: When can an obstetric practitioner with suspected or confirmed COVID-19 return to work? When they return to work, what personal protective equipment (PPE) do they need to wear on a regular basis?

  Last updated September 2, 2020 at 10:01 a.m. EST.

  Obstetricians or other obstetric practitioners can return to work when they meet the CDC criteria to discontinue transmission-based precautions, as outlined below.

  A test-based strategy is no longer recommended (except as noted below) because, in the majority of cases, it results in excluding from work health care practitioners (HCPs) who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.

  Symptom-based strategy:

  HCP 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: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive viral diagnostic test.

  HCP 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 
  • 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: HCPs who are severely immunocompromised but who were asymptomatic throughout their infection may return to work 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 to allow HCP to return to work earlier than if the symptom-based strategy were used. However, many individuals will have prolonged viral shedding, limiting the utility of this approach. A test-based strategy could also be considered for some HCP (e.g., those who are severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the HCP being infectious for more than 20 days.

  The criteria for the test-based strategy are:

  HCP who are symptomatic:

  • Resolution of fever without the use of fever-reducing medications and
  • Improvement in symptoms (eg, 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).

  HCP 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).

  After returning to work, HCP should:

  • Wear a facemask for source control (having the infected person wear a cloth face covering or facemask over their mouth and nose to contain their respiratory secretions) at all times while in the health care facility until all symptoms are completely resolved or at baseline. A facemask instead of a cloth face covering should be used by these HCPs for source control during this time period while in the facility. After this time period, these HCPs should revert to their facility 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 HCP will meet the criteria for returning to work, but still have lingering symptoms.
    • A facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated (see What personal protective equipment (PPE) should clinicians and patients wear for potential or confirmed COVID-19 patients?).
  • Self-monitor for symptoms and seek re-evaluation from occupational health 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 December 14, 2020 at 1:53 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). Given the growing evidence, the CDC now includes pregnant women in its “increased risk” category for COVID-19 illness. 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). Pregnant patients with comorbidities such as obesity and gestational diabetes may be at an even higher risk for severe illness consistent with the general population with similar comorbidities (Ellington MMWR 2020, Panagiotakopoulos MMWR 2020, Knight 2020, Zambrano MMWR 2020). Importantly, analyses so far are limited by a large amount of missing data. Similar to the general population, 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).  

  Currently, there are insufficient data in pregnant health care personnel that stratify these risks by either gestational age, medical comorbidities, the availability of recommended personal protective equipment (PPE), capacity to screen for SARS-CoV-2 infection, or the effect of the level of community prevalence of SARS-CoV-2 infection. 
  
  Importantly, the correct and comprehensive use of recommended PPE, 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. Recent data suggests that universal masking and close evaluation of extended use or reuse of N95 respirators in the health care setting can play a crucial role in decreasing health care-related COVID-19 infections (Degesys 2020, Seidelam 2020), but that community acquired infection for health care personnel may still remain at the same incidence rate as for other community members (Seidelam 2020). As such, ACOG recommends the following, based on local staffing availability:

  • All health care personnel, including pregnant women, should be:
    • provided and appropriately using the recommended PPE, especially face masks (Degesys 2020, Seidelam 2020), for preventing nosocomial infection with COVID-19. The improper use of PPE in health care personnel has been associated with increased odds of being diagnosed with COVID-19 (Ran 2020); and
    • following public health guidance to avoid community acquisition.
  • Health care facilities may consider limiting exposure of pregnant health care personnel to patients with confirmed or suspected COVID-19 infection, especially during higher risks procedures (CDC). 
  • When all recommended PPE is not available, pregnant health care personnel should avoid exposure to high-risk procedures in patients with suspected or confirmed COVID-19. Health care personnel are not ethically obligated to provide care to high-risk patients without adequate protections in place (see COVID-19 FAQs for Obstetrician-Gynecologists, Ethics).
  • Pregnant individuals may continue to work in patient-facing roles until they give birth if they so desire and if all recommended PPE is available. 
  • Pregnant individuals 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. Thus, any recommendations related to the work environment specific to health care personnel with comorbidities should be applied to pregnant health care personnel with similar comorbidities.

  Pregnant health care personnel should follow CDC risk assessment and infection control guidelines, including use of appropriate PPE for health care personnel exposed to patients with suspected or confirmed COVID-19. Adherence to recommended infection prevention and control practices is critically important for protecting all health care personnel in health care settings. 
  
  These suggestions are based on risk to the pregnant individual (see Does COVID-19 present an increased risk of severe morbidity and mortality for pregnant women compared with nonpregnant women?). 
  
  We understand that pregnant individuals are experiencing increased concern due to COVID-19, and we appreciate that these are unsettling times. 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 increased risks to pregnant individuals compared to nonpregnant individuals from COVID-19, ACOG will update our recommendations accordingly.

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

  Last update July 27, 2020 at 11:35 a.m. EST

  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. 

  General considerations:

  • 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.

  • Gloves
    • 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.
  • Gown
    • 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: 
        • Dressing
        • Bathing/showering
        • Transferring
        • 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. 

• Q: How can facilities prepare obstetric care clinicians to respond to COVID-19?

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

  Hospitals that provide maternity services should create, or—if already established—mobilize their perinatal subcommittee in charge of disaster preparedness (likely to include representatives from obstetric, pediatric, family medicine, and anesthesia teams among others) (Committee Opinion 726).

  In some areas with high prevalence and community spread, a shortage of obstetric health care personnel may occur. Regardless of whether an area is currently experiencing wide community spread, ACOG encourages all facilities to begin strategizing how to expand their obstetric work force. Facilities should consider rapid credentialing and privileging of temporary obstetric care clinicians not currently practicing obstetrics to enable augmentation of the work force (Committee Opinion 726), retraining these individuals as necessary, and ensuring proper insurance coverage.

  Additionally, if not already doing so, facilities are encouraged to find innovative ways to collaborate with family physicians, midwives who are certified by the American Midwifery Certification Board (or its predecessor organizations) or whose education and licensure meet the International Confederation of Midwives Global Standards for Midwifery Education, and other obstetric care professionals.

• Q: How can elective procedures be managed to optimize personnel and resources?

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

  In areas where COVID-19 is particularly prevalent or where there is particular stress on the health care system, it may be advantageous to identify and modify surgical scheduling, including for procedures that are medically indicated, when a patient’s health and safety would not be harmed by such delay.

  For obstetrics, it may be appropriate to temporarily consider tubal sterilization only when performing cesarean birth (unless the patient is considered high risk) and all others as elective, so long as an alternative form of contraception is provided (eg, immediate postpartum long-acting reversible contraception), if desired by the patient. However, any decision regarding which procedures to consider elective should be made on a local and regional level, considering the risks and resources specific to each area. Obstetric and gynecologic procedures for which a delay will negatively affect patient health and safety should not be delayed. This includes gynecologic procedures and procedures related to pregnancy for which delay would harm patient health.

  See ACOG’s Joint Statement on Elective Surgery for additional information.

• 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. 

• Q: How can facilities prepare to manage an influx of obstetric patients with COVID-19?

  Last updated April 21, 2020 at 3:30 p.m. EST.

  One public health intervention to reduce exposure risk is cohorting—co-locating patients with suspected or confirmed COVID-19 into a designated area of the hospital. Although not all facilities are able to create an independent obstetrics COVID-19 unit, attempts to designate specific locations for the purposes of containment have the intention of limiting the exposure of unaffected patients and staff (SMFM).

• Q: Should facilities consider special scheduling tactics to preserve the obstetric work force?

  Last updated April 21, 2020 at 3:30 p.m. EST.

  Yes, facilities can consider strategies such as:

  • For hospitals that have the staffing capacity, consider using a designated team of trained clinicians to care for patients in these designated COVID-19 units or spaces (SMFM)
  • Proactively log staff who enter and leave these designated COVID-19 units or spaces to enable systematic tracking of potential exposure. (SMFM)
    • This tracking could be considered more broadly for all patient rooms (ie, those off the cohorted unit), depending on local epidemiology, to facilitate  tracking of exposures in cases where COVID-19 specific PPE is not being used.
    • Tracking is performed by asking clinicians entering the room to log their name and time of entry. Logging can be done by documentation of all  clinical encounters within the electronic medical record or via a physical document placed just outside the patient’s room.
• Q: What aspects need to be considered regarding the resumption of routinely recommended obstetric care schedules and services?

  Last updated May 18, 2020 at 2:26 p.m. EST.

  Practices, hospitals, and health care systems are beginning to identify and consider how to safely resume care for non-COVID-19-related issues, such as preventive services, primary care, and non-urgent surgeries.  ACOG recognizes the importance of using a data-driven approach to base decisions regarding re-opening specific areas and services. There are a number of aspects that need to be considered, including timing and scaling up of healthcare services, logistics in outpatient and inpatient facilities, COVID-19 testing and surveillance, current community prevalence, use of personal protective equipment (PPE), COVID-19 effect on the health care workforce, and others.  An ACOG Position Statement  has been developed that addresses these considerations in general and relevant to resumption of comprehensive routine women’s health care. It is important to recognize that strategies for resuming care will need to be developed on an individualized basis at the local, state, and regional level as national, regional, and local regulations and circumstances will influence the pace of, and approach to, resuming aspects of routine women’s health care. 

  The Centers for Medicare and Medicaid Services (CMS) has released suggested guidance regarding the timing of resumption of elective surgeries as well as non-surgical care. CMS and the White House recommend that hospitals should not resume surgical scheduling until the state or local regions meet “Gating Criteria”, including a downward trend in the rate of COVID-19 positive tests and patients with symptoms for at least 14 days, that hospitals must be able to treat all patients without resorting to crisis care, and must have robust testing in place for at-risk healthcare workers. 

  CMS strongly encourages maximizing the use of all telehealth modalities. The COVID-19 pandemic has resulted in a number of policy changes designed to enhance implementation of telehealth, and it is likely that some of the telehealth implementation strategies can be maintained in a resumption of care process. Consideration may be given to a phased approach to increasing non-urgent visits, with an emphasis on virtual visits early on and gradually increasing in-person visits as necessary. It is important that infection control considerations be maintained when resuming care, which may include continued telehealth visits. Planning for virtual visits must account for the types of visits that could be conducted virtually, recognizing that aspects such as physical examination, radiology, or laboratory testing would require an in-person visit. Some systems may consider maintaining telehealth in the provision of care on a more permanent basis especially if telehealth services were safe, effective, and well-received by the patient community. 

  Key considerations include:

  • Surgery: Guidance from the American College of Surgeons and a joint document from the American College of Surgeons, the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, and the American Hospital Association are available. In addition, the American College of Surgeons has developed a checklist for readiness to resume surgery (ACS). Policies and processes in these documents may be helpful in developing or modifying approaches to surgical obstetric care as well as nonobstetric surgery during pregnancy (Committee Opinion 775).
  • COVID-19 testing: Widespread testing capabilities are essential to monitor and to inform adjustments to a phased approach in resuming routine care. Depending on local prevalence, capacity, and supply, some hospitals have implemented universal testing on labor and delivery units to identify patients with COVID-19. COVID-19 testing strategies may be determined based on community prevalence, facility capacity, availability of test kits, and test characteristics (type, sensitivity, specificity) of available tests, among other factors.
  • Policies regarding optimizing PPE availability and use, masking, and hand hygiene for clinicians, staff, and patients also are necessary both in the outpatient and inpatient settings, including labor and delivery and surgery. Several systems are implementing masking for both patients and clinicians in outpatient settings, and types of PPE used in the labor and delivery or surgical setting may be determined based on admission or preoperative testing.
  • Outpatient visits: Facilities are using a variety of approaches, including:
    • Universal mask policy for clinicians, staff, patients, and visitors. Patients are encouraged to use cloth facial coverings to preserve mask supplies for medical use.
    • Limiting the number of visitors and attendants.
    • Changing waiting room and clinic space to accommodate physical distancing (for example, spacing of furniture in the waiting area and marking floors and elevators).
    • Considering having patients wait off-site and notified when to enter the clinic space.
    • Hand hygiene stations for patients before entering the facility or waiting room.
    • Maximizing use of all telehealth modalities.
    • Preserving in-person visits for those patients requiring physical evaluation or interventions (such as ultrasonography, blood draws, and immunizations).
    • Consolidating visits so that patients do not have to return to the facility or move among several locations for laboratory tests or ultrasonography.
    • Prioritizing in-person visits for those with greatest medical need for in-person examination, followed by elective visits.
    • Employing an extended hours strategy to space visits and to maintain physical spacing in the care and waiting areas.
  • Screening: Screening patients for in-person visits may include strategies similar to those used during the height of COVID-19, including pre-appointment phone screening, symptom and temperature checks at the building entrance, and possible masking. Facilities may consider routine screening for women and visitors in labor and delivery units until the local prevalence has significantly decreased. CMS suggests establishing “Non-COVID-19 Care” zones that would screen all patients for COVID-19 symptoms.

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

General Considerations

• Q: Is there a personal protective equipment (PPE) shortage?

  Last updated August 4, 2020 at 4:45 p.m. EST

  Yes, many facilities are currently experiencing a PPE shortage, 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. For ethical considerations on caring for patients when PPE is limited, see COVID-19 FAQs for Obstetrician-Gynecologists, Ethics, specifically "What are the ethical considerations associated with caring for patients during the COVID-19 pandemic, including in the absence of adequate PPE?" (See also What personal protective equipment (PPE) should clinicians and patients wear for potential or confirmed COVID-19 patients?)

• 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 women compared with nonpregnant women? REVISED

  Last updated December 17, 2020 at 9:58 a.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). Given the growing evidence, CDC now includes pregnant women in its “increased risk” category for 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). Pregnant patients with comorbidities such as obesity and gestational diabetes 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). Importantly, analyses so far are limited by a large amount of missing data. Similar to the general population, 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). 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).

  Although these data from the CDC suggest an increase in risk of severe outcomes in pregnant women with symptomatic SARS-CoV-2 infection, 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 2012; Mosby 2011). ACOG recognizes the critical need for further analysis and peer review literature on SARS-CoV-2 infection during pregnancy. 

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

  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 FAQ How can I help my pregnant and postpartum patients manage stress, anxiety, and depression?) and to encourage patients to communicate regularly with their health care team. Clinicians are encouraged to share ACOG’s patient resources as appropriate.

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

  Last updated December 17, 2020 at 9:55 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). Some studies have suggested that there may be an increased rate of preterm delivery and stillbirth in pregnant women with active SARS-CoV-2 infection compared with those in the general population (Knight 2020, Delahoy MMWR 2020, Panagiotakopoulos MMWR 2020, Woodworth MMWR 2020). It is unclear if these outcomes are directly due to SARS-CoV-2 infection or an indirect effect that results from severe maternal illness or iatrogenic intervention.  Further, in a report from the PRIORITY study, among 263 initial infants enrolled, no difference in adverse outcomes, including preterm birth, NICU admission, and respiratory disease, were found between those born to mothers testing positive for SARS-CoV-2 and those born to mothers testing negative. Black and Latina women were underrepresented in the PRIORITY study population as compared with previous assessments of the racial/ethnic distribution of SARS-CoV-2 infection in the U.S., highlighting a key limitation of the study (Flaherman, 2020). Another report of pregnancy outcomes by SARS-CoV-2 exposure of 252 individuals in a more racially and ethnically diverse cohort also suggested no differences in a composite outcome of preterm birth, preeclampsia with severe features, or cesarean for abnormal fetal heart rate (Adhikari 2020). Specifically, preterm delivery rates did not differ between groups (RR 1.02, (95% CI 0.70-1.48). More data are needed to understand the possible association between SARS-CoV-2 infection and delivery timing, placental function, and neonatal outcomes.

  Population 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).

  ACOG continues to monitor the emerging literature on these topics.

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

  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 FAQ How can I help my pregnant and postpartum patients manage stress, anxiety, and depression?) and to encourage patients to communicate regularly with their health care team. Clinicians are encouraged to share ACOG’s patient resources as appropriate.

• Q: Should pregnant patients wear a mask or a cloth facial covering?

  Last updated August 20, 2020 at 10:21 a.m. EST.

  Pregnant patients should follow the same recommendations as the general population as outlined by the CDC with regard to wearing a mask or a cloth facial covering. ACOG recommends all individuals older than two years of age wear a mask or cloth face covering in public and when around people outside of the household, especially in settings where other social distancing measures are not feasible. In particular, all persons entering a health care facility should wear a cloth face covering or facemask for the duration of their visit. Patients also should adhere to respiratory hygiene, cough etiquette, and hand hygiene and follow triage procedures throughout the duration of the visit.

  The cloth facial coverings recommended are not surgical masks or N95 respirators. Surgical masks and N95 respirators are critical PPE supplies that must continue to be reserved for health care workers and other medical first responders, as recommended by current CDC guidance. Further, 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).

  Consistent with recommendations for the general population, masks should be worn when feasible.  However, in the setting of second stage of labor, pushing while wearing a facemask may be difficult and forceful exhalation may significantly reduce the effectiveness of a mask in preventing the spread of the virus by respiratory droplets. This situation further underscores the need for all health care personnel to use appropriate PPE while caring for a person with suspected or confirmed COVID-19. Even in the setting of COVID-19, delayed pushing is not recommended as a strategy to avoid forced exhalation due to the adverse maternal outcomes associated with delayed pushing (Committee Opinion No. 766).

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

  Last updated May 13, 2020 at 2:57 p.m. EST.

  The risk of intimate partner violence is increased in the context of recommendations to shelter in place, physical distancing, financial hardships, and potential isolation and quarantine. 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 women do not or cannot disclose abuse each time they are asked. During the COVID-19 pandemic, screening may need to be provided by telehealth. Unfortunately, screening for intimate partner violence by telehealth may not allow women 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?

  Last updated May 13, 2020 at 3:00 p.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. Especially during this challenging time, obstetrician–gynecologists and other maternal health care professionals should 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). Obstetrician–gynecologists and other maternal health care professionals should reassure patients that even during this time, there are effective treatment and support options. 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.
  
  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 800-944-4773 (extension 4) 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).

  (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?

  Last updated September 10, 2020 at 8:52 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). In both the inpatient and outpatient settings, it is recommended that the number of visitors be reduced to the minimum necessary, for example, those essential for the pregnant individual’s well-being (emotional support persons). 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: What are key factors in considering or applying universal diagnostic testing in labor and delivery units?

  Last updated September 9, 2020 at 1:16 p.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 prioritized for testing (CDC, ACOG Practice Advisory, AMA statement). In addition, facilities may consider additional molecular (eg, PCR by nasopharyngeal swab) testing strategies, such as universal testing because there is the potential for asymptomatic patients to present to labor and delivery units, particularly in high prevalence areas.

  Key factors in considering expanded or universal diagnostic (PCR) testing in labor and delivery units include:

  • Prevalence of COVID-19. Expanded or universal testing has the potential to identify asymptomatic COVID-19 positive patients presenting to labor and delivery units. As such, and given the considerations listed below, this approach is likely most beneficial in areas where there is wide community spread with the potential for many asymptomatic individuals.  
    
  • Testing capacity. If universal testing is being considered for a labor and delivery unit, testing capacity must include the ability to provide rapid results (eg, up to a few hours) in order to affect care during labor. Other types of expanded testing (non-rapid) may be appropriate for situations when a longer turnaround time is acceptable, such as pre-admission testing for scheduled deliveries. 
    
  • Test characteristics. Due to variation in the type of diagnostic tests being offered and the local prevalence of COVID-19, the predictive capability of rapid tests will vary by location. Because of the emergence of many COVID-19 tests that have different characteristics, the sensitivity, specificity, and predictive values may vary widely from test to test. Both false-negative and false-positive results can adversely affect patient management and outcomes and misdirect critical resources. In areas of low prevalence, the positive predictive value may be particularly low, depending on the test being used. In communities where COVID-19 is more prevalent, adverse outcomes associated with false-negatives may have a greater negative impact. 
    
  • Declining testing. Individuals may decline testing for a variety of reasons including stigma, mistrust, and fear of possible mother–baby separation. Facilities should have a plan for the care of individuals who decline COVID-19 testing.  

  Considerations for Other Tests 

  • Antigen tests for SARS-CoV-2 are generally less sensitive than viral tests that detect nucleic acid using reverse transcription polymerase chain reaction (RT-PCR) and perform best when the person is tested in the early stages of infection with SARS-CoV-2 when viral load is generally highest. See FDA’s list of In Vitro Diagnostics Emergency Use Authorization (EUA) for more information about the performance of specific authorized tests. There are limited data to guide the use of rapid antigen tests as screening tests on asymptomatic persons to detect or exclude COVID-19, or to determine whether a previously confirmed case is still infectious. Proper interpretation of antigen test results is important for accurate clinical management of patients with suspected COVID-19, or for identification of potentially infected persons when used for screening. Clinicians should understand antigen test performance characteristics in order to recognize potentially false negative or false positive results and to guide patient management. 
  • Serologic (antibody) tests are non-diagnostic for acute COVID-19 infection, and it is unknown whether the presence of antibodies confers immunity (WHO).  Although the FDA has allowed the conduct of some serological testing for surveillance of community or population-level infection and disease, obstetricians should be aware of their limitations. Serological (antibody) tests should not be used as the sole basis to diagnose COVID-19, to determine staffing decisions or decisions regarding the need for PPE, or to determine if a person has immunity to COVID-19 (AMA, AAFP, IDSA). Instead, these tests should be used as information about whether a person may have previously been exposed. The FDA’s authorized tests, including serological tests, are listed on the Emergency Use Authorization (EUA) page.  
• Q: How should thromboprophylaxis be managed for pregnant and postpartum patients with suspected or confirmed COVID-19 infection?

  Last updated June 1, 2020 at 1:46 p.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. Although evidence is lacking for or against thromboprophylaxis for pregnant and postpartum patients with suspected or confirmed COVID-19, it is reasonable to consider anticoagulation treatment for these patients, particularly if they have severe or critical disease. 
  
  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 pregnant patients continue to receive routine care or specialty (nonobstetric) care or both routine and specialty care?

  Last updated November 4, 2020 at 12:47 p.m. EST

  In most cases, pregnant women should continue or resume necessary preventive health care visits and should also receive care, as needed, with specialists for nonobstetric conditions. Data indicate that preventive health care visits drastically declined at the beginning of the pandemic, which resulted in a concerning decrease in important routine screenings, tests, and vaccines. Pregnant patients who require care for serious medical conditions are strongly encouraged to maintain or resume necessary appointments. 

  Obstetrician–gynecologists and other obstetric care practitioners should counsel their pregnant patients that health care facilities are taking precautions to protect patients and staff from SARS-CoV-2 infection. This may include reducing the number of appointments or spacing the visits further apart, mask requirements, screening individuals for SARS-CoV-2 exposure before their appointment, reducing the number of support persons allowed to attend the appointment, and increased cleaning protocols. Obstetrician–gynecologists can encourage pregnant patients to ask about facility precautions at the places where they may seek additional care. Further, telehealth visits remain an option for many types of health care appointments. Pregnant patients should be counseled to continue to follow recommended prevention measures when entering a health care facility. This includes wearing a face mask, maintaining at least six feet distance from others, and practicing hand hygiene frequently. 

• Q: Should monoclonal antibodies be used as a treatment option in pregnant patients? NEW

  Last updated December 17, 2020 at 9:56 a.m. EST

  Monoclonal antibody treatments have not been tested in pregnant patients and more data are needed in order to make a broad recommendation for this population. Currently, monoclonal antibody treatments are available only under emergency use authorization (EUA) (NIH 2020). These treatments should not be considered the standard of care for treatment of COVID-19. More data are needed to assess the effect of monoclonal antibodies on the disease course of COVID-19 and to identify those people who are most likely to benefit from the drug. These treatments may be in limited supply and should be reserved for patients with mild to moderate COVID-19 who are at high risk for progressing to severe disease. The majority of pregnant patients with COVID-19 will not meet this criterion. However, these products should not be withheld from a pregnant individual who also has a condition that poses a high risk of progression to severe COVID-19, if the clinician thinks that the potential benefit of the drug outweighs potential risk. Examples may include (but are not limited to) a pregnant patient with a history of solid organ transplant or someone with advanced vascular disease related to other comorbidities such as type 1 diabetes mellitus. Efforts should be made to ensure that communities most affected by COVID-19 have equitable access to these treatments. Future data will likely inform optimal use of this therapeutic option in pregnant patients.

Prenatal Care

• Q: How can obstetrician–gynecologists counsel pregnant patients regarding the safety of working in the non-health care environment? REVISED

  Last update December 14, 2020 at 2:03 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). 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). Importantly, analyses so far are limited by a large amount of missing data. Yet, there are insufficient data that stratifies this risk by gestational age, wearing a facemask, capacity to screen for SARS CoV-2 infection, or the effect of the level of community prevalence of SARS-CoV-2 infection.
  
  Importantly, pregnant individuals may continue to work until they give birth. For many women, not working is not feasible.  Employers should support pregnant individuals working throughout pregnancyand accommodations should be made. Depending on the state, employers may be required by law to provide accommodations to pregnant and breastfeeding employees that minimize risk of exposure to COVID-19. Employers typically are prohibited from forcing a pregnant employee out of work. ACOG recommends that:

  • Pregnant individuals who continue to work should be provided the ability to occupy roles in which there is reduced risk of exposure to COVID-19 if they so choose.
  • Employers follow current CDC guidance and direction from local and state health departments (CDC). 
  • Employers assess the hazards to which their workers may be exposed; evaluate the risk of exposure; and select, implement, and ensure workers use controls to prevent exposure (Department of Labor). 
  • Prevention practices, including physical distancing, hand hygiene, surface decontamination, and wearing a cloth face covering or facemask (for source control), should be applied to all individuals given the potential for asymptomatic SARS-CoV-2 transmission.
  • Accommodations related to the work environment specific to nonpregnant employees with comorbidities should be applied to pregnant employees with similar comorbidities. This is because pregnant individuals with comorbidities continue to be at increased risk of severe illness consistent with the general population with similar comorbidities. 

  If a pregnant individual requests a letter to support a COVID-19-specific work accommodation, maternal health care professionals can respond to the request in the context of the risk to the pregnant individual considering the particular patient’s circumstances. Further, maternal health care professionals should advocate for every possible protection from exposure to COVID-19 (eg, masks, gloves, remote working, proper ventilation, etc) for pregnant women in the work place. 
  
  Requests for leave will depend on the patient’s individual work situation (see Committee Opinion No. 733, Employment Considerations During Pregnancy and the Postpartum Period, for more information on writing a work accommodation note and key resources to provide patients). We understand that our patients are experiencing increased stress because of COVID-19. When counseling pregnant patients about COVID-19, it is important to acknowledge that these are unsettling times (see the FAQ “How can I help my pregnant and postpartum patients manage stress, anxiety, and depression?”). Health care professionals are encouraged to share ACOG’s patient resources as appropriate. ACOG will continue to diligently monitor the literature for COVID-19 risk signals in pregnancy.

• Q: Is it appropriate to modify prenatal care delivery to decrease the risk of COVID-19 spread and exposure?

  Last updated September 2, 2020 at 10:22 a.m. EST.

  Yes. Alternate prenatal care delivery approaches have been proposed as a strategy in the effort to control the spread of COVID-19 among patients, caregivers, and staff. Although evidence is limited regarding the safety and efficacy of these approaches, ACOG recognizes the need to implement innovative strategies during this rapidly evolving public health emergency, with consideration of differences in care settings and population risks. Emerging evidence suggest that with the appropriate precautions, in-person obstetric health care can be safely performed and is not likely to be an important risk factor for infection (Reale 2020). Any decision to modify prenatal care delivery should be made at the local and individual level.

  • Obstetrician–gynecologists and other obstetric care clinicians should continue to provide medically necessary prenatal care, referrals, and consultations. 
  • Obstetric care clinicians should be prepared to explain the rationale for any change in prenatal care or delivery scheduling, emphasizing that these modifications have been made in order to limit the risk of exposure to the virus for the mother and the fetus or infant.
  • It is recommended that the patient–clinician discussion regarding a plan for alternate prenatal care in the setting of the COVID-19 pandemic be documented in the medical record.

  Some examples of approaches to modifying prenatal care that may be considered are listed below. However, modifying or reducing care is only appropriate because the risk of inadvertent exposure from receiving or delivering care can be high at this time; normal care approaches and schedules should resume when this risk subsides. Plans for modified care are best made at the local level with consideration of patient populations and available resources.

  • Spacing out appointments.
    • Health care clinicians may choose to continue in-person prenatal care appointments for patients who are not sick, if staffing is available, but space out in-person appointment times where appropriate to reduce the number of patients in the office or facility at one time.
    • This may be accompanied by postponing some nonemergent gynecologic or well-woman appointments to facilitate social distancing and to maintain availability to accommodate medically necessary appointments; appointments for which a delay will negatively affect patient health and safety should not be delayed.
  • Alternate or reduced prenatal care schedules.
    • Consider grouping components of care together (eg, vaccinations, glucose screenings, etc) (Committee Opinion 718) to reduce the number of in-person visits.
    • Examples of alternate or reduced prenatal care schedules are listed below as resources. These examples are shared with the express permission of their developers, and without identification when requested. These examples, along with relevant journal publications listed below, are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists.
      • Examples of Alternate or Reduced Prenatal Care Schedules

  Resources

  Webinar topics include: ultrasound timing; implementing a variety of telehealth modalities; testing strategies and screening procedures; PPE; staffing models; L&D management and strategies, mother-baby approaches; obstetric critical care; and discharging processes.

  • ACOG Safe Motherhood Initiative and the New York State Department of Health New York State Perinatal Quality Collaborative Webinar: Guided Discussion on COVID-19 & Pregnancy, May 7, 2020
  • ACOG Safe Motherhood Initiative and the New York State Department of Health New York State Perinatal Quality Collaborative Webinar: Guided Discussion on COVID-19 & Pregnancy, April 23, 2020

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

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

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

  Yes, and 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. Importantly, the ability to access telemedicine may vary by patient resources and some assessment of this—although often challenging in times of crisis—will be necessary to ensure equitable 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 clinicians 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.

  The Drug Enforcement Administration has released guidance allowing health care clinicians 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).

• 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: Which antenatal fetal surveillance and ultrasound examinations are essential to continue as recommended?

  Last updated November 4, 2020 at 1:52 p.m. EST.

  Antenatal fetal surveillance and ultrasonography (Practice Bulletin 175) should continue as medically indicated when possible. Elective ultrasound examinations should not be performed (Practice Bulletin 175), and ultrasonography should be used prudently and only when its use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient (Committee Opinion 723). Prior to any in-person visit, clinicians should inform patients of any guidance in place regarding visitors. Visitors must be screened prior to entering the clinic space (SMFM ultrasound). ACOG recommends all individuals older than two years of age wear a mask or cloth face covering in public and when around people outside of the household, especially in settings where other social distancing measures are not feasible. In particular, all persons entering a health care facility should wear a cloth face covering or facemask for the duration of their visit. (See the How should visitation rules be modified in the setting of the COVID-19 pandemic? FAQ).

  It may be appropriate to postpone or cancel some testing or examinations if the risk of exposure and infection within the community outweighs the benefit of testing. However, this should be a decision made at the local practice or facility level, balancing the risks and benefits of decreased exposure, completing the test, and site capacity. As with other components of prenatal care, reducing care is only appropriate because the risk of inadvertent exposure from receiving or delivering care can be high at this time; normal antenatal testing or ultrasonography scheduling should resume when this risk subsides.

  Any modifications made to care should be relayed to patients with a discussion of the altered balance of risks and -benefits of coming to the office for testing or ultrasonography in the setting of a global pandemic, and should be documented in the medical record.

• 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: Are there any special considerations regarding use of low-dose aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) during pregnancy or the postpartum period in a patient with suspected or confirmed COVID-19?

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

  ACOG is aware of news reports suggesting that the use of nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, could worsen COVID-19. ACOG also is aware of the Lancet article hypothesizing that NSAIDs (ibuprofen in particular) could aggravate COVID-19 symptoms, although pregnancy was not specifically addressed in this article.

  Currently, ACOG is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms. As such, and because of the prevalence of low-dose aspirin use during pregnancy and the importance of low-dose aspirin in preeclampsia prevention (Committee Opinion 743, Practice Bulletin 202), low-dose aspirin should continue to be offered to pregnant and postpartum women as medically indicated. For patients with suspected or confirmed COVID-19 for whom low-dose aspirin would be indicated, modifications to care may be individualized.

  ACOG continues to monitor the situation and the FDA continues to investigate the issue.

• Q: Are there any special considerations regarding GBS collection?

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

  Group B streptococcus (GBS) screening should occur as indicated during the recommended time period, 36 0/7–37 6/7 weeks of gestation (Committee Opinion 797). Consideration may be given to grouping other components of care during the GBS screen at 36 0/7–37 6/7-week window to reduce the number of in-person prenatal visits needed. Alternatively, patients can self-collect with proper instruction on how to collect a vaginal-rectal swab if the resources and infrastructure are in place to do so.

• Q: How should I counsel patients who are considering home birth because of concerns about COVID-19? REVISED

  Last updated December 14, 2020 at 2:03 p.m. EST.

  Although recognizing that many patients are experiencing new concerns because of the COVID-19 pandemic, hospitals and accredited birth centers remain the safest settings for birth (Committee Opinion 697, “Planned Home Birth”), even during COVID-19. 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 (Ellington MMWR 2020, Zambrano, 2020) highlight the importance of delivering at a hospital or accredited birth center. Patients concerned that delivering in a hospital or accredited birth center setting will increase their risk of exposure to COVID-19 should be assured that hospitals and accredited birth centers continue to be safe with strict infection control procedures. ACOG, AAFP, ACNM, and SMFM have released a statement with additional information.

  Please see:

  • Committee Opinion 697, Planned Home Birth, for additional guidance, including counseling regarding risk and benefits and absolute contraindications.
  • How should visitation rules be modified in the setting of the COVID-19 pandemic? FAQ for information about visitors.
  • Coronavirus (COVID-19), Pregnancy, and Breastfeeding Patient FAQs.
  • ACOG’s Practice Advisory for key postpartum points, including the importance of shared decision making between the mother and the clinical team.

   

• Q: Are there additional components to prenatal care that should be considered? REVISED

  Last updated December 14, 2020 at 2:03 p.m. EST.

  Yes. Obstetrician-gynecologists and other maternal health care clinicians should:

  • 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 women with symptomatic COVID-19 infection.
  • Emphasize the importance of taking all available precautions to avoid exposure to COVID-19 and to prevent infection 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

  It may also be necessary to:

  • Offer mental health or social work services or referrals to provide additional resources, particularly for patients who are experiencing anxiety regarding the COVID-19 pandemic or are at an increased risk of intimate partner violence (Committee Opinion 518).
  • Provide enhanced anticipatory counseling to patients regarding:
    
    • Any potential changes to length of hospital stay and postpartum care.
    • How to best communicate with their obstetric care team, especially in the case of an emergency.
    • Signs and symptoms of labor and when to call their obstetric care clinician.
    • Any special considerations for infant feeding.
    • Checking with their pediatric clinician or family physician regarding newborn visits because pediatric clinicians or family physicians also may be altering their procedures and routine appointments (American Academy of Pediatrics).
    • Postpartum contraception. Ideally, all methods of contraception should be discussed in context of how provision of contraception may change within the limitations of decreased postpartum in-person visits. For patients who express interest in postpartum contraception, clinicians should discuss the additional benefit of immediate postpartum long-acting reversible contraception (LARC): an additional visit for placement is not needed (Committee Opinion 670) and placement is not resource intensive. (For information on tubal sterilization, please see How can elective procedures be managed to optimize personnel and resources?)
    • Any potential changes to their postpartum care team and support system. Most patients will likely have had changes to expected care support resources at home (eg, family who can no longer travel, childcare providers who are no longer available). To the extent possible, patients should be connected to community support resources.

  It should be noted that it may be necessary to provide these services or other enhanced resources by phone or electronically where possible. If telehealth visits are anticipated, patients should be provided with any necessary equipment (eg, blood pressure cuffs) if available and as appropriate.

   

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

  Last updated April 29, 2020 at 4:00 p.m. EST.

  Yes. Maternal immunizations continue to be an essential component of prenatal care during the COVID-19 pandemic. 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: Are there special considerations regarding recommended use of antenatal corticosteroids for fetal benefit for a patient with suspected or confirmed SARS-CoV-2 infection?

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

  At the beginning of the COVID-19 pandemic, based on experience in both SARS and MERS, recommendations cautioned against the use of systemic corticosteroids due to risk of worsening clinical status, delayed viral clearance, and adverse events (IDSA). Based on these concerns for potential maternal harm and weighing them against the neonatal benefits of antenatal corticosteroid administration during different gestational ages, ACOG originally suggested to continue offering antenatal corticosteroids in the preterm period for women with suspected or confirmed COVID-19 but to not offer antenatal corticosteroids to pregnant individuals with suspected or confirmed COVID-19 at 34 0/7 – 36 6/7 weeks of gestation. However, based on recent data supporting the use of corticosteroids in severely ill patients in the treatment of COVID-19, it does not appear that the administration of corticosteroids leads to maternal harm. Therefore, ACOG now recommends offering antenatal corticosteroids, as indicated, for fetal benefit, as outlined in Committee Opinion 713, including during the late preterm period.

  ACOG will continue to diligently monitor the literature on the use of corticosteroids for patients with suspected or confirmed COVID-19.

   
• 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?

  Last updated November 6, 2020 at 12:35 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.

  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: How can scheduled inductions of labor or cesarean deliveries be managed to optimize personnel and resources?

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

  Inductions of labor and cesarean deliveries should continue to be performed as indicated. Decisions on how to schedule these procedures in the time of the COVID-19 pandemic are best made at the local facility and systems level, with input from obstetric care professionals and based on health care personnel availability, geography, access to readily available local resources, and coordination with other centers. (For information on elective procedures, please see How can elective procedures be managed to optimize personnel and resources?)

• 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 should umbilical cord blood banking be managed during the COVID-19 pandemic?

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

  Respiratory diseases are typically not transmitted by the transfer of human cells. Currently, there are no reported cases of transmission of COVID-19 by blood products (FDA); therefore, umbilical cord blood banking can continue to be managed according to clinical guidance (Committee Opinion 771), in the setting of appropriate clinician personal protective equipment. A variety of circumstances may arise during the process of labor and delivery that may preclude adequate cord blood collection. Umbilical cord blood collection should not compromise obstetric or neonatal care or alter routine practice of delayed umbilical cord clamping with the rare exception of medical indications for directed donation (Committee Opinion 771).

• 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: Should intrapartum oxygen continue to be used in the setting of COVID-19?

  Last updated April 29, 2020 at 4:00 p.m. EST.

  Oxygen should continue to be considered if maternal hypoxia is noted (Practice Bulletin 116). Based on limited data, high-flow oxygen use is not considered an aerosol-generating procedure (CDC). Still, there is insufficient evidence about the cleaning and filtering when using oxygen. As such, facilities should consider suspending routine use of intrapartum oxygen for indications where benefits of use are not well-established (eg., category II and III fetal heart rate tracings).

• Q: Should intrapartum fever be considered as a possible sign of COVID-19 infection?

  Last updated April 29, 2020 at 4:00 p.m. EST.

  Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Fever is the most commonly reported sign; most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (cough, difficulty breathing). However, other causes of intrapartum fever should not be overlooked.

  Data regarding COVID-19 in pregnancy are limited; according to current information, presenting signs and symptoms are expected to be similar to those for non-pregnant patients, including the presence of fever.

  Other considerations that may guide testing are epidemiologic factors such as the occurrence of local community transmission of COVID-19 infections. As part of evaluation, clinicians are strongly encouraged to test for other causes of respiratory illness and peripartum fever. For more information please see: Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19).

• 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: Should expedited discharge be considered during the COVID-19 pandemic?

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

  Yes. To limit the risk of inadvertent exposure and infection, it may be appropriate to expedite discharge when both the mother and the infant are healthy (Committee Opinion 726). For example, discharge may be considered after 1 day for women with uncomplicated vaginal births and after 2 days for women with cesarean births depending on their status. Early discharge will require discussion with the facility’s pediatric care team and should be linked to home telehealth visits for the mother and infant.

• Q: Are there additional components to postpartum care that should be considered?

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

  Yes. It may be necessary to:

  • Offer mental health or social work services or referrals to provide additional resources, particularly for patients who are experiencing anxiety regarding the COVID-19 pandemic or are at an increased risk of intimate partner violence (Committee Opinion 518).
  • Offer modified postpartum counseling regarding:
    
    • Any potential changes to the length of hospital stay and postpartum care.
    • How to best communicate with their postpartum care team, especially in the case of an emergency.
    • When and how to contact their postpartum care clinician.
    • Any special considerations for infant feeding.
    • Checking with their pediatric clinician or family physician regarding newborn visits because pediatric clinicians or family physicians also may be altering their procedures and routine appointments (American Academy of Pediatrics).
    • Postpartum contraception. Ideally, all methods of contraception should be discussed in context of how provision of contraception may change within the limitations of decreased postpartum in-person visits.
    • Any potential changes to their postpartum care team and support system. Most patients will likely have had changes to expected care support resources at home (eg, family who can no longer travel, childcare providers who are no longer available). To the extent possible, patients should be connected to community support resources.

  It should be noted that it may be necessary to provide these services or enhanced resources by phone or electronically where possible. If telehealth visits are anticipated, patients should be provided with any necessary equipment (eg, blood pressure cuffs) if available and as appropriate.

• Q: Is it appropriate to modify postpartum care delivery approaches to decrease the risk of COVID-19 exposure?

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

  As with prenatal care, yes (see Is it appropriate to modify prenatal care delivery to decrease the risk of COVID-19 spread and exposure? for important considerations). However, modifying or reducing care is only appropriate because the risk of inadvertent exposure from receiving or delivering care can be high at this time; normal care approaches and schedules should resume when this risk subsides. Plans for modified care are best made at the local level with consideration of patient populations and available resources. Some examples of approaches to modifying postpartum care that may be considered are listed below.

  • Perform the initial three week (or sooner) assessment (Committee Opinion 736), wound checks, and blood pressure checks by phone or telehealth visits, if possible.
  • Delay the comprehensive postpartum visit to 12 weeks, with the intention of seeing the patient for the comprehensive assessment in person and using telehealth visits as needed before 12 weeks. However, it should be noted that some patients may lose insurance before 12 weeks postpartum; in this case, the comprehensive postpartum visit should be prioritized and scheduled before the patient loses insurance and also can be completed by telehealth visit.
• Q: How should newborn male circumcisions be managed during the COVID-19 pandemic?

  Last updated April 29, 2020 at 4:00 p.m. EST.

  If requested, well newborn male circumcision is considered indicated care (American Academy of Pediatrics). However, given the current demands on medical personnel, it may not always be possible to provide this service. Facilities are encouraged to consult with their obstetric, pediatric, and family medicine teams and temporarily modify their policies based on COVID-19 community spread, health care personnel availability, and access to readily available local resources.

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

  Last updated June 9, 2020 at 12:04 p.m. EST.

  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. 

  
  
• 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?

  Last updated April 29, 2020 at 4:00 p.m. EST.

  Prisons, jails, and detention facilities are high-risk environments for COVID-19 transmission. For pregnant people who must remain in custody, prisons, jails, and detention facilities should implement measures for social distancing, hygiene, screening, testing, medical care, 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, postpartum care and breastmilk expression, and timely assessment of pregnancy-related or COVID-19 symptoms, in accordance with ACOG guidance. Barriers to accessing care within institutions, such as co-pays for incarcerated individuals, should be removed.

COVID-19 FAQs

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