Last updated July 8, 2021
Summary of Key Updates (July 8, 2021)
Below is a summary of recent updates to this Practice Advisory.
- This Practice Advisory has been updated to reflect the current status of the COVID-19 pandemic in the United States. Recommendations regarding COVID-19 vaccination can be found in ACOG’s Practice Advisory: COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care
- ACOG has additional information on a broad range of topics related to COVID-19 in its Frequently Asked Questions.
General Information Regarding Pregnant Individuals and COVID-19
The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (SMFM) have developed an algorithm to aid practitioners in assessing and managing pregnant individuals with suspected or confirmed COVID-19. View the algorithm (Spanish version).
Available data suggest that symptomatic pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Khan 2021). CDC includes pregnant and recently pregnant individuals in its “increased risk” category for severe COVID-19 illness. Although the absolute risk for severe COVID-19 is low, available data indicate an increased risk of ICU admission, need for mechanical ventilation and ventilatory support (ECMO), and death reported in pregnant women with symptomatic COVID-19 infection, when compared with symptomatic non-pregnant women (Zambrano MMWR 2020, Kahn 2021). Additionally, compared to asymptomatic pregnant patients, severe–critical COVID-19 illness has been associated with adverse perinatal outcomes such as increased risk of hypertensive disorders of pregnancy, while mild-to-moderate illness has not been associated with adverse perinatal outcomes (Metz 2021). Findings related to increased risk of cesarean birth related to COVID-19 illness have been inconsistent (Metz 2021, Wei 2021). Pregnant and recently pregnant patients with comorbidities such as obesity, diabetes, hypertension, and lung disease may be at an even higher risk of severe illness consistent with the general population with similar comorbidities (Ellington MMWR 2020, Panagiotakopoulos MMWR 2020, Knight 2020, Zambrano MMWR 2020, Galang 2021). Further, the risk of moderate-to-severe or critical illness during pregnancy appears to increase with increasing maternal age (Metz 2021, Galang 2021). Black and Hispanic individuals who are pregnant appear to have disproportionate SARS CoV-2 infection and death rates (Ellington MMWR 2020, Moore MMWR 2020, Zambrano MMWR 2020). 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 (Afshar, 2020).
Clinicians should counsel pregnant individuals and those contemplating pregnancy about the potential risk of COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for these individuals and their families. Pregnant individuals are encouraged to take all available precautions to avoid exposure to COVID-19 and optimize health including:
- Talking to their clinician about COVID-19 vaccination during pregnancy or postpartum, if not already vaccinated
- Follow routine hygiene practices including washing hands often
- Continue following safety measures to prevent COVID-19 infection if not fully vaccinated, including wearing a mask, maintaining physical distancing, and limiting contact with other individuals as much as practical
The increased risk of severe illness for pregnant and recently pregnant people highlights the critical importance of vaccination for family members and clinicians caring for these individuals. Pregnant and recently pregnant people can receive a COVID-19 vaccine to protect themselves. Information on vaccination is available in the ACOG Practice Advisory “COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care.”
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.
The Centers for Disease Control and Prevention (CDC) suggests that fully vaccinated people can refrain from routine screening testing if feasible. Some facilities may decide that testing does not need to be performed for patients with documentation of vaccination. The yield of testing for identifying asymptomatic infection might be lower among vaccinated patients because a growing body of evidence suggests that fully vaccinated people are less likely to have asymptomatic infection. However, testing vaccinated individuals might continue to be useful in some situations to inform the type of infection control precautions used (e.g., room assignment/cohorting, or personal protective equipment used) and routine performance of SARS-CoV-2 viral testing upon admission to labor and delivery for all patients may still be done at the discretion of the facility.
Routine testing has the potential to identify unvaccinated asymptomatic COVID-19 positive patients presenting to labor and delivery units. As such, this approach is likely most beneficial in areas where there is wide community spread or low vaccination rates with the potential for many asymptomatic individuals.
Regardless of vaccination status, individuals may decline testing for a variety of reasons including stigma, mistrust, and fear of possible mother–baby separation. Facilities that continue to practice routine screening testing in labor and delivery should have a plan for the care of individuals who decline COVID-19 testing.
Addressing Inequities in Racial and Ethnic Minority Populations
Obstetrician–gynecologists and other women’s health care professionals can work toward addressing inequities in the health care system by confronting individual and structural biases. Communities of color, particularly among Black, Latinx, Asian American and Pacific Islander, and Native American people continue to experience disproportionate rates of COVID-19 infection, severe morbidity, and mortality. Social determinants of health, current and historic inequities in access to health care and other resources, and structural racism contribute to these disparate outcomes. These inequities also contribute to disproportionate rates of comorbidities in these communities that place individuals at higher risk of severe illness from COVID-19. Access to vaccines, testing, and health care resources also may be limited in these communities. Additional data are needed to understand the full extent of these disparities and inequities and to guide equitable allocation of health care resources and other public health interventions.
Infection Prevention and Control in Inpatient Obstetric Care Settings
The CDC has published Considerations for Inpatient Obstetric Healthcare Settings. These considerations apply to health care facilities providing obstetric care for pregnant individuals with confirmed COVID-19 or pregnant persons under investigation in inpatient obstetric health care settings including obstetric triage, labor and delivery, recovery, and inpatient postpartum settings.
ACOG encourages physicians and other obstetric care professionals to read and familiarize themselves with the complete list of recommendations.
Key highlights from the recommendations include:
- Health care professionals should follow their health care facility’s policies and their local and state health department policies for notification of a person under investigation for COVID-19. Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms may be reserved for patients undergoing aerosol-generating procedures.
- Infants born to patients with known COVID-19 at the time of delivery should be considered infants with suspected COVID-19. As such, infants with suspected COVID-19 should be tested, isolated from other healthy infants, and cared for according to the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19).
- Infants born to a pregnant individual with suspected COVID-19 for whom testing is unknown (either pending results or not tested) are not considered to be infants with suspected COVID-19.
- Discharge for postpartum individuals with suspected or confirmed COVID-19 should follow recommendations described in CDC’s Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) in conjunction with guidance from the local and state health department and health system.
Precautions for Health Care Personnel: Personal Protective Equipment
COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care. Personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) can be found here, and CDC provides strategies for how to optimize the supply of PPE.
As vaccination rates increase, it is still critical to maintain general infection control strategies in health care settings. Regardless of vaccinations status, obstetric care clinicians should still wear adequate and appropriate PPE when caring for patients with suspected or confirmed COVID-19.
Location of the Mother-Infant Dyad
Early and close contact between the mother and neonate has many well-established benefits including increased success with breastfeeding, facilitation of mother-infant bonding, and promotion of family-centered care. Although some data have demonstrated that co-location of mother-neonate dyads may be associated with late-onset neonatal COVID-19 infections, other data on this topic demonstrate no difference in risk of SARS-CoV-2 infection whether a neonate is cared for in a separate room or remains in the mother’s room (Raschetti 2020, CDC 2020). 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, using appropriate safety measures to minimize the risk of transmission (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 practitioners should respect maternal autonomy in the medical decision-making process. Decision-making around rooming-in or separation should be free of any coercion, and facilities should implement policies that protect an individual’s informed decision.
For mothers with suspected or confirmed COVID-19, rooming-in should be combined with safety measures to minimize the risk of transmission, including:
- Mother using a mask or cloth face covering and practicing hand hygiene prior to and during all contact with the neonate. Masks or cloth face coverings should not be placed on neonates or children younger than 2 years of age.
- Engineering controls such as using physical barriers (eg, placing the neonate in a temperature-controlled isolette) and keeping the neonate 6 feet or more away from the mother as often as possible.
- If it is possible to have a non-health care professional caregiver provide care for the neonate while in the hospital, it should be an individual who is not at increased risk for severe illness and uses appropriate infection prevention precautions (e.g., wearing a mask, practicing hand hygiene).
While enabling rooming-in is a key practice to encourage and support breastfeeding, there may be circumstances (related to COVID-19 or otherwise) where temporary separation is appropriate for the well-being of the mother and neonate. Decisions about temporary separation should be made in accordance with the mother’s wishes.
Considerations for counseling patients considering temporary separation include:
- Mothers with suspected or confirmed SARS-CoV-2 infection do not pose a potential risk of virus transmission to their neonates if they have met the criteria for discontinuing isolation and precautions:
- At least 10 days have passed since their symptoms first appeared (up to 20 days if they have more severe to critical illness or are severely immunocompromised), and
- At least 24 hours have passed since their last fever without the use of antipyretics, and
- Their other symptoms have improved.
- Mothers who have not met these criteria may choose to temporarily separate from their neonates in an effort to reduce the risk of virus transmission. However, if after discharge they will not be able to maintain separation from their neonate until they meet the criteria, it is unclear whether temporary separation while in the hospital would ultimately prevent SARS-CoV-2 transmission to the neonate, given the potential for exposure from the mother after discharge.
- Separation may be necessary for mothers who are too ill to care for their infants or who need higher levels of care.
- Separation may be necessary for neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care).
- Consideration for separation as an approach to reduce the risk of transmission from a mother with suspected or confirmed SARS-CoV-2 to her neonate is not necessary if the neonate tests positive for SARS-CoV-2.
If temporary separation is undertaken, mothers who intend to breastfeed should be supported and encouraged to express their breastmilk to establish and maintain the milk supply. If possible, a dedicated breast pump should be provided.
Infant Feeding with Breastmilk
Breastmilk provides protection against many illnesses and there are few contraindications to breastfeeding (Committee Opinion 756, CDC's Pregnancy and Breastfeeding). According to the CDC, breastmilk is not likely to be a source of COVID-19 infection. While breastmilk samples occasionally test positive for COVID-19 genetic material, no replication-competent virus has been detected. Therefore, suspected or confirmed maternal COVID-19 is not considered a contraindication to infant feeding with breastmilk.
Individuals with suspected or confirmed COVID-19 can transmit the virus through respiratory droplets while in close contact with the infant, including while breastfeeding. Therefore, obstetrician-gynecologists and other maternal care practitioners should counsel patients with suspected or confirmed COVID-19 who intend to infant feed with breastmilk on how to minimize the risk of transmission, including:
- Breastmilk expression with a manual or electric breast pump. This includes the importance of proper hand hygiene before touching any pump or bottle parts and following recommendations for proper pump cleaning after each use. If possible, individuals should consider having someone who does not have suspected or confirmed COVID-19 infection and is not sick feed the expressed breastmilk to the infant. Additionally, individuals should be counseled on whether the facility is able to provide a dedicated breast pump.
- Safety measures if breastfeeding. A mother with suspected or confirmed COVID-19 who wishes to breastfeed her infant directly should take all possible precautions to avoid spreading the virus to her infant, including hand hygiene and wearing a mask or cloth face covering, if possible, while breastfeeding.
Even in the setting of the COVID-19 pandemic, obstetrician–gynecologists and other maternal care practitioners should support each patient’s informed decision about whether to initiate or continue breastfeeding, recognizing that the patient is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal (Committee Opinion 756).
ACOG will continue to review emerging literature on this topic.
The American College of Obstetricians and Gynecologists will continue to closely monitor the evolution of the 2019 novel coronavirus (COVID-19) in collaboration with the CDC. New and updated information will be shared as it becomes available. Obstetrician-gynecologists and other health care practitioners are encouraged to check ACOG’s COVID-19 webpage and FAQs and CDC’s COVID-19 webpage regularly for updated information.
This Practice Advisory was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group in collaboration with Laura E. Riley, MD; Richard Beigi, MD; Denise J. Jamieson, MD, and Brenna L. Hughes MD.