standard operating procedure · 4 cdn: c132 v 3.0 title: standard operating procedure sars cov-2...

CDN: C132 V 3.0

Title: Standard Operating Procedure SARS COV-2 Infection in Pregnancy

Issued 25/06/2020

Standard Operating Procedure

Standard Operating Procedure for the Management and

Surveillance of SARS COV-2 Infection in Pregnancy

CATEGORY: Procedural Document

CLASSIFICATION: Clinical

PURPOSE To ensure a standardised process for women accessing maternity care at UHB who are suspected or confirmed Covid -19 positive. The aim for these women to receive standardised advice and treatment based on the best available current evidence and recommendation. This includes appropriate review of symptoms, early intervention, process for surveillance and reduction of transmission of SARS COV-2.

Controlled Document Number:

C132

Version Number: 3

Controlled Document Sponsor:

Pratima Gupta (Deputy Divisional Director)

Controlled Document Lead:

Controlled Document Contributors:

Irshad Ahmed (Consultant obstetrician & LW Lead)

Tracey Johnston (Consultant in Maternal and Fetal Medicine,

Deputy Chief Medical Officer, BWCH)

Joselle Wright (Consultant Midwife)

Alison Talbot (Head of Midwifery)

Joan Lilburn (ANC Matron)

Suzanne Wilson (Ward Matron)

Natalie Rossiter (Guideline Lead Midwife)

Ella Vitue (GHH Matron)

Peter Thompson (MFM Consultant, BWCH)

Yasmin Poonawala (Consultant Obstetric Anaesthetist,

BWCH/UHB)

Approved by: Medical Scientific Advisory Group

On: June 2020

Review Date: June 2021

Distribution: Essential Reading for:

This procedure applies to all practitioners and staff groups working within the Obstetrics and Gynaecology directorate within University Hospital Birmingham (UHB). All staff who may come into contact with and who are providing care for SARS COV-2 maternity patients within the UHB such as clinicians (obstetricians, midwives anaesthetists, neonatologist, MSW, administrative staff).

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CLINICAL APPROVAL FOR:

Standard Operating Procedure

Hospital surveillance of suspected and confirmed SARS CoV-2 maternity cases

Name:

Title: Signature

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Contents

1. Procedure Statement 5

2. Introduction 5

3. Identification of at Risk Women 5

4. SARS COV-2 symptoms 6

5. Section A: Management of SARS COV-2 in the Hospital setting;

Antenatal care in Antenatal Clinic (ANC) in women with suspected or confirmed SARS

COV-2

Diabetic

7-8

6. Suspected SARS COV-2 infection in women presenting at the maternity Unit, initial assessment

Triage & Admission

8

7. Admission to Hospital of a Woman with Suspected or Confirmed SARS COV-2 9

8. Timing of Delivery in SARS COV-2 or Suspected SARS COV-2 Women with Significant Respiratory

Compromise

10-11

9. Induction of Labour 11

10. Care during labour for mild, moderate & severe suspected or confirmed SARS COV-2 women 12-13

11. Emergency & Elective Caesarean Sections (LSCS) 14

12. Post- natal management 15

13. Neonatal care 15

14. Thromboprophylaxis for suspected/confirmed SARS COV-2 15-17

15.

16.

Cleaning rooms after use

Homebirth

17

17

17. Section B: Community surveillance of suspected and confirmed SARS COV-2 maternity cases

Flow chart 1: Process of Community Surveillance for Women Suspected or Confirmed SARS COV-2 positive

Testing for SARS COV-2 and Management of these Women

18-21

18. Ultrasound and UKOSS Reporting 21

19. Roles and Responsibilities of the Covid Surveillance Team 21-22

20. Guidance for Delivery, Self-testing and Reporting SARS COV-2 swabs for Maternity Patients at UHB 22

21. References 23

22. Appendices 24-27

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1) Procedure Statement

This is an interim measure in response to the current SARS COV-2 Pandemic, and this will be reviewed every 6 weeks to enable updates to be made and review/ assessment if procedure is still required.

This standard operating procedure (SOP) aims to provide clear and concise instructions in regards

to monitoring and surveillance of women in the hospital and community setting with SARS COV-

2.This document has been written in align with the latest NHS England and Royal College of

Obstetricians & Gynaecologists guideline on ‘Coronavirus (SARS COV-2) Infection in pregnancy,

information for healthcare professionals, Version 8 Published 17th April 2020. This SOP is mainly

divided in to two sections; firstly the management of SARS COV-2 in hospital setting, the second

section will deal with community surveillance for women suspected or confirmed SARS COV-2

positive.

2) Introduction

Novel Coronavirus (SARS-COV-2) is a new strain of coronavirus causing SARS COV-2. SARS-COV-2 virus can be isolated from respiratory secretions, faeces and fomites (everyday objects or materials). There are two routes by which the virus can be spread.

o Through close contact with an infected person (within 2 metres) where respiratory secretions can enter the eyes, mouth, nose or airways. This risk increases the longer someone has close contact with an infected person who has symptoms.

o Indirectly via the touching of a surface, object or the hand of an infected person contaminated with respiratory secretions and subsequently touching one’s own mouth, nose or eyes

Healthcare practitioners such as midwives, obstetricians and maternity support workers can be at risk of greater exposure due to the nature of their repeated close contact with women and their families. Staffs are advised to continually update themselves and adhere to the most recent UHB guidance for PPE.

3) Identification of at Risk Women

Although the incidence is unknown it is important to be aware that there is evolving evidence to suggest that within the general population there may be a cohort of people who are carrying the virus but display only minor symptoms or may even be asymptomatic.

With regards to vertical transmission (transmission from a woman to her baby antenatally or intrapartum) emerging evidence suggests this is possible although the proportion of pregnancies

affected and the significance to the neonate is yet to be determined. It is widely accepted that, whilst pregnant women are not necessarily more susceptible to viral illnesses, changes to their

immune system in pregnancy may be associated with more severe symptoms.

All women from 16 weeks gestation onwards and who test positive for SARS COV-2 and are seen / admitted at BHH, GHH, Solihull site will be captured by a SARS COV-2 Surveillance Team (See section B) and data will be forwarded to the UK Obstetric Surveillance System (UKOSS).

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4) SARS COV-2 symptoms

4.1 Most women who contract COVID -19 will only experience mild or moderate symptoms and recover

relatively quickly.

Symptoms described include;

New continuous cough

High temperature (Fever)

Shortness of breath

Headache

Cold/Flu like symptoms

Sore Throat

Wheezing

Loss of sense of smell or taste (Anosmia)

Gastro intestinal disturbance

Local intelligence suggests that women who are most at risk of SARS COV-2 are those from a Black, Asian

and Minority Ethic backgrounds (BAME) in particular, Asian, Black Afro Caribbean and Black African

backgrounds, these women already have significantly poorer outcomes than other ethnic groups. Other high

risk groups include those with pre-existing medical conditions, BMI> 30, smokers and other specific

vulnerable groups e.g. people with diabetes or safeguarding concerns.

Safeguarding

The Royal College of Obstetricians and Gynaecologists (RCOG) highlight that within the general population

this pandemic will inevitably increase levels of anxiety, the aetiology of which is likely to arise from;

COVID-19 itself

The impact of social isolation- leading to reduced support from wider family and friends

The potential for reduced household finances

Major changes to Antenatal and other NHS care including the change in schedule of appointments

and moving from face to face to telephone consultations.

In addition bereavement, insecurity and inability to access support systems is widely recognised as

risk factors for mental health.

COVID-19 increases the risk of Domestic Violence, Routine enquiry should continue to be asked in

line with UHB Domestic Abuse Policy.

Overall the change in appointment style poses real challenges for all women with existing and/or

new safeguarding concerns, referrals should continue to be made where indicated.

The RCOG recommends that women should be asked about mental health at every contact and signposted

to resources to support them during this time. If any safeguarding concerns are identified women should

continue to be referred to the appropriate services, please refer to the relevant UHB guidance/policy or

contact the safeguarding team if further support is needed.

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Section A: Management of SARS COV-2 in the Hospital setting

5) Antenatal care in Antenatal Clinic (ANC) in women with suspected or confirmed

SARS COV-2

The ANC has been led by consultants (Mr Wyldes at BHH and Dr Howland at GHH) with junior

doctors.

Increase telecommunication ANC appointments. Some appointments will be maintained in hospital

setting particularly USS appointments, GTT Now HbA1C and RBS, pre-op, follow up in DAU & MAC

GTT will be reinstated on all sites from 29th June 2020.

All patients, who are considered clinically safe to deliver to receive antenatal consultation via

telephone. They will be contacted and triaged by designated staff 1-2 days prior to the clinic and the

communication will be recorded on Badgernet. They will be asked not to come in for their

appointment to ANC. Instead they will all be contacted around their appointment times on the day of

the ANC – asked to ensure phone is switched on. Women with mild-moderate symptoms are advised

to self-isolate at home, according to government guidelines. Please refer to section B of this policy

Community surveillance of suspected and confirmed SARS COV-2 maternity cases.

USS for fetal growth surveillance after 14 days following resolution of acute illness. Please refer to

section B of this policy Community surveillance of suspected and confirmed SARS COV-2

maternity cases.

Before calling the patient, doctor should go through patient’s notes on the badger-net. This includes

patient’s obstetric, medical history, antenatal booking plan, growth chart and recent trends of her

observations (BP & urine analysis). After consultation doctor must document clearly on the badger-

net about the consultation including advice about foetal movements and a follow up plan. Ensure

that patient will get appropriate follow up with her community midwife (CMW) particularly in her 3rd

trimester.

Conversation regarding mode of delivery can be discussed over the phone. Make sure there is an

appropriate follow up with the community midwife during her 3rd trimester.

o If opted for vaginal birth after caesarean (VBAC): provide appropriate consultation and advice

backed up with clear documentation on the Badger-net. Arrange a telephone follow up plan

at 40/40 to discuss &doctor to arrange induction of labour (IOL) if not delivered.

o If opted for Caesarean Section (C/S); provide appropriate consultation and advice backed up

with clear documentation on the badger-net. Discuss sterilization and document on the

Badgernet. Doctor to complete elective C/S proforma & give it to ANC clerk to book her C/S

date and also arrange pre-op appointment 2 days prior to her LSCS for covid swab and also

MRSA swabs , bloods and consent. Send appointment via post.

o At pre-op: consent (also check any additional procedures she is having such as sterilization,

oophorectomy etc.), omeprazole to be given, MRSA swabs, Covid swabs and bloods done.

High risk patients such as mild pregnancy induced hypertension (PIH); pre-eclampsia (PET) etc. will

require frequent blood pressure (BP) & urinalysis. These patients may need to come in ANC unless

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CMW is happy to do the observation on weekly basis and escalate to delivery suite of any abnormal

findings. Note: CMW are assisting in ensuring care delivered in the safest setting therefore will assist

wherever possible to undertake necessary observations. Is this agreed

Specialised joint obstetrics clinics: neurology, diabetes, haematology, rheumatology, respiratory,

renal, preterm prevention clinic (PPC), fetal medicine clinics will be left to discretion of the clinician

who is running the particular clinic.

Diabetic Clinics:

Pregnant women with pre-existing diabetics& gestational diabetes mellitus (GDM) who have

Covid have additional risk and hence they should also be seen in antenatal clinic on the day of their

scan.

Pregnant women with SARS COV-2 infection appear to have a greater risk of hyperglycaemia

and ketones with or without a known diagnosis of diabetes. SARS COV-2 disease precipitates

atypical presentations of diabetes emergencies (e.g. mixed diabetic ketoacidosis (DKA) &

hyperosmolar states).

Blood glucose should be checked in everyone on admission plus a blood ketones check in those

with known diabetes and everyone with capillary glucose over 12mmol/L.

When admitting women with diabetes with suspected or confirmed SARS COV-2 to hospital,

STOP Metformin and SGLTZ inhibitors.

Routine appointments for women with suspected or confirmed SARS COV-2 (growth scans,

HbA1C and random blood sugar (RBS), antenatal community or secondary care appointments)

should be delayed until after the recommended period of self-isolation. Advice to attend more

urgent pre-arranged appointments (fetal medicine surveillance, high risk maternal secondary

care) will require a senior decision on urgency and potential risks/benefits.

6) Suspected SARS COV-2 Women Presenting at the Maternity Unit; Initial

assessment, Triage & Admission

Women may attend maternity units in person, or call maternity services by telephone, to report

symptoms which are suggestive of SARS COV-2.

At Heartlands Hospital BHH: If a woman requires a medical assessment, she should be asked to

alert a member of maternity staff to their attendance when on the hospital premises by telephone.

Women are met at the main entrance of the Princess of Wales (POW) by a staff member wearing

appropriate personal protective equipment (PPE). Woman should be given a surgical facemask to

wear and escorted to Willow Suite (in future Aspen Ward may be used as a Covid Ward).

Women who are presenting at the doors of Delivery suite to be asked the screening questions as

listed above in section 4 by the ward clerk through the closed glass window. If positive to questions,

labour ward co-ordinator to be informed and escort woman with surgical facemask to either Willow or

delivery room 7 or 12. The staff member must wear appropriate PPE.

At Good Hope (GHH): Triage calls are taken in MAC, screening questions asked as above.

Suspected or confirmed cases are met at the main entrance of Fothergill by staff wearing

appropriate PPE and escorted to delivery suite, using the lift. Surgical facemask given to woman to

wear. Any woman with suspected of confirmed SARS COV-2 will be seen on Delivery suite in room

7 or 8.

Low risk birth: women who have SARS COV-2 symptoms will have consultant led care.

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7) Admission to Hospital of a Woman with Suspected or Confirmed SARS COV-2

In the event of a pregnant woman attending with an obstetric emergency and being suspected or

confirmed to have SARS COV-2, maternity staff must follow the Trust PPE procedure. This can

be time consuming and stressful for women. Once PPE is in place, the obstetric emergency should

be dealt with as the priority.

All suspected SARS COV-2 women who are seen in hospital must have a viral swab taken. The

healthcare professionals should also consider other differential diagnoses such as urinary tract

infection, chorioamnionitis, pulmonary embolism etc.

There should be a high threshold for admission (aim is to send home women not in labour with low

obstetrics concern). There should be a clear follow up plan documented on Badgernet and

communicated with the woman.

Labouring women or women with significant obstetric concerns to be admitted on the delivery room

7 or 12 at POW and room 7 or 8 at GHH delivery Suite. Other suitable rooms if SARS COV-2

dedicated rooms are in use.

All suspected COVID 19 patients who are being/are admitted to hospital with one of the following:

o Clinical/radiological evidence of pneumonia,

o Acute Respiratory Distress Syndrome (ARDS),

Fever ≥37.8 AND at least one of acute persistent cough, hoarseness, nasal

discharge/congestion, shortness of breath, sore throat, wheezing or sneezing.

Inform on-call obstetric, anaesthetist, infection disease and neonatal consultants

(neonates only if gestation >23 or more weeks) regarding discussion of her

management.

Isolated fever should be investigated according to the UHB O&G Sepsis and Bacterial

Infections in Pregnancy and the Puerperium guidelines. This will include sending a full blood

count. SARS COV-2 swab should be taken. If any concerns discuss with on call infectious

disease consultant.

The diagnosis of PE should be considered in women with chest pain, worsening hypoxia (particularly

if there is a sudden increase in oxygen requirements) or in women whose breathlessness persists or

worsens after expected recovery from SARS COV-2.

Steroids for fetal lung maturation can be given when indicated per NICE guidance.

Observe all suspected /confirmed SARS COV-2 women for further 48 hours after improvement as

some women can deteriorate. On discharge, advise the woman to return immediately if she

becomes more unwell.

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8) Timing of Delivery in SARS COV-2 or Suspected SARS COV-2 Women with

Significant Respiratory Compromise

This guidance is in accordance with the Birmingham Women Hospital (written by Dr. Tracey

Johnstone) as part of LMS.

Due to the current lack of evidence, a pragmatic approach is required when making decisions

regarding delivery in SARS COV-2 positive or suspected SARS COV-2 positive women with

respiratory compromise.

Preterm delivery has a gestation related impact on the outcome for the baby, risk & benefit analysis

must be considered.

Senior multidisciplinary decision making is essential.

Caesarean section will usually be the most appropriate mode of birth particularly below 34 weeks.

Signs of decompensation include;

If oxygen saturations are <94% on air and requiring supplemental O2 to maintain

saturation ≥94%

the respiratory rate is ≥ 30/min

reduced consciouness level (AVPU) even if the saturations are normal

a respiratory acidosis (pH < 7.3)

there is radiological evidence of pneumonia

reduction in urine output

These are triggers for escalating care urgently using SBAR to consultant level for MDT discussion

(obstetrician, obstetric anaesthetist, neonatologist, intensivist & labour ward co-ordinator). Escalate urgently

if any of these signs develop in a woman who is pregnant or has recently given birth.

1) 34+0 weeks or more, expedite delivery as this may improve oxygenation and avoid the

need for ventilation. Do not give steroids for fetal lung maturation as there is less

evidence of benefit (NICE Clinical Guideline 25 – Preterm Birth & Labour 2015, 2019

update).

2) 28+0 – 33+6 weeks: consider administration of antenatal corticosteroids. If respiratory

symptoms are worsening then do not delay delivery for steroid administration. Give

MgSO4 cover for fetal neuroprotection.

3) 23+0 - 27+6 weeks, in the absence of an obstetric reason for immediate delivery, give

antenatal corticosteroids as above and employ appropriate respiratory support in the

correct clinical environment. If respiratory support fails to maintain oxygenation,

individualise care involving the woman regarding delivery with MgSO4 cover for fetal

neuroprotection OR intubation and ventilation to assess response before moving to

delivery with MgSO4 cover for fetal neuroprotection.

4) Below 20 weeks gestation the benefits of emptying the uterus to relieve aortocaval

compression and decrease oxygen requirements are less pronounced.

All pregnant women who are admitted in the hospital should be reviewed daily by Obstetrician &

Anaesthetist (phone discussion if patient is admitted on the main side of hospital). Fetal monitoring

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should be performed daily where appropriate per UHB & OG Antenatal Fetal Monitoring guideline.

Viability will be checked daily.

These women are at increased risk of VTE and should be prescribed LMWH prophylaxis unless

contraindicated. If LMWH contraindicated or the woman is post-surgery, TEDS should be used-

please refer to Thromboprophylaxis section of this policy.

If patient is ventilated:

These women require consultant level MDT discussion with obstetrician / anaesthetist / neonatologist

/ physician/ intensivist to facilitate appropriate decision-making regarding delivery.

Patient must be reviewed daily on ITU by Consultant Obstetrician and Intensivist in view to expedite

delivery if clinically deteriorating.

If oxygenation is being maintained, continue the pregnancy and await recovery.

Avoid respiratory acidosis and aim to keep pH>7.3 (to protect the foetus)

Patients at 20 weeks gestation or more should be nursed with left lateral tilt using a wedge under the

pelvis.

Proning may be difficult / impossible to achieve in the pregnant woman. As an alternative, the

pregnant woman can be placed in complete lateral position (lateral decubitus position). The proning

teams should be used to assist with the turns and the frequency of these turns determined by the

proning protocols. Consultation with tissue viability specialists should be sought and a clear plan

made on the patients record.

Early ECHO after ICU admission must be performed as emerging evidence suggests increased

tendency to develop cardiomyopathy in the sick COVID pregnant women.

Irrespective of gestation, if oxygenation of the mother cannot be maintained (indicated by PaO2<

8kPa even on FiO2 0.8 and alternative therapies such as position change) or there is reduced lung

compliance affecting CO2 clearance (as indicated by PaCO2>8kPa or pH<7.3) despite optimizing

ventilator settings, consider expediting delivery in maternal interests (if the gestation is between 23+0

– 33+6 weeks administer MgSO4). Do not delay delivery for antenatal corticosteroids. Below 23+0

weeks, terminate the pregnancy by surgical means under clause A or Clause F of the 1967 Abortion

Act.

If ventilation is ongoing after 10 days, there should be an MDT discussion regarding the potential benefits of delivery to aid maternal oxygenation, and the potential timing of this.

9) Induction of Labour

Women should be admitted into an isolation room for the entirety of their labour if possible. At POW,

admit in room 7, 12 or 2 bed Induction bay (toilet is outside the room and needs to be cordoned off),

ideally deliver in that room. Alternatively, transfer suspected / confirmed SARS COV-2 to GHH as

their all delivery rooms have en-suite toilet.

At GHH: Inductions of labour to be admitted onto delivery suite into a single use room.

Consultant to review all induction ladies on the IOL list on the previous day to confirm whether

inductions are appropriate.

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10) Care during labour for mild, moderate & severe suspected or confirmed SARS

COV-2 women

Birth in hospital.

Do not use birthing pool due to possibility SARS COV-2 faecal contaminants.

If labour is confirmed, then care in labour should ideally continue in the same isolation room.

All labouring women should have FBC & G/S sent during admission in case an epidural or

emergency caesarean section is required

Full maternal and fetal assessment including assessment of the severity of SARS COV-2 symptoms

should take place. Inform the multi-disciplinary team (obstetrician, anaesthetist, neonatal, infectious

disease consultants, midwife, and neonatal nurse in charge).The priority for medical care should be

to stabilise the woman’s condition with standard supportive care therapies.

Observations and assessment as per guidelines including temperature, respiratory rate and oxygen

saturations. MEOWS should be completed as medically indicated/instructed- Look out signs &

symptoms of deterioration (difficulty in breathing increased resp rate, use of accessory muscles,

noisy breathing pallor or cyanosis SATS <94% in air, fever greater than 38.0oC).

Signs of decompensation include an increase in oxygen requirements or FiO2 > 40%, a respiratory

rate of greater than 30, reduction in urine output, or drowsiness, even if the saturations are normal.

Escalate urgently using SBAR to obstetric & anaesthetist consultants if any of these signs develop in

a woman who is pregnant or has recently given birth.

If required, radiographic investigations should be performed as for the non-pregnant adult; this

includes chest, X-ray and CT of the chest. Consider additional investigations to rule out differential

diagnoses e.g. ECG, CTPA, echocardiogram as appropriate. Do not assume all pyrexia is due to

SARS COV-2 and also perform full sepsis-six screening and treat per UHB O&G Sepsis and

Bacterial Infections in Pregnancy and the Puerperium guidelines.

Hourly oxygen saturation monitoring Give supplementation oxygen if required aiming to keep

saturation >94%. Escalate to Labour ward coordinator, Obs Consultant and Anaesthetist any

increased requirements for oxygen.

Given the association of SARS COV-2 with acute respiratory distress syndrome, women with

moderate to severe symptoms of SARS COV-2 should be monitored using hourly fluid input/output

charts. Efforts should be targeted towards achieving neutral fluid balance in labour, in order to avoid

the risk of fluid overload pulmonary oedema.

Continuous Electronic Fetal Monitoring, document and escalate in accordance with the UHB Fetal

Monitoring in Labour Guidelines.

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If the woman presents with fever, investigate and treat as per UHB O&G guidelines on Sepsis and

Bacterial Infections in pregnancy, but also consider active SARS COV-2 as a cause of sepsis and

perform SARS COV-2 swab and appropriate PPE & infection control precautions should be initiated.

If woman present asymptomatically and then develops isolated pyrexia during labour without any

respiratory or gastrointestinal symptoms, treat her according to UHB O&G guideline on Sepsis and

Bacterial Infections in Pregnancy. If she develops new onset of respiratory symptoms with/without

pyrexia during labour could be suspected SARS COV-2. Perform SARS COV-2 swab and

appropriate PPE & infection control precautions should be initiated.

Entonox can be used as it is not an aerosol generating device. Early epidural is recommended

(reduces need for GA if urgent delivery is required). Neither epidural nor spinal analgesia are

contraindicated in presence of SARS COV-2.

Mode of birth should not be influenced by the presence of SARS COV-2, unless the woman’s

respiratory condition demands urgent delivery (see section below on mode of delivery). Can

consider shortened 2nd

stage if mother becomes exhaustive, breathing becomes difficult, hypoxia

etc. An individualised assessment of the woman should be made by the MDT to decide whether

emergency caesarean birth or induction of labour is indicated, either to assist efforts in maternal

resuscitation or where there are serious concerns regarding the foetal condition. Individual

assessment should consider: the maternal condition, the foetal condition, the potential for

improvement following elective birth and the gestation of the pregnancy. The priority must always be

the wellbeing of the woman.

Consider early caesarean section for suspicious CTG, avoid FBS & FSE. If caesarean section is

deemed necessary, then transfer to the dedicated emergency obstetric theatre.

Staff caring for suspected / confirmed SARS COV-2 in labour should wear PPE as per

recommendations.

For Category 1 CS, donning PPE is time consuming. This may impact on the decision to delivery

interval but it must be done. Women and their families should be told about this possible delay.

Delayed cord clamping is still recommended as long as there are no other contraindications.

Umbilical Cord blood for pH are done as normal per Trust guideline.

Do not take additional equipment / personal items such as phones into rooms and do not bring out

pens or any equipment

All PPE is removed before leaving the delivery room apart from the face mask which is removed

once outside and discarded in a bin with orange bag.

Hands should be gelled before mask removed and after discarding mask and then washed at the

sink.

Minimise the number of staff members entering the room and theatre. All staff in the operating

theatre must wear appropriate PPE.

One birth partner in labour only. Asymptomatic birth partner should be treated as possibly infected

and asked to wear a mask and wash their hands frequently. If symptomatic, birth partner should

remain in isolation and not attend the unit.

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11) Emergency & Elective Caesarean Sections (LSCS)

The number of staff in the operating theatre should be kept to a minimum and all staff must wear

PPE.

At POW, theatre 1 is the main Covid theatre. If not available then use the back-up theatre. If both

theatres are in use then consider an elective theatre. At GHH, theatre 2 is the Covid theatre.

All PPE is removed before leaving the theatre apart from the face mask which is removed once

outside and discarded in a bin with orange bag.

Hands should be gelled after discarding the facemask and then washed at the sink.

Amber cleaning after each suspected case.

All Elective C/S list must continue as usual.

Suspected case on the elective C/S list will be done at the end of the list followed by full

postoperative theatre clean as per UHB Trust protection guidance.

MSW / midwife from elective theatres will phone the patients listed for following day’s elective list to

check if patient has symptoms as per screening questions. If symptomatic to discuss with the

obstetric consultant and if concerned arrange an assessment on the Willow Suite on the day of

caesarean section. If unlikely to be SARS COV-2 then continue with the elective C/S list. If

suspected then either admit to side room on Cedar/ Maple ward or Willow and do C/S at the end of

elective list followed up by amber cleaning.

All staff (including maternity, neonatal and domestic) should have been trained in the use of PPE.

Anaesthetic management for women with symptoms or confirmed SARS COV-2 should be with

reference to anaesthetic guidance.

General anaesthesia (GA) is an aerosol generating procedure (AGP). Therefore, all procedures (e.g.

C/S, manual removal of placenta, examination under anaesthesia) irrespective of SARS COV-2

status requiring GA or high risk of conversion to GA (e.g. accreta, praevia), all staff in the theatre

must wear FFP3 mask with enhanced PPE. The scrub team should scrub and don PPE before the

GA is commenced.

All COVID positive / suspected cases irrespective of the anaesthetic technique should have

enhanced PPE with FFP3 masks. Birthing partner with surgical mask can attend in the theatre

unless GA.

Regional anaesthesia (spinal, epidural or CSE) is not an AGP. FFP3 masks are not required.

All non SARS COV-2 patients having caesarean section under regional anaesthesia does not

require PPE.

There will be no Saturday elective C/S section list.

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Extra elective C/S will be done on the Delivery suite as category 3 on daily basis if required.

12) Post- natal management

All babies born to suspected or confirmed SARS COV-2 who are asymptomatic do not require SARS

COV-2 swab testing. Symptomatic babies or those admitted in neonatal units require SARS COV-2

Swab testing.

Ensure correct thromboprophylaxis management is in place (see section 14 of this policy)

All babies born to SARS COV-2 positive mothers should have close monitoring and early involvement

of Neonatal care.

Keep mums and babies together as much as possible.

Benefits of breastfeeding outweigh risks, precautions can be taken.

Hand washing before touching the baby, breast pump or bottles.

Wearing a facemask for feeding.

Use of dedicated pump in hospital for expressing milk.

If not able to be discharged directly from delivery suite, to be admitted to the single rooms on Maple

and Cedar wards.

Early discharge for normal births from 6 hours if mum and baby well.

Early discharge for instrumental births within 12- 24 hours if mum and baby well.

Aim for discharge at 24 -48 hours for all C/S if mum and baby well.

Involve neonatal team to review babies if necessary.

No visitor (partner) on the postnatal ward.

Any women or babies requiring readmission for postnatal obstetric or neonatal care during the period

of self –isolation due to suspected or confirmed SARS COV-2 are advised to telephone neonatal unit

and labour ward ahead of arrival.

13) Neonatal care

Suspected / confirmed COVID-19 women with healthy babies, not otherwise requiring neonatal care,

are kept together in the immediate postpartum period.

A risk and benefits discussion with neonatologists and families to individualise care in babies that

may be more susceptible is recommended. These babies will be followed up in the community by

the neonatal unit using telephone consultation.

Queries regarding routine Newborn Screening for babies of suspected/ confirmed COVID-19 should

be discussed with the Screening Team.

14) Thromboprophylaxis for suspected/confirmed SARS COV-2

Pregnant and postpartum women admitted with COVID should have the standard VTE risk

assessment completed. Thrombotic risk for SARS COV-2 patients admitted to hospital is high

regardless of mobility. Assess bleeding risk against usual criteria (accepting that lower platelet

counts are tolerated).

All pregnant women admitted with SARS COV-2 infection or suspected SARS COV-2 infection should receive prophylactic low molecular weight heparin (LMWH), unless contraindicated or birth is expected within 12 hours.

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A postnatal women admitted to hospital with SARS COV-2 infection should receive at least 6 weeks

of prophylactic LMWH, following discharge from hospital.

For women who are self-isolating at home, ensure they stay well hydrated and are mobile

throughout this period. If women are concerned about the development of VTE during a period of

self-isolation, a clinical review (in person or phone) should be attempted to assess VTE risk, and

thromboprophlaxis considered and prescribed on a case-by-case basis. If their VTE risk score at

booking is 3 or more then commencement of prophylactic (LMWH) should be recommended.

If patient is already on anticoagulation with LMWH, maintain this during admission.

*Conditions include: acute bacterial endocarditis, after major trauma, epidural anesthesia, haemophilia or other significant

hemorrhagic disorders, peptic ulcer, recent cerebral haemorrhage, recent surgery to eye, recent surgery to nervous system,

spinal anesthesia, and history of heparin-induced thrombocytopenia and during labour.

**If Platelet count between 30-50 and/ or Fibrinogen <2 review risk of bleeding; if needed liaise with Hematology before

commencing LMWH.

Assess COVID 19 patient status according to table beneath:

Presentation Action

COVID 19 positive pregnant patients in the

community

No anticoagulation prophylaxis unless indicated as per

RCOG guideline

Symptomatic COVID 19 pregnant patients

assessed in hospital but not admitted

(High suspicion of COVID 19 infection/COVID

19 positivity)

Discuss directly with Obstetric Team looking after

patient

For patients under UHB Obstetrics: Consider 7 days of

LMWH based on VTE risk assessment

Antenatal patients admitted for COVID 19

infection

Offer anticoagulation throughout admission and for 4

weeks post discharge (extend to 6 weeks if close to

delivery to cover postnatal period)

Admission in ITU Discuss cases directly with Obstetric team looking after

BLEEDING RISK / EXCLUSIONS

Any contraindication to LMWH*

Evidence of active bleeding including from lungs/respiratory tract or gastrointestinal tract

Platelet count <30 x109/L

**

Recent stroke in preceding 4 weeks

Fibrinogen level< 0.5 g/L**

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patient and Haematology.

If no strict contraindications, give VTE prophylaxis according to the table beneath:

ACTUAL BODY

WEIGHT

<50 kg 50-90 kg 91-130kg 130-170kg >171Kg

ENOXAPARIN

DOSE GIVEN

SUBCUT

20mg

ONCE

DAILY

40mg ONCE

DAILY

60mg ONCE

DAILY

80mg ONCE

DAILY

0.6

mg/Kg/day

(discuss with

haematology

and give

calculated

dose twice

daily)

CRITICAL CARE: SUGGEST 40 mg TWICE DAILY

RENAL

FUNCTION:

If eGFR<30mls/min, reduce dose by 50%.

For immobile patients on ITU with contraindications to LMWH, consider Intermittent Pneumatic Compression (flotrons®) or GEKO device.

15) Home birth

The current home birth rate at University Hospitals Birmingham is 0.2% . Maternity units across the

country have reported an increased demand in homebirth being requested. Local intelligence within

these units suggests that women appear to be choosing home birth as a means of avoiding hospital

which is associated with increased risk of contracting COVID-19

When a woman requests homebirth the community midwife is to detail her reasons for doing so. The

home birth service is currently suspended and women are advised to attend hospital for the birth of

their baby

In exceptional circumstances a request for home birth may be granted, for example if a woman is

shielding herself or someone in her household.

It is important to bear in mind that some women will refuse hospital birth and remain adamant that

they have a home birth. In these cases the Head of Midwifery, consultant midwife and clinical

service lead to agree a way forward and a robust plan.

16) Cleaning rooms after use

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All clinical areas used must be cleaned after use, as per health protection guidance. Normally amber

clean is sufficient. Domestic staff should wear a mask – surgical mask is appropriate.

17)Section B: Community surveillance of suspected and confirmed

SARS COV-2 maternity cases

Women with mild-moderate symptoms are advised to self-isolate at home, according to government guidelines. However, some women will experience more severe symptoms such as shortness of breath prolonged fever. The goal of surveillance is to identify pregnant women who may be experiencing these severe symptoms and ensure they have timely clinical assessment. The aim of the surveillance is to provide a process whereby women who are identified as at risk of deteriorating are identified via robust consultations regarding symptoms through daily surveillance and ensure that women with suspected or confirmed SARS COV-2 infection, who report deterioration in their symptoms, have appropriate and timely clinical review, by midwives, obstetricians, and Infectious Diseases specialists if indicated. Furthermore, escalate any concerns if the process of identifying women who are at risk is not successful.

All women 16 weeks gestation and above will be included in the surveillance for symptoms of SARS COV-2.

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Flow chart 1: Process of Community Surveillance for Women Suspected or Confirmed SARS COV-2 positive (See Appendix 1)

All women 16 weeks/gestation and above

Woman discharged from hospital suspected or confirmed SARS COV-2 positive

Woman contacts maternity unit and during triaging disclosed she is suspected or confirmed SARS COV-2 positive

Woman who has had an antenatal appointment or scan delayed due to showing symptoms on triage

Women identified by the community midwifery team

SARS COV-2 testing performed

NEGATIVE with NO symptoms

A midwife from surveillance team

will conduct daily consultation

call for 5 days and beyond that

woman to call surveillance line if

any concerns regarding

symptoms.

POSITIVE

Suspected Confirmed

A midwife from surveillance team will review by

daily consultation call for 16 days if asymptomatic.

If continues to be asymptomatic discuss with

infectious diseases consultant.

Symptoms


High temperature (Fever)

Shortness of breath

Sore Throat

Wheezing



SYMTOMS MILD

Continue daily consultation with surveillance

midwives and advise woman to contact maternity

unit if symptoms worsen

SYMPTOMS MODERATE TO SEVERE

Woman to attend Aspen Ward at Heartlands Hospital.

Initial assessment to be performed by midwife and

obstetrician & anaesthetist. Once this is completed

Infectious Diseases consultant to review.

Inform the neonatal team

Document all interactions with women and members of multiprofessional team on BadgerNet

Update surveillance spread sheet (See Appendix 1)and inform community midwife.

Ensure all cases are notified to surveillance team email.

Covid positive women to receive an USS for fetal growth assessment 14 days following resolution of symptoms

Ensure women has LWMH

Heparin if indicated

NEGATIVE with symptoms

Retest in 48hrs from last swab. If swab

remains negative, a midwife from

surveillance team will conduct daily

consultation call for 16 days. If

symptoms continue discuss with

infectious diseases consultant.

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Testing for SARS COV-2 and Management of these Women Following women will be tested for SARS COV-2:

o Woman discharged from maternity unit with suspected SARS COV-2 symptoms but hadn’t

been tested for SARS COV-2.

o Woman contacts maternity unit and during triaging discloses that she has symptoms of SARS COV-2.

o Woman who has had an antenatal appointment or scan delayed due to SARS COV-2

symptoms on triage.

o Women identified by the community midwifery teams.

Details of all women suspected or confirmed SARS COV-2 (see appendix 1) should be sent to the email: [email protected]

If a woman is identified in the community setting a testing kit will be delivered to her home by a community maternity support worker. The woman will be provided with clear instructions on how to take the swab; the swab will be collected by the person delivering the swabs and returned to the hospital for testing. Swab collection must be documented on BadgerNet.

The test result will be followed up by a member of the maternity surveillance team who will inform

the woman of the result. If the result is positive then the on-call consultant is to be informed. The result should be documented in BadgerNet and on the SARS COV-2 spreadsheet/proforma (see appendix 1). The date of the positive swab notification will be day 1 for surveillance calls.

Women who test positive for SARS COV-2 whether symptomatic or asymptomatic will receive a

consultation call by the maternity surveillance team for 16 days. If at day 16 the woman is asymtomatic she will not require any further calls. If the woman remains symptomatic, continue daily calls and liaise with the on call infectious diseases consultant for advice.

Women who test negative for SARS COV-2 and remain asymptomatic on day 5 will not require any

further calls.

Women who test negative for SARS COV-2 and are symptomatic will receive a consultation call by the maternity surveillance team for 16 days. If at day 16 the woman is still asymptomatic she will not require any further calls. If the woman remains symptomatic continue daily calls and liaise with the on call infectious diseases consultant for advice.

If women in the community test SARS COV-2 positive and have moderate to severe symptoms they should attend Aspen Ward. Heartlands Hospital for review and the decision should then be made regarding admission. If admitted to the maternity unit women should be nursed in a side room if this is not available then they should be cared for as a cohort on Aspen Ward.

During telephone consultation if women appear very unwell e.g. very short of breath refer them to Accident and Emergency immediately.

Infectious Disease consultants are available via switchboard 24 hour and will be able to offer advice and see women as necessary. An alternative is to Bleep 2728 for the Infectious Disease Registrar if advice is required and the consultant cannot be contacted.

mailto:[email protected]

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The multiprofessional teams are to be mindful that SARS COV-2 patients can deteriorate rapidly and a full holistic review of the woman is necessary.

If women test SARS COV-2 positive, neonatal services should be informed. These include SARS COV-2 positive pregnant women >= 23 weeks gestation who are admitted in the hospital and new COVID positive women who have delivered within the last 14 days. The neonatologist should also be informed when women with suspected or confirmed SARS COV-2 has given birth. The community midwife should also be informed.

The neonatal team will be providing surveillance to all infants who have a diagnosis of SARS COV-2 following a sample taken before 29 days of age and is receiving inpatient care (this includes postnatal ward, neonatal unit or paediatric inpatient wards), where the mother had confirmed SARS COV-2 at the time of birth or suspected SARS COV-2 at the time of birth that has subsequently been confirmed, and the baby was admitted for neonatal care. The surveillance will either be via telephone or face to face by the neonatal team. The frequency and nature of which will be determined by the named neonatal consultant based on individualized clinical need.

Women who are not booked at University Hospitals Birmingham should be asked to contact the triage department of the hospital they are booked with for advice.

18) Ultrasound and UKOSS Reporting

In cases of confirmed SARS COV-2, women should be referred for a fetal growth scan 14 days after resolution of symptoms. Pallavi Karkhanis, Consultant Obstetrician is leading on this and can be contacted on [email protected].

Women identified as having SARS COV-2 are required to be reported to UKOSS. The lead reporter to UKOSS is Mani Malarselvi, Consultant Obstetrician who will be collecting this data and can be reached on [email protected]

The maternity surveillance email [email protected] can also be used to alert the team of women who may require an USS and adding to UKOSS database

19) Roles and Responsibilities of the Covid Surveillance Team

Ensure that the SARS COV-2 tracker is up to date with every SARS COV-2 suspected or confirmed case.

Make daily surveillance call to women who are suspected or confirmed following guidance from ID Consultants.

Ensure call is documented in BadgerNet and tracker updated.

Ensure woman is asked to attend SARS COV-2 area (Aspen Ward) if required. If necessary alert ID Consultant on-call, Midwifery Co-ordinator on Labour ward and on-call Obstetrician to the pending admission.

Take phone calls from women who have symptoms and arrange for home swabbing to take place and ensure tracker is updated.

Take phone calls from Community Midwives and AN Clinic staff that had to delay appointments because women have SARS COV-2 symptoms. Arrange home swabbing for these women and add to tracker.

Follow up every swab taken and alert women of their result. If they are positive ensure they have daily surveillance. Also inform ID Consultant On Call, Midwifery Co-ordinator on Labour ward and On Call Obstetrician


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Make twice daily phone calls to A & E on all three sites, and site leads on all three sites to ensure we are aware of every woman who has presented with SARS COV-2 symptoms or who is an inpatient with SARS COV-2 symptoms and add them to the surveillance tracker.

Liaise with Matrons and/or Maternity Bleep Holder as necessary.

Liaise with Lead Consultant for UKOSS reporting and research midwife to ensure all women who are SARS COV-2 positive are reported to UKOSS.

Ensure that an USS for antenatal SARS COV-2 women is performed at required interval.

Alert Head of Midwifery to any woman who is admitted to ITU and keep them updated of progress.

Check the [email protected] email regularly throughout the day to ensure tracker up to date.

20) Guidance for Delivery, Self-testing and Reporting SARS COV-2 swabs for Maternity Patients at UHB (see appendix: 3) i) This guidance has been developed to provide a clear process for safe, effective and timely delivery, testing and return of swabs to the pathology departments of UHB ii) This document sets out the detailed steps to be taken when undertaking SARS COV-2 testing for women displaying symptoms. iii) This document may be amended from time to time provided that such amendments are compliant with the procedure.

Process

i) Women can self-refer to the SARS COV-2 Surveillance line on 0121 424 1720 (see Appendix 2), and

community maternity staff should encourage women to call this number. However, if there are language difficulties or the community midwife feels the situation is urgent she may call on the woman’s behalf. ii) The woman’s full address and contact details should be taken by the midwife on the maternity surveillance hotline. This surveillance midwife will then contact the community midwives administrator who will contact the maternity support worker to inform them of the woman who requires testing. At weekends the midwife on the surveillance hotline is to contact the on call community midwife. The test kit (swab, specimen bag to seal swab and “Self-Swabbing Leaflet”- See Appendix 3) will be delivered to the woman by the maternity support worker. The support worker is to knock the door or ring the bell and leave the test kit on the doorstep and stand back at least 2 metres. The woman is to go inside and complete the test, then put it in the specimen bag and place it on her doorstep and then return indoors. The maternity support worker then retrieves the swap. iii) The maternity support worker then places the swab in the bag that has been provided for SARS COV-2 testing and returns this to the closest pathology department; this may be Good Hope Hospital or Birmingham Heartlands Hospital. Ensure it is documented on BadgerNet that the woman has been tested and inform the SARS COV-2 maternity surveillance line on [email protected] iv) If a test cannot be delivered this should be documented on BadgerNet as a non-delivery and an email should be sent to the SARS COV-2 Surveillance team. The woman will be contacted by the surveillance team to arrange another time within 24 hours to deliver the testing kit.

v) The woman should be contacted with the result of the swab as soon as it is available. The processing of swab results can take up to 48hr. Once the result is collected ensure this is documented on BadgerNet and the necessary clinicians are informed.


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21) References

Guidance on social distancing for everyone in the UK, Updated 30 March 2020; https://www.gov.uk/government/publications/SARS COV-2 -guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults Royal College of Obstetricians and Gynaecologists (2020) Coronavirus (SARS COV-2) Infection in Pregnancy Ver 7.https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-09-coronavirus-SARS COV-2-infection-in-pregnancy.pdf Accessed 9

th April 2020

Royal College of Obstetricians and Gynaecologists (2020) Coronavirus (SARS COV-2) Infection in Pregnancy Version 8. https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdf

Accessed 19th

April 2020.

SARS COV-2 : investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases

University Hospital Birmingham, (2020) ‘Coagulopathy in SARS COV-2: Guidance on Thromboprophylaxis for COVID patients

(https://www.uhb.nhs.uk/coronavirus-staff/clinical-info-pathways/uhb-internal-guidance.htm; downloads section).

https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults

https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults

https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-09-coronavirus-SARS%20COV-2-infection-in-pregnancy.pdf

https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-09-coronavirus-SARS%20COV-2-infection-in-pregnancy.pdf

https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdf

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases

https://www.uhb.nhs.uk/coronavirus-staff/clinical-info-pathways/uhb-internal-guidance.htm

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22) Appendices Appendix: 1

Proforma: Community surveillance of suspected and confirmed SARS COV-2 NEW CASES ONLY

Telephone call taken by Date Time PID

Woman’s name Lead professional

Gravida Parity Gestation EDD

BMI Ethnic group Please use UK census codes provided on pg.2

Ask below questions and place a “x” in any question where the answer is yes

Symptoms (indicate if mild of moderate)

Pregnancy problems

Previous or pre-existing medical problems, including;

Cold/Flu like symptoms Gestational diabetes

Cardiac Disease


Hyperemesis Renal disease

Shortness of breath FGR Endocrine disorders – Hypo/hyperthyroidism, Diabetes

Headache

P.E.T Inflammatory disorders

Tiredness/ lethargy Hypertension- chronic or gestational

HIV

Asthma

High temperature Obstetric Cholestasis

Cancer


Pregnancy Loss Haematological disorders e.g. Sickle cell disease

Other – please specify

Thrombotic event


Auto immune diseases

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Mental Health Concerns

Any other concerns or symptoms

Covid -19 Status or X

Follow up action Required Please give exact details of actions taken or planned, and refer to SARS COV-2 Maternity cases SOP

Suspected Invite for testing

Confirmed by virology or imaging

ID consultant review

Asymptomatic Obstetric consultant review

Household member with symptoms – Who?

Call next day for follow up

Any other relevant information

Community midwife updated

Neonates informed

Covid 19 tracker updated Reported to UKOSS

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UK Census Coding for ethnic group WHITE 1. British 2. Irish 3. Any other white background MIXED 4. White and black Caribbean 5. White and black African 6. White and Asian 7. Any other mixed background ASIAN OR ASIAN BRITISH 8. Indian 9. Pakistani 10. Bangladeshi 11. Any other Asian background BLACK OR BLACK BRITISH 12. Caribbean 13. African 14. Any other background CHINESE OR OTHER ETHNIC GROUP 15. Chinese 16. Any other ethnic group

Appendix: 2 (Covid Flyer)

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Appendix: 3

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standard operating procedure · 4 cdn: c132 v 3.0 title: standard operating procedure sars cov-2...

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