Coronavirus, Pregnancy & Breastfeeding

I am writing this post on 9th March 2020, immediately after the release of the new RCOG guidelines on management of coronavirus, pregnancy & breastfeeding. The day is mentioned intentionally, because new advice and evidence is coming to light all the time.

*BLOG UPDATED 9th AUGUST 2020 FOLLOWING FURTHER RCOG UPDATES*

The guidance released today is quite comprehensive. It includes a guideline for health professionals & a Q&A document for pregnant women and their families .

These documents can be hard to read, or find the relevent information. So I have shared some of the key information, depending on where you are in your journey here:

During pregnancy

What are the risks to mum?

It has long been known that, whilst pregnant women are not necessarily more susceptible to viral illness, changes to their immune system in pregnancy mean if they catch infections, they may experience more severe symptoms. This is particularly true towards the end of pregnancy, in the third trimester.

Pregnant women do not appear to be more likely to contract coronavirus, or develop complications as a result than the general population. The main complication is pneumonia and respiratory distress, although this is extremely rare.

Severe infection with Covid-19 is likely to increase the risk of getting a blood clot (venous thromboembolism). Similar to the general population, pregnant women with other serious health problems (such as diabetes, cancer and lung conditions) are more likely than those without such conditions to develop severe infection should they contract coronavirus.

As this is a new virus, how it may affect you is not yet clear. It is expected that the large majority of pregnant women will experience only mild or moderate cold/flu like symptoms.

Who is at higher risk?

Risk factors that appear to be associated with hospital admission with COVID-19 illness include:

1. Black, Asian or minority ethnicity (BAME)
2. Overweight or obesity
3. Pre-existing comorbidity (other pre-pregnancy illnesses) eg Diabetes
4. Maternal age >35 years

What effect will mum having the infection have on baby?

There is no evidence to suggest an increased risk of miscarriage.

There is no current evidence that contracting the virus can cause abnormalities in your baby, but we will need to see what happens over time. It is possible that Covid-19 might predispose to fetal growth restriction (where baby does not grow at the expected rate while in the womb).

However, this is solely a possibility at present and based only on data from pregnancies affected by other coronaviruses and not Covid-19.

Across the world, emerging reports suggest some babies have been born prematurely to women who were very unwell with coronavirus. It is unclear whether coronavirus caused these premature births, or whether it was recommended that their babies were born early for the benefit of the women’s health and to enable them to recover.

Could I pass coronavirus to my baby?

As this is a new virus, there is limited evidence about managing women with coronavirus infection throughout their pregnancy and after having just given birth.

Emerging data indicates that vertical transmission is possible, which is where the virus passes from mother to baby whilst still in utero. However, the newest evidence suggests that the risk of a pregnant woman with coronavirus passing the infection to her baby is very small.

A recent study that gathered data from over 600 births found that only 4% of babies with mothers known to have Covid-19 tested positive for the infection after birth (1). The risk to babies of getting coronavirus does not appear to be greater if they are born vaginally (compared to by C-section) or breastfed.

It is important to emphasise that in all reported cases of newborn babies developing coronavirus very soon after birth, the babies were well.

Given current evidence, it is considered unlikely that if you have the virus it would cause problems with your baby’s development.

What can I do to reduce my risk of catching coronavirus?

The most important thing to do is to wash your hands regularly and effectively. There is useful advice on the NHS website on the best way to reduce any infection risk.

Whilst pregnant women are considered vulnerable, they are not in the shielded category unless they have underlying health conditions. This means that you can follow the advice for the general population. However, it is sensible if you are pregnant to do everything possible to reduce your chances of coming into contact with anyone who could be carrying the virus.

These are important steps to reduce your risk:

• Wash your hands regularly (the NHS has produced an excellent video showing you the best way to wash your hands)
• Use a tissue when you or anyone in your family coughs or sneezes, discard it and wash your hands
• Avoid contact with someone who is displaying symptoms of coronavirus (these symptoms include high temperature and/or new and continuous cough)
• Avoid non-essential use of public transport when possible
• Work from home, when possible
• Avoid large and small gatherings in public spaces (although many pubs, restaurants, leisure centres and similar venues are opening their doors again, it is important to remember that infections spread easily in enclosed spaces where people gather together)
• Avoid gatherings with friends and family; keep in touch using remote technology such as phone, internet and social media
• Use telephone or online services to contact your GP or other essential services

For women of BAME background:

Regarding vitamin D:

Women of BAME background with melanin pigmented skin often develop vitamin D deficiency; it is estimated that as many as 94% of the South Asian population in the UK are affected by vitamin D deficiency in the winter.

Recently, vitamin D supplementation has been suggested to be
beneficial in reducing the risk of respiratory tract infections, although data are limited.

The current UK advice recommends vitamin D supplementation to all individuals of BAME background, regardless of the COVID-19 pandemic.

Women of BAME background should be advised that they may be at higher risk of complications of COVID-19; we advise they seek advice without delay if they are concerned about their health.

Doctors should be aware of this, and have a lower threshold for recommending treatment or admission to hospital.

Where possible, remote consultations should be encouraged, to minimise face-to-face contact.

What are the effects on normal maternity services at this time?

Maternity services are doing all they can right now to ensure that routine antenatal care continues for all women with as little disturbance as possible. However, it is worth noting that during this time, there may be some disruption to maternity services for everyone. Athough it is considered an essential service (like A&E) which means elective C sections etc cannot be cancelled entirely, the system will not run as normal.

There may be longer response times when calling for services, and your overall number of appointments may be reduced and times or dates shifted around.

You may be asked to conduct some of your appointments virtually (e.g. over telephone or video conferencing); it is important to remember that virtual consultations will be conducted with the same respect for confidentiality and level of professionalism you would expect from your in-person appointments.

There may also be a need to reduce the number of antenatal visits you have–this might mean that some less essential appointments are cancelled or that you have fewer but longer appointments where numerous investigations (e.g. bloods tests or scans) are done at the same time. This will be communicated to you, and will be done as safely as possible, taking into account available evidence on the safe number of visits required. Do not reduce your number of visits without agreeing this first with your maternity team.

In the first trimester:

Even during the pandemic, you should still refer yourself and your pregnancy to a hospital as usual. This can usually be done by phone or internet.

It’s very important that if you have any concerns about yourself or your baby at any time throughout your first trimester, you contact your local early pregnancy unit straight away to discuss them.

Some symptoms, such as pelvic pain, cramping and/or bleeding during early pregnancy, are linked to ectopic pregnancy and miscarriage so you should seek urgent medical advice.

Hospital appointments

You may be asked to keep the number of people with you to a minimum. This will include being asked to not bring children with you to maternity appointments.

In labour, the RCOG advises that women should be permitted and encouraged to have a birth partner present with them in their labour and during birth. Having a trusted birth partner present throughout labour is known to make a significant difference to the safety and well-being of women in childbirth.

It is important to be aware that health professionals will be wearing a mask, and apron when they see you throughout your pregnancy and birth. It is likely that you, and anyone who accompanies you to a hospital appointment, will also be asked to wear a mask. This can make communication an added challenge, even if you don’t have coronavirus or any symptoms.

A single, asymptomatic birth partner should be permitted to stay with the woman, at a minimum, through pregnancy and birth, unless the birth occurs under general anaesthetic.

Additional restrictions, such as having only one (rather than 2) birth partners, not being allowed visitors to antenatal or postnatal wards, and preventing swapping will be determined by your hospital policy.

The current times may understandably cause an increase in anxiety levels or other mental health difficulties for everyone, and especially those who are pregnant.

If you have any concerns about your mood or mental health, you should contact a trusted healthcare professional (e.g. midwife or GP) without delay, who will be able to provide support and refer you onto the right service if needed.

Can I travel?

The travel advice for pregnant women is the same as for the general population. You should check the FCO advice for countries to avoid, and this guidance is updated regularly.

What if I have symptoms of coronavirus?

1. Self-Isolate for 7 days and Self-refer for a coronavirus swab test.

These symptoms are mainly cough, fever, shortness of breath and a change in sense of smell/ taste.

If someone you live with has symptoms of coronavirus, you should self-isolate for 14 days.

2. If you are needing to come to hospital for any reason eg relating to pregnancy/ birth, and simultaneously have symptoms of coronavirus (eg fever >37.8 or persistent cough), please call ahead before turning up and wear a mask.

You will be tested on admission and should be managed as though you have coronavirus until the results come back.

Currently, the test involves swabs being taken from your mouth and nose. You may also be asked to cough up sputum, a mixture of saliva and mucous.

3. Do not attend your routine midwife or hospital appointments. Instead phone triage/ your midwife and inform them of your symptoms.

It is likely that routine antenatal appointments will be delayed until isolation ends. If your midwife or doctor advises that your appointment cannot wait, the necessary arrangements will be made for you to be seen. That may be a different time, or in a different clinic, to protect other patients. If you need to self-isolate, follow usual government advice.

If you live alone, the appointments will be delayed at least 7 days. If you live with others, the self-isolation applies to the whole household so appointments will be delayed by 14 days.

4. If you have concerns for yourself or your unborn baby during self-isolation, contact your midwife, or if out-of-hours, your maternity team. They will provide further advice, including whether you need to attend hospital.

If attendance at the maternity unit or hospital is advised, pregnant women are requested to arrange their own travel. Alert the maternity triage reception once on the premises, prior to entering the hospital.

5. If you need to be admitted to hospital you will be cared for in an isolation room, bay or ward. To keep everyone safe, it is important that only staff essential to your care enter these areas. General guidance is that visitors should be kept to an absolute minimum during your stay but your hospital will have their own visitor policies for women in this situation.

It is important to remember that the advice in this section also applies to women who are self-isolating because someone in their house has symptoms of Covid-19.

A note on blood clots:

There is an increased risk of blood clots whilst infected with COVID-19. If you have a mild-moderate illness, your midwife/ doctor will assess your personal risk as to whether you need blood-thinner injections.

If you are admitted to hospital with COVID-19 you will have the injections regardless.

What happens after I have recovered from coronavirus?

You should have any missed antenatal appointments due to isolation rearranged as soon as possible.

If you experienced serious or critical symptoms, your ongoing antenatal care should be planned together with a consultant obstetrician.

Women who have been seriously or critically unwell should be offered a fetal growth scan approximately 14 days following recovery from their illness in the first instance. This is because in a similar virus, SARS, two-thirds of reported pregnancies were affected by growth restriction. We do not yet know if the same is true of COVID-19.

There is currently no additional advice if you had symptoms consistent with coronavirus and self-isolated but were NOT TESTED, so discuss your own case with your midwife or doctor for specific follow-up.

In labour with suspected COVID-19

If you go into labour, you should call your maternity unit for advice, and inform them that you have suspected or confirmed coronavirus infection.

If you have mild symptoms, you will be encouraged to remain at home (self-isolating) in early labour, as per standard practice.

Your maternity team have been advised on ways to ensure you and your baby receive safe, quality care, respecting your birth plan as closely as possible.

When you and your maternity team decide you need to attend the maternity unit, general recommendations about hospital attendance will apply:

• You will be advised to attend hospital via private transport where possible, or call 111/999 for advice as appropriate.
• You will be met at the maternity unit entrance and provided with a surgical face mask, which will need to stay on until you are isolated in a suitable room.
• Your birth partner(s) will be able to stay with you throughout if they have no symptoms but they will be asked to wear a mask and wash their hands regularly. They will be screened for symptoms of coronavirus when you arrive in hospital. If any concerning or persistent symptoms are revealed, they will be asked to leave the maternity unit and self-isolate at home. Visitors will be kept to a minimum, or not allowed entirely.
• If your birth partner has symptoms or is currently in a period of self-isolation, they will need to remain in self-isolation and cannot accompany you in labour.

Can I still go to a birth centre?

If you have no symptoms and test positive within 7 days of birth, there should be no change to your place of birth or need for continuous monitoring. You will have the option of whether you wish to deliver in a birth centre or on the labour ward and receive continuous monitoring.

This is because it is unclear if women without symptoms have any increased risk of compromise to the baby and we don’t know if continuous monitoring will give you any extra benefit.

The newest recommendation on continuous minoring is that it is not required solely because a woman has tested positive for Covid-19 and is only necessary if there are other reasons for its use (e.g. previous C-section). However, options for fetal monitoring during your labour will be discussed with you fully so that you and your maternity team can make the best, safest decision for you and baby.

If you have symptoms at the time of labour, you should give birth on a delivery suite (not in a birth centre or at home) so you can have continuous monitoring of your baby.

How will my baby be born?

There is currently no evidence to suggest C section or vaginal delivery are better. Therefore decisions should be taken based on your birth preferences. There is also no reason you cannot have gas and air (Entonox) or an epidural for pain relief.

If you have suspected or confirmed coronavirus at the time your baby is born, your baby will be tested for coronavirus.

Planned inductions and C sections

Wherever possible, inductions and C section for non-emergency reasons should be delayed until after the quarantine period has elapsed. If this is not deemed to be safe, then you will be admitted during the self-isolation period and additional isolation precautions will be taken.

Wherever possible, C sections will be done under epidural/ spinal anaesthetic.

Can I still have a water birth?

If you have no symptoms of coronavirus and are suspected or confirmed to not have Covid-19, then you should be able to have a water birth if requested (provided your maternity team can wear appropriate PPE). Water births are not recommended for women with symptoms of coronavirus.

There is currently a lack of evidence on the risk of coronavirus transmission in water; there is, however, a small theoretical risk that Covid-19 could be passed to a baby through water contaminated with bodily secretions or faeces from an infected mother.

As a result, there is no concrete guidance on the safety of water births for women who test positive for Covid-19 but have no symptoms. If you fall into this category, you should discuss your individual circumstance and potential birthing options with your obstetrician or midwife.

After birth with suspected COVID-19

Will I be able to stay with my baby/give skin-to-skin if I have suspected or confirmed coronavirus?

Yes, if that is your choice. Provided your baby is well and doesn’t require care in the neonatal unit, you will be kept together after you have given birth and supported to practice skin-to-skin/kangaroo care as you wish.

Some countries were previously advising women with coronavirus should be advised to separate from their baby for 14 days. However, this may have potential negative effects on feeding and bonding.

If your baby needs to be cared for on the neonatal unit after birth, it will be necessary to take steps to limit the risk of mother-to-baby transmission of coronavirus. This might involve a period of separation following birth or a delay (or use of additional safety measures, such as gowns, gloves and masks, etc.) in the initiation of skin-to-skin contact.

A discussion about the risks and benefits should take place between you and your family and the doctors caring for your baby (neonatologists) to individualise care for your baby. Everyone involved in your baby’s care will ensure you are actively involved in all decisions and that bonding and attachment needs are prioritised.

Will I be able to breastfeed my baby if I have coronavirus?

Yes. At the moment there is no evidence that the virus can be carried in breastmilk, so it’s felt that the well-recognised benefits of breastfeeding outweigh any potential risks of transmission of coronavirus through breastmilk.

The main risk of breastfeeding is close contact between you and your baby, as you may share infective airborne droplets, leading to infection of the baby after birth.

If you choose to breastfeed your baby, the following precautions are recommended:

• Wash your hands before touching your baby, breast pump or bottles
• Avoid coughing or sneezing on your baby during feeds
• Wear a face-mask for feeding at the breast
• Follow recommendations for pump cleaning after each use
• Consider asking someone who is well to feed expressed breast milk to your baby.

If you wish to breastfeed, but are not well enough to do so (or it is otherwise not practical for you to do so), you should be supported to express breastmilk by hand expression or by pump. You should also be offered access to donor breastmilk where needed.

If you choose to feed your baby with formula or expressed milk, it is recommend that you follow strict adherence to sterilisation guidelines. If you are expressing breast milk in hospital, a dedicated breast pump should be used.

What happens after I leave hospital?

If you had coronavirus at the time of your baby’s birth, the entire household should self-isolate for 14 days after leaving hospital.

You should be provided with all the usual postnatal care per national guidance. Much of your postnatal care, including physical examinations (e.g. wound checks following C-section or assisted deliveries), the newborn blood spot test and baby weight and well-being checks, will still be conducted in-person (either at home or in clinic).

It might be necessary for some of your appointments to be virtual (e.g. conducted over the telephone or video). However, this should be communicated to you early and will always take into account the best interests of you and your baby.

References:

(1) Maternal transmission of SARS‐COV‐2 to the neonate, and possible routes for such transmission: a systematic review and critical analysis. Authors: Walker KF, O’Donoghue K, Grace N, et al. Published: June 12 2020. Accessed: August 9 2020.