On this page

1. Introduction
2. Antenatal education and vaccinations – respiratory viruses in pregnancy
3. COVID-19 symptoms
4. COVID-19 testing
5. Antenatal care provision
6. Participants in Care (Birth partners)
1. Key principles
2. Participants in care who are in self-isolation due to COVID-19 status or test positive during surveillance screening
7. Care of pregnant women who are COVID-19 positive or who have had a COVID-19 infection during pregnancy
• Care of pregnant women with COVID-19 in the community
• Care following COVID-19 infection in pregnancy
• Care of COVID-19 positive women – Intrapartum
• Care of COVID-19 positive women and their baby – Postnatal
8. Document information

Introduction

The safety of maternity patients and staff is a health system priority. The care of women should be individualised and based on comprehensive systematic A‑G assessment irrespective of a diagnosis of COVID‑19.

The utmost priority is the immediate medical and care needs of the pregnant woman and her baby. There should be no delay in providing optimal care for the woman or her baby regardless of the woman’s COVID‑19 status, vaccination status or whether the woman and her family reside in areas with high COVID‑19 prevalence.

Maternity services should monitor the COVID‑19 transmission risk level and respond according to COVID‑19 Infection Prevention and Control Manual. The manual includes information regarding personal protective equipment, outpatient appointments and visitors and participants in care. For information regarding participants in care during birth see Participants in Care (Birth partners)

Antenatal education and vaccinations – respiratory viruses in pregnancy

Maternity care providers should inform pregnant women that they are at increased risk of severe disease of respiratory illnesses in pregnancy, this includes COVID‑19 and influenza.

Pregnant women should be advised of when and how to access care if required. This care may be provided by their GP, emergency department or maternity care provider as appropriate. Consumer resources include:

• Testing positive to COVID‑19 and managing COVID‑19 safely at home
• COVID‑19 advice for pregnant women and new parents
• Pregnant women and influenza.

Vaccination reduces risk of severe disease from respiratory viruses during pregnancy. Pregnant women should be encouraged to ensure their COVID‑19 vaccinations are up to date and to have the influenza vaccine:

• COVID‑19 vaccinations are recommended for women who are pregnant, breastfeeding or planning pregnancy. Information on COVID‑19 vaccination, including third dose and boosters, is available in the Shared decision making guide for women who are pregnant, breastfeeding or planning pregnancy.
• Influenza vaccination is recommended for all pregnant women regardless of gestation, and for women planning pregnancy, see Influenza (flu) vaccine.
• COVID‑19 vaccines can be co-administered (i.e. on the same day) with an influenza vaccine as per Australian Immunisation Handbook – Influenza.

COVID‑19 symptoms

Coronavirus Disease 2019 (COVID‑19) CDNA National Guidelines state the most common symptoms of COVID‑19 are fever, cough, shortness of breath, sore throat and loss of smell or loss of taste. Other non-specific symptoms of COVID‑19 include fatigue, headache, runny nose, acute blocked nose (congestion), muscle pain, joint pain, diarrhoea, nausea/vomiting and loss of appetite.

COVID‑19 testing

• COVID‑19 testing of pregnant women should occur as per Getting tested for COVID‑19
• Pregnant women who have COVID‑19 symptoms or who have been exposed to someone with COVID‑19 should have a PCR test as they are more accurate.
• Pregnant women who have COVID‑19 symptoms and test negative on a rapid antigen test, should be encouraged to have a PCR test as they are more accurate.
• If a rapid antigen test is positive and therapeutic care is required, it should not be delayed.
• For recommendations for COVID‑19 surveillance testing, refer to CEC –COVID‑19 Infection Prevention and Control Manual – Appendix 2B: Recommendations for COVID‑19 surveillance testing in NSW healthcare facilities.

Antenatal care provision

Antenatal assessment can occur face-to-face or via virtual care. The decision regarding face-to-face visits should be made based on clinical risk and the woman's preference, irrespective of COVID‑19 status. Virtual care, also known as telehealth, safely connects patients with health professionals to deliver care when needed and can replace some antenatal appointments where physical examination is not required.

Changes to care should be based on all pregnancy risks, including but not limited to COVID‑19 status.

For home visits please refer to CEC –COVID‑19 Infection Prevention and Control Manual Chapter 8: Home visits

Local decisions should be made regarding the mode of delivery of antenatal classes. Classes may be held face-to-face, virtually or a hybrid model. Consumer need and COVID‑19 transmission risk level should be considered.

Participants in Care (Birth partners)

Having a trusted birth partner as a participant in care is known to make a significant difference to the safety and wellbeing of women during labour and birth and contributes to care being woman centred. A participant in care can be described as someone actively providing care, physical and/or emotional support.

Key principles

• All women should be supported to nominate at least one person to actively participate in her care, during labour, birth and the immediate postnatal period, while in the birthing room/environment.
• All women should be encouraged to choose an alternative participant in care if her nominated participant in care is unable to attend.
• Participants in care should be supported to attend during labour, birth and the immediate postnatal period, regardless of their COVID‑19 vaccination status.
• Consideration should be given locally, for the provision of continuous support in the birth room for those women who do not have a participant in care with them.
• All participants in care should be risk assessed on arrival, which should as a minimum, include their ability and willingness to be compliant with PPE, hand hygiene and directions from the healthcare team.
• Participants in care should have surveillance testing if indicated as per COVID‑19 Infection Prevention and Control Manual – Appendix 2B: Recommendations for COVID‑19 surveillance testing in NSW healthcare facilities.
• A COVID‑19 negative participant in care who attends with a COVID‑19 positive woman will become a contact as per Information for people exposed to COVID‑19. When deciding to participate in the birth, the participant in care should consider their own health risk status, including COVID‑19 vaccination status.

Participants in care who are in self-isolation due to COVID‑19 status or test positive during surveillance screening

There is an Exemption to the Public Health (COVID‑19 Self Isolation) Order (No 4) 2021 that allows for a person required to self-isolate to attend a birthing unit/environment for the purposes of providing care and physical/emotional support during labour, birth and the immediate postnatal period. The Exempt Person is subject to conditions, including that they must only attend with the informed consent of the pregnant woman (which is documented in the woman's healthcare record) and if permitted to do so by staff at the healthcare facility.

For maternity services who are seeking to support the attendance of participants in care who are COVID‑19 positive or contacts, the following guidance applies:

Local procedures should be in place to reduce the risk of COVID‑19 exposure to healthcare workers and patients as per COVID‑19 Infection Prevention and Control (IPAC) Manual, including the following requirements for the participant in care:

• PPE application (minimum of surgical mask) prior to entry to the healthcare facility
• being escorted by a staff member directly to the birthing unit/environment
• screening on arrival to ensure that a participant in care is able to understand and follow the directions of staff whilst in the birthing unit/environment and comply with directions to wear appropriate PPE safely
• remaining in the allocated isolated room at all times
• consideration of the hydration, nutrition and personal hygiene requirements
• wearing of PPE and following guidance from staff while in the birthing unit/environment
• maintaining social distancing from healthcare workers wherever possible
• being escorted directly out of the healthcare facility.

• the need to contact the birthing unit prior to the attendance at the healthcare facility
• that a participant in care should consider their hydration, nutrition and personal hygiene requirements, noting that the need to remain in the isolated room at all times
• that if the woman needs to be transferred to an operating theatre, then the participant in care may not be able to attend
• that once the birthing woman leaves the birthing unit/environment, they will be escorted out of the healthcare facility by a member of staff. They will then be required to immediately return to their place of residence/isolation by the most practicable direct route as stated in the Exemption.

Care of pregnant women who are COVID‑19 positive or who have had a COVID‑19 infection during pregnancy

Care of pregnant women with COVID‑19 in the community

Most pregnant women will be able to safely stay at home while they have COVID‑19. Every person who tests positive to COVID‑19 by PCR or who registers their positive rapid antigen test will receive a text message linking to Testing positive to and managing COVID‑19 safely at home, this includes the following advice for pregnant women:

• Have plenty of fluids, like you would with a regular cold or flu. If you feel unwell, paracetamol can also be taken to help with symptoms. Ibuprofen is not recommended to take while you are pregnant.
• It is important to remain hydrated and mobilise regularly to reduce your risk of developing blood clots. If you have a history of blood clots or you are obese, please contact your GP or maternity care provider to discuss your management options.
• It is important to keep a close eye on your baby’s movements. Call your maternity care provider immediately if your baby’s movements change or if you experience:
• vaginal bleeding
• abdominal pain
• constant clear watery vaginal discharge
• contractions any time before 37 weeks
• persistent fever
• headaches
• sudden swelling of your face and hands
• you are in labour
• have any serious concerns about your pregnancy.
• If you have difficulty breathing, develop chest pressure or pain, have severe headaches or dizziness you should call 000 immediately. Ensure that you tell them you have COVID‑19 and are pregnant.
• After recovering from COVID‑19 it is important to continue your regular antenatal care. If you have missed an antenatal care appointment during your self-isolation, reschedule as soon as possible.

If a pregnant woman contacts their maternity care provider with concerns related to their COVID‑19 infection, the maternity care provider should complete the following assessment, care plan and education.

Assessment

Assessment should include:

• pregnancy gestation
• assessment of obstetric risk factors
• COVID‑19 vaccination and booster status (including dates of administration)
• date of symptom onset
• assessment as per Caring for adults and children in the community with COVID‑19
• clinical symptoms
• high-risk medical history
• high-risk social factors
• VTE risk assessment as per Maternal venous thromboembolism VTE risk assessment tool (consider VTE risk factors such as dehydration and immobility, that may occur due to COVID‑19 infection).

Care plan

Following assessment, all pregnant women with COVID‑19 should have a documented, individualised care plan as per Caring for adults and children in the community with COVID‑19 - Flow chart and care protocols.

The care plan should be developed with collaboration between the woman and maternity care provider and include:

• medical assessment and/or hospital admission if moderate or severe clinical symptoms or other indication
• consideration for disease modifying therapy if indicated as per:
• ACI –Guidance for the use of anti SARS-CoV-2 monoclonal antibodies and antiviral agents as prophylaxis or to prevent severe infection from COVID‑19 in NSW
• National COVID-19 Clinical Evidence Taskforce Drug treatments for pregnant or breastfeeding women with COVID‑19
• VTE prophylaxis if indicated as per Maternal venous thromboembolism VTE risk assessment tool
• frequency of planned contact, noting that pregnant women who do not have additional risk factors of severe disease severity may not require repeated planned contact.

Education

The woman should be provided with information regarding:

• importance of staying hydrated and mobile
• how to access care if she has any concerns
• potential risks of deterioration and when to seek medical attention
• importance of maternal awareness of fetal movements as per GL2021_019 Care pathway for women concerned about fetal movements.

Care following COVID‑19 infection in pregnancy

All pregnant women who have had COVID‑19 in pregnancy should be provided with information regarding:

• the importance of maternal awareness of fetal movements as per GL2021_019 Care pathway for women concerned about fetal movements
• awareness of signs and symptoms of pre-eclampsia
• how to access care if she has any concerns.

If any routine antenatal appointments have been missed during self-isolation, reschedule as soon as practical.

Care following asymptomatic or mild COVID‑19 in pregnancy (not requiring admission to hospital)

Antenatal, labour and birth care should remain unchanged.

Care following moderate, serious or critical COVID‑19 (requiring hospital admission)

• an individualised care plan should be created with a consultant obstetrician, in collaboration with the woman, prior to discharge including:
• VTE prophylaxis if indicated as per Maternal venous thromboembolism VTE risk assessment tool Prophylactic anticoagulants should be continued for at least 14 days after discharge or until COVID‑19‑related morbidity (including immobility, dehydration and/or shortness of breath) has resolved.
• recommendation for an ultrasound to assess the fetal biometry approximately 14 days following recovery, unless indicated earlier. Repeat ultrasounds as clinically indicated.
• consideration of additional antenatal appointments if indicated
• consideration of continuous electronic fetal monitoring in labour
• consideration of placental histology as per GL2014_006 Maternity - Indications for Placental Histological Examination.

Care of COVID‑19 positive women – Intrapartum

All pregnant women with COVID‑19 should be risk assessed on presentation and an individualised plan of care be made regarding model of care and place of birth.

A comprehensive systematic A-G maternal and fetal assessment (as per Recognition and management of patients who are deteriorating) should be undertaken on presentation and be repeated as required. This includes:

• surveillance testing if indicated as per COVID‑19 Infection Prevention and Control Manual – Appendix 2B: Recommendations for COVID‑19 surveillance testing in NSW healthcare facilities
• maternal assessment and observations (including oxygen saturations)
• consideration for disease modifying therapy if indicated as per:
• ACI –Guidance for the use of anti‑SARS‑CoV‑2 monoclonal antibodies and antiviral agents as prophylaxis or to prevent severe infection from COVID‑19 in NSW
• National COVID‑19 Clinical Evidence Taskforce Drug treatments for pregnant or breastfeeding women with COVID‑19
• VTE risk assessment and prophylaxis if indicated as per Maternal venous thromboembolism VTE risk assessment tool
• fetal monitoring based on the woman's risk factors and assessment outcomes:
• Symptomatic women – continuous electronic fetal monitoring is recommended
• Asymptomatic women – continuous electronic fetal monitoring in labour is not recommended in the absence of other risk factors as per Maternity – Fetal heart rate monitoring.

Water immersion and water birth

Symptomatic women – should not labour and birth in water.

Asymptomatic women – water immersion or birth is not contraindicated, providing adequate PPE can be worn by maternity care providers.

Nitrous oxide

Entonox can be used with a single-patient viral/microbiological filter that performs at or above 99.997% efficiency.

Check with the nitrous oxide equipment manufacturer to determine if there are recommendations for filters to be added into an individual delivery system in relation to COVID‑19. The make, model, other associated parts and delivery systems will be different across NSW hospitals.

Epidural

Symptomatic women – an early epidural should be recommended in labour, particularly for women with acute respiratory symptoms, to minimise the need for general anaesthesia if urgent intervention for birth is needed.

Asymptomatic women – an epidural should not be routinely recommended solely because of a positive test.

Fetal blood sample or fetal scalp electrodes

There is no contraindication in women who are COVID‑19 positive to performing fetal blood sampling or applying a fetal scalp electrode if clinically indicated.

Mode of Birth

As per usual clinical practice – shared decision making, considering all individual risk factors and maternal and fetal clinical condition.

Placenta

Placenta(e) should be sent for histological examination to local pathology services following serious or critical COVID‑19 infection at time of birth or if indicated as per GL2014_006 Maternity - Indications for Placental Histological Examination.

In the event of a perinatal or neonatal death, the placenta should be sent to a perinatal post-mortem service.

Newborn resuscitation

Refer to NSW Health Guidance for Neonatal Services.

Care of COVID‑19 positive women and their baby – Postnatal

Care of the newborn – NSW Health Guidance for Neonatal Services is relevant to all postnatal wards, special care nurseries and neonatal intensive care units and provides guidance regarding care of the well as well as COVID‑19 affected newborn.

When mothers, babies/families are separated/isolated for any reason staff should acknowledge that this may be a trigger for anxiety. This may be an especially difficult time for Aboriginal families and refugees. Staff will need to identify mothers and families that may require additional support on referral or early intervention. Staff will need to partner quickly with appropriate local support, for example Aboriginal liaison officers, Aboriginal health workers, multicultural health staff, and social work. Staff should seek advice from clinical leads to ensure that the best plan for additional support is developed with local resources.

Transferring babies between areas/wards

Where possible, transfer the baby in a closed incubator between locations in the facility. For further information refer to: NSW Health Guidance for Neonatal Services.

Infant Feeding and skin to skin contact

Refer to Guidance on infant feeding.

Cord blood collection and donation

Private cord blood banking should be managed in line with contractor management.

Family cord blood collection and donation should be managed through a risk assessment process and in accordance with local protocols.

Discharge planning

Individualised according to the woman's COVID‑19 disease severity and obstetric and neonatal outcomes.

Midwifery care in the home

For home visits please refer to CEC –COVID‑19 Infection Prevention and Control Manual Chapter 8: Home visits.

Document information

Health and Social Policy Branch (HSPB), NSW Ministry of Health.

Consultation

• COP Maternity Working Group
• CEC Infection Prevention and Control Team.

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Reviewed

• Clinical leads, Child and Family Health community of practice
• Clinical Excellence Commission

For use by

Maternity services.