Pregnancy, Birth, and #COVID19
Updated: May 19, 2020
-See our list of updated links for resources and information about COVID-19 and pregnancy/birth/breastfeeding.
-DOD has released an updated clinical practice management guide for COVID-19. As in the original, this document mandates a support person will accompany a birthing patient through labor, delivery, and postpartum; shared decision-making regarding whether or not to separate newborn from birthparent postpartum when either is COVID19+ or PUI, and full support for establishing lactation and breastfeeding/human milk feeding for newborns.
-CDC has released updated guidance for pregnant, birthing, and breastfeeding patients with confirmed or suspected COVID-19.
-DOD has released its clinical practice management guide for COVID-19 which includes support for breastfeeding and specific guidance on pregnancy/birth/postpartum. 3/27/2020 Updates: -One case of possible transmission from mother to fetus in utero has been published, but it is inconclusive and the infant never became symptomatic.
Welcome to the second in our 3-part series on Coronavirus and breastfeeding military families. We are so excited to be partnering with milspouse, veteran, and IBCLC Shondra Mattos of Mattos Lactation to pull together helpful, clear, relevant information to help you during this pandemic. Last week, we talked about breastfeeding and COVID-19, and this week we want to talk about what to prepare for if you are experiencing pregnancy, childbirth, and postpartum during the outbreak. Stay tuned for our third post, a Breastfeeding in Combat Boots feature with all the information needed for breastfeeding military servicemembers and COVID-19.
Are pregnant people at elevated risk from COVID-19?
The truth is that because this virus is so new, we don’t really know. However, based on the data gathered from the known cases so far (at the time of this writing, 3/24/2020), most major health organizations are following the guidance of the World Health Organization
Current data do NOT show pregnant people to be at a higher risk of severe illness than the general population.
Pregnancy itself can cause people to be more susceptible to respiratory infections, so pregnant people should take precautions to limit the risk of exposure and report any symptoms such as fever, cough, or difficulty breathing to their healthcare provider.
Precautions include frequent handwashing with soap or alcohol sanitizer, cough into your elbow, maintain social distancing (don’t get closer than 6 feet to people outside of your family, and avoid all people who are sick), and avoid touching your nose, eyes, and mouth.
Pregnant and immediately postpartum patients should continue to receive routine care from their healthcare providers. Telehealth and virtual health visits have been widely recommended and adopted by many providers and insurers in the US, including Tricare. Patients should consult with their providers to determine what options are available and recommended in their specific location and circumstances.
What about giving birth?
Unfortunately, right now is a time of great uncertainty and inconsistency for birthing and immediate postpartum. Because this is a novel virus--new to human beings--there’s still a lot that the experts just don’t know yet about how it impacts birth parents and newborns during the birth process. Here’s what we DO know, based on the information available from the WHO and the studies that have been published so far:
There is no evidence on mother-to-child transmission when infection manifests in the third trimester, and no studies have demonstrated mother-to-child transmission during the delivery process regardless of birth method (vaginal or c-section).
There are a few published cases of expectant parents with COVID19 having preterm labor; however, it is unclear whether or not the viral infection caused prematurity. Note: in several of the limited case studies reported, the premature births appeared to be iatrogenic (physician-caused).
COVID19 in a birthing patient can lead to fevers, respiratory concerns, and other symptoms that may complicate labor. Still, there is no higher risk of birth complications than in non-infected patients.
COVID19 in a birthing patient DOES pose a higher risk of contagion to the healthcare professionals and support persons attending the birth, so it makes sense to limit the number of people in contact with a confirmed positive birthing person, and for all in attendance to use PPE.
A newborn may become infected with Sars-Cov-2 after delivery if any parent tests positive due to exposure after birth. With that said, according to the largest study to date, no infants have died from the infection. We yet to have complete data from other countries, but at the time of this writing (3/26/2020), it appears that the consensus among health organizations is that infants are less likely to get seriously ill, requiring intensive care, and less likely to die than older children and adults. Additionally, there are no confirmed deaths in any children ages 0-9. UPDATE 5/19/2020: There is now a growing number of reports of a multisystem inflammatory syndrome in children or MIS-C, similar to Kawasaki disease, affecting children who have previously recovered from COVID-19.
Many hospitals and birthing facilities are imposing restrictions on the number of people allowed to attend a birth. This is to comply with social distancing recommendations and minimize potential exposure to COVID-19 by limiting the number of people in a hospital. It is also to minimize the risk that a support person may be an asymptomatic carrier--that is, they may have been exposed to the virus and they may spread it without having any symptoms or knowing that they have it. However, this must be balanced against the rights of pregnant and birthing people to have the support they need in order to birth safely and without trauma. Although there is no universal guidance, most MTFs and most state, county, and city regulations limiting hospital visitors make an exception to allow at least one support person to accompany a birthing patient.
UPDATE 5/19/2020: DOD COVID-19 Practice Management Guide affirms
previous guidance on support person for pregnant/birthing person. UPDATE 4/1/2020: DoD COVID-19 Practice Management Guide states that each pregnant/birthing person will be allowed one support person to accompany them through labor, delivery, and postpartum. It must be the same person who comes to support them through the entirety of their MTF stay. UPDATE 4/4/2020: CDC has issued updated guidance for pregnant, birthing, and breastfeeding patients recommending that at least one support person be allowed to accompany them through labor, delivery and postpartum, and that breastfeeding should be encouraged and supported.
When you go to a hospital or birthing facility in labor, you will be screened for COVID-19 symptoms. If you have symptoms, you will likely be tested, and per CDC guidance, you will be considered as possibly (suspected) infected, until your test results come back. If you are suspected or confirmed of having COVID-19, your healthcare team and support person(s) will be required to wear personal protective equipment (PPE) while taking care of you, and you will be put into an isolation room. This is to protect the healthcare workers from catching the virus from you, so that they can continue to keep caring for you and other patients. According to WHO,
All pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth. This includes antenatal, newborn, postnatal, intrapartum and mental health care, including:
Being treated with respect and dignity;
Having a companion of choice present during delivery;
Clear communication by maternity staff;
Appropriate pain relief strategies:
Mobility in labour where possible, and birth position of choice.
UPDATE 5/19/2020: DoD COVID-19 Practice Management Guide affirms previous statement. UPDATE 4/1/2020: DoD COVID-19 Practice Management Guide states that decisions about labor and birth augmentation, interventions, and method (vaginal vs. c-section) will be made strictly based on maternal and fetal indications. COVID-19 is not an indication for automatic interventions. UPDATE 4/4/2020: CDC updated guidance states that decisions about labor and birth augmentation, interventions, and method should be made based on maternal and fetal indications, not on COVID-19 status.
How to Prepare:
Minimize your risk of exposure to COVID-19 by washing hands frequently, minimizing going out of the house, wearing a mask in public, and staying at least 6 feet away from people you don’t live with. Ask your prenatal provider about telehealth or virtual health options for any upcoming appointments, or to answer questions you may have.
Talk to your healthcare provider about what precautions the hospital or birth facility you’re using has put into place.
Determine which one support person is most important for you to have.
Go over any consent forms you have been offered or signed, and decide if you want to consent in advance, or if you want to revoke any pre-signed consent (such as for invasive interventions, c-section, etc).
Consider other options for birthing. If you are low-risk, contact Tricare or your insurance provider to discuss options for homebirth. If you are uncomfortable with the restrictions at your chosen hospital, check with other hospitals and birthing facilities to see if there is a better fit for you.
Maintain open communication with your provider about what is important to you for your birth, and ask for updates to hospital or provider policies at every appointment. Ask for the written policy.
Talk to your healthcare provider about specific concerns you have about the birth, such as a previous history of birth trauma or sexual assault. Make a plan with your provider to accommodate your needs, and ask for a written copy of the plan to carry in your birth bag. Ask your provider to note your plan in your chart and ensure that the entire care team is aware of it.
Talk to your provider and birthing facility about allowing other family members to attend the birth by video chat. Many MTFs are already equipped for this and have had deployed partners attending births via skype from downrange!
Breastfeeding and Postpartum
See Part 1 of our #COVID19 blog series for a deeper look at breastfeeding. The WHO, CDC, UNICEF, ACOG AAP and ABM all recommend that COVID-19 positive parents who choose to breastfeed should be encouraged to initiate and continue breastfeeding. Many hospitals are instituting policies of separate isolation quarantine for birth parents and babies when the birth parent tests positive for COVID-19. We have a list of helpful questions and phrases to use when talking to your provider. It’s important to know that both the WHO and CDC recommend
Any decision about whether to room-in or separately isolate birth parent and newborn must be made with the parent’s informed consent, taking into account the individual circumstances. UPDATE 5/19/2020: DoD COVID-19 Practice Management Guide states: "To reduce the risk of post-natal transmission from mother to infant, the CDC and American Academy of Pediatrics recommends consideration of temporarily separating a symptomatic PUI or COVID-19 positive mothers from her infant (e.g. separate rooms). In the absence of more definitive data, this decision should reflect an individualized risk - benefit consideration for the mother and infant, cognizant of the potential for delayed maternal-child bonding and impaired breastfeeding. This will require an additional healthy (non-infected) adult to care for the infant while separated from mother." UPDATE 4/1/2020: DoD COVID-19 Practice Management Guide affirms that it is the parent's decision whether to separate or co-locate with a newborn immediately postpartum.
Any birth parent who is positive for COVID-19 must wear a mask and wash hands frequently before and during caring for their baby. UPDATE 5/19/2020: DoD Covid-19 Practice Management Guide affirms previous statements for protective measures to prevent infection transmission. UPDATE 4/1/2020: DoD COVID-19 Practice Management Guide affirms that mask and handwashing hygiene should be followed to minimize the risk of exposure to the infant.
Breastmilk is the optimum nutrition for human babies, and a parent’s choice to breastfeed should be supported. UPDATE 5/19/2020: DoD COVID-19 Practice Management Guide affirms breastfeeding and human milk is optimal feeding method and should be supported for all patients who desire. UPDATE 4/1/2020: DoD COVID-19 Practice Management Guide affirms that breastfeeding and providing human milk is the optimal infant feeding method for COVID-19 patients.
Ensure proper milk handling & storage
If your newborn baby is isolated or sent to the NICU, you can still provide your milk. The hospital should provide you with a pump, and you can ask to see a lactation consultant to help ensure you have a proper fit and you know how to use it. Each NICU typically has specific instructions for safely expressing and storing milk. If you are COVID-19 positive, it is especially important to remember
Wash your hands before handling any pump parts.
Sanitize your pump parts with alcohol wipes before and after each use.
Do not use alcohol wipes on your breasts! Wash with soap and water.
UPDATE 5/19/2020: DoD COVID-19 Practice Management Guide no change. UPDATE 4/1/2020: DoD COVID-19 Practice Management Guide contains specific instructions for safely expressing and handling human milk. It also states that no person who is positive for COVID-19, nor anyone who is a household contact with a positive COVID-19 patient will be allowed to visit the NICU. If you are separated from your baby and unable to visit the NICU, here are some suggestions to stay connected: Ask the staff if it's possible to see video clips or photos of your baby. These can be especially helpful to look at while you're pumping.
Ask if you can provide a special outfit, blanket, or stuffed toy for your baby's isolette (properly cleaned and wrapped to avoid possible transmission of the virus)
Connect with other NICU parents to talk about what you're going through. Postpartum Support International runs a weekly online NICU support group.
Take care of your mental health
Pregnancy and postpartum are both times when people may experience mental health struggles, due to a combination of shifting hormones and neurochemicals and the heightened state of bringing a new person into the world! People with pre-existing mental health conditions, such as depression and anxiety, are also at greater risk for perinatal mental health struggles. Now that we are in a global pandemic situation, with so much changing, increased stress, and restrictions on our normal life, we are also seeing a drastic increase in mental health struggles. During this time, it is very important to pay attention to your mental health, and seek help if you are feeling anxious, depressed, or overwhelmed. See the mental health section in Part 1 of our COVID-19 blog series for detailed information and resources on caring for your mental health.
Do you have questions or concerns about pregnancy, birth, and breastfeeding during the COVID-19 pandemic? Has your MTF or civilian provider recently updated policies? Let us know on Facebook at Mom2Mom Global or Breastfeeding in Combat Boots. Do you need lactation support? Check out our Chapters or the Military Breastfeeding Support database to find a support group or lactation professional near you. And follow Mattos Lactation for more great breastfeeding information and resources.
Contributing authors for this blog post are Shondra Mattos, IBCLC and Amy Barron Smolinski, MA, ALC, CLC.