Pregnancy, Birth, and Breastfeeding with Covid-19
Midwifery Today, Issue 134, Summer 2020.
Join Midwifery Today Online Membership
We are in the midst of a pandemic caused by the novel coronavirus—Covid-19. Midwives and pregnant women need guidance on how to proceed and whether their babies are at risk.
We are on new ground with this virus and how to deal with it during the perinatal period. It is not known whether—like Zika virus—it can cause problems in the development of babies in the first trimester. We also do not know whether it can have other adverse effects on babies during the rest of pregnancy or delivery. Another unknown is whether pregnant women without another pre-existing condition are more likely to become seriously ill if they contract Covid-19. This is why it is important to try to minimize the risks.
Guidelines from the Center for Disease Control and Prevention (CDC) suggest that pregnant women take the same actions as others in stopping the spread of the virus. These include coughing into a tissue or elbow, avoiding those who are sick, and washing the hands often with soap and water or an alcohol-based hand sanitizer. When washing hands, it is important to clean the whole hand and wash for at least 20 seconds (or sing “Happy Birthday” twice). Other recommendations are to avoid touching one’s face, avoid touching surfaces when in public, and practicing “social distancing.” If possible, pregnant women should stay home as much as possible, and not allow visitors.
The National Health Service (NHS) in the UK advises the following for pregnant women who work in the NHS or other jobs in the UK:
- Women who are less than 28 weeks pregnant should practise social distancing but can continue working in a patient-facing role, provided the necessary precautions are taken.
- Women who are more than 28 weeks pregnant, or have underlying health conditions, should avoid direct patient contact.
During Birth and Postpartum
According to CDC’s FAQ, no babies were believed to have been infected if their mothers had Covid-19 during pregnancy or at the time of the birth. No virus has been found in amniotic fluid or breastmilk, either. However, there are not enough cases at this point to be definitive. Part of the thinking in how this virus will act relates to prior coronaviruses, such as SARS and MERS.
Some hospitals have developed policies prohibiting visitors that include spouses and other support persons during birth—to the distress of pregnant women. Others are removing the baby from a mother who is infected.
The CDC and American College of Obstetricians and Gynecologists (ACOG) have developed guidelines that encourage facilities to consider temporarily separating mothers confirmed to have Covid-19 or under investigation for the disease from their babies, and treat them according to infection control guidelines. The length of separation (or any separation at all) should be made on a case by case basis, between health care providers and the mother, and can vary depending on where the mother is in her disease process.
In regard to breastfeeding when a mother is symptomatic or has confirmed Covid-19, the CDC recommends a decision between mother, family, and health care providers. They also recommend taking “all possible precautions” to avoid infecting the baby, including handwashing, wearing a face mask while breastfeeding. If she is pumping breastmilk, she should follow instructions for cleaning the pump, and possibly have another person feed the baby.
Homebirth midwives should take all of the previous advice for avoiding Covid-19, including social distancing, sanitizing, and washing well. If a midwife or other birthworker does get exposed to the virus, it is prudent to not assist at a birth until the two week quarantine period has passed with no symptoms.
If a client is infected with Covid-19, has been exposed, or has symptoms of it, a homebirth midwife who decides to continue to serve that client must take the same precautions as are recommended for hospital workers: N95 mask, gown, gloves, and extreme caution given to cleanliness.
In some cases, a decision will have to be made to transport the client to the hospital. This is clearer if she is showing serious symptoms. Hospital staff need to be informed in advance to ensure that she is isolated from other patients, including other birthing mothers.
In Minnesota, a 36 weeks-pregnant woman was exposed to the virus by her parents, who both tested positive. She does not have symptoms yet, so is unable to be tested due to limited numbers of test kits. According to doctors there, her baby would have to be separated from her at birth, unless she has tested negative.
The Times of Israel reported that a baby in Jerusalem was in the neonatal intensive care unit with Covid-19. The baby, born prematurely two months earlier and underweight with serious complications, was believed to have contracted the virus from a hospital worker. Staff and parents have been isolated.
A pregnant woman in the UK was hospitalized for pneumonia and had her baby several days later. Both mother and baby tested positive for Covid-19 and have since been separated from each other for treatment. No more information was available on how the baby was infected (in utero or during or after birth) or how sick it is.
On March 26, 2020, in New York, a 3-month-old infant became the youngest person to be diagnosed with Covid-19 in the US. The baby was hospitalized for several days and now is being treated at home. There was no information on how the baby was infected and whether the parents or other family members had tested positive.
As this pandemic ramps up and then starts to resolve, we will undoubtedly learn much more about the risks to pregnant women, their babies, and their midwives and other care providers. At that point, we will be able to provide more definitive advice—which we can apply during the next spike in disease. According to Anthony Fauci, “It’s more likely than not that this is going to turn around and come back in another season.” In the meantime, please continue to socially distance, wash your hands, don’t touch your face, and avoid people with the illness.
The nonprofit Organization of Teratology Information Specialists (OTIS) is doing a telephone-based study to determine short and long-term effects of Covid-19 virus in pregnancy and breastfeeding. It is open to pregnant and breastfeeding women in the US and Canada who have verified or suspected Covid-19 infection.
To learn more or participate in the study, which launched on March 23, go to mothertobaby.org/join-study or call the MotherToBaby Pregnancy Studies at 877-311-8972. Health care providers can refer pregnant and breastfeeding patients with known or suspected infection at this link.