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Information and advice for pregnant women during the COVID-19 Pandemic

My heart is with all the pregnant mama’s out there right now and I’m here to support you. I would like to give you the updated evidence on COVID-19 in relation to pregnancy, birth, and breastfeeding. Giving birth in a world with NO pandemic is one of the most powerful things you will do in your life, so add the stress of this pandemic, and you’re now faced with additional challenges. I am convinced that you and your family will emerge even stronger and with more confidence due to the fact that you now have to rely on yourself and your partner more than ever bfore. You were put on this earth to achieve your greatest self, to live out your purpose, and to do it courageously. Imagine… If we changed the rhetoric from one of fear to one of bravery?

1. How should I be looking after my pregnancy to avoid Covid-19?

Until we come up with a vaccine for this virus, the best way you can protect yourself is with physical distancing (stay 2-3m) from people in the community and avoiding public spaces. Washing your hands often for 2 minutes and avoiding touching your face, while frequently wiping down surfaces. These measures have been drilled into us and should be common practice by the time you’re reading this! Avoid hospital appointments where possible, complete your antenatal appointments via telehealth and find an online childbirth education course that suits your needs. Stay at home as much as possible! It is also important to report any symptoms early so that you can get tested and treated as soon as possible.

2. What is your advice on looking after mine and my baby’s health in a time with reduced antenatal appointments and NO face to face education classes?

Staying healthy and relaxed is more important now than ever. As you will have seen in the media, the infected non pregnant population who are a bit older and have comorbidity’s, like diabetes and high blood pressure have worse outcomes than those fit and healthy younger ones! Therefore, putting pregnancy induced hypertension, pre-eclampsia, and gestational diabetes into a higher than normal risk category for women who acquire the COVID-19 infection.

Early diagnosis and treatment will be vital for maintaining your health and the health of your baby and with the reduction in antenatal appointments, my fear is that these conditions may “slip through the cracks”. If possible, I would recommend buying a blood pressure monitoring device from your chemist to take your own blood pressure. It is only necessary to take it once a week, but you should write down your findings and discuss them with your OBGNY, midwife, nurse or GP. It is also important that you keep on top of your scheduled blood tests and GTT (glucose tolerance test). But, the best indicator of your baby’s health is their movements, so become familiar with their movement patterns, and check out the following website. http://movementsmatter.org.au/information-for-women

Getting enough sleep and eating a well-balanced diet are vital for cell function, both of which will boost your immune system. Start by increasing your intake of fruit and vegetables and limit processed food and sugar, step one done! Meditation and pregnancy yoga are a great way to relieve stress and improve sleep. Practicing mindfulness is another way to achieve a calm state, and there is now emerging research showing that this can lead to a calmer newborn. Walking for 30 minutes a day is now more important than ever, due to our social isolation, we are becoming more sedentary. The added benefit of walking in the sunshine is the boost to your Vitamin D levels. Studies have linked vitamin D deficiency during pregnancy with an increased risk of preterm birth, gestational diabetes, preeclampsia (very high blood pressure during pregnancy), and bacterial vaginosis. So, if you are not able to get into the sunshine for a walk each day, you should consider using a vitamin D supplement. And lastly, what about doing your childbirth education online? Consider your birth plan, and then find a suitable course to watch with your partner. My online classes are a mix between mindfulness and evidence – based education, feel free to check them out. https://themindfulmama.com.au/mindful-childbirth-education/

3. Is there any evidence of Mother-to-Baby transmission of COVID-19 during pregnancy?

This is known as “vertical” transmission. Currently (12th of April) there is only one case that is being investigated, but this case has still not confirmed that it was vertical transmission, instead the science is investigating if the newborn could have acquired COVID-19 from either the health care worker or the infected mother immediately after birth, not necessarily during the womb or during birth.

4. Am I at higher risk of contracting Covid-19 because of my pregnancy?

So far, there is no evidence that pregnant women are at greater risk of infection or severe illness with COVID-19 compared to the general population. A recent study of pregnant women in New York support these findings from China and Italy, which is reassuring.
From a sample of 43 pregnant women who tested positive for COVID-19…
86% had mild symptoms
9% were severe
5% critical
Interesting … 14 (33%) reported NO symptoms on arrival to the birthing unit: Of these asymptomatic women, 10 did end up developing mild symptoms over the course of their stay, giving rise to the question of why we are not testing all pregnant women on arrival to birth suite?

5. Why is pregnancy considered an “at risk” population during this epidemic if the evidence states pregnancy is not a risk factor?

During pregnancy your body goes through some physiological changes that can put additional pressure on your heart and lungs. Usually these do not present any problems. We know from previous influenza infections, that pregnancy predisposes women to respiratory complications when they get infected. But this has not been proven with the COVID-19 virus and currently the research is showing us that
contracting influenza while pregnant poses a higher risk in pregnancy than contracting the COVID-19 virus. When a virus is this new and large groups of populations have yet to be studied, the scientists look at similar patterns with similar virus’s, so they are treating the risk the same as if it was an influenza outbreak. I guess the medical community feel it is better to err on the side of caution. A study by the WHO in February of 147 pregnant women who were suspected or confirmed infected with COVID-19, showed that the percentages of serious illness was no different to the population of non-pregnant people who contract COVID-19, leading them to put out a statement that the category of “at risk” was purely a precautionary measure.

6. When do you start being contagious?

The average incubation period is 5 days, with the longest being 12 days. So, once you have caught Covid–19 from another person, you will most likely show symptoms after 5 days, but it could take as long as 12 days to show infection. Meaning that for those 5 – 12 days you could potentially be transmitting the disease to everyone you come into contact with. Hence why the isolation periods were set at 14 days. It is the long incubation period that has us midwives questioning the issue of TESTING among other things…

• How do we know that a woman presenting in labour, has the infection but has not yet showed any signs?
• And, therefore do we treat everyone in labour as a potential risk of having Covid–19 or just those who are showing symptoms (however mild)?
• It is very common for women in labour to develop mild fevers. This can be related to epidurals, synthetic oxytocin, and chorioamnionitis.So therefore, it will present a problem in discriminating between a Covid-19 infection and an obstetric fever.
• For midwives to better support women in labour, testing with quick results would be optimal. If the primary care midwife tests negative and the woman and support person test negative, then the labour and birth can continue as it would have prior to the pandemic.
And again, this might have changed as testing is now becoming widespread in the fight against COVID -19.

7. What can I expect when I go to hospital to give birth to my baby?

Many of the changes you will encounter upon arriving at your chosen place of birth will be procedures that have been put in place to protect yourself, your family and the midwives and doctors who are caring for you. You might see health care workers walking around in masks, you might find the environment more “clinical” than it used to be. You might be asked to wash your hands frequently or shown to your room using physical distancing. These are all very counterintuitive to our role as a midwife. Usually we would do whatever it takes to make you feel safe, comfortable and cared for and this used to involve a lot of touch! The staff may be more stressed than usual, and they may also be more sensitive. As a community, I feel that becoming more aware and “in tune” to other people’s feelings and sensitivities can be a new way of expressing compassion and understanding. So, as much as it should be all about you on your special day, it may be worth considering the simple task of showing up for work now takes on a whole new meaning for midwives and doctors.

The biggest change for any woman who is giving birth in this current pandemic, is the limited support network during labour and in the postnatal period. This does vary from hospital to hospital, but in my research for this article, most hospitals around the world are only allowing 1 support person through labour and into the postnatal period. Understandably, this is causing much anxiety, particularly to first time mothers, with many women having to choose between parents, doulas, and partners. It is not easy to know who would best support you during labour, and if it is not your partner, imagine having to ask them to move aside and miss seeing the birth of their baby, in favour of a more emotionally supportive person? Touch choices ahead. I firmly believe that it is vital and empowering to take the positives out of this issue of “support”. My philosophy is always one of “what can we learn from this?” And my gut feeling is, we will learn how to depend more on the people who truly love us and show up to support us in any way we need. It might bring more closeness to the family unit and allow more time initially to bond with your baby, leaving all the distractions at the door!
If you have tested positive or are suspected of COVID-19 infection the guidelines are listed below….

8. What can I expect after the birth of my baby?

Most hospitals only 1 support person on the ward, so again it is the issue of support that is most affected by birthing during the pandemic. Many hospitals can arrange a 6-hour discharge to home for low risk births, that had no interventions. This might suit mothers who have done this all before! The usual classes that you expect on the postnatal ward, like breastfeeding and mother-crafting, will be delivered one to one from your primary midwife. If anything, you might find that you receive a more personalised service in a quieter environment!
Although controversial, what we as midwives have noticed on the maternity ward, is a sense of calm. Often women can get inundated with visitors, and it is up to us to advocate for women and ask the visitors to leave. We have noticed in the last month, increased skin to skin and breastfeeding on demand. Plus, additional education and support by midwives as they are not tiptoeing around visitors! I personally feel like it enables a postnatal midwife to support a new family in the way which we were taught!
If you or your baby have tested positive for COVID-19 then the guidelines are below.

9. Do I have to have a C-Section or Induction if I am confirmed to be COVID-19 positive?

No, the WHO/RANZCOG/AGOG/RCOG states that your mode of birth should be individualised based on your current preference and the obstetric indications. Performing a C/S or induction should only be used when medically indicated. The indications for an induction should be based on gestational age of your unborn baby and the severity of your infection.

10. Can I breastfeed my baby if I test positive or are suspected of having COVID-19?

Yes, women with COVID-19 can breastfeed if they wish to do so. There is no evidence of the COVID-19 in the breastmilk of infected mothers.
The advice for breastfeeding follows:
• Wash your hands before and after touching your baby
• Routinely clean and disinfect surfaces you have touched
• The current guidelines (see below) are in favour of “rooming in”, as the benefits of skin to skin and breastfeeding outweigh the risk of your baby contracting the virus.

11. Current Guidelines for COVID-19 Positive Pregnant Mamas (updated April 9th)

The current worldwide evidence is based on small sample groups and the following list is the source of information for maternity care providers.

WHO: World Health Organisation
ISUOG: International Society of Ultrasound in Obstetrics and Gynaecology
RANZCOG: Royal Australian and New Zealand College of Obstetrics and Gynaecology
RCOG: Royal College of Obstetricians and Gynaecologists
CDC: Centre of Disease Control
ACOG: American College of Obstetrics and Gynaecology

Below are the guidelines for the care of women in labour who have a suspected or confirmed to have COVID-19 infection.

All pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth. A safe and positive childbirth experience includes:
• Being treated with respect and dignity
• Having a companion of choice present during delivery
• Clear communication by maternity staff
• Appropriate pain relief strategies: the research is not clear on the risk of using Entonox gas and the spread of the virus, so each health care facility is using their best judgement on this, most say it is OK to use. Epidurals are safe.
• Mobility in labour where possible, and birth position of choice
• No water immersion due to the possible transmission through faecal contamination.
**(RANZCOG guidelines are the only ones who support water immersion) **
• Delayed cord clamping still recommended
Although, these organisations have been consistent in their advice around managing the birth of a COVID positive woman, there has been    much debate about the potential risks of mother-to-baby transmission and how this should be managed. Until a few days ago, the recommendations for the care of her newborn were inconsistent. The CDC, ACOG were more concerned with mother–to–baby transmission of the virus and RANZCOG, RCOG, WHO were looking at the risk of separating mother and baby. They believe the research on the benefits of “rooming in” outweighed the risk of transmission. Thankfully, the CDC and AGOG have come into line with the other world organisations and updated their policy from the 9th of April. Recommendations are now consistent and stated below. This is a big win for all the infected mothers who were scared of being separated from their newborns.

Below are the guidelines for the care of a newborn by a mother who has been confirmed or suspected of COVID-19.

When caring for your baby, if you have tested positive or are suspected of having COVID-19, skin to skin contact and early and exclusive breastfeeding should be supported to help your baby to thrive.
This includes:
• Breastfeed safely, with good respiratory hygiene, consider wearing a face mask and if you are feeding your baby with expressed milk, have your support person feed the EBM to your baby.
• Hold your newborn skin-to-skin, and initiate breastfeeding within the first hour of birth.
• Share a room with your baby
• Below are is the evidence to support skin to skin and rooming in.
• The evidence for supporting skin to skin and rooming in for babies is as follows: More effective suckling during the initial BF session. Less crying – babies who received skin to skin care were 12 times less likely to cry during the observation period. Heart rate, breathing, oxygen levels were more likely to remain stable if rooming in. Beneficial for the baby’s blood sugar levels.

What we do know today: 11th of April
• 1 maternal death
• No evidence on outcomes related to infection in the 1st or 2nd trimester
• No confirmed cases of vertical transmission during pregnancy. Samples of amniotic fluid, placenta, cord blood, and breastmilk have so far been negative in pregnant mothers who tested positive of COVID-19
• UNSURE whether there is a higher incidence of preterm birth in COVID-19 positive women.

This is where you come in…
Intuition: your rights as a mother, who do you listen too…
I hope that the information, advice and some of my own opinions have helped you to navigate your birth plan in such a stressful situation!
As we face these inevitable challenges, we will realise that deep down we already possess the strength and insight to deal with them. Here is a little poem I found on Inner Strength…

“You have to strength to change and evolve.
You are constantly growing into a better person.
Listen to yourself first.
Know you are safe and secure when you are true to yourself.
Believe in your own answers.
Resisting pressure in order to do what feels right empowers you.
Giving yourself what you need makes you stronger for others.
You are a strong, independent woman.
You can choose to reject limitations.”

I wish you well on this journey and I encourage you to find ways to gather this inner strength. I have always said, it is the parenting journey that requires the most of us, the birth is just one day. Times like this help us to put life into perspective and the lessons of the Corona Virus will hopefully remind us what we value and what we know is real and true.
My hope for the future is that the world will remember what it was like to…