COVID-19 Clinical FAQ

COVID-19

The information displayed on this page is based on a review of existing research and clinical guidance on COVID-19. To develop these responses, the AOM has largely referred to guidance produced from local and provincial public health authorities and national guideline development groups including the World Health Organization (WHO), the Society of Obstetricians & Gynaecologists of Canada (SOGC), and the Royal College of Obstetricians & Gynaecologists (RCOG).

This content will be continually monitored and updated as new evidence continues to emerge. A date stamp has been added at the end of each response to indicate the date this information was last accessed and updated.
 

 

NEW! Top Questions about the Omicron Surge 

What are the symptoms of COVID-19? 

The Ministry of Health has updated the list of symptoms for COVID-19 (PDF, 70 KB).

The most common symptoms of COVID-19 that require immediate self-isolation and, if eligible, COVID-19 testing include:

  • fever (temperature of 37.8°C/100.0°F or greater) and/or chills
  • cough (that is new or worsening and not related to other known causes or conditions for which current symptoms do not represent a flare-up/exacerbation related to infection)
  • shortness of breath (that is worse than usual if chronically short of breath and not related to other known causes or condition)
  • decrease or loss of smell or taste, not related to other known causes or conditions (e.g., nasal polyps, allergies, neurological disorders)

TWO or more of the following symptoms of COVID-19 require immediate self-isolation and, if eligible, COVID-19 testing

  • extreme fatigue, lethargy, or malaise (general feeling of being unwell, lack of energy, extreme tiredness) that is unusual or unexplained and not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia, malignancy, receiving a COVID-19 or flu vaccine in the past 48 hours)
  • muscle aches or joint pain that are unexplained, unusual, or long-lasting and not related to other known causes or conditions (e.g., fibromyalgia, receiving a COVID-19 or flu vaccine in the past 48 hours)
  • nausea, vomiting and/or diarrhea, not related to other known causes or conditions
  • sore throat (painful swallowing or difficulty swallowing) not related to other known causes or conditions (e.g., post nasal drip, gastroesophageal reflux)
  • rhinorrhea or nasal congestion (runny nose or stuffy nose) not related to other known causes or conditions (e.g., returning inside from the cold,
  • chronic sinusitis unchanged from baseline, seasonal allergies)
  • headache that is new and persistent, unusual, unexplained, or long-lasting, not related to other known causes or conditions (e.g., tension-type headaches, chronic migraines, receiving a COVID-19 or flu vaccine in the last 48 hours)

Midwives should use the above symptoms to screen clients for COVID-19. The provincial self assessment tool has been updated to reflect this new symptom list. 

[January 7th 2022] 
 

Who can get tested for COVID-19 during the Omicron surge? 

PCR or rapid molecular testing is being restricted for certain priority groups:

  • Pregnant people are being prioritized for PCR testing. 
  • Patient-facing healthcare workers including midwives and midwifery clinic/birth centre staff are still being prioritized for PCR testing.
  • Symptomatic/asymptomatic people who are from First Nation, Inuit, and Métis communities and individuals travelling into these communities for work can also access testing. 

Others may be eligible for testing. Midwives can refer to the COVID-19 Integrated Testing & Case, Contact and Outbreak Management Interim Guidance: Omicron Surge for that guidance. 

The protocol on testing prior to scheduled procedures (e.g. booked c/s) will vary across regions. It is expected that: "Regardless of vaccination status, patients should only go out for essential reasons (e.g. work, school) for as close to 10 days prior to a scheduled procedure as is feasible."

[January 14th 2022] 

When should midwives use PPE when interacting with a client? 

All health-care providers should perform an individual point of care risk assessment with all clients prior to any interaction to help determine the correct PPE required to protect the health-care worker.

The AOM recommends the use of droplet/contact PPE for all clinical encounters as best practice, however, based on a PCRA, midwives may chose to wear N95s respirators in all settings. Eye protection should also be considered for ALL clinical encounters (even with clients who have screened "negative"). 

When providing direct care for patients with suspect or confirmed COVID-19, (PDF, 902 KB) midwives should wear:

  • N95 respirator (fit-tested, seal-checked)
  • Isolation gown
  • Gloves
  • Eye protection (goggles or face shield)
  • Negative pressure room (if available)

PCMCH continues to recommend (PDF, 399 KB) that the labouring person who is suspected or confirmed for COVID-19 should be given a surgical/procedure mask for all stages of labour, if tolerated.

[January 7th 2022] 

We need PPE. Where can we get it? 

Midwives can still access PPE, free of charge, through the Pandemic PPE Transitional Support (PPTS) program. To access this PPE (including N95 respirators) as well as rapid antigen testing kits and COVID-19 swab kits, complete the appropriate request form on this page.  

[January 11th 2022] 

If a midwife tests positive for COVID-19, who do they need to notify? 

All test-confirmed COVID-19 cases (i.e. people who test positive on PCR, rapid molecular, or RAT) should notify high risk contacts of their exposure. High risk contacts include: 

  • anyone with whom the COVID-19 positive person came into close contact within the 48 hours prior to symptom onset if symptomatic, or 48 hours prior to the test date if asymptomatic, and until the positive person started self-isolating.
  • Close contact means you were in close proximity (less than 2 meters) to them for at least 15 minutes or for multiple short periods of time without appropriate measures such as masking and use of personal protective equipment (as per Management of Cases and Contacts of COVID-19 in Ontario (PDF, 522 KB)).

Current guidance from the Ministry of Health states that if a healthcare worker, in the context of a standard clinic visit, was wearing contact and droplet precautions, which includes a well-fitted procedure/surgical mask or kN95, or non fit-tested n95, eye protection, gown and gloves, then an exposure from the client is not considered high-risk. 

However, if it is the midwife who tests positive or becomes symptomatic, the midwife may still need to notify clients of a high risk exposure since the clients are not necessarily wearing PPE. PPE protects the wearer of the PPE from exposure from those around them, it is less effective at protecting others from exposure from the person wearing the PPE. As such, midwives should try to limit prolonged close contact (as clinically appropriate) with clients and consider providing clients with medical masks for visits if the clients do not have appropriate masks to protect themselves.

[January 7th 2022] 

If a midwife has been exposed or is sick with COVID-19, when can they return to work? 

Midwives follow guidance specific to high-risk settings when exposed to someone with COVID-19. The flow-chart below outlines this guidance. 

Generally speaking, if a midwife tests positive or is symptomatic, they should avoid work for 10 days from symptom onset.

However, midwives may return to work on day 7 from the date of symptom onset or positive test, whichever is earlier, if they meet the following criteria:

  • have two consecutive negative RATs at least 24 hours apart (e.g. day 6 and 7) AND
  • symptoms have been improving for at least 24 hours (or 48 hours if gastrointestinal symptoms).

[January 7th 2022] 

What is work self-isolation and what does it mean for me?  

During critical staff shortages, midwives and other health care workers may be asked to return to work when they would otherwise be on self-isolation at home. This is called work self isolation. 

Staff who are household contacts of cases or have otherwise advised to self-isolate, may return to work on work self-isolation if:

  • they remain asymptomatic; AND
  • are actively screened ahead of each shift; AND
  •  are fully vaccinated; AND
  • continuously test negative on required testing.

Staff who are cases (symptomatic or tested positive) may return to work, ideally only beginning on day 7 after two negative rapid tests at least 24 hours apart, on work self-isolation, if they:

  • remain asymptomatic; AND
  • are fully vaccinated; AND
  • wear a fit-tested, seal-checked N95 respirators at all time during work

The Ministry of Health has released the document COVID-19 Interim Guidance: Omicron Surge Management of Critical Staffing Shortages in Highest Risk Settings (PDF, 179 KB). This document provides additional information for staff in high risk settings such as healthcare, to return to work under certain conditions when they should otherwise be isolating due to exposure to COVID-19, a positive test for COVID-19 or a history of symptoms consistent with COVID-19.

Midwives considering returning to work under "work self isolation" should follow direction from their occupational health department and may call the AOM On Call for support in determining the appropriateness of this plan.

The conditions (for example, a critical number of midwives unable to work due to illness, not enough OB coverage in the community to transfer care, etc.) that led to midwives working under work self isolation should be documented to demonstrate that the risk of midwives not working at all was greater than the risk of midwives working under work self isolation.

[January 14th 2022] 

We are facing HHR and service constraints, what can we do? 

We are already seeing some devastating impacts on health human resources and the availability of services (critical numbers of midwives unable to work due to illness or isolation, labour and delivery units closed, no availability for EMS services, etc.) due to the Omicron surge. 

Considerations for human health resources planning 

Midwifery practice groups should review their practice group's outbreak and pandemic protocol (template available to members) to update contingency plans as necessary with the increasing risk of having a reduced workforce.

Labour and delivery (L&D) departments may be impacted. If a hospital closes the L&D unit and is redirecting patients, CritiCall should provide direction as to where clients should go. If this situation arises, midwives should attempt to manage client expectations and explain to clients that their midwife most likely cannot accompany them to a hospital where the midwife does not have privileges.

Midwives will need to recognize that there are limits to the provision of safe care and unfortunately, at times when there are not enough midwives available, care needs to be transferred to physician colleagues. It may be appropriate to proactively discuss contingency planning with interprofessional colleagues in the hospital and community to assess who may have capacity to take over or provide care if midwives cannot.

Whenever care significantly differs from the usual practice, midwives should document in greater detail, including:

  • what the plan would be under normal circumstances ("plan A")
  • the extenuating circumstances (e.g. closed L&D, no ultrasound capacity for anatomy scan)
  • the current plan, taking into consideration the evolving situation ("plan B")
  •  the discussion with the client

Considerations for choice of birthplace

Home or birth centre births have the potential to relieve strain on an overburdened hospital in the context of a pandemic. Pregnant people may either have difficulty accessing hospital care for normal birth or may not want to go into the hospitals in the midst of pandemic conditions.

However, during the pandemic, there may be circumstances where midwives cannot safely offer out of hospital birth to clients. Midwives must draw upon their clinical skills and judgement to keep birth as safe as possible for both their clients and themselves, taking into account local context, resources and rapidly evolving circumstances.

Choice of birthplace may be limited by:

  •  the unavailability of midwives or second attendants to attend a birth at home
  • the availability and capacity of timely EMS services
  •  access to sufficient and adequate PPE supplies and the ability to maintain the integrity of PPE during the labour and birth to keep midwives and second attendants safe

Midwives should endeavor to discuss any conditions that may impact choice of birthplace with clients in a timely manner and document those discussions.

[January 11th 2022] 

What are the recommendations for clients who have symptoms? 

Symptomatic individuals who are unable to access or are ineligible for PCR/rapid molecular testing are advised to self-isolate as soon as possible after symptom onset and are presumed to have COVID-19 infection if presenting symptoms.

  • If the individual is fully vaccinated OR is a child under the age of 12 years old, they should self-isolate for at least 5 days from symptom onset AND until their symptoms have been improving for 24 hours (or 48 hours if gastrointestinal symptoms), whichever is longer in duration.
  • If the individual is not fully vaccinated and is 12 years old or older, or if they are immune compromised, they should self-isolate for 10 days from symptom onset AND until their symptoms have been improving for 24 hours (or 48 hours if gastrointestinal symptoms) and they are afebrile, whichever is longer in duration.

All household members of the symptomatic individual, regardless of vaccination status, should stay at home while the symptomatic individual is isolating for at least 5 days due to the high rate of transmission within households. If a household member develops symptoms, they should follow isolation directions for symptomatic individuals and if eligible for testing, seek testing.

This flowchart from the Ministry of Health is a useful demonstration of current guidance:

[January 7th 2022] 

What are the recommendations for clients with rapid antigen test results? 

If a rapid antigen test (RAT) is available to the person with any of the symptoms, RAT may be used to assess the likelihood that symptoms are related to COVID-19. 

  • A positive RAT is highly indicative that the individual has COVID-19, and the individual is required to self-isolate. 
  • A negative RAT may represent a false negative and does not mean that an individual can stop isolating.
    • If two consecutive RATs, separated by 24-48 hours, are both negative, the symptomatic individual is less likely to have COVID-19 infection, and is advised to self-isolate until symptoms are improving for at least 24 hours (or 48 hours if gastrointestinal symptoms).
    • The household members of the symptomatic individual with two negative tests may also discontinue self-isolation.

[January 7th 2022] 

What are the recommendations for clients who have been exposed to someone with COVID-19?  

Midwives can use this flowchart to guide clients when they have been exposed to someone with COVID-19:

[January 7th 2022] 

Can pregnant and chest/breastfeeding clients receive the COVID-19 vaccine? 

All pregnant individuals are eligible and recommended to be vaccinated as soon as possible, at any stage in pregnancy, as COVID-19 infection during pregnancy can be severe, and the benefits of vaccination outweigh the risks. Vaccination may be considered at any gestational age, including the first trimester.

Pregnant people can receive booster doses of COVID-19 vaccine three months after their last dose from the primary series.

Please see the COVID-19 Vaccination Recommendations for Special Populations for further details on COVID-19 vaccination for pregnant individuals. This recommendation aligns with the Society of Obstetricians and Gynaecologists (SOGC) statement on COVID-19 Vaccination in Pregnancy (reaffirmed on Nov 4th, 2021) which states that pregnant individuals should be offered vaccination at any time during pregnancy or while breastfeeding if no contraindications exist. 

Resources for midwives to help counsel clients on vaccination include:

[January 7th 2022] 

How can midwives collect data on pregnancy and newborn outcomes for clients with COVID-19 during the omicron surge?

In the absence of PCR testing availability, BORN Ontario recommends that all midwives continue to submit the mandatory data elements (shaded orange) of the case report form. 

[January 11th 2022]

COVID-19 and Different Populations

What effect does COVID-19 have on pregnant people?

The 4th CANCOVID-Preg Report was released on June 3rd 2021 and includes outcome data from 3678 pregnant individuals. The report continues to show that pregnant individuals are at increased risk of hospitalization (RR = 4.26, 95% CI: 3.45 to 5.1) and two times more likely to be admitted to the ICU (RR=2.68, 95% CI: 2.02 to 3.40) than their non-pregnant counterparts diagnosed with COVID-19, although overall rates of ICU admission are low (2.8%) among pregnant people. 

Most cases (40.1%) of COVID-19 were diagnosed between 14 and 27 weeks' gestation and infection was most often acquired via the community at large (43.7%). The most common underlying conditions were obesity (12.9%), diabetes (11.2%) and cardiovascular disease (3.3%). (Money 2021) These comorbidities are strongly tied to the social determinants of health; emerging disaggregated data shows that communities of colour, and people living in poorer neighbourhoods are experiencing disproportionately higher rates of COVID-19 infection, severe disease, and mortality. (SOGC 2021)

Of note, the report does not include data on variants of concern or infection following vaccination. Reports from many health-care jurisdictions in Canada which faced a third wave of COVID-19 pandemic activity in April and May faced an increased number of pregnant individuals with COVID-19 who were being admitted to the hospital and ICU. The next analysis of CANCOVID-Preg data should help elucidate trends for pregnant individuals during the third wave. 

[June 8th 2021] 

What effect does COVID-19 have on the fetus/neonate?

Results from the 4th report of the CANCOVID-Preg study largely show positive pregnancy outcomes. Of 1821 reported pregnancy outcomes affected by COVID-19, there were 19 (1%) stillbirths and < 6 newborns who were tested for COVID-19 received a positive result. . Importantly, in this sample, stillbirth rates were 10.6 per 1000 compared to 5.44 per 1000  in the general population (derived from CIHI-DAD 2020 data). Although the stillbirth estimate in our COVID-19 positive cases is slightly higher than the general population, the absolute numbers are still quite small. (Money 2021

Of the 1769 cases with delivery and gestational age data, 87.1% occurred at term and 12.9% at preterm gestation. Of the 228 (12.1%) preterm infants, 34.6% were medically indicated preterm deliveries and 39.9% were spontaneous. This preterm birth rate is twice the rate of preterm birth in the general pregnant population. This is likely associated with severity of infection. (Money 2021; SOGC 2021

CANCOVID-Preg data also reported that the majority of infants (82.6%) were in the normal range for birth weight (2500-4000 grams) and most infants (84.8%) were not admitted to the NICU. (Money 2021

The CANCOVID data affirms a growing consensus that vertical (intrapartum) transmission is very uncommon although it may be possible, and there may be an association between severity of maternal illness and vertical transmission. (Money 2020; SOGC 2020) However, most studies show reassuring pregnant outcomes, with newborns testing negative after birth. (SOGC 2020).  In all reported cases of newborn babies developing coronavirus soon after the birth, the babies were well. (RCOG 2020)

[June 8th 2021]

Which risk factors put people at higher risk of more severe outcomes associated with COVID-19?

Pre-existing medical conditions
Based on a review of the available evidence, the CDC has identified adults of any age with the following conditions are at increased risk of severe illness from COVID-19: 

  • Cancer
  • Chronic kidney disease
  • COPD (chronic obstructive pulmonary disease)
  • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
  • Immunocompromised state (weakened immune system) from solid organ transplant
  • Obesity (body mass index [BMI] of 30 or higher)
  • Pregnancy
  • Sickle cell disease
  • Smoking
  • Type 2 diabetes mellitus

The CDC found limited or conflicting evidence that people with the following conditions might be at increased risk of severe illness from COVID-19: 

  • Asthma (moderate-to-severe)
  • Cerebrovascular disease (affects blood vessels and blood supply to the brain)
  • Cystic fibrosis
  • Hypertension or high blood pressure
  • Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
  • Neurologic conditions, such as dementia
  • Liver disease
  • Overweight (BMI > 25 kg/m2, but < 30 kg/m2)
  • Pulmonary fibrosis (having damaged or scarred lung tissues)
  • Thalassemia (a type of blood disorder)
  • Type 1 diabetes mellitus

The CDC used evidence from published reports, articles in press, unreviewed pre-prints, and internal data from December 1, 2019 to July 10, 2020 to form these lists.  Any condition that met the following criteria was included in the list: 

  • consistent evidence from multiple small studies or a strong association from a large study
  • multiple studies that reached different conclusions about risk associated with a condition
  • consistent evidence from a small number of studies 

More information about their methods, as well as the studies that informed their decision-making can be found here

A rapid review of the evidence from Alberta Health Services also identifies BMI, diabetes mellitus, pregnancy, smoking, hypertension, cardiovascular disease, COPD, asthma and kidney disease as associated with poor outcomes from COVID-19. 

[December 04, 2020]

Other risk factors: age and biological sex
A rapid review of the evidence from Alberta Health Services also finds older age to be associated with higher risk of severe outcomes from COVID-19, and this association is strongest in those over 65. Male biological sex has also shown to be associated with higher risk of severe outcomes from COVID-19. 

[September 2, 2020]
 

What advice can midwives provide to pregnant workers in regards to COVID-19?

Current guidance for pregnant workers is varied around the world.

The SOGC (Canada) states that pregnant workers can continue to work during the pandemic.  Pregnant clients and midwives should discuss an individualized plan related to working during the pandemic. Decisions about continuing to work should take into consideration:

  • Local epidemiology
  • Work-related risk of infection (e.g., type of work, exposure, access to PPE, etc.)
  • Individual risk for COVID-19 related morbidity (e.g., health history and current status including relevant comorbidities)
  • Ability to advocate for safer work conditions or accommodations, without risking lost income or employment
  • Mental health and anxiety related to workplace exposure and infection with COVID-19 during pregnancy

In situations where work-related exposure is substantial or individual risk factor for COVID-related morbidity is high, consideration should be given to accommodations made to reduce exposure (use of PPE, physical distancing, etc.) or absence from work for pregnant workers. 

RANZCOG (Australia and New Zealand) recommends that, where possible, pregnant health care workers be allocated to patients and duties that have reduced exposure to patients with confirmed or suspected COVID-19. Consideration should also be given to reallocation to lower-risk duties, working from home, or leave of absence. RANZCOG states that this advice can be extrapolated to other professions with a relatively high risk of exposure such as teachers or child-care workers. All personnel are advised to observe strict hygiene protocols and have full access to PPE. 

The UK government generally recommends that pregnant workers who can work from home should continue to do so. Pregnant workers should perform an individual risk assessment with their employer to modify the working environment to limit contact with suspected or confirmed individuals with COVID-19 to minimise the risk of infection as far as possible. A pregnant employee should only continue working if the risk assessment advises that it is safe to do so. 

ACOG (US) recommends that pregnant people who continue to work should have the ability to occupy roles with reduced risk of exposure, and that health-care providers advocate that pregnant clients have every possible protection from exposure to COVID-19 (eg, masks, gloves, remote working, proper ventilation, etc) in their workplaces. 

What inferences can we draw from this guidance on pregnant workers and COVID-19?

In general, health care organizations, including the AOM, support approaches that minimize or lessen the risk of exposure to COVID-19 for pregnant workers. 

Midwives should discuss an individualized care plan with their clients related to working during the COVID-19 pandemic. Midwives should help clients understand the available evidence in the context of their own personal health history, preferences, and personal circumstances ensuring clients are able to make an informed choice regarding their health and decisions to work. As primary care providers, midwives can use their clinical judgement to write notes for clients related to workplace accommodations/leaves of absence as long as the reason is within the midwifery scope of practice. 

[April 23rd 2021]

COVID-19 and Health-Care Workers

What should pregnant health-care providers consider in regards to COVID-19?

Current guidance for pregnant health care workers is varied.

The SOGC (Canada) states that pregnant workers can continue to work during the pandemic. For all pregnant workers, the SOGC advises that the following should be considered related to working during the pandemic:

  • Local epidemiology
  • Work-related risk of infection (e.g., type of work, exposure, access to PPE, etc.)
  • Individual risk for COVID-19 related morbidity (e.g., health history and current status including relevant comorbidities) 
  • Ability to advocate for safer work conditions or accommodations, without risking lost income or employment
  •  Mental health and anxiety related to workplace exposure and infection with COVID-19 during pregnancy

Pregnant health-care workers who are required to wear an N95 respirator, must ensure that their N95 respirator fit-test is up to date. Pregnant workers who are at increased risk should have reasonable workplace accommodations made to reduce exposures from the public and/or from those with COVID-19.

RANZCOG (Australia and New Zealand) recommends that, where possible, pregnant health care workers be allocated to patients and duties that have reduced exposure to patients with confirmed or suspected COVID-19. All personnel are advised to observe strict hygiene protocols and have full access to PPE. 

The RCOG  (UK) recommends that all pregnant workers have a risk assessment with their managers and that work environments be modified to limit contact with suspected or confirmed COVID-19 patients to minimize risk. Pregnant health-care workers under 28 weeks' gestation are able to continue working in client facing roles if risk assessment indicates this is acceptable, and if the health-care worker chooses to do so. Pregnant health-care workers from 28 weeks’ gestation, or with underlying health conditions, are recommended to stay home. 

CDC guidance suggests that facilities may want to consider limiting exposure of pregnant health-care providers to patients with confirmed or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures).

What inferences can we draw from this guidance on pregnant health-care workers and COVID-19?

Midwives have risen to the challenge of the physical and psychological risks posed by COVID-19. Several months into the pandemic, with no end in sight, the duty to care for clients while you yourself are pregnant may feel even more stressful than it did in March. 

Recommendations from the SOGC and RANZCOG approaches appear to be evidence-based and balance the potential risk of increased complications with our understanding that most individuals experiencing COVID-19 during pregnancy will have favourable outcomes; and yet the AOM supports approaches that minimize or lessen the risk of exposure to COVID-19 for pregnant health care workers. 

Duty to care and duty to accommodate for pregnant health-care workers

As the University of Toronto Joint Centre for Bioethics has stated: "Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability, and workplace conditions."

These ethical obligations are reflected in health and safety legislation, where the right to refuse unsafe work is limited for health-care workers if the refusal puts the life, health or safety of another person in danger.

Workplaces (e.g., MPGs) have a duty under human rights law to try to accommodate workers (including pregnancy or underlying health conditions) to the point of undue hardship.

The bar of what constitutes 'undue hardship' is normally rather high. What is considered sufficient accommodation depends on each case, the evidence of the harm to those workers and, of course, these unusual times.

Where feasible, accommodations should be made to ensure the safety of vulnerable health care providers. These may include:

  • Avoiding direct, in-person client contact
  • Conducting virtual prenatal and postnatal visits
  • Reviewing and entering lab and ultrasound reports
  • Taking pages (including for other midwives) and triaging them as necessary
  • Administrative duties

In a pandemic, requested accommodations may reach the threshold of an 'undue hardship' for an MPG that, under usual circumstances, would not be met or be able to accommodate as they would during normal times.

There is no clear answer to this question, but various factors must be balanced. The AOM On Call team can help to do that in individual circumstances.

[December 11th, 2020]

What guidance is available on accommodations for health-care workers with pre-existing health conditions?

Public Health Ontario (PDF 160KB) guidance released on March 27th 2020 points to the Ontario Human Rights Commission policy statement on the COVID-19 pandemic, which states that “employers have a duty to accommodate in relation to COVID-19, unless it would amount to undue hardship based on cost, or health and safety”. Health-care workers with concerns should initiate request for accommodation and management should work with health and safety departments to attempt to accommodate by redeploying or reassigning to non-risk areas or other appropriate work. When accommodation is not possible, employees should stay home and be able to access: sick leave, EI or other banks such as vacation or overtime banks.

[September 24, 2020]

Duty to care and duty to accommodate for health-care workers with pre-existing health conditions

Midwives have risen to the challenge of the physical and psychological risks posed by COVID-19. Several months into the pandemic, with no end in sight, the duty to care for clients and to accommodate the special needs of other midwives may feel even more stressful now than it did in March. Members are encouraged to reach out to the AOM, individually or as a practice group, for support to make decisions and access resources by calling the AOM On Call team. 

Duty to care:

As the University of Toronto Joint Centre for Bioethics has stated (PDF 147KB): "Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability, and workplace conditions."

These ethical obligations are reflected in health and safety legislation, where the right to refuse unsafe work is limited for health-care workers if the refusal puts the life, health or safety of another person in danger.

Duty to accommodate:

Workplaces (e.g., MPGs) have a duty under human rights law to try to accommodate workers (including pregnancy or underlying health conditions) to the point of undue hardship.

The bar of what constitutes 'undue hardship' is normally rather high. What is considered sufficient accommodation depends on each case, the evidence of the harm to those workers and, of course, these unusual times.

Where feasible, accommodations should be made to ensure the safety of vulnerable health care providers. These may include:

  • Avoiding direct, in-person client contact
  • Conducting virtual prenatal and postnatal visits
  • Reviewing and entering lab and ultrasound reports
  • Taking pages (including for other midwives) and triaging them as necessary
  • Administrative duties

In a pandemic, requested accommodations may reach the threshold of an 'undue hardship' for an MPG that, under usual circumstances, would not be met or be able to accommodate as they would during normal times.

There is no clear answer to this question, but various factors must be balanced. The AOM On Call team can help to do that in individual circumstances.

The burden of responsibility on midwives to care for clients and provide accommodations for colleagues can feel more onerous when government and facilities have not done a good job shouldering their responsibilities to health care workers, described by the University of Toronto Joint Centre for Bioethics "... if workers are to take high risks, there is a duty upon society, in particular on their institutions, to support them. The institutions need to plan to help workers cope with the high stress of a pandemic, to acknowledge that their work is dangerous. For example, they  need to provide for the health and safety of workers, and for the care of those who fall ill on duty." The AOM continues to advocate for midwives to receive the support they need and deserve during the pandemic. 

[October 7, 2020] 

How can midwives contribute to data collection on pregnancy and newborn outcomes for clients with COVID-19?

BORN Ontario is inviting all midwives and other obstetrical health care providers to collect data on pregnancy and newborn outcomes for clients with COVID-19. To learn more about how midwives can be involved in this important work, view this infographic.

MPGs that have not yet contacted BORN to collect this data are still welcome to opt in by emailing covid@bornontario.ca with the name of your practice group and contact information for your organization’s COVID-19 key contact person.

[October 1st 2020]

COVID-19 Screening and Testing

What are the case definitions for confirmed and suspected COVID-19?

As of May 21, 2021, the Ontario case definitions for COVID-19 are: 

Confirmed cases are:

Individuals with laboratory confirmation of SARS-CoV-2 infection documented by:

  • Detection of at least one specific gene target by a validated laboratory-based NAAT assay (e.g. real-time PCR or nucleic acid sequencing) performed at a community, hospital or reference laboratory (e.g. Public Health Ontario Laboratory or the National Microbiology Laboratory), or
  • A validated POC NAAT that has been deemed acceptable by the Ontario Ministry of Health to provide a final result (i.e. does not require confirmatory testing), or
  • Demonstrated seroconversion within a four-week interval in viral specific antibody in serum or plasma using a validated laboratory-based serological assay for SARS-CoV-2.

Probable cases are a person who: 

1. Has symptoms compatible with COVID-19:

  • AND
    • Traveled to or from an impacted area, including inside of Canada in the 14 days prior to symptom onset or
    • High-risk exposure (close contact*) with a confirmed case of COVID-19 or
    • Was exposed to a known cluster or outbreak
  • AND
    • In whom a laboratory-based nucleic acid amplification test (NAAT)-based assay (e.g. real-time PCR or nucleic acid sequencing) for SARS-CoV-2 either has not been completed OR is inconclusive, or
    • SARS-CoV-2 antibody is detected in a single serum, plasma, or whole blood sample using a validated laboratory-based serological assay for SARS-CoV-2 collected within 4 weeks of symptom onset

OR

2. Is asymptomatic 

  • AND
    • Had high-risk exposure (i.e. close contact) with a confirmed case of COVID-19
    • Was exposed to a known cluster or outbreak
  • AND
    • In whom a laboratory-based nucleic acid amplification test (NAAT)-based assay (e.g. real-time PCR or nucleic acid sequencing) for SARS-CoV-2 is inconclusive

OR

3. Is tested with a validated Health Canada-approved point-of-care (POC) NAAT for SARS-CoV-2 and the result is preliminary positive detected

 

[May 25th 2021]

*Close contact is defined as a person who had a high-risk exposure to a confirmed or probable case during their period of communicability. This includes household, community and health-care exposures as outlined in Ministry guidance on cases and contacts of COVID-19

When should midwives screen clients for COVID-19? 

All midwifery practice groups (MPG) should conduct screening of clients and household members for COVID-19 prior to any in-person visits. Screening for COVID-19 comprises of both active and passive screening:

  • Active screening: clients should be screened over the phone before their appointment and then again when entering the clinic or before the midwife goes into a client’s home for a home visit. Those conducting in-person screening should remain behind a barrier (such as a plexiglass barrier) or at least 2 metres away from the client as a precaution from droplet or contact spread. Midwives should use the current symptom list to screen clients for COVID-19. The provincial self assessment tool has been updated to reflect this new symptom list. 
  • Passive screening: signage should be posted and visible to visitors at the entrance of the clinic and at reception. Screening messaging can also be included in voicemail greeting messages and on MPG websites.

When a client screens positive over the phone, the in-person visit should be postponed assuming no direct in-person clinical care is required. The client should be instructed to self-isolate and the midwife should offer testing.

If a client screens positive at the office, the client should be moved to a separate room or asked to return to their car (if available and appropriate) where they can wait on their own until the midwife can provide further direction. Midwives can review page 6 of the COVID-19 Guidance: Primary Care Providers in a Community Setting  (PDF, 206KB) for a full set of instructions on what to do when someone screens positive in the clinic setting.

Midwives should don PPE for all clinical encounters when physical distancing of 2 meters or more is unable to be maintained including when testing a client for COVID-19.

Specific testing guidance may be found through the Public Health Ontario and Ministry of Health websites.

For clients who have suspected or confirmed COVID-19 and who require ambulance transport, this information should be provided when calling EMS.

[January 7th 2022] 

How should midwives document the results of COVID screening? 

Midwives are encouraged to adopt a consistent and standardized approach to documenting client COVID-19 screening results. According to HIROC, results from COVID-19 screening “record an assessment of clinical condition at a specific point in time and may become relevant in litigation” and should be “maintained for the same period of time that you would keep other clinical records.”

COVID-19 screening results form part of the clinical record regardless of setting: clinic, home/community, birth centre, hospital. Presumably, hospitals have an internal process for documenting screening results that are maintained by the institution. Other care settings need a way of recording the screening, with the client name and date. Examples of appropriate documentation include:

  • "COVID-19 screen performed as per Ontario Ministry of Health guidelines. No symptoms or exposures/relevant risks reported."
  •  "COVID-19 screen performed as per Ontario Ministry of Health guidelines.  Symptoms reported include headache and sore throat.[Describe follow-up, e,g. appointment rescheduled, discussed testing.]

We understand that this might be new practice for some MPGs, but we encourage midwives to adopt this practice on a go-forward basis.

If a third party is conducting COVID-19 screening on your behalf (e.g. if screening is done in the lobby of a shared medical building), it is recommended that you have a protocol outlining this. For example, in the protocol it should state that those who do not pass the screening are not admitted to the clinic. This otherwise implies that clients who have in-person visits did pass the screening.

Practice groups should also have a protocol around screening (even if it is self-screening) of midwives, staff, students, etc., including expectations for communication and documentation.

[November 25th, 2020]

Can I test my clients and/or their newborns for COVID-19?

Yes. Midwives can order laboratory tests for COVID-19 for their clients and infants born within their care in accordance with Reg. 682 (Appendix B) under the Laboratory and Specimen Collection Centre Licensing Act. Midwives can provide COVID-19 testing at any point in time during the prenatal and postpartum period.

As per the December 21st update from the CMO, midwives are permitted to perform some, but not all, tests for COVID-19.

  • Midwives are not permitted to perform nasopharyngeal swabs (NPS) and deep nasal swabs on their own authority as they require the performance of the controlled act of “putting an instrument, hand or finger beyond the point in the nasal passages where they normally narrow.” Under the Midwifery Act, 1991, midwives do not have the authority to perform this controlled act.
  • Midwives are permitted to perform anterior nasal swabs and throat swabs, as they do not require the performance of a controlled act.

Pregnant people/birthing parents and neonates should be tested as soon as possible if they are exhibiting any COVID-19 symptoms (see here for the Ministry's updated list of symptoms (PDF, 134KB)). 

  • When evaluating clients for COVID-19 symptoms, midwives should consider whether clients' symptoms are new, worsening, or different from an individual's baseline health status. The Ministry's updated symptoms list includes chronic or other potentially related conditions/causes for each symptom that may rule out COVID-19. 
  • Newborns should be tested for COVID-19 within 24 hours of birth if their birthing parent had confirmed COVID-19 at the time of delivery, regardless of symptoms. 
    • Midwives should not test asymptomatic clients who are considered low risk or who have been fully vaccinated. Midwives should recommend or perform a test for asymptomatic clients that were recently in contact with someone with confirmed COVID-19, regardless of vaccination status.

All specimens that are submitted for testing will be accepted. Clients who require more information about testing can be directed to the Ministry's COVID-19 website. 

For more information about testing, please see our midwives ordering testing tip sheet for COVID-19 (updated Sep 1, 2021). 

[September 15th 2021]

How do I test for COVID-19?

Midwives are only required to submit a single upper respiratory tract specimen for COVID-19 testing. 

If unable to get a medical directive to perform NPS testing, midwives can collect specimens for COVID-19 testing using the following swabs* (in the order of most to lest sensitive):

·       Combined oropharyngeal/throat and both anterior nostrils
·       Anterior nostril swab (both sides)
·       Throat/oropharyngeal swab
 
*These tests are not as sensitive as a nasopharyngeal swab, the recommended swab for COVID-19 according to PHO and the MOH; test results may also take longer to obtain. If midwives are unable to collect a nasopharyngeal swab or there are barriers to clients accessing this swab in the community, a combined swab of the throat and both nostrils is the preferred swab.
 
Please visit PHO’s chart titled Preferred and Acceptable Specimen Types for COVID-19 Testing by Patient Characteristic to determine when a given swab is preferred or acceptable for your client, including instructions for specimen collection by swab type. Please also see PHO’s requirements for submitted specimens (including requisition(s) required and minimum volume thresholds). 

Midwives should don droplet and contact precautions when testing for COVID-19.

[May 26th 2021]

Personal Protective Equipment

How do I properly put on and remove PPE equipment?

Proper application and removal of personal protective equipment (PPE) is important to protect against risk of infection transmission. Watch these videos on donning and doffing techniques. [March 18th 2020]

How can midwives prolong the use of PPE when experiencing critical shortages?

In response to the current shortage of masks and respirators, the Public Health Agency of Canada has issued guidance on optimizing the use of masks during the shortage.

To manage expected shortages of PPE, midwives can:

  1. Restrict surgical masks to use by midwives, rather than clients for source control (e.g., handmade cloth masks could be used by clients).
  2. In a clinic setting, wear the same face mask and eye protection for repeated close contact encounters with different clients, without removing the face mask.
    • Remove and discard mask when it becomes soiled, damaged or hard to breathe through.
    • If using cloth masks, change as soon as possible if they become damp or soiled. Wash in hot water with detergent and dry on the hot cycle.
    • Eye protection should be removed, cleaned and disinfected if it becomes visibly soiled or difficult to see through.
    • Learn how to safely reuse face and eye protection.
  3. Reuse (remove and re-donn) surgical masks between client encounters.
    • Surgical masks with ear hooks are easier to reuse, if available.
    • When removing, fold the mask so the outer surface is held inward and against itself.
    • Store the mask in a clean sealable paper bag or breathable container.
    • Watch this short video to learn how to safely store a face mask.
    • Dispose of the mask when it becomes soiled or damaged.
    • Perform hand hygiene when taking off and putting on the mask.
  4. Shift gown use toward cloth isolation gowns
    • Untie and retie for reuse without laundering in between.
    • Change cloth gown when it becomes soiled and store for cleaning in a dedicated container.
    • Launder as appropriate.
    • Use expired gowns beyond the manufacturer-designated shelf life for patient care activities.
    • There is evidence from a study on SARS that absorbent material, such as cotton, is preferred to non-absorptive material for personal protective clothing for routine patient care where risk of large spillage is unlikely.
  5. Shift eye protection supplies from disposable to reusable devices (i.e., goggles and reusable face shields).
    • Consider using safety glasses (e.g., trauma glasses) that have extensions to cover the side of the eyes.
    • While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.
    • Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with disinfectant solution.
    • Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.
    • Fully dry (air dry or use clean absorbent towels)
    • Remove gloves and perform hand hygiene.
    • Eye protection should be discarded if damaged.
    • Hand hygiene should be performed if eye protection is touched or adjusted.

These suggestions are not according to manufacturers or public health standards. However, in times of severe shortage, they may be necessary.

For more detailed information, the CDC has released guidance on how to optimize supply of face masks, gowns and eye protection

The CDC has also developed a PPE Burn Rate Calculator that may be helpful for planning and optimizing PPE use. The Burn Rate Calculator is also available in app format

[September 11 2020]

How do I store PPE for reuse?

Special considerations must be made when midwives are storing PPE for reuse. Review these infographics to refresh your memory on how to properly store surgical masks, N95s and gowns. 

 

 [September 11 2020]

What guidance exists for using expired PPE supplies in the case of a critical shortage?

In response to the current shortage of masks and respirators, the Public Health Agency of Canada has issued guidance on optimizing the use of masks during the shortage.
 
Midwives can use this guidance to assess masks and respirators that are past date (possibly from the H1N1 boxes that were distributed in 2007 or from donations from the community).

N95 Respirators 
The Ontario Ministry of Health has also stated that N95 respirators that are beyond their shelf life (PDF, 845 KB), and that no longer meet the standard for airborne precautions, may be used by health-care providers for contact and droplet precautions where surgical masks are not available. [September 11 2020]
 
Prior to use, inspect the N95 respirator to confirm:

  • The straps are intact
  • There are no visible signs of damage or contamination
  • They can be fit-tested 

For contact and droplet precautions, the model of N95 does not need to be the one the individual was fit-tested to. N95s should not be provided to patients or clients as they can cause breathing resistance, which is particularly significant in patients with respiratory symptoms. 

There is no specific timeframe beyond the expiry dates for N95 respirators at which they would no longer be considered suitable for use for droplet and contact precautions.

Surgical Masks:
Surgical masks can still be used beyond their shelf life to protect health-care providers. Check that straps are intact and that there are no visible signs of damage. There is no specific timeframe beyond the expiry dates for surgical masks at which they would no longer be considered suitable for use.
 

[September 11 2020]

Occupational Health and Safety

Can vaccination status against COVID-19 be used as a condition of employment?

As vaccination against COVID-19 has become more widely accessible, and has been demonstrated to be safe, effective, and an important step in curtailing the pandemic, questions arise as to whether workplaces can require proof of vaccination. Can hospitals require credentialed staff to be vaccinated? Can midwifery practice groups require midwives and administrative staff to be vaccinated?

Unfortunately, there is not an easy answer to this question and there are many factors to consider with rapidly changing information. In Ontario, there is no legislation mandating vaccination against COVID-19. However, as of July 1, long term care homes are required to have vaccination policies that require all staff to either:

  • provide proof of vaccination of each dose;
  • provide a documented medical reason for not being vaccinated; or
  • participate in an educational program about the benefits of vaccination and the risks of not being vaccinated.

As we have seen with policies requiring influenza vaccination, mandatory vaccination policies risk complaints and grievances if they do not include alternatives to vaccination such as those required of long-term care policies. Although, there has yet to be a legal case regarding the COVID-19 vaccine, legal and ethical experts generally agree that (see the World Health Organization policy brief):

  • the benefits of vaccination (including benefits to the client population) must outweigh the risks to the person being vaccinated;
  • the benefits must be significant enough to warrant infringing individual choice and potentially the individual's human rights; and
  • other less-invasive means of protecting clients and other vulnerable people must be considered (e.g. use of PPE, distancing, rapid testing).

These types of policies could be extended to other sectors but it is unlikely that mandatory vaccination (without the opt out provisions above) would be widely accepted.

The AOM will continue to monitor trends in vaccine requirements as they relate to health care workers and encourages all eligible midwives to get vaccinated if they have not already. If midwives encounter challenges with hospitals or other health care spaces requiring vaccination of if MPGs are considering requiring vaccination of their staff, midwives can contact AOM On Call.

[July 13th 2021]

How can MPGs keep workers safe in the clinic setting?

In addition to the measures that must be in place as per the Operational Guidelines, (see question above for detailed information on guideline measures) Midwifery Practice Partners should consider the following for keeping clinic staff safe, particularly if admin or other staff had been working remotely and are now planning a return to working in person in the clinic:

  • Minimize staff in the midwifery clinic at one time
    • Stagger staff start times, breaks and lunches
    • Continue remote work or offer work hours outside of regular clinic hours, when possible
  • Keep employees 2 meters apart from other workers and clients
    • Droplet/ contact precautions should be made available to admins if not protected by a barrier or are unable to maintain a 2-metre distance
  • Assign admins to work at one station or dedicated workspace. Discourage the sharing of phones, desks or office supplies.
    • If shared use is unavoidable, disinfect equipment after each use
  • Instruct workers to stay home if they are sick
  • Designate a space in the office for staff isolation for when an employee develops symptoms while at work

Remember! Under Ontario law, employers have the duty to take every reasonable precaution to protect workers. Employees have the right to refuse work that is unsafe to oneself or another worker.

For more information, midwives may consult the Public Services Health and Safety Association resource Health and Safety Guidance during COVID-19 for Physician and Primary Care Provider Employers (PDF, 266 KB). 

[September 28th 2020]

How should a public clinic space (e.g. waiting room, staff offices, lunch rooms) be cleaned during COVID-19?

The Provincial Infectious Diseases Advisory Council (PIDAC) (PDF, 3.34 MB) states that public spaces (e.g. waiting room, staff offices, lunch rooms) should be cleaned to the level of a “Hotel Clean” – a basic level of cleaning based on visual assessment. In addition to routine cleaning, Public Health Ontario (PDF, 463.63 KB) suggests cleaning and disinfecting frequently touched surfaces twice per day, as well as when visibly dirty.

If the public space has been used by someone who is suspected or confirmed to have COVID-19, it should be cleaned and disinfected, using a hospital grade disinfectant with a Drug Identification Number (DIN). Public Health Ontario (PDF, 1.2 MB) recommends the use of Droplet and Contact Precautions, including: surgical/procedure mask, isolation gown, gloves and eye protection (goggles or face shield).

Please see the AOM’s resource on disinfecting midwifery equipment (PDF, 311.36 KB), as well as Health Canada’s information on disinfectants and hand sanitizers accepted under COVID-19 interim measures.

[September 28th 2020]

How should a clinic room be cleaned during COVID-19?

Clinical space (e.g. clinic rooms, washrooms, reprocessing area) must be “health care clean”, which requires cleaning with a detergent, then disinfection with a hospital-grade disinfectant. Infection control measures such as increased frequency of cleaning and auditing are also implemented.

The AOM offers resources on how to clean a clinic room, including a Clinic Cleaning video, and a template Office Cleaning Checklist (DOCX, 69 KB).

If a clinic room has been used by someone who has tested positive for COVID-19, it should be cleaned and disinfected, using a hospital grade disinfectant with a Drug Identification Number (DIN). Public Health Ontario (PDF, 1.06 MB) recommends the use of Droplet and Contact Precautions, including: surgical/procedure mask, isolation gown, gloves and eye protection (goggles or face shield). Please see the AOM’s resource on appropriate disinfectants (PDF, 311.36 KB), as well as Health Canada’s information on Disinfectants and hand sanitizers accepted under COVID-19 interim measures.

[September 28th 2020]

Antenatal Care and Routine Testing

What Ontario guidelines exist related to general pregnancy care in the prenatal period?

The Provincial Council of Maternal and Child Health updated the Maternal-Neonatal COVID-19 Pregnancy Care Guideline (PDF, 711 KB) in July 2021, to help standardized practice across all antenatal care settings across the province. 

The recommendations reflect the spectrum of care provided during pregnancy including, but not limited to:

  • early pregnancy loss, stillbirth and termination
  • prenatal screening and ultrasound use
  • perinatal mood disorders and substance use
  • intimate partner violence
  • birth planning: choice of birthplace, IOL, TOLAC
  • birth in rural and remote communities
  • modifications to staffing and the care environment including care in the home setting 

Care providers should tailor the guideline recommendations to each pregnant person's individual circumstances. 

 [December 23rd, 2021]
 

Do clients with COVID-19 need additional antenatal surveillance during their period of self-isolation? 

Clients should be instructed to notify their midwives if they have been diagnosed with COVID-19. During their period of self-isolation, clients should be advised to contact their midwives if they have any concerns about their or their baby’s wellbeing. 

For example, the SOGC in its COVID-19 in Pregnancy guidance (updated December 1st 2020) writes: “given that the impacts on the placenta are still unknown, pregnant people convalescing from COVID-19 should be instructed to monitor for fetal movements (where appropriate based on gestational age) and decreased fetal movement should be assessed as per standard care.”

There is no guidance about the timing of frequency for follow-up when a client is isolating at home; based on the clinical picture and other follow up the client is receiving, midwives may consider checking in with their clients over the phone or via a virtual platform within 2 weeks of a COVID-19 diagnosis (SMFM, 2020) While the use of virtual platforms offer the opportunity to provide care during a client's infectious period,  if in-person care is medically indicated, it should not be delayed. Any in-person visits should be accommodated with appropriate infection control measures including droplet and contact PPE. (SOGC, 2020)

Recommendations from ACOG (2020) emphasize that pregnant people can decompensate after several days of apparently mild illness, and thus should be instructed to call or be seen for care if symptoms, particularly shortness of breath, worsen. Similarly, the SOGC (2020) recommends that “close virtual follow-up should be instituted to permit rapid admission should clinical conditions worsen.”

In light of the evidence that suggests that pregnant individuals with risk factors such as obesity, hypertension, diabetes, and heart disease are at higher risk of severe illness, midwives should not hesitate to assess and refer their pregnant clients to ambulatory settings for clinical assessment if symptoms are worsening. 

[December 18th, 2020] 

What are the considerations for antenatal care for clients who have recovered from COVID-19? 

Current international guidance provides a number of recommendations for antenatal care after recovery from COVID-19:

  • The RCOG (UK): recommends that clients who have missed antenatal appointments because of self-isolation should be seen as early as possible after the period of self-isolation ends.  
    • For clients who experience severe COVID-19 illness requiring hospitalization, ongoing antenatal care should be planned together with a consultant obstetrician prior to hospital discharge. A single fetal growth ultrasound scan a minimum of 14 days following resolution from acute illness of COVID-19 that required hospitalization should be performed. 
  • The SOGC (Canada) currently recommends additional monitoring for fetal well-being with monthly ultrasounds for growth and anatomy.
  • The ACOG (USA) states that in the setting of a mild infection, management similar to that for a patient recovering from influenza is reasonable. Given how little is known about this infection, a detailed mid-trimester anatomy ultrasound examination may be considered following pre-pregnancy or first-trimester maternal infection. Interval growth assessments could be considered depending on the timing and severity of infection, with the timing and frequency informed by other maternal risk factors. 

[December 11th, 2020] 

If my client has suspected or confirmed COVID-19, can I still refer them for a prenatal ultrasound?

Presently, there is no province-wide guidance for who can access a prenatal ultrasound (excluding those in self-isolation). Ultrasound clinics are conducting their own screening and may, for instance, not offer ultrasounds to people who have travelled outside of Canada within 14 days of their appointment or who are exhibiting COVID-19 symptoms. Midwives should remind clients to be mindful of the clinic’s screening protocols and arrange alternative prenatal screening in the event that their client is unable to attend their ultrasound appointment(s).

[August 31st, 2020]

My client does not have suspected or confirmed COVID-19. Can they still attend their regularly scheduled ultrasound appointments?

The COVID-19 pandemic is impacting prenatal screening services in Ontario, and clients will likely face disruptions to accessing routine prenatal ultrasounds in the coming months. Some diagnostic imaging centres are no longer offering dating and nuchal translucency (NT) ultrasounds for the time being (see FAQ ‘my client missed their NT ultrasound’ for more information about prenatal screening options).

Midwives should remind clients who are being referred to an ultrasound clinic to be mindful that the clinic’s visitor protocols may have changed. Many ultrasound clinics throughout the province are no longer allowing pregnant people to bring guests with them to their appointment.

[August 31st, 2020]

For more information, please visit Prenatal Screening Ontario’s COVID-19 FAQ.

My client missed their their nuchal translucency ultrasound. What alternative can I suggest to them?

If your client has not had access to their nuchal translucency ultrasound, they should be assured that there are additional options for screening available. This includes the second trimester maternal serum quad screen (MSS Quad), which is available between 15–20 weeks’ gestation. Clients may also have the option of accessing OHIP-funded or self-funded NIPT, which can be done at any time in the pregnancy [August 31st, 2020].

Clients should be aware, however, that the performance of both of these alternative screening options will be impacted if the date of their last menstrual period is not accurate, or if it is unknown at the time of blood work whether there is more than one fetus. [August 31st, 2020]

If your client is carrying twins and does not have access to a nuchal translucency ultrasound or is 35 years of age or older, the Ministry of Health is temporarily covering expenses for non-invasive prenatal tests (NIPT). [August 31st, 2020]

For more information about alternative screening options, please visit Prenatal Screening Ontario’s COVID-19 FAQ.

How are midwives managing the OGCT during the COVID-19 pandemic?

Practices for managing the Oral Glucose Challenge Test (OGCT) while promoting social distancing may include:

  • Clients present themselves to the clinic, drink their glucose drink and are then asked to sit and wait in their vehicle for 1 hour. Alternatively if they do not have a vehicle, they can sit in an empty clinic room if one is available with the door closed. After the hour, they are called back and their blood is drawn.:
  • Clients are sent home with their glucose drink at the previous visit, they are advised to finish their drink 1 hour before their appointment.

[September 29 2020]

What are alternate screening methods for GDM?

The SOGC and the Diabetes Canada Clinical Practice Guidelines Steering Committee released an urgent update for obstetric health care providers regarding screening for gestational diabetes during the COVID-19 Pandemic called a “Temporary Alternative Screening Strategy for Gestational Diabetes Screening During the COVID-19 Pandemic.” The consensus statement suggests a temporary change to gestational diabetes (GDM) screening during the COVID-19 pandemic in the event that there is a reduction in access to laboratory testing due to issues with staffing or locations, public health recommendations or if pregnant people become concerned regarding the safety of attending a laboratory. This change in testing would serve to minimize exposure to pregnant people and limit health-care resource utilization.

The alternative screening strategy for GDM suggested by the SOGC and the Diabetes Canada Clinical Practice Guidelines Steering Committee is to use the HbA1c test and combine it with a random plasma glucose test instead of the standard glucose challenge test and glucose tolerance test.

[September 29, 2020]

HbA1c

In the nonpregnant population, an HbA1c value ≥ 6.5% is used to diagnose diabetes mellitus. The HbA1c test is also used to identify individuals with impaired glucose tolerance and to assess glycemic control in known diabetics. (WHO; Berard) Typically HbA1c is not recommended as a screening test between 24 to 28 weeks’ gestation as it has a high specificity but low sensitivity which will result in not diagnosing as many pregnant people with GDM as the current GCT/GTT. (AOM PDF, 460 KB; SOGC 2020)

In order to mitigate the concerns regarding the reliability of the HbA1c on its own, the SOGC along with the Diabetes Canada Clinical Practice Guidelines Steering Committee have recommended combining the HbA1c with a random plasma glucose. The clinical rationale they provide for adding the random plasma glucose to the HbA1c is that this can avoid missing high glucose levels in a person with a condition where HbA1c is not reliable (ex. hemoglobinopathy). These tests are also recommended as an alternate because they are easy, widely accessible, do not require fasting (increasing the flexibility of testing for the pregnant person), and they require minimal laboratory resources compared to other screening tests.

HbA1c is currently not a blood test that midwives can order. 

[September 29, 2020]

What is the SOGC recommending as an alternate screening for GDM?

Recommendation from the Joint Consensus Statement for GDM Screening During COVID-19 Pandemic. Read the full recommendation.

  1. Continue with usual practice for GDM screening in pregnancy
    • May be used as long as there are only minimal disruptions to capacity for lab testing or treatment of GDM
    • Between 24 to 28 weeks gestation, obstetric care providers are to continue with current GDM screening as per 2018 CPG guidelines.
      • Offer screening to all pregnant people without pre-existing diabetes using a 50 g glucose challenge followed by a 75 g OGTT in those with a one-hour glucose of 7.8-11.0 mmol/L (Diabetes Canada CPG).
    • Strategies for GCT/GTT during COVID-19
      • Clients present themselves to the clinic, drink their glucose drink and are then asked to sit and wait in their vehicle for 1 hour. Alternatively if they do not have a vehicle, they can sit in an empty clinic room if one is available with the door closed. After the hour, they are called back and their blood is drawn.
      • Clients are sent home with their glucose drink at the previous visit, they are advised to finish their drink 1 hour before their appointment.

        OR
         
  2. Implement new HbA1c screening strategy
    • May be used if the COVID-19 pandemic causes severe disruptions to laboratory testing and treatment, and/or patient refusal
    • Between 24-28 weeks gestation:
      •  All pregnant people without pre-existing diabetes will be screened with an HbA1c and non-fasting random plasma glucose.
      • Pregnant people with an HbA1c of <5.7% and a random plasma glucose <11.1 mmol/L require no further testing or treatment.
      • Those with an HbA1c ≥5.7% or a random plasma glucose of ≥11.1 mmol/L are identified as having GDM and should be referred to the interprofessional diabetes and pregnancy health-care team.

[September 29, 2020]

Antenatal and Postpartum Visits

If my client has suspected or confirmed COVID-19, should they receive an in-person visit?

Midwives should delay or cancel in-person visits for clients with probable or confirmed COVID-19 (PDF, 106 KB) until after the period of self-isolation (PDF, 655 KB) is complete. Offer a virtual visit if applicable (when physical care is not required).  When determining when to resume in-person visits, midwives should refer to the COVID-19 Public Health Guidance on Testing and Clearance which provides detailed information on the different approaches to clearing clients.

Public Health Ontario updated their Interim IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 (PDF, 902 KB) on December 15, 2021. Given the undetermined impact of the Omicron (B.1.1.529) variant, the interim recommended PPE when providing direct care for patients with suspect or confirmed COVID-19 includes:

  • fit-tested, seal-checked N95 respirator (or equivalent or greater protection)
  • eye protection
  • gown
  • gloves

If in-person care is urgently required and cannot be deferred until after the period of self-isolation, midwives may conduct the in-person visits donning PPE and following appropriate infection prevention and control (IPAC) measures.

These measures include:

  • Wiping down surfaces with a hospital grade low level disinfectant (e.g., Accel or Cavi wipe)
  • Ventilating the space as much as is reasonable
  • Frequent hand hygiene (e.g., using alcohol based hand rub or washing and drying with disposable towels)
  • Following IPAC standards for equipment cleaning and disinfection

[December 23rd, 2021]

How can midwives maintain social distancing if clients are visiting the midwifery clinic?

In order to maintain social distancing (PDF, 253 KB), midwives may consider the following:

  • Close your waiting room
  • Ask clients to wait in their car until their appointment begins or offer a clinic room to wait in if client does not have a car to support social distancing while waiting for the appointment
  • Moving seating two metres apart
  • Ask clients to come to appointments without support people
  • Limit the number of overlapping appointments
  • Delineate a two metre distance from support staff work space

[September 24, 2020]

Should clients wear masks or face coverings for their appointments with their midwives or during labour?

As of October 2, 2020 the province of Ontario requires the use of face masks/face coverings in indoor public areas.  The provincial COVID-19 Guidance: Primary Care Providers in a Community Setting (updated October 19, 2021) states that “All patients [and visitors], regardless of screening should wear a mask and perform hand hygiene while at the office/clinic.” 

In many parts of the province, labour wards are only requiring labouring clients to wear masks if they have tested positive for COVID-19, or are symptomatic. The recommendation from the Provincial Council for Maternal and Child Health (PCMCH) (PDF, 399 KB) is that "pregnant patients who screen positive for signs/symptoms of COVID-19 should be treated as suspected for COVID-19, and should be given a surgical/procedure mask for all stages of labour (if tolerated), and that support people and care providers wear PPE for all labours. PCMCH has not recommended that clients who have not tested positive and have no symptoms wear masks in labour.

Public Health Ontario has revised the PIDAC: Interim Guidance for IPAC of SARS-CoV-2 Variants of Concern for Health Care Settings. PIDAC reiterates that: "There is no recommended change in PPE practices related to the emergence of the B.1.1.7 VOC or other VOCs in Ontario." However, they do recommend that: "Health care facilities and health care providers should provide patients with a medical mask if the patient does not have their own mask. As it may not be clear whether cloth masks worn by patients meet recommendations for acceptable mask design, some health care facilities and providers may choose to provide patients with medical masks to replace their own personal masks."

The Public Health Agency of Canada (PHAC) released Infection prevention and control for COVID-19: Interim guidance for outpatient and ambulatory care settings and recommend that "Medical masks are recommended to be worn by all patients (where tolerated)". 

[November 4th, 2021]

What if clients refuse to wear a mask?

Midwives may encounter clients (or their support person) who refuse to wear a mask. These are very complex issues, midwives can call the AOM On Call to access advice and support regarding their particular situation.

Before considering how and if to provide care to such a client, explore the client’s rationale. It may be based on past trauma, a health condition, or a perception of health risk from wearing a mask. Personal circumstances warrant special consideration, and misunderstandings of risk can be addressed by reviewing the evidence.

The College of Physicians and Surgeons of Ontario provides advice on balancing the care needs of the individual declining to wear a mask and the need to protect other clients, the care provider, and staff of the clinic:

If you encounter a situation where a patient declines to wear a mask, sensitively explain the expectation that they wear a mask and the importance of protecting public health by following the recommendations of public health organizations. Depending on your patient’s needs, your ability to safely isolate them from other patients, and your ability to safely provide care, you may need to defer or reschedule their appointment or redirect them to a setting that can safely provide care. Be aware that some patients have health conditions that make it difficult or uncomfortable to wear a mask, so plan ahead to help accommodate their needs and find ways to help them access care safely (e.g. providing as much care virtually, scheduling appointments during specific times, etc.).

Clients should be informed that they may be required to self isolate (PDF, 714 KB) if they are exposed to COVID-19 through their midwifery care and were not wearing a mask, even if the midwives were wearing masks.

Similarly, midwives need to carefully consider their professional and ethical obligations to this client, to themselves and to other clients and staff. Consider:

  • Having a practice protocol/policy about masking that is shared with all clients on intake
  • A client's decisions and understanding may change over time; a client that refuses to wear a mask at one appointment may choose to wear a mask in the future or wear one in certain circumstances (i.e. only when the midwives are within 2 metres distance)
  • The safety of midwives (e.g. can the midwives wear full PPE during visits with the unmasked client, just as health-care providers caring for patients with COVID-19 do, including gowns and face shields/goggles?)
  • The safety of other clients, virtual care and visit scheduling to avoid contact with other clients
  • The occupational health and safety of clinic staff, avoiding or reducing contact
  • Thinking ahead to birth plans: if the client is symptomatic for COVID-19 and refusing to mask, in areas of high community spread, or in other higher risk situations, consider the use of the highest level mask you have available (level 3, or even N95) upon completion of a point-of-care risk assessment
  • What can be done to enhance the safety of the space for home visits or home births, such as ventilation, designating a separate disinfected bathroom for the midwives, etc. (see the AOM's guidance on home birth during COVID-19 [PDF, 768 KB] for further suggestions)
  • Making a decision about whether to continue to provide care before the client is term, to ensure adequate time to transfer care if needed
  • Documenting all discussions and the plan of care thoroughly

There may be circumstances where interactions about this issue contribute to a breakdown in the trust relationship between client and midwife. If this occurs, the midwife should consult CMO standards and guidance documents about loss of trust and ending the client/midwife relationship.

[December 18th 2021]

Which antenatal visits should I provide to best care for my clients while limiting community transmission of COVID-19?

A reduced antenatal visit schedule is being offered in order to reduce community transmission. The Ontario College of Family Physicians has produced this handy tool to help providers determine when to offer virtual or in person care.

Please note: the current pandemic situation is moving fast and midwives may need to reconfigure their services based on changing factors such as: spread of illness, midwife and health care system human health resources and the capacity/availability of hospital and laboratory systems.

  • One contact during the first trimester
  • Two contacts during the second trimester: at 16-20 weeks; 28 weeks
    • A third contact between 25-26 weeks may be offered
  • Five contacts during the third trimester: at 31-32 weeks; 34-36 weeks; 38 weeks; 40 weeks; 41 weeks
  • As always, midwives should use their clinical judgement in determining if antenatal visits outside of or in addition to this schedule are necessary. Individualized care plans may be necessary according to a client's clinical circumstances.

This schedule has been determined using guidance from the WHO on optimal antenatal care. WHO recommends a minimum of eight contacts, after an examination of the evidence found a schedule of eight vs. four contacts made no difference in rates of caesarean section or birthing parent mortality, though a limited schedule of four contacts probably increases perinatal mortality. Further research showed there are no important differences in outcomes for those who received eight contacts vs. more (11-15) contacts. 

In providing these eight antenatal contacts, consider delivering by virtual visit whenever possible.

When in-person clinical care is required, midwives may consider shortening the in-person appointments in order to focus on physical assessments only. There is no evidence on the optimal length of an in-person visit to minimize risk of exposure while providing appropriate client care. Midwives should use their clinical judgement to determine the shortest appointment length possible considering clinical circumstances. The remainder of the appointment can be delivered by virtual visit. See this comparison chart (PDF, 144 KB) to select an appropriate virtual platform. 

Topics to be covered in a virtual visit may include:

  • Prenatal screening and/or ultrasound bookings
  • Informed choice discussions
  • Prescription orders
  • General questions related to pregnancy and birth

[August 9th 2021]

What are benchmarks of clinical care for the antenatal period in the context of the COVID-19 pandemic?

Recommended antenatal care during a pandemic includes approximately 8 instances of contact. A contact is an active connection between a midwife and a client using technology or in-person. Due to the changing realities of the pandemic, the schedule of antenatal visits, organization of clinic and midwife collaboration must be responsive to emerging circumstances, and the following benchmarks may need to change accordingly. Antenatal care should be organized to ensure specific care objectives are met by certain weeks of gestation. Midwives may offer to review results, answer client questions, provide health education and conduct informed choice discussion by virtual visit (phone or videoconferencing) while specimen collection may be performed in a community lab or completed at in-person clinic visits alongside clinical assessments.  

1. Before 12 weeks
  • Offer genetic screening
  • Offer routine dating ultrasound
2. By 16 weeks
  • Baseline physical exam
  • Sexual and reproductive health screening
  • Routine pregnancy bloodwork
  • Urine C & S
  • Offer routine anatomy scan
3. By 28 weeks
  • Offer gestational diabetes screening
  • Repeat prenantal antibodies and WinRHO/ Rhlg, if indicated
  • TDap, if applicable
  • Blood pressure assessment
  • Fetal wellbeing check: growth and FHR

4. At 30-34 weeks

  • 2nd Trimester CBC
  • Blood pressure assessment
  • Fetal wellbeing check: growth and presentation
  • US, if indicated, for growth
5. At 34-36 weeks
  • Offer GBS swab
  • Blood pressure assessment
  • Fetal wellbeing assessment: growth and presentation
6. At 38-40 weeks
  • Blood pressure assessment
  • Fetal wellbeing assessment: growth and presentation
7. 41 weeks
  • Blood pressure assessment
  • Fetal wellbeing assessment: growth and presentation
  • Biophysical profile, if indicated
  • Offer a repeat GBS swab, if indicated
  • Offer postdates management options

[September 24, 2020]

Which postpartum visits should I provide to best care for my clients while limiting community transmission of COVID-19?

A reduced postpartum visit schedule are being offered in order to reduce community transmission. This schedule has been determined using the AOM's guidance on postpartum visit schedules (PDF, 748 KB).

  • Visit the parent-infant dyad within the first 48 hours of birth
    • As appropriate, offer newborn screening and feeding support
  • Visit the client at least one more additional time in the first week
  • Offer additional visits, including the discharge visit virtually: by phone or videoconference

If your client's clinical circumstances require in-person assessment (e.g., weight or feeding concerns, unwell infant, concerning jaundice, secondary PPH, postpartum infections, etc.) make arrangements to visit following appropriate health precautions.

Postpartum care for those who are COVID-19 positive

Clinical decompensation may be possible for birthing parents in the postpartum period. In one case series, three pregnant people with COVID-19 who underwent caesarean section had significantly worsened symptoms postpartum, though it is unclear whether caesarean section affected these outcomes. No comorbidities in the cases were described.

In mild-moderate cases of COVID-19, increasing dyspnea (shortness of breath) appears to be the most common indicator of potential decompensation. Signs of decompensation may also include a reduction in urine output and drowsiness. 

RCOG (PDF, 643 KB) recommends escalating urgently if any signs of decompensation develop. 

Clients with COVID-19 should be advised to contact their midwife immediately if existing symptoms worsen or new symptoms arise.

 [September 24, 2020]
 

What online platforms can I use to conduct virtual visits with my clients?

Virtual visits are an excellent IPAC strategy in many clinical situations during this pandemic. Take a look at our comparison chart of popular virtual platforms (PDF, 54 KB).

Some are compliant with privacy legislation (PHIPA) and others are not. A secure platform is preferred. 

If you need to conduct a visit on a virtual platform that is not compliant with PHIPA, inform the client so that they may choose whether to disclose personal health information while using it. Include this discussion and their consent (verbal consent is fine) in your documentation of the virtual visit in the perinatal or postpartum record. 

[September 24, 2020]

What about clients who may require more visits?

A reduced antenatal and postpartum visit schedule are currently being offered in order to reduce community transmission. Virtual care is being advised wherever possible.  Midwives may consult the above question: "What are the benchmarks of clinical care for the antenatal period in the context of the COVID-19 pandemic?", in order to determine which visits should be offered in person and when.

Despite the reduced schedule, midwives should use clinical judgement to determine which clients may require additional visits. Special considerations and additional in-person visits may be warranted for clients at higher risk of complications, clients experiencing complications and clients with psychosocial concerns.

[September 24, 2020]

How can midwives record virtual visits in the BORN Information System?

Changes to midwives antenatal and postpartum visiting schedule during COVID-19 has resulted in questions about how midwives ought to reflect the these new visit schedules in the BORN Information System (BIS).

For example, many midwives are offering care that includes both a virtual (phone or teleconference) and an in-person component that prior to COVID-19 may have been conducted as a single in-person visit.

In consultation with BORN and with midwife researchers, it is recommended that virtual visits should be documented as their own point of contact.  That means that for the example provided, two visits would be captured in BORN for client visits during COVID-19 that contain both a virtual and in-person component.

Remember:

  • If the virtual visit occurs in conjunction with or replaces a clinic visit, add it to Clinic Visits
  • If the virtual visit occurs in conjunction with or replaces a home visit, add it to Home Visits

[September 24, 2020]

Labour Considerations

Is having COVID-19 a risk factor for venous thromboembolism (VTE) in pregnant and postpartum people?

An increase in coagulopathy and thrombotic complications in non-pregnant patients with severe symptoms of the COVID-19 virus has been reported. Due to this thrombosis organizations have recommended prophylactic dose Low Molecular Weight Heparin (LMWH) in all patients who require hospital admission for COVID-19 infection (Thrombosis CanadaInternational Society on Thrombosis and Haemostasis). 

The increased risk of coagulopathy in COVID-19 patients has raised concerns regarding pregnancy, already a hypercoagulable state, and the potential for COVID-19 to increase the risk for Venous Thromboembolism (VTE) and the conditions it causes Pulmonary Embolism (PE), Deep-Vein Thrombosis (DVT) and post-thrombotic leg syndrome. Due to this emerging research the RCOG recommends that all pregnant people admitted [to hospital] with suspected or confirmed positive COVID-19 receive prophylactic LMWH unless birth is expected within 12 hours. The SOGC, in their "Committee Opinion No. 400: COVID-19 and Pregnancy" (PDF, 745KB) updated on December 1st, 2020, does not make any specific recommendation regarding thromboprophylaxis for pregnant people with COVID-19. 
 
To date the evidence is limited regarding COVID-19 coagulopathy in pregnancy, therefore any COVID-19 specific recommendation for thromboprophylaxis in pregnancy is based on small studies and expert opinions. To read an analysis of the case reports on COVID-19 coagulopathy in pregnancy, a critical review on this topic was published in August 2020 and can be found HERE.

Midwives should use their clinical judgment regarding the risk of coagulopathy in pregnant people with COVID-19 experiencing mild symptoms. For pregnant people admitted to hospital with moderate to severe COVID-19 symptoms, midwives should work with obstetric consultants regarding initiation of LBWH and course of treatment.

Safety of LMWH in pregnancy and the postpartum

LMWH is thought to be safe in pregnancy as it does not cross the placenta and has not been shown to be a teratogen based on animal studies. (SOGC) Whether or not LMWH use in pregnancy increases the risk of postpartum hemorrhage (PPH) is the subject of debate. A systematic review from 2019 found a significant increase in the incidence of PPH (RR 1.45, 95%CI 1.02-2.05) associated with LMWH use in pregnancy but not in mean blood loss at delivery or blood transfusion. An older systematic review (2005) showed that LMWH was associated with significant bleeding (antepartum hemorrhage, wound hematoma and PPH) in less than 2% of pregnancies. This is not higher than the global incidence of PPH, thought to be between 2% and 6%. Typically LMWH is discontinued 12 hours before expected delivery, which is thought to help mitigate the risk of PPH.

According to the RCOG Green Top Guideline on Thromboembolism, LMWH is associated with a very low risk of osteoporosis and fractures as well as allergic skin reactions. LMWH is considered safe in breastfeeding and was found to be as effective and safer compared to other thromboprophylaxis treatment such as unfractionated heparin.

[December 18th 2020]

Why is routine epidural being recommended by my hospital for pregnant people with suspected or confirmed COVID-19?

Routine and early use of epidural for all birthing people and/or birthing people with confirmed or suspected COVID-19 may be recommended by some hospitals during the COVID-19 pandemic as a way to avoid a general anaesthetic (GA) intrapartum if urgent intervention is required. A general anaesthetic requires procedures, such as intubation, that can generate aerosols which increases the risk of transmission of the virus to health care providers, hospital staff and potentially other hospital patients. 

The SOGC, in their “COVID-19 in Pregnancy” statement released Mar 13th, 2020 and most recently reaffirmed February 15th, 2021 does not make the specific recommendation for early and routine epidural for a labouring person with confirmed or suspected COVID-19. (SOGC) In addition COVID-19 specific guidance for Ontario birthing parents and their newborns released on April 30th and updated on July 2021 by the Ontario Provincial Council for Maternal and Child Health (PCMCH), continues to state that the use of “analgesia options (e.g. epidural, opioids) is not changed by COVID-19 positive status.”   

During the COVID-19 pandemic, midwives should be aware of the concerns regarding use of general anaesthetic when making decisions regarding the care of clients in the intrapartum period. If there are hospital protocols in place that recommend epidurals to all labouring clients with suspected or confirmed COVID-19 or generally, midwives should discuss the rationale for this recommendation with clients as part of their informed choice discussions and document client decision making accordingly. 

[December 23rd, 2021]

What type of fetal monitoring is appropriate for a client with suspected or confirmed positive COVID-19?

For afebrile, term clients who have mild illness associated with COVID-19 and in whom no other co-morbidities1 present, it is reasonable to offer Intermittent Auscultation (IA). An informed choice discussion with the client about the risks and benefits of Electronic Fetal Monitoring (EFM) compared with IA should occur. Continuous EFM (cEFM) would be indicated for standard obstetric indications, if there is a change in the birthing person’s condition or if abnormal fetal heart rate is detected by IA and is unresponsive to corrective measures.

If a client has current confirmed or suspected COVID-19 and has severe symptoms, or those with mild illness who have comorbidities, cEFM is indicated as the pregnant person is more likely to be hypoxemic, which in turn could affect fetal oxygenation in labour.  People with comorbidities who present with mild illness have a higher risk of rapid deterioration. (WHO)

To date, research examining the effects of COVID-19 on the pregnant person and the fetus shows that outcomes are largely good, that they appear to be closely associated with the severity of the birthing person’s illness and that preterm birth, primarily iatrogenic, appears to be the most commonly reported adverse outcome. To see an analysis of the research examining the effect of COVID-19 on the pregnant person and the fetus/neonate, see COVID-19 and Different Populations at the beginning of our FAQ. 

While updated guidance from the SOGC continues to recommend cEFM for labouring people with COVID-19, the Ontario’s Provincial Council for Maternal and Child Health (PCMCH), recommends that decision-making regarding fetal health surveillance be based on obstetric indications rather than COVID-19 status alone.

[December 23rd, 2021]

Footnotes

1. Co-morbidities may include:  chronic respiratory disease, chronic heart disease, people who are immunocompromised, BMI ≥ 40 or certain underlying medical conditions, particularly if not well controlled (diabetes, renal failure, liver disease may be at risk). 

Why is my hospital prohibiting use of nitrous for labouring clients?

At the onset of the COVID-19 pandemic in March 2020 there arose concern and uncertainty regarding whether or not 50:50 nitrous oxide (N20 also known as Entonox or “nitrous”) was an aerosol generating medical procedure (AGMP) and therefore could increase the risk of COVID-19 transmission. Many institutions and obstetric organizations took the position that nitrous was a possible AGMP and recommended against or discontinued its use.

To date there is no evidence that nitrous is an AGMP, that it could lead to aerosolization of the COVID-19 virus or that it contributes to an increased viral load in the environment of the labouring person. Nitrous gas is inhaled and exhaled through a mask with a tight seal and exhaled gases are filtered and either scavenged or released into the air. A small amount of exhaled gas can escape filtration and scavenging and, like gas in a regular breath, can contain aerosols contaminated with COVID-19. To date, these aerosols have not been shown to cause COVID-19 infection and whether or not they can increase the viral load in the environment is unknown. 

Systematic and thorough cleaning of nitrous units should be performed as per established protocols to prevent the risk of cross-infection when using nitrous units between labouring people. Currently, there is no evidence (PDF, 203 KB) demonstrating cross-infection of patients associated with nitrous oxide units.

Despite the lack of evidence that nitrous is an AGMP, there are many diverging positions regarding whether or not nitrous should be used by labouring people:

  • In Canada, the SOGC has not included any recommendations regarding intrapartum use of nitrous in their “Committee Opinion No. 400: COVID-19 and Pregnancy” (last updated December 1st 2020).
  • Guidance from Ontario’s Provincial Council on Maternal and Child Health (PCMCH) (PDF, 399 KB) was updated in July 2021 and states that there is a lack of comprehensive and definitive evidence on the risk of nitrous oxide use and COVID-19. PCMCH suggests that a biomedical filter should be applied along with adequate sanitization of equipment if nitrous oxide is used during labour and delivery.  
  • The British Columbia CDC and BC Ministry of Health in their guideline updated on Sept 4th, 2020, supports nitrous use in birthing people confirmed or suspected COVID-19 and advises a filter be applied to nitrous units in this circumstance.
  • The Royal College of Obstetricians and Surgeons (RCOG) guideline “Coronavirus (COVID-19) infection in Pregnancy”, acknowledges that nitrous can be safely offered with a standard single-patient microbiological filter
  • New Zealand’s Ministry of Health supports the use of nitrous for pregnant people with suspected or confirmed COVID-19 as long as standard precautions are being followed and health care providers are wearing the appropriate PPE.
  • A Cochrane Review released May 6th, 2020 looked at national COVID-19 clinical practice guidelines around the world for pregnant people and their babies and could not find consensus about nitrous use. While some countries, such as the UK and Turkey appear to support N2O use under any circumstances, including use in a person who is COVID-19 positive, countries such as Austria only permit its use for a labouring person who is asymptomatic and not at risk.

What can I do to minimize risk of COVID-19 transmission when using nitrous oxide?

  • Midwives should follow their local protocols for obtaining clean nitrous units for client use. If the midwife is unsure whether a nitrous unit is clean, that nitrous unit should not be used. 
  • A single-use microbiologic filter is recommended.
  • Discontinue if nitrous use is inducing coughing or vomiting.
  • Midwives should use contact and droplet precautions when a client is using nitrous. 
  • Increase ventilation of the space.
  • For a labouring person either choosing to wear or requiring a mask during labour, use of nitrous is not feasible.

 [December 18th 2020]

What information can I provide to clients who are concerned about what to do with their other children during labour? 

Clients may wonder if grandparents or other support people who do not live in the household can come and care for other children during labour. From a public health and social distancing perspective, it is important to consider the risk that this poses to the family and midwives. For this reason, some midwifery practices and hospitals are limiting the number of people present during a home birth and during home visits. 

It is also important to consider some of the equity implications when thinking about limiting the number of support people present during home births and home visits, and when considering infection prevention and control recommendations. Policy exceptions and/or alternative solutions may be required when working with clients who may experience socio-economic disparities, where they may not have access to disinfectants to adhere to IPAC recommendations, whose support persons may have to work and cannot self isolate, or who live in inter-generational homes or in small homes where physical distancing may not be practical. By recognizing and addressing the barriers and inequities within policies and recommendations, midwives can better support all clients to access safe care. 

If clients need to ask for child care from someone outside their household, consider the following (case-by-case assessment is necessary to develop an equitable plan):

  • Everyone (child care support person, household members) should be symptom-free;
  • No one should be under isolation orders (due to illness or recent contact with someone with COVID-19); and
  • To the extent possible none of the parties involved should be at risk of developing serious complications if they are infected with COVID-19. 

If possible, use one person to provide support who:

  • Lives close by;
  • Does not need to travel to and from work; and
  • Has been isolating for a period of time leading up to providing support. 

Discuss the following infection prevention and control considerations with clients:

  • Support people should keep 2 meters away from household members if possible;
  • Split up responsibilities to facilitate physical distancing if possible (e.g. support person takes care of preparing meals and cleaning, while parents take care of children and pets);
  • Have someone regularly clean and disinfect high-touch surfaces and objects (e,g, toys, light switches, door handles); and
  • Avoid sharing personal items such as bedding, dishes, etc. 

(French - Couillard, 2020)
 
[September 24th 2020]

What considerations regarding ventilation can be implemented to reduce the spread of COVID-19 during labour?

Poor indoor air quality combined with a return to more indoor, in-person contact can accelerate the spread of COVID-19. An editorial in the British Medical Journal (BMJ), Covid-19 has redefined airborne transmission, explains the importance of ventilation in preventing the spread of the virus. Here are a few tips for improving air quality in clinic spaces:

  • Identify the air vents in the space and keep them clear of obstructions. Ensure at least six inches of vent clearance from all furniture and other items.
  •  Holding a tissue directly in front of the vent may assist in determining if the vent is working properly to move air into or out of the space. Ventilation systems typically cycle off and on, so it may be necessary to check at different times before concluding that the vent is not operating.
  •  Hire (or request the landlord provide) skilled trades people to fix broken ventilation systems and provide maintenance including filter changes on heating and cooling units. Cleaning vents and ducts can also help to improve airflow and air quality.
  • If the space has operable windows or a door to the outside, opening them daily, even for a few minutes can improve indoor air quality.
  • According to research by Public Health Ontario and the US Center for Disease Control (CDC), portable HEPA filtration units can improve air quality and have the potential to reduce transmission of COVID-19. Units should be appropriately sized for the space, and units adequate for midwifery clinical spaces may be affordable within practice group budgets.

Some of these tips, like making sure your equipment is not blocking a vent, can also be helpful at home births and visits in the community.

Good ventilation does not replace the need for PPE, social distancing and other mitigation measures, but it can enhance protection as more transmissible variants continue to spread.

[November 4th, 2021]

Home Birth

Should clients consider a home birth during a pandemic?

The home birth during the COVID-19 pandemic (PDF, 885 KB) reference guide has been updated to reflect considerations for maintaining ventilation at home births. The guidance provides information to midwives and clients engaged in complex decision-making on choice of birthplace during a pandemic.

The guide includes:

  • The latest research on birth outcomes for pregnant people with COVID-19
  • Nine considerations for offering choice of birthplace during a pandemic
  • Tips on how best to maintain PPE and IPAC practices in the home setting

This resource is also available in French: L'accouchement à la maison pendant la pandémie de COVID-19 (PDF, 523 KB). 

[April 16, 2021]

Water Birth and Hydrotherapy

If my client has suspected or confirmed COVID-19, can they have a water birth?

Water birth is not currently recommended for clients who have suspected or confirmed COVID-19.

  • The stools of people with COVID-19 have been found to carry the live virus. If the client passes stool in the water, water birth may expose both the newborn and midwife to an additional route of transmission of the virus (via the fecal-oral route).
  • Providing care to clients having a water birth increases the likelihood that PPE will become wet, reducing its effectiveness. If this happens, midwives will need to change PPE which may increase the potential for further contamination. Moreover, there is currently a critical shortage of PPE throughout the province.

For more information, please visit our guidance on water birth and hydrotherapy (PDF, 315 KB) for people with suspected or confirmed COVID-19.

[October 5, 2020]

If my client has suspected or confirmed COVID-19, can they use hydrotherapy (i.e., a shower or deep submersion in water) for pain relief?

Due to existing shortages of PPE, and the higher likelihood that a midwife’s PPE may become wet if providing care to clients during hydrotherapy, midwives should consider offering alternate methods of pain relief to clients with suspected or confirmed COVID-19.

  • With hydrotherapy, there is a risk that midwives’ PPE may become wet, reducing its effectiveness.
  • Midwives should assess the risk of their PPE becoming wet on a case by case basis and take into account the feasibility of changing their PPE if it becomes wet, considering the existing shortages. Midwives should inform their clients with suspected or confirmed COVID-19 that hydrotherapy may not be possible during their labour (given availability of PPE) and discuss alternate forms of pain relief with them.
  • Midwives may mitigate the risk of their PPE becoming wet by reducing the risk that their PPE will come in contact with the water. For instance, midwives can:
    • Recommend that the client has a shower as opposed to being submersed in water
    • Assess fetal heart rate by asking clients who are submersed in water to adjust their position so that their hands do not need to be submerged in the water or by asking clients to get out of shower/turn water off
    • Ask the client’s support person to assist the client in entering and exiting the tub or shower
    • Ask clients to get out of the water prior to the second stage of labour
  • If the midwife does provide care to a client using hydrotherapy who has suspected or confirmed COVID-19, they should consider having additional PPE on hand in the event that their PPE becomes wet and they need to change their PPE.

For more information, please visit our guidance on water birth and hydrotherapy (PDF, 315 KB) for people with suspected or confirmed COVID-19.

[October 5, 2020]

Mental Health

What resources and mental health supports are available for midwives and other health care providers during this time?

Midwives are at a significantly increased risk for mental illness and burnout as a result of the COVID-19 pandemic. Further, the toll of being a frontline worker disproportionately impacts people who identify as women, IBPOC folks and those who play other caregiving roles in their personal life. Prioritizing your mental health and psychosocial well-being has never been more important and challenging at the same time.

“Take care of yourself.” “Put your oxygen mask on first.” You have heard it all before but where do you fit it all in, especially now? It may be helpful to stop and think about stress reduction and coping strategies that have worked for you in the past. Below are some supportive reminders and options you can consider. 

  • Acknowledge and normalize your psychological responses; it is okay to not be okay. 
  • Connect with the people in your inner circle: your friends, family, spiritual or faith community.
  • Limit the time you spend engaging with the news. The more we engage with the news cycle, the more susceptible we are to "negativity bias." Negativity bias is the psychological tendency to dwell on negative information more readily than the positive or neutral information we're exposed to. 
  • Remember, you are not alone. Seek out peer support, talk with your colleagues, take time in your Zoom meetings to check in with each other, join a support group for health-care providers working during COVID-19 like this one

Mental Health and Wellness Resources Available to Midwives 

  1. The Association of Midwives Benefit Trust (AOMBT) offers members a wealth of mental health resources including access to:
    • SSQ paramedical coverage for counselling services (i.e. psychologist, social work, psychotherapist)
    • Optima Global Health's Member Assistance Program
    • Dialogues Virtual Telehealth Program
  2. Self-Referral Psychotherapy for frontline clinicians: The Ministry of Health and Ontario Health has partnered with five hospitals to provide confidential services for frontline healthcare providers. You can connect with these services through the following sites:
  3. Peer Support for healthcare providers and health professions students: ECHO Coping with COVID is a support group for healthcare providers and students that meets twice monthly on Friday afternoons from 2:00-3:00 PM EST to discuss and share ways of building resilience and overall wellness. 
  4. Digital Mental Health Supports: MindBeacon provides free personalized one-to-one digital mental health support with a registered therapist. 
  5. Canadian Psychological Association provides a listing of psychologists who have volunteered to provide psychological services to frontline health-care workers. 
  6. Breaking Free from Substance Use: Breaking Free is a free online, evidence-based, self-guided wellbeing and recovery support program available 24/7.
  7. 10 Percent Happier Meditation App: Health-care workers are eligible for 40% off a subscription to the Ten Percent Happier App.
  8. AOM On Call is a confidential resource for members who seek support for concerns arising from practice. You can get free support advice 24/7 from the AOM On-Call team. To reach AOM On Call, contact the AOM office at: Toll Free: 1-866-418-3773 OR Local: 416-425-9974

[November 30, 2021]

What support and information can midwives provide to clients that are concerned about COVID-19?

The WHO has developed a resource (PDF, 521.56 KB) on mental health and psychosocial considerations during COVID-19. They recommend that although clients may feel concerned and anxious, it is especially important to practice empathy and compassion for those affected by COVID-19 by not attaching any ethnicity or nationality to the disease and by using person first language (e.g. “people who have COVID-19”as opposed to “COVID-19 cases”). This practice will help reduce stigma associated with COVID-19.

To help reduce feelings of anxiety, midwives may advise clients to practice self-care by:

  • Reducing time spent watching, reading or listening to the news to once or twice a day
  • Seeking information only from trusted sources including the WHO and local health authorities (e.g. Public Health Ontario and Toronto Public Health)
  • Meditating, stretching, exercising, and eating nutrient-dense foods
  • Connecting with friends and family
  • Prioritizing sleep and relaxation

Clients who are interested in more information on coping and stress management during the COVID-19 pandemic may visit CAMH’s website, which provides a variety of helpful tips, including information on how to cope with quarantine and isolation.

CAMH has also completed a national survey from May 2020 to July 2020 to explore Canadian's experiences of anxiety during the pandemic. For more information on the results of this survey visit CAMH's website.

[September 14th 2020]

What mental health support can I provide to clients that are self-isolating for suspected or confirmed COVID-19?

According to the WHO (PDF, 521.56 KB), clients who are self-isolating can consider the following practices to reduce anxiety:

  • Maintain social networks through e-mail, social media, video conference and telephone
  • Attempt to maintain personal daily routines including sleep schedules or create new routines as necessary
  • Engage is healthy activities that elicit joy or relaxation
  • Limit exposure to news reports and outbreak information to one or two specific times during the day
  • Seek information updates and guidance from health professionals and accredited health authorities only
  • Avoid listening to or following rumours that elicit discomfort

[September 14th 2020]

What can practice partners and head midwives do to support the mental health of their MPG during this time?

Practice partners and head midwives should attempt to:

  • Ensure good quality communication and accurate information updates are provided to all staff/colleagues.
  • Monitor stress levels of staff/colleagues and reinforce safety procedures.
  • Build time for colleagues to provide social support to each other.
  • Facilitate access to and ensure staff are aware of resources to support mental health such as the 10 Percent Happier Meditation App (free for 6 months for health-care providers), and the employee assistance program offered to AOM midwife members.

[September 14th 2020]

What mental health resources are available for members of Indigenous communities?

There are a variety of virtual mental health resources available to Indigenous communities. While some supports and resources are available due to addressing pandemic related stress, anxiety and trauma, multiple resources are pre-existing and ongoing to assist with an  individuals needs in their healing.  Culturally safe and wholistic approaches to care are important components of services being offered to the Indigenous population. Currently, services are accessible through online and telephone mediums such as Hope for Wellness that is offered in the official languages as well as in Ojibwe, Cree and Inuktitut.

It is important that Indigenous communities have easy and fast access to trustworthy, factual, and effective resources to support their mental wellness during this challenging time. There are numerous platforms with information on what's available.

For your information, here is a snapshot of current examples of resources (PDF, 240 KB) developed for First Nations, Métis, and Inuit populations from Indigenous Services Canada. If you have clients interested in more information, sites like the Chiefs of Ontario have a comprehensive mental health resource page and can assist in navigating where to access resources based on geographic location.

[October 8th 2020]

Chest/Breastfeeding

Can COVID-19 be transmitted from birthing parent to infant through human milk?

Currently, there is no evidence of viral transmission through human milk. A systematic review that cumulated evidence from 82 birthing parents who were determined to be positive for COVID-19, found that nine out of 84 samples of human milk tested positive for SARS‐CoV‐2. Of the six infants exposed to human milk positive for COVID-19, four infants tested positive. However, it cannot be confirmed that SARS‐CoV‐2 infection in these infants was due to human milk consumption. This is because each infant was potentially exposed to the virus through close contacts (family members and individuals in their community) who tested positive for COVID-19.

Although there is some evidence to support that the SARS-CoV-2 virus may be present in human milk, the likelihood of this occurrence is still considered to be rare. According to the Canadian Pediatric Society, the presence of respiratory droplets on or around the breast/chest area remains the primary concern for viral transmission from birthing parent to infant during chest/breastfeeding.

[November 19th 2020]

If my client has suspected or confirmed COVID-19, can they still chest/breastfeed their infant?

The current guidance from the Canadian Paediatric SocietyWorld Health Organization, the Society of Obstetricians & Gynaecologists of Canada, and the Royal College of Obstetricians & Gynaecologists all suggest that the benefits of chest/breastfeeding outweigh the risk of potential transmission. Midwives should continue to encourage clients to chest/breastfeed after discussing the risks and benefits this may pose for the infant and parent.

Clients that choose to chest/breastfeed should engage in the following precautions to limit the
spread of infection:

  • Practice good hand washing regularly, especially before and after touching their infant (hand sanitizer is not recommended for infant use or for use on the breast/chest area).
  • The breast/chest area should be washed with mild soap and warm water prior to feeding if the client has coughed over their exposed breast or chest. The chest area does not need to be washed before each feed, particularly if the breast/chest area was covered before feeding.
  • Avoid coughing or sneezing on their infant
  • Wear a face mask (if available) while holding or feeding their infant
  • Properly sterilize any feeding equipment (e.g., pumps, bottles)
  • Properly sterilize any potentially contaminated and/or frequent touched surfaces

Clients that are not well enough to chest/breastfeed should consider the following options:

  • Expressing human milk to feed to their infant with a cup or bottle while wearing a mask (if available), after washing their hands
  • Having someone who is well feed expressed human milk in a cup or bottle to their infant

[December 18th 2020]

Newborn Care

If my client has suspected or confirmed COVID-19, are they able to stay with their newborn and practice skin-to-skin contact?

According to the WHO, clients should be enabled to remain with their infants and should be supported in the practice of skin-to-skin contact, whether or not these clients have suspected or confirmed COVID-19. Similarly, RCOG also recommends that infants should remain with their birthing parent in the immediate postpartum unless neonatal care is required.

Midwives should engage clients in an informed choice discussion about the risks and benefits of skin-to-skin contact in light of potential or confirmed COVID-19 infection. This discussion should include information on the importance of good handwashing and the use of a mask, if available, while engaging in newborn care.

For clients with suspected or confirmed COVID-19, midwives may consider developing a plan with their client to separate birthing parent from newborn if:

  • An appropriate adult care-provider (e.g. spouse or family member) that is negative for COVID-19 is available to consistently provide skin-to-skin contact and all other necessary care to the newborn, AND one of the following conditions are met:
    • The birthing parent is unable to care for their newborn due to hospitalization and/or the presence of significant symptoms.
    • The birthing parent specifically requests separation to prevent post-natal transmission of COVID-19 to the baby.

[September 22nd 2020]

Will I still be able to conduct routine newborn screening?

Midwives should still offer routine newborn screening within the first 48 hours of birth. 

​​​​​​Newborn Screening Ontario (NSO) is still accepting and processing screening samples, and there are currently no reported disruptions to this service. [September 21st, 2020]

I am struggling to screen all newborns for hyperbilirubinemia while also trying to practice social distancing. What can I do?

The AOM’s Clinical Practice Guideline on Hyperbilirubinemia currently recommends that “the risks and benefits of universal screening should be discussed with all clients as part of an informed choice discussion” and that “if visible jaundice develops, obtaining a bilirubin measurement is recommended.”

Due to the current extraordinary circumstances resulting from the COVID-19 pandemic and recent guidance aimed at reducing in-person visits, midwives may consider forgoing universal screening of healthy term neonates and limiting screening to only to those neonates who develop visible jaundice or other clinically meaningful signs of severe hyperbilirubinemia (e.g. suboptimal feeding, lethargy, dark urine, pale chalky stools).

Guidance from the National Institute for Health and Clinical Excellence (NICE) 2016 Guideline on Neonatal Hyperbilirubinemia (PDF, 7.55 MB) sets a precedent for this recommendation as it recommends that only infants who have suspected or obvious jaundice require bilirubin screening. This recommendation was made before the outbreak of COVID-19.

Midwives should continue to have discussions with their clients about how visible jaundice, poor feeding, dehydration and weight loss impacts the risk of developing severe hyperbilirubinemia. Clients should be advised to immediately contact their midwife if any clinically meaningful signs of severe hyperbilirubinemia develop.

[September 21st, 2020]

Can I still refer my clients to outpatient bilirubin clinics?

Outpatient bilirubin screenings are still generally taking place at labs and clinics throughout Ontario. Midwives should remain mindful of the potential changes in practice at the lab or clinic they typically refer their clients to.

[September 21st, 2020]

If my client has suspected or confirmed COVID-19, what should I do if their newborn requires resuscitation?

Current research suggests that vertical transmission of COVID-19 from the pregnant person to the newborn is unlikely and remains very uncommon. As such, if a newborn develops respiratory distress at birth, it is unlikely that this is related to the birthing parent’s suspected or confirmed COVID-19 infection. Because evidence is still accumulating and vertical transmission of COVID-19 from parent to newborn cannot be completely ruled out, COVID-19 infection may be considered a possible cause, however, respiratory distress is more likely to be due to other common neonatal respiratory issues.

Given the low risk of vertical transmission and low risk of aerosol exposure from neonatal resuscitation, PCMCH in their Maternal-Neonatal COVID-19 General Guideline, (PDF, 399 KB) states that droplet/contact precautions are suitable for the initial resuscitation of newborns, including those newborns born to suspected or confirmed COVID-19 parents. 

The Canadian Pediatric Society (CPS) recommends the following if neonatal resuscitation is required for the newborn of a birthing parent with COVID-19:

  • A distance of two meters should be kept between the neonatal resuscitation team (if applicable in addition to midwives providing care) and the birthing parent with COVID-19.
    • If the midwife who has caught the newborn is needed to assist the second midwife/attendant with newborn resuscitation, they should consider changing their gloves if feasible prior to assisting with the resuscitation.
  • If a distance of two meters can be maintained between the birthing parent and the bed in which a newborn will be resuscitated, care can be provided in the same room.
  • Newborns should be resuscitated in an adjacent room if the birthing parent requires intubation or other aerosol generating medical procedures, since the newborn cannot be protected against airborne transmission.
  • In the asymptomatic or mildly symptomatic birthing parent who is COVID-19 suspect or positive, droplet/contact precautions are recommended during the initial steps of resuscitation. 
  • In the birthing parent with severe COVID-19 (experiencing respiratory distress or needing respiratory support), it is recommended that those all health-care workers present at resuscitation use enhanced droplet precautions including an N95 mask and eye protection. 

[April 15, 2021]

Can clients still access routine immunizations during the COVID-19 pandemic?

The National Advisory Committee on Immunization (NACI) has released interim guidance on continuity of immunization programs during the COVID-19 pandemic.

There are concerns with individuals not accessing routine immunizations — either individuals choosing to not seek them out while physically distancing at this time or providers not providing immunizations at this time.

The NACI guidance stresses that routine vaccinations are essential and provides advice on prioritization and safety measures to administer vaccines during the pandemic.

The Ontario MOH's Immunization Guidance document (PDF, 215 KB) has been updated and replaces the Guidance for Immunization Services During COVID-19 that was originally posted in August 2020. This guidance has been updated to include information on extended vaccine eligibility for some publicly funded vaccines, as well as guidance on the co-administration of COVID-19 vaccines with other vaccines. This document also includes guidance on catching up on missed doses of vaccines (for infants, children, adolescents and adults) that may have been missed or delayed due to the pandemic.

[November 4th 2021]

Vaccination and Pregnancy

 

What information is available regarding COVID-19 vaccination during pregnancy in Ontario?

The Better Outcomes Registry Network (BORN) Ontario has just released a second descriptive report on COVID-19 vaccination during pregnancy and accompanying infographic

With support from the Public Health Agency of Canada, through the Vaccine Surveillance Reference Group and the COVID-19 Immunity Task Force, BORN Ontario is evaluating COVID-19 vaccination in pregnant individuals in Ontario. Highlights of the report include

  • monthly uptake of COVID-19 vaccination during pregnancy increased substantially over the reporting interval from an estimated 0.02% in December 2020 to 45.4% in June 2021
  • cumulative incidence rates of pregnancy and birth outcomes among vaccinated individuals based on this preliminary data do not suggest any pattern of increased risk

[August 27th 2021]

What are the reasons for medical exemptions from COVID-19 vaccine requirements? 

The Ministry of Health has released guidance on Medical exemptions to COVID-19 vaccination (PDF, 219 KB). The potential reasons for medical exemption from vaccine requirements are listed and are very specific.

According to this document, midwives are not eligible to provide documentation of medical exemption: "Documentation of a medical exemption must be provided by either a physician or a nurse practitioner.... The exemption must clearly indicate the reason why the individual cannot be vaccinated against COVID-19 (i.e., clear medical information that supports the exemption)."

If a client requests a vaccine exemption document, midwives should inform clients that they are unable to provide the required documentation and direct the client to a physician or nurse practitioner familiar with the condition for which they are seeking exemption.

[September 17th 2021]

What information is available regarding the COVID-19 vaccination and rare outcomes of thrombosis?

On April 20, 2021, the SOGC released a statement on the COVID-19 vaccines and rare adverse outcomes of thrombosis associated with low platelets. These rare events of  of arterial and venous thrombosis associated with low platelets following the adenovirus vector COVID-19 vaccines (AstraZeneca, COVISHIELD, Janssen COVID-19 vaccines).

  • These events occur in as few as 1 in every 125,000 to 1 in 1 million people. Approximately 1 in 10 pregnant individuals will require hospital admission and 1 in 100 pregnant individuals will require intensive care following infection with COVID-19
  • There is no known association between this syndrome and pregnancy and no physiologic basis to increase this risk in pregnancy

Preventing COVID-19 disease among pregnant individuals must be considered a priority and vaccination is a central tool to protect individuals from severe COVID19 infection. 

[April 23rd 2021]

What information is available regarding the COVID-19 vaccination and rare outcomes of myocarditis/pericarditis?

On June 3rd, 2021, the Public Health Agency of Canada (PHAC) published a report on the occurrence of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining around the heart) following COVID-19 vaccination. Symptoms of these conditions include shortness of breath, chest pain, or the feeling of a rapid or abnormal heart rhythm. After a review of available information from Israel and the United States, PHAC specifies that:

  • Cases were more commonly reported after the second dose.
  • Symptom onset was typically within several days after vaccination.
  • Cases were mainly adolescents and young adults.
  • Cases were more often males compared to females.
  • Cases experienced mild illness, responded well to conservative treatment and rest, and their symptoms improved quickly.

To date, there is has been no clear and established association between myocarditis/pericarditis and mRNA vaccines. Further, adverse events occurring after vaccination are not necessarily related to the vaccine. The benefits of the mRNA vaccines continue to outweigh their potential risks in authorized populations.

PHAC is closely monitoring the occurrence of these conditions via Canadian safety surveillance systems and has provided weekly online adverse events reports updated with the latest numbers. This work has found that there are not currently higher rates of myocarditis or pericarditis than would be expected in the general population. 

Clients that have develop symptoms related to myocarditis or pericarditis post-vaccination should consult with a cardiologist. It would also be important to rule out other potential causes of myocarditis and pericarditis by consulting with infectious disease and/or rheumatogoloy specialists. Midwives should report all cases of myocarditis or pericarditis following vaccination to the local health authority.

[June 8th 2021]

Vaccination and Health Care Workers

Is vaccination mandatory for health care workers?

Midwives who have hospital privileges or who do any work in hospitals will be required to comply with the COVID-19 vaccination policies of their hospitals. Directive 6 (PDF, 248 KB) from the Chief Medical Officer of Health sets out the minimum requirements for hospital vaccination policies to ensure that all workers:

  1. be fully vaccinated, OR
  2. have a medical exemption (such as a known allergy to one of the components of the vaccine), OR
  3. participate in an education session about the risks of being unvaccinated

All hospital workers, including midwives, students and second attendants, who are unvaccinated (category B or C) will need to do regular testing.

Directive 6 specifically allows hospitals to remove option C and require all workers to be fully vaccinated or provide documentation of a medical reason for not vaccinating. Hospital policies must be implemented by September 7, 2021, but some hospitals may choose to act sooner.

Midwives are advised to check the requirements of each hospital where they work because the directive sets out only the minimum policy requirements. Hospitals can add requirements and will determine the details of implementation. For example, the directive requires antigen testing at least once per week for workers who are not fully vaccinated, but hospitals can require more frequent testing. Hospitals’ policies will determine where and when the testing will be done and if proof of off-site testing will be accepted. This is critical information for unvaccinated midwives.

It is anticipated that many hospitals will adopt rapid antigen testing upon entry to the hospital for unvaccinated workers. For more information about rapid antigen testing and how it can be used by midwives, see the AOM's COVID-19 Clinical FAQ. Midwives who are unvaccinated may want to ask their hospitals if they can conduct their own off-site rapid antigen testing if this is already being done or could be set up in their clinic.

Hospital policies must require testing for all workers who are not fully vaccinated, including those who have a medical reason. Some hospitals may decide that only those who show proof of vaccination or a documented medical reason to be unvaccinated will be allowed to work. Documentation of a medical exemption must be obtained from a physician or nurse practitioner; it cannot be issued by a midwife.

Here are some key logistical issues for midwives to consider within their practice groups and with their hospitals:

  • What form of documentation needs to be provided to the hospital for vaccinated and unvaccinated workers and what is the deadline for submission? For example, what information needs to be included in documentation for a medical reason to be unvaccinated.
  • How will unvaccinated midwives ensure that the testing requirements do not result in delays in client care? Will the midwives need to wait at the point of entry into the hospital for the results of an on-site rapid antigen test, which will delay arrival into the client care area by at least 20 minutes? Will the hospital consider alternatives such as showing proof of off-site test results for midwives and other on-call staff?
  • If the hospital has a requirement for education sessions for unvaccinated workers, how can unvaccinated midwives ensure that they meet these requirements in time?
  • If your hospital decides that only those who are fully vaccinated or who have a documented medical reason for not vaccinating can work in the hospital, how will this impact workload, scheduling, and client care in your midwifery group?

If possible, midwives might consider raising these questions and making suggestions about implementation to their hospitals before the hospital policies are issued. Changing a policy that has already gone through the approval processes may take more time and effort than flagging midwifery concerns for policy makers at an early stage of the process.

Members with questions or concerns about Directive 6 and hospital vaccination policies can call the confidential AOM On Call helpline for support.

[August 25th 2021]

Do midwifery practice groups need a vaccination policy?

There is no requirement for midwifery practices to have a vaccination policy under Directive 6 issued by the Chief Medical Officer of Health on Aug. 18, 2021. Midwifery does not fall under the legal definition of community and home care specified in Directive 6.

Practices should consider the advantages of adopting a vaccination policy or protocol to ensure compliance with the hospital policies required by Directive 6 and to keep all workers and clients at the practice safe.

The Ministry of Health has produced a resource guide to assist with policy development and implementation for Directive 6. It contains information about topics such as obtaining proof of vaccinations, medical exemptions for vaccination, the use of rapid antigen testing and content for vaccination education sessions. A sample policy is also provided. 

[August 27th 2021]