COVID-19 Clinical FAQ

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.
 

COVID-19 and Different Populations

What effect does COVID-19 have on pregnant people?

There is limited scientific information about the impact of COVID-19 on pregnant people and guidance may change as more information becomes available. At the moment, pregnant people do not appear to be at higher risk of infection with COVID-19 than the general population. (RCOG 2020, PDF 442KB) In most case reports, there has been no evidence of vertical (birthing parent to infant) transmission. In the case reports where amniotic fluid, cord blood, placenta swabs, genital fluid and breastmilk samples were tested, all have returned negative for the virus. (ChenLiuZhang; Li) Emerging evidence from a case study of one maternal-infant dyad suggests the possibility of in utero infection; SARS-CoV-2 IgM was detected in the infant’s serum at birth. (Dong) If vertical transmission is possible, further research is required before we understand the proportion of pregnancies that are affected and the significance to the neonate.

In three small case studies (n=29), pregnant individuals presented with mild/moderate COVID-19 pneumonia during the third trimester. Pregnancy outcomes have been generally good, with spontaneous and iatrogenic preterm labour the most commonly reported adverse pregnancy outcome. (Chen; LiuZhang)

RANZCOG and the CDC both suggest that pregnant people may be at increased risk of complication from any respiratory disease, due to physiological changes of pregnancy. The SOGC suggests that outcomes may be correlated with degree of maternal illness.

[March 31st 2020]

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

There is limited scientific information about the impact of COVID-19 on the fetus/neonate and guidance may change as more information becomes available.

In three small case studies (n=29), five cases of fetal distress (undefined) were reported, though it is unclear if fetal distress was directed related to COVID-19 or another clinical factor such as prematurity. In these studies, no cases of severe neonatal asphyxia or neonatal death were reported. (ChenLiuZhang)

One non peer-reviewed case-control study (34 cases, 142 controls) reported no differences in intrauterine fetal distress across groups, and no infant in either group experienced severe neonatal asphyxia. (Li)

[March 23rd 2020]

Which pre-existing health conditions put people at higher risk of more severe outcomes associated with COVID-19?

Populations at increased risk of more severe outcomes associated with COVID-19 have been identified by the CDC as:

  • People aged 65 years and older
  • People with existing conditions, such as people with chronic lung disease or moderate to severe asthma, people who have serious heart conditions
  • People who are immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV and prolonged use or corticosteroids and other immune weakening medications
  • People of any age with severe obesity or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure or liver disease might also be at risk

[April 1st 2020]

Why are these conditions associated with higher risk?

A meta-analysis of six studies suggests that the most frequent comorbidity in COVID-19 patients is hypertension, followed by diabetes, chronic cardiovascular conditions, cerebrovascular diseases, COPD and chronic kidney illnesses (Li 2020). In an analysis of the case-fatality rate of 44,672 cases in China, the overall case-fatality rate was 2.3%, compared with 8% for those 70-79 years, 14.8% for those over 80, 10.5% for those with cardiovascular disease, 7.4% for those with diabetes, 6.4% for chronic respiratory disease, 6.0% for those with hypertension and 5.6% for those with cancer. (Wu 2020)

Research has shown that those over the age of 65 generally have a higher viral load, lasting up to 14 days, compared with younger patients who have a much lower viral load. (Ji 2020) Mechanisms for high morbidity/mortality for those with comorbid conditions are unknown, though it has been suggested that elevated plasminogen in those conditions may contribute to susceptibility and fatality. (Ji 2020)

[April 1st 2020]

COVID-19 and Health-Care Workers

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

What effect does COVID-19 have on pregnant people?

There is limited scientific information about the impact of COVID-19 on pregnant people and guidance may change as more information becomes available. At the moment, pregnant people do not appear to be at higher risk of infection with COVID-19 than the general population. (RCOG 2020, PDF 442KB) In most case reports, there has been no evidence of vertical (birthing parent to infant) transmission. In the case reports where amniotic fluid, cord blood, placenta swabs, genital fluid and breastmilk samples were tested, all have returned negative for the virus. (ChenLiuZhang; Li) Emerging evidence from a case study of one maternal-infant dyad suggests the possibility of in utero infection; SARS-CoV-2 IgM was detected in the infant’s serum at birth. (Dong) If vertical transmission is possible, further research is required before we understand the proportion of pregnancies that are affected and the significance to the neonate.

In three small case studies (n=29), pregnant individuals presented with mild/moderate COVID-19 pneumonia during the third trimester. Pregnancy outcomes have been generally good, with spontaneous and iatrogenic preterm labour the most commonly reported adverse pregnancy outcome. (Chen; LiuZhang)

RANZCOG and the CDC both suggest that pregnant people may be at increased risk of complication from any respiratory disease, due to physiological changes of pregnancy. The SOGC suggests that outcomes may be correlated with degree of maternal illness.

[March 31st 2020]

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

There is limited scientific information about the impact of COVID-19 on the fetus/neonate and guidance may change as more information becomes available.

In three small case studies (n=29), five cases of fetal distress (undefined) were reported, though it is unclear if fetal distress was directed related to COVID-19 or another clinical factor such as prematurity. In these studies, no cases of severe neonatal asphyxia or neonatal death were reported. (ChenLiuZhang)

One non peer-reviewed case-control study (34 cases, 142 controls) reported no differences in intrauterine fetal distress across groups, and no infant in either group experienced severe neonatal asphyxia. (Li)

[March 23rd 2020]

What guidance is currently provided by health care organizations for pregnant healthcare workers?

Current guidance for pregnant health care workers is varied.

The SOGC states that pregnant healthcare workers can continue to work during the pandemic. They recommend that PPE should be used in situations where a worker may be exposed to a person with suspected or confirmed COVID-19; no additional PPE measures are required for pregnant healthcare workers. Where possible, avoiding unnecessary exposure to those with suspected or confirmed COVID-19 should be considered. [March 27th 2020]

For pregnant healthcare workers with comorbidities, the SOGC suggests contacting the prenatal care provider with respect to their risk and that they may wish to modify their risk of exposure accordingly. [March 27th 2020]

RANZCOG 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. [March 25th 2020]

The RCOG recommends that all pregnant healthcare workers be offered the choice of whether to work in patient-facing roles. For pregnant healthcare workers <28 weeks gestation who choose to work in patient facing roles, they are advised to minimize the risk of transmission and avoid working in areas with patients with suspected or confirmed COVID-19, where possible. Pregnant healthcare workers >28 weeks, as well as pregnant healthcare workers with underlying health conditions, are advised to stay at home, and may undertake telephone or videoconference consultations or administrative duties. [March 26th 2020]

CDC guidance for pregnancy heath care workers suggests that risk assessment and infection control guidelines need to be followed for health care providers. [March 16th 2020]

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

Recommendations from the SOGC and RANZCOG approaches appear to be evidence-based and balance the potential risk of increased complications with current lack of evidence on outcomes for those experiencing COVID-19 during pregnancy. In general, health care organizations, including the AOM, support approaches that minimize or lessen the risk of exposure to COVID-19 for pregnant health care workers. [March 23rd 2020]

Duty to care and duty to accommodate for pregnant healthcare 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 healthcare 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.

[March 23rd 2020]

If I, as a midwife and health-care provider, develop symptoms resembling COVID-19, when can I return to work?

The ministry has updated the quick reference guidance (PDF, 310 KB) on testing and clearance. This replaces the document previously issued on March 25th and provides guidance specific for health care providers.

  • Workers with symptoms and a negative test, may return to work 24 hours after symptom resolution.
  • Workers with symptoms and a positive test, may return to work 24 hours after symptom resolution; AND continue with appropriate PPE at work until 2 negative tests (if no longer doing clearance swabs, continue until 14 days after symptoms); AND continue with work-self-isolation* for 14 days after symptom onset.
  • Workers with symptoms who have not been tested may return to work at 14 days after symptom onset; OR return to work 24 hours after symptom resolution with appropriate PPE and work self-isolation* until 14 days from symptom onset.
  • Workers with no symptoms and a positive test, may return to work immediately; AND continue with appropriate PPE at work until 2 negative tests (if no longer doing clearance swabs, continue until 14 days after positive test result); AND continue with work-self-isolation* for 14 days after test result.

*work self isolation means that a health care worker is self isolating at all times (while at home and in the community) except that they are going to work and wearing PPE at all times while at work. Going to work is contingent on having and wearing PPE. If midwives do not have PPE to wear while at work, they should not go to work and should continue to self-isolate.

Midwives with questions about how this applies in their particular case, should contact their local public health unit or occupational health department at their hospital.

[March 28th 2020]

What guidance is available on accommodations for healthcare 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”. Healthcare 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.

[April 6th, 2020]

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

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 healthcare 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.

[March 31st, 2020]

COVID-19 Testing and Transmission

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

As of March 30th 2020, the Ontario case definitions for COVID-19 (PDF, 117 KB) are: 

Confirmed cases are individuals with laboratory confirmation of COVID-19 infection using a validated assay, consisting of positive nucleic acid amplification test (NAAT; e.g. real-time PCR or nucleic acid sequencing) on at least one specific genome target. Laboratory confirmation is performed at reference laboratories (e.g., The National Microbiology Laboratory or Public Health Ontario Laboratory) or non-reference laboratories (e.g., hospital or community laboratories).1

Suspected cases (a.k.a. probable cases) are individuals:

  1. With a fever (over 38 degrees Celsius) and/or onset of (or exacerbation of chronic) cough, AND any of the following within 14 days prior to onset of illness:
    • Travel to an impacted area, or
    • Close contact* with a confirmed or probable case of COVID-19 or
    • Close contact* with a person with acute respiratory illness who has been to an impacted area AND
    • In whom laboratory diagnosis of COVID-19 is not available, inconclusive, or negative (if specimen quality or timing is suspect)2,3,4
  2. A person with fever (over 38 degrees Celsius) and/or onset of (or exacerbation of chronic) cough AND in whom laboratory diagnosis of COVID-19 is inconclusive3,4

[March 30th 2020]

*Close contact is defined as a person who provided care for the patient, including healthcare workers, family members or other caregivers, or who had similar close physical contact OR who lived with or otherwise had close prolonged contact with a probable or confirmed case while the case was ill.

 

Footnotes

1. Some hospital and community laboratories have implemented COVID-19 testing in-house and report final positive results, which is sufficient for case confirmation. Other hospital and community laboratories will report positives as preliminary positive during the early phases of implementation and will require confirmatory testing at a reference laboratory (e.g. Public Health Ontario Laboratory or the National Microbiology Laboratory).
2. Laboratory confirmation may not be available due to no possibility of acquiring samples for laboratory testing of COVID-19.
3. Inconclusive is defined as an indeterminate on a single or multiple real-time PCR target (and no positives) without sequencing confirmation, or a positive test with an assay that has limited performance data available.
4. An indeterminate result on a real-time PCR assay is defined as a late amplification signal in a real-time PCR reaction at a predetermined high cycle threshold value range (e.g. Ct >38). This may be due to low viral target quantity in the clinical specimen approaching the limit of detection of the assay, or alternatively may represent nonspecific reactivity (false signal) in the specimen. When clinically relevant, indeterminate samples should be investigated further by testing for an alternate gene target using a validated real-time PCR or nucleic acid sequencing at the community, hospital or reference laboratory that is equally or more sensitive than the initial assay or method used.

My client is concerned that they have developed symptoms resembling a COVID-19 infection. What information can I provide them?

The Ministry of Health has included a self-assessment tool on their webpage to help the public determine if they should seek assessment for COVID-19. Midwives should advise their clients to use this self-assessment tool and to follow the instructions provided. [March 18th 2020]

The Ministry of Health has also advised the public to contact Telehealth Ontario at 1-866-797-0000 or their local public health unit if they are experiencing symptoms of the 2019 novel coronavirus. The province is increasing capacity of Telehealth to take more calls. [March 18th 2020]

Symptomatic clients should self-isolate while waiting to reach Telehealth Ontario or seeking medical attention. [March 18th 2020]

Is anosmia (loss of smell) a symptom of COVID-19?

Anosmia (loss of sense of smell) may be a symptom of COVID-19. In a recent letter published by ENT UK (PDF, 79KB), authors state that anosmia following a viral infection is believed to account for about 40% of all anosmia cases, with coronaviruses accounting for about 10-15% of these cases. There is limited evidence that has shown that anosmia is associated with COVID-19. Emerging literature includes findings from a survey conducted in Germany (hyperlink in German) with over 100 people who had COVID-19, in which two-thirds of participants reported a loss of sense of smell and taste. In Italy, 59 people with COVID-19 were surveyed, and one-third of participants reported at least one taste or olfactory disorder. In South Korea (hyperlink in Korean), one clinician reported that roughly 30% of patients with COVID-19 experienced anosmia. At this point in time, anosmia that is reported appears to be temporary.

COVID-19 is a coronavirus, as such it is conceivable that anosmia might occur as a result of this viral infection. However, more rigorous research is needed to better understand this association. The World Health Organization has not yet included anosmia in their symptoms list for COVID-19, but midwives may consider this symptom when screening clients as part of a broader screening strategy.

[April 3rd 2020]

When should I recommend screening for COVID-19 to my client?

The Ministry of Health issued a quick reference guide for health-care providers related to COVID-19 testing (PDF, 310 KB).

Testing for COVID-19 should be based on clinical assessment and not on case definition. At this time, there are no criteria for testing and all specimens will be tested if submitted. 

However, when there are shortages of testing supplies, the following groups should be prioritized:

  • Symptomatic health-care workers (regardless of care delivery setting) and staff who work in health-care facilities
  • Symptomatic residents and staff in long-term care facilities and retirement homes
  • Hospitalized patients admitted with respiratory symptoms (new and exacerbated)
  • Symptomatic members of remote, isolated, rural and/or Indigenous communities
  • Symptomatic travellers identified at a point of entry to Canada

PHO is not currently recommending routine testing asymptomatic persons for COVID-19. If midwives would like to further discuss the role for testing, the PHO Microbiologists on-call are available and can be contacted through the PHO Laboratory's Customer Service Centre at 416-235-6556 / 1-877-604-4567 or the After-Hours Emergency Duty Officer at 416-605-3113.

[March 30th 2020]

What evidence exists on asymptomatic cases of COVID-19 and can these cases transmit this virus?

There is evidence from small studies of asymptomatic individuals who test positive for COVID-19. Asymptomatic individuals have been found to have viral loads consistent with symptomatic individuals, making them effective transmitters of COVID-19. (Zuo; Wang; Chan) Research from a study of 24 asymptomatic cases found that these individuals might:

  • Go on to eventually develop symptoms and/or show clinical abnormalities (such as ground-glass chest found in CT scans, or stripe shadowing in the lungs), OR
  • Never develop any symptoms and have normal CT images.

There is also evidence to support that pre-symptomatic cases of COVID-19 may be particularly effective at transmitting the virus to others. A study in China suggested that infectiousness starts about 2.5 days before the onset of symptoms and peaked at about 15 hours before symptom onset. These researchers estimated that 44% of transmission could occur before the first symptoms develop, emphasizing the importance of social distancing and general hygiene (ex. hand washing, wiping commonly used surfaces, coughing and sneezing in sleeve or tissue) to control the spread in the community.

To track the spread of COVID-19, an epidemiological computer model has been developed using observations of reported infection within China, in conjunction with mobility data. The authors of this work estimate that 86% of all infections prior to January 23rd 2020 travel restrictions in China were undocumented, possibly because these individuals were asymptomatic or mildly symptomatic. Undocumented infections were estimated to be responsible for 79% of the documented infections.

Asymptomatic or pre-symptomatic individuals with COVID-19 may transmit the virus through spitting or touching their mouths and then touching a surface. They may also occasionally cough or sneeze which is common in healthy individuals.

Midwives should be mindful that clients may not be aware if they have COVID-19. Maintaining important hygiene behaviours with all clients can help to decrease the risk of transmission. Midwives should also provide virtual visits and limit non-essential in-person care (as described in the “Antenatal and Postpartum Visits” section of this FAQ), and may consider wearing a mask for all clinical encounters if there is sufficient stock of masks available.

[March 30th 2020]

Self-Isolation and Social Distancing

What is isolation? Self-isolation? Are these the same as social distancing?

Isolation is recommended for symptomatic individuals that have been diagnosed with COVID-19 or are waiting for the results of a lab test for COVID-19. Individuals in isolation are to stay at home and avoid contact with other people until a Public Health Agency advises the person that they are no longer at risk of spreading the virus to others. 

Self-isolation is recommended for individuals who have travelled outside of Canada within the last 14 days or have been identified as a close contact of someone diagnosed with COVID-19.  Self-isolate means to avoid contact with other people by staying home. Individuals who are self-isolating should avoid being in the same room with others within the home setting. If this cannot be avoided, a distance of at least 2 metres should be maintained from others. 

Clients that do not meet this criteria may also choose to stay home and practice social distancing. Social distancing means limiting the number of people you come into close contact with. Clients interested in social distancing may review Toronto Public Health’s fact sheet.

[March 18th 2020]

When and how should I advise my client to self-isolate? 

According to the Public Health Agency of Canada, your client will need to stay home and self-isolate for 14 days if:

  • They have travelled from anywhere outside of Canada, including the United States, within the past 14 days.
  • They have had close contact* with a confirmed or probably case. 
  • They have had close contact* with a person with acute respiratory illness who has been to an impacted area

Clients that meet this criteria may follow guidance from Toronto Public Health on how to properly self-isolate. [March 24th 2020]

* Close contact is defined as: a person who provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact OR who lived with or otherwise had close prolonged contact with a probable or confirmed case while the case was ill. (PHO, 2020) 

Personal Protective Equipment

When should midwives use PPE when interacting with a client?

PHO recommends all healthcare providers 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 healthcare worker.

While in hospital, midwives should follow the hospital's IPAC policies. In clinic and while doing home visits, it is reasonable for midwives to wear some or all aspects of droplet and contact PPE (if available) with all clients according to clinical judgement and following a risk assessment.

When conducting antenatal or postpartum visits, midwives can use the antenatal or postpartum visits decision tree (PDF, 168 KB) to determine when to use PPE if client and household members are self-isolating and/or symptomatic. 

When attending home births, midwives can use the home or community birth decision tree (PDF, 885 KB) to determine when to use PPE if client and household members are self-isolating and/or symptomatic. 

[April 8th 2020]

What PPE is needed for clients who has a suspected or confirmed COVID-19 infection?

Public Health Ontario updated the IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 as of April 6th 2020.

PHO continues to recommend that health-care providers providing direct care to patients with suspect or confirmed COVID-19, including nasopharyngeal and oropharyngeal swab collection, should use droplet and contact precautions, including:

  • Surgical/procedure mask
  • Isolation gown
  • Gloves
  • Eye protection (goggles or face shield)

Midwives can use the PPE performance levels chart (PDF 440KB) to better understand the level of masks and gowns or coveralls they need when ordering supplies. [April 6th 2020]

Health-care providers doing aerosol-generating medical procedures (e.g., endotracheal intubation, cardio-pulmonary resuscitation, open airway suctioning, positive pressure ventilation, etc.) performed on suspect or confirmed COVID-19 patients should use airborne, droplet and contact precautions, including:

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

[April 8th 2020]

Where can midwives go to place orders for face shields?

The AOM has been able to vet and suggest two Canadian suppliers of face shields with whom midwives can place orders. 

  1. 3D Printing Canada is offering FREE face shields to midwives! They are MK2 face shields with medical mask strap and ear guards, and are Health Canada certified. Max order is 50. Delivery is within one week and shipping cost varies by location. Orders can be placed on the website
    Midwives should use a work email address, not a gmail or hotmail account, to place their order. Select "Front-line hospital worker" from the drop down menu. Follow-up inquiries can be directed to Stephen at support@3dprintingca.zohodesk.com. Again, this company is donating FREE face shields to midwives. Apparently the manager is a fan of midwives and acknowledges them as essential first-line workers. 
  2. Inksmith is another Canadian supplier of Health Canada-certified face shields. Cost is $7 per shield if order is less than 1000 pieces, and $6 per shield if order is 1000+. Minimum order is 75 units. Delivery time is 7 days (maybe less) with shipping costs varying by location. Contact Richard Wright-Gedcke at richard@inksmith.ca or at (519) 504-5497. Access their website here.

Due to the a number of risks with overseas PPE sources - quality of product, difficulty in accountability and validity of supplier, interference and redirection at international borders - the AOM is concentrating its efforts on finding PPE suppliers within Canada. MPGs making PPE orders from overseas should be aware of the risks with out of country products. Midwives who would like to share a Canadian PPE lead can contact Anna Ianovskaia. PPE donation leads can be directed to Lwam Mehari

[April 7th 2020]

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 facemask and eye protection for repeated close contact encounters with different clients, without removing the facemask.
    • Remove and discard mask when it becomes soiled, damaged or hard to breathe through.
    • If using cloth masks, change every 6 hours or when 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
    • Watch here to learn how to safely reuse face and eye protection.
  3. Re-use (remove and re-donn) surgical masks between client encounters.
    • Surgical masks with ear hooks are easier to re-use, 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
    • 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 re-use 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 re-usable 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
    • Surface clean goggles and face shields, even if they are not intended for repeated use

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.

[March 31st 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).
 
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.
 
N95 Respirators 
The Ontario Ministry of Health has also stated that N95 respirators 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. [March 27th 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.

[March 26th 2020]

What does the research say about the efficacy of homemade cloth masks? Should they be used?

In light of the current PPE shortage, there is a strong interest in the viability and efficacy of homemade face masks. There is, however, there is limited research available on this topic.

Use Among Midwives

While higher rates of respiratory infections have been found in HCPs using cloth masks compared to surgical masks, the degree to which cloth masks provide protection compared to no masks is unclear. As such, current CDC guidance suggests that homemade masks should only be used as a last resort by HCPs to prevent droplet transmission if commercial supplies are unavailable. Where possible, they should be used in conjunction with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.

However, homemade masks are not considered PPE as their capability to protect against the virus is currently unknown. Homemade masks are not recommended as a method of reducing transmission of the virus from aerosol generating procedures (i.e. intubation).

At present, we cannot recommend the use of homemade cloth masks for midwives unless they are being used as a last resort (where there is no mask available in the community or hospital), in which case a cloth mask is better than no mask.

Use Among Clients

The Public Health Agency of Canada and the CDC are now recommending that all individuals wear non-medical masks in public settings where social distancing measures are difficult to maintain. There is also limited evidence which indicates that improvised masks worn by infected individuals are better than no protection and can also be considered as a last resort to prevent droplet transmission. 

Cloth face masks may also be considered for clients with suspected of confirmed COVID-19 who are chest/breastfeeding their babies, who do not have access to a supply of surgical masks.

Some Considerations

Some of the key challenges associated with cloth masks are related to the physical properties of the mask, poor filtration, re-use, frequency and effectiveness of cleaning and moisture retention, all of which may increase the chances of infection for HCPs. There is concern that use of homemade masks may give users a false sense of protection, which could encourage risk taking behavior and/or decrease attention to other hygiene measures.

When considering use of a homemade mask, the following are important:

  • Comfort and fit (ensure mask doesn’t require frequent re-adjusting) to avoid touching face
  • Proper donning and doffing procedures
  • Changing masks every six hours or when they become damp or soiled
  • Use of separate clearly labeled containers for clean and dirty masks to prevent contamination
  • Regular cleaning of dirty masks with hot water and detergent. Dry completely on the hot setting.

Caution should be exercised to avoid any unnecessary risks, given the reduced protective capabilities of this option. This may include limiting direct physical contact to the extent possible when providing care and practicing social distancing to the extent possible.

[April 6th 2020]

Which materials and patterns can be used for homemade face masks? 

Mask Material

There is very limited evidence available on which types of materials provide the best protection for homemade masks. A small body of research suggests that for infected individuals, single layer pillowcases, 100% cotton t-shirts or tea towels are the most suitable materials for an improvised mask given their optimal balance of particle capture and breathability. In particular, t-shirts are the preferred choice because their slight elasticity provides a better fit. While vacuum cleaner bags were found to be the most effective at capturing virus particles, they were not recommended because they are difficult to breathe through.

[March 31st 2020]

Is there a mask pattern that the AOM recommends?

There isn't a lot of literature on homemade masks, and even less comparing different patterns. As a result, we can't recommend anything specific. However, many healthcare institutions are now requesting homemade cloth mask donations and providing instructions and patterns. Most are currently recommending a 2 ply design using a tight weave cotton for the mask and elastic, bias tape or fabric strips for the ties.

Here is a list of pattern options with varying levels of difficulty:

  • Michael Garron Hospital in Toronto recently put out a call to the public to sew cloth masks for approved hospital visitors and discharged patients using this simple pattern.
  • The CDC has posted sew and no-sew patterns made out of easy to find household materials.
  • Doctors without Borders recommends this basic pattern and filter. (PDF 3.2MB)

[April 6th, 2020]

Routine Antenatal Testing

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

Your client’s ultrasound appointment should be postponed if:

  • They have suspected or confirmed COVID-19;
  • Have travelled outside of Canada within 14 days of their appointment; OR
  • Have been in contact with someone who has suspected or confirmed COVID-19.

Clients with suspected or confirmed COVID-19 may attend their prenatal ultrasound appointments after they have fully recovered from COVID-19 infection. [March 18th 2020]

Clients who have travelled outside of Canada or who have been in contact with someone who has suspected or confirmed COVID-19 may attend their prenatal ultrasound appointments after completing 14 days of self-isolation with no symptoms. [March 18th 2020]

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

Yes. At this point in time, clinics in Ontario providing ultrasound services remain open, however most clinics are operating on a day-by-day basis and will be responding accordingly as the COVID-19 outbreak evolves. This may mean that clients will face disruptions to accessing routine prenatal ultrasounds in the coming months. [March 23rd 2020]

If COVID-19 is resulting in there being no availability for ultrasound in your community, please
contact Prenatal Screening Ontario. [March 23rd 2020]

For midwives who are referring their clients to a separate clinic to receive an ultrasound, they should remind their clients to be mindful that clinic’s respective 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. [March 19th 2020]

My client missed their enhanced first trimester screening due to self-isolation. What alternative can I suggest to them?

Clients who miss the window for enhanced first trimester screening (eFTS) due to illness or self-isolation, 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. [March 23rd 2020]

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

During the Member Webinar on March 18th 2020, some midwives shared how they are managing the Oral Glucose Challenge Test (OGCT) while promoting social distancing. The measures currently being implemented in some practices 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.

[March 18th 2020]

Can I still do a Pap test for my clients?

At this point in time, Cancer Care Ontario is asking that all screening be paused (irrespective of an individual’s COVID-19 status). If a client must be screened, midwives should contact their community laboratory to inquire if Pap samples are still being processed. [March 27, 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 confirmed or suspected COVID-19 (PDF, 117 KB) until after the period of self-isolation (PDF, 508 KB) is complete. Offer a virtual visit (by phone, Skype, etc.) if applicable (when physical care is not required).

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 (surgical mask, gown, gloves and eye protection) 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

[March 20th 2020]

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

[March 20th 2020]

What should I consider when visiting with a client?

Flow chart for PPE considerations during visits.

[March 20th 2020]

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

A reduced antenatal visit schedule will be offered in order to reduce community transmission. 

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.

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

[March 20th 2020]

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 an 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

[March 27th 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 will be 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.

[March 20th 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. 

Also, AOM staff have been working with the Ontario Telemedicine Network to facilitate a process to onboard midwives as quickly as possible. More details to come shortly.

[March 25th 2020]

Labour Considerations

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

Some hospitals are recommending the routine use of early epidurals for all birthing people diagnosed with COVID-19. This recommendation is in line with RCOG guidance stating that “epidural analgesia should be recommended before, or early in labour, to women with suspected/confirmed COVID-19 to minimise the need for general anaesthesia if urgent delivery is needed.” Of note, the SOGC, in their “COVID-19 in Pregnancy” statement released March 13th, 2020 does not make this recommendation.

While a general anaesthetic is used rarely intrapartum, it may be used when urgent delivery by cesarean section is required for fetal or indications in the birthing person and there is insufficient time to introduce neuraxial anesthesia (epidural or spinal) or there is a concern that neuraxial anesthesia may not work.

[March 27th 2020]

Does COVID-19 make a client more at risk of urgent delivery?

There is limited data currently regarding whether or not pregnant people infected with COVID-19 are at higher risk of adverse outcomes. To date, there have been case reports suggesting a potential increased rate of “fetal distress” in labouring people with COVID-19, although it remains unclear if fetal distress was directly related to COVID-19 or another clinical factor such as prematurity. (ChenLiuZhang) Currently, the SOGC states that pregnancy outcomes in the reported COVID-19 cases have been largely positive.

There is only one case report of severe morbidity in the pregnant person secondary to COVID-19. Urgent delivery could be needed in a pregnant person with COVID-19 with severe illness and/or who is rapidly decompensating.

[March 27th 2020]

Why is a general anaesthetic of concern with COVID-19?

A general anaesthetic requires procedures that generate aerosols such as endotracheal intubation, manual ventilation before intubation and positive pressure ventilation. Guidance from the WHO has indicated that aerosol generating procedures can potentially cause airborne transmission of COVID-19 which increases the risk of transmission of the virus to health care providers, hospital staff and potentially other hospital patients.

According to the American Society of Anesthesiologists, measures and precautions can be taken to protect against COVID-19 becoming airborne during a GA but they add time and complexity to the procedure. These involve:

  • Use of N95 masks.
  • Additional filters and increased scavenging of gases.
  • Certain procedures being avoided in favour of using more timely or complicated procedures to reduce the risk of transmission. Hospitals may decide to prioritize the most experienced anaesthesiologist on staff where possible due to these additional complexities.
  • Increased time spent in the operating room due to these additional precautions, which reduces the availability of the operating room for other patients. There may also be additional time spent in the operating room recovering the postpartum person as well as increased time needed to clean and ventilate the operating room once the procedure is completed.

Potential impact on the fetus:

  • Additional precautions may increase the time spent between introduction of GA and delivery, which can cause a greater transfer of anesthetic agents to the fetus causing cardio-respiratory depression and decreased tone of the infant. (Rollins)

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, midwives should discuss the rationale for this recommendation with clients as part of their informed choice discussions and document client decision making accordingly.

[March 27th 2020]

Home Birth

Should clients consider a home birth during a pandemic?

The home birth during the COVID-19 pandemic (PDF, 885 KB) reference guide was developed to provide 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
  • A decision tree on when to use PPE at home births depending on the health status of the client and/or household member

[April 3rd 2020]

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.

[March 27th 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.

[March 27th 2020]

Mental Health

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.

[March 19th 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

[March 19th 2020]

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

The WHO (PDF, 521.56 KB) encourages all health care providers to attempt to use personal coping strategies that have worked well in the past. The self-care strategies midwives may benefit from are the same as those recommended to clients, including:

  • Reducing time spent watching, reading or listening to the news to once or twice a day
  • Seeking information only from trusted sources
  • Meditating, stretching, exercising, and eating nutrient-dense foods
  • Connecting with friends and family
  • Prioritizing sleep and relaxation

The WHO (PDF, 521.56 KB) advises that some healthcare workers may experience avoidance by their family or community due to stigma or fear, which can be challenging to cope with. If possible, stay connected with your loved ones and turn to your colleagues or other trusted persons for social support.

Resources for midwives include:

  1. Ontario COVID-19 Mental Health Network: Midwives, as front-line health care providers during the COVID-19 pandemic, can access free mental health services through Ontario COVID-19 Mental Health Network. After registering online, up to 5 teletherapy sessions with a psychologist, psychotherapist or social worker will be coordinated.
  2. Daily Media Briefings: Stay informed with accurate information about the province’s ongoing response to COVID-19 by attending these briefings from the Ministry of Health.
  3. 10 Percent Happier Meditation App: Healthcare workers are being offered a free six-month subscriptions to the Ten Percent Happier app, no strings attached. This app allows users to follow guided meditations to support them in this trying time.
    • To access:
      • Download the app
      • Create an account on that website or log in
      • Enter gift code to redeem: HEALTHCARE
    • IMPORTANT: Make a note of the way you registered your account (email, Facebook, etc.) because you must log into the app using the same method you used to claim your code on the website
    • For those that do not wish to download the app, the 10 Percent Happier team also offers several free resources including podcasts and meditations on their website
  4. Optima Global Health (Health InSight Support Services) is the new employee assistance program offered to AOM midwife members and immediate family to assist with a variety of different work/life issues that may threaten their health, impair their work performance, or affect their work attendance.
  5. 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: 416-425-997

The Ontario government is also increasing it's capacity to support the mental health of all individuals, those on the front lines of the pandemic. Mental health agencies will receive emergency funding to hire and train more staff and purchase necessary equipment, appropriate technology and additional licenses. For more information and resources visit the Ontario government website

[April 3rd 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 healthcare providers), and the employee assistance program offered to AOM midwife members.

[March 19th 2020]

Medication

How can midwives advise clients who are asking about the use of Ibuprofen to treat suspected or confirmed COVID-19?

Current guidance from the WHO does not recommend avoiding the use of ibuprofen to manage symptoms of COVID-19. Health Canada also claims that there is “no scientific evidence that establishes a link between ibuprofen and the worsening of COVID-19 symptoms”. As always, use of ibuprofen should be avoided in pregnancy > 30 weeks. [March 20th 2020]

WHO infographic on the use of ibuprofen to treat COVID-19.

For management of fever, acetaminophen may be used, as it is not contraindicated in pregnancy, except in cases of hypersensitivity to paracetamol and liver disease. [March 19th 2020]

My client has asked me about the use of anti-malarial, antibiotic and antiviral therapies to treat COVID-19. What information should I provide them with?

There has been significant mention in both social media and on the internet on the use of certain anti-malarial, antibiotic and antiviral therapies in the treatment of COVID-19 patients. Even though the suggested drugs — a combination of two medications: hydroxychloroquine sulfate (brand name Plaquenil®) and azithromycin (brand name Zithromax®) are not in the midwifery pharmacopeia, clients may still request prescriptions from their midwives.

The Ontario Pharmacists Association, Ontario Medical Association and the Registered Nurses' Association of Ontario issued a joint statement (PDF, 176 KB) for their members regarding the lack of evidence and the risks associated with these drugs.

If clients request prescriptions for these drugs, they should be informed that:

1. There is no evidence for their use, and; 
2. They are not in the midwifery pharmacopeia.

Chest/Breastfeeding

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

There has been no documentation of viral transmission through human milk. There has also been no detection of viral DNA in the analyses of human milk from individuals with confirmed COVID-19. New evidence is continuing to emerge on this topic. [March 18th 2020]

If my client has suspected or confirmed COIV-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
  • Clean the chest area with soap and water before each 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

[April 7th 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. [March 19th 2020] Similarly, RCOG also recommends that infants should remain with their birthing parent in the immediate postpartum unless neonatal care is required. [March 21st 2020]

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. [March 19th 2020]

Will I still be able to conduct routine newborn screening?

Newborn Screening Ontario (NSO) is still accepting and processing screening samples, and there are currently no reported disruptions to this service. [March 17th 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.

[March 24th 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. [March 18th 2020]