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.
 

COVID-19 and Different Populations

What effect does COVID-19 have on pregnant people?

Many healthcare jurisdictions in Canada are facing a third wave of COVID-19 pandemic activity, driven by low rates of vaccine coverage and circulation of new variants of concern (VOC) of COVID-19 that have been demonstrated to be more transmissible and severe compared to the type of virus which predominated previously.

There is consistent data that pregnant individuals are at increased risk of severe illness and this appears to be worsening during the 3rd wave. Data from the 3rd CANCOVID-Preg Report (released February 25th 2021) suggests that pregnant individuals are at increased risk of hospitalization (RR = 5.33, 95% CI: 4.51 to 6.2) and five times more likely to be admitted to the ICU (RR=5.88, 95% CI: 3.8 to 8.22) than their non-pregnant counterparts diagnosed with COVID-19, although overall rates of ICU admission were low (1.6%) among pregnant people. Most cases (38.7%) of COVID-19 were diagnosed between 14 and 27 weeks' gestation and infection was most often acquired via the community at large (50.6%). The most common underlying condition was obesity (11.9%). (Money 2020

These findings are supported by international data. A large systematic review of 13,118 pregnant individuals (77 studies) similarly found that pregnant individuals with COVID-19 were more often admitted to ICU (OR 1.62) and had greater need for invasive ventilation (OR 1.88) than non-pregnant individuals of reproductive age who had COVID-19. Mortality from COVID-19 does not appear to be higher for pregnant individuals with COVID-19 compared to those who are not pregnant. (Allotey 2020

Importantly, the risk of severe COVID-19 morbidity in pregnant people appears to be strongly associated with risk factors including age greater than 35, asthma, obesity and pre-existing medical conditions such as pre-existing lung disease, hypertension, heart disease and diabetes. (Allotey 2020; Molteni 2020)This is consistent with evidence from the general population. 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 2020)

[March 12th 2021] 

How have variants of concern impacted hospital and ICU admissions for pregnant people in Ontario?

The SOGC issued a statement on April 15th, 2021, warning that: “According to SOGC members, there is currently a wave of daily pregnant women coming into Ontario ICUs, many requiring ventilators. These women are getting extremely sick, very quickly.” Pregnancy is a known risk factor for COVID-associated morbidity with data clearly and consistently illustrating that pregnant individuals are at increased risk for hospitalization, ICU admission, mechanical ventilation and death compared to non-pregnant individuals. As a result of these factors, many Canadian centres are facing increased numbers of pregnant individuals infected with COVID-19 being admitted to the hospital and ICU.

The SOGC recommends that to reduce risk of infection, pregnant people:

  • limit contact with others as much as possible
  • Avoid contact with anyone who has symptoms
  • Wear a cloth face mask in public
  • Keep about 2 meters of distance between yourself and others beyond your household
  • Focus on taking care of yourself and your baby and don’t hesitate to contact your health care providers if you have any concerns about your physical and mental health

[April 23rd 2021] 

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

Results from the 3rd report of the CANCOVID-Preg study largely show positive pregnancy outcomes. Of 757 reported pregnancy outcomes affected by COVID-19, there were 9 (1.2%) stillbirths and < 6 newborns who were tested for COVID-19 received a positive result. Stillbirth rates were very rare and were not statistically higher than the national estimate of stillbirth (Money 2020)

Of the 738 cases with delivery and gestational age data, 82% occurred at term and 12.3% at preterm gestation. Of the 91 (12.3%) preterm infants, 40.% were medically indicated preterm deliveries and 45.1% 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 2020; SOGC 2020

CANCOVID-Preg data also reported that the majority of infants (82.1%) were in the normal range for birth weight (2500-4000 grams) and most infants (83.3%) were not admitted to the NICU. (Money 2020

There is currently no evidence to suggest the COVID-19 causes fetal malformations or other developmental problems. There has not been an increase in stillbirth or neonatal death among pregnant people with COVID-19. (Atolley 2020) There is insufficient evidence to comment on the risk of miscarriage. One study reporting on 176 neonates found that 5.7% of all infants were congenitally infected as SARS-CoV-2 was found to invade the placenta. This transplacental transmission, while very rare, may potentially cause miscarriage. (Raschetti 2020) Robust data from pregnant individuals who become infected in the first and second trimester of pregnancy is still required to conclusively determine if congenital infections and the risk of congenital anomaly associated with COVID-19, are occurring.

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 2020SOGC 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)

[March 12th 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 healthcare 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

As an asymptomatic healthcare worker, should I be social distancing at home? 

Midwives are balancing many difficult decisions as primary healthcare providers during a pandemic, and may be concerned about how their work impacts the health and safety of their families. Some may be considering physical distancing at home in order to further reduce risks to their families, particularly if they live with those at higher risk. 

A review of the evidence from the Centre for Evidence-Based Medicine found no studies on the effectiveness of social distancing of asymptomatic healthcare workers from family members, in order to reduce the risk of transmission of COVID-19. The review notes that there is, however, evidence that confined spaces have been associated with high risk of infection from COVID-19. In previous coronavirus outbreaks, low rates of transmission were reported in household members of healthcare workers. 

Though there is no direct evidence on social distancing at home of asymptomatic healthcare workers during COVID-19, current evidence supports: rigorous hand hygiene, the use of droplet/contact PPE at all clinical encounters where physical distancing cannot be maintained as well as minimizing patient contacts as means to reduce the risk of transmission.  

Midwives who work in higher risk settings, or those with higher risk family members may consider social distancing at home.  

[October 7th 2020]

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 healthcare 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 healthcare workers under 28 weeks' gestation are able to continue working in client facing roles if risk assessment indicates this is acceptable, and if the healthcare worker chooses to do so. Pregnant healthcare 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 healthcare 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 healthcare 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 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.

[December 11th, 2020]

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

The Ministry of Health's COVID-19 quick reference guidance on testing and clearance (PDF, 139 KB) was updated on March 5, 2021. 

This new update recommends that:

  • Health care workers (HCWs) should follow isolation and clearance with a non-test–based approach, if they have required hospitalization during the course of their illness, a test-based approach may be used at the discretion of the hospital while they are admitted. Some HCWs may be directed to have test-based clearance by their employer/Occupational Health and Safety.
  • Symptomatic HCWs awaiting testing results must be off work.
  • Asymptomatic HCWs awaiting testing results may (in certain circumstances) continue to work using the appropriate precautions recommended by the facility, which will depend on the reason for testing. Asymptomatic midwives self-isolating while awaiting test results following a high-risk exposure should not be working, unless advised to do so by their occupational health department. 
  • Asymptomatic HCWs exposed to a symptomatic household member should isolate until the symptomatic individual has received a negative COVID-19 test result or an alternative diagnosis from their healthcare provider. If testing is not conducted then the midwife should self-isolate for 14 days from last exposure. 

When in doubt, regarding symptoms or exposure, midwives should self-isolate and await guidance from their local public health unit or occupational health department, as appropriate. 

[April 29th, 2021]

If a midwife is fully vaccinated and has been exposed to COVID-19, what is the guidance regarding when they can return to work? 

The Ministry of Health has released new guidance on COVID-19 fully vaccinated individuals: Case, contact and outbreak management interim guidance (PDF 158 KB). The purpose of this interim guidance document is to supplement the Management of cases and contacts of COVID-19 in Ontario guidance (PDF, 480 KB) with recommendations for case and contact management of fully vaccinated individuals in Ontario.

This interim guidance does not apply to individuals who have an incomplete vaccine series. An incomplete vaccine series is when an individual has only received the first dose of a two-dose vaccine series; or it has been less than 14 days after they received the only/ last dose of the vaccine series.


All partially and fully vaccinated individuals should continue to follow general public health guidance and recommended infection prevention and control measures (i.e. continue with use of PPE and physical distancing even when with others who have been fully vaccinated).

If you are fully vaccinated and symptomatic, test positive for COVID-19 or have a high-risk exposure, read the full guidance as it differs from the guidance for those who are not vaccinated or partially vaccinated. If you have any questions, contact your local public health unit, occupational health and safety department or the AOM On Call.


Highlights of changes for fully vaccinated individuals include:

  •  All fully vaccinated individuals who have symptoms of COVID-19 should be managed in accordance with the Management of cases and contacts of COVID-19 in Ontario guidance (i.e. self-isolate and be tested for SARS-CoV-2 immediately).
  • Upon receiving a negative PCR test result, symptomatic individuals who are fully vaccinated can be cleared from isolation once symptoms have resolved for at least 24 hours (as per Quick reference guidance on clearance and testing (PDF, 221 KB).
  • Asymptomatic individuals who are fully vaccinated with high-risk exposures are not required to self-isolate. However, they should still be tested in accordance with the Provincial testing guidance (PDF, 190 KB) and must report their exposure to their employer and follow any restrictions from work as specified by their manager and/or occupational health department.
  • Household members of fully vaccinated individuals with high-risk exposures are not required to “stay at home except for essential reasons.”
  • Fully vaccinated individuals who are household members of a symptomatic person are not required to stay at home until the symptomatic individual tests negative.
  • In the event that the local public health unit has information about the VOC testing results of the index case that the asymptomatic fully vaccinated individual was exposed to (e.g. had known B.1.351 or P.1 lineage or E484K mutation), self-isolation may still be required at the discretion of the local public health unit, as the vaccine effectiveness against these variants of concern is less well established.
  • If the fully vaccinated individual with a high-risk exposure to a case becomes symptomatic, they must self-isolate immediately and get tested.
  • At this time, travellers entering Canada are not excluded from federal quarantine requirements, even if they have been vaccinated.

The updated Management of cases and contacts of COVID-19 in Ontario (PDF, 480 KB) provides complete guidance for case and contact management, including detailed guidance on isolation and timing of testing.

[May 12th, 2021]

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.

[September 24, 2020]

Duty to care and duty to accommodate for healthcare 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 healthcare 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 Testing and Transmission

What are the symptoms of COVID-19?

Symptoms of COVID-19 can be mild – akin to the flu and other respiratory infections. Some symptoms may be more severe.

The MOH updated their COVID-19 reference document for symptoms (PDF, 50 KB) on September 21, 2020.  The updated reference documents recommends that when assessing for the symptoms on the list, the focus should be on evaluating if they are new, worsening, or different from an individual’s baseline health status (usual state). Symptoms should not be chronic or related to other known causes or conditions. 

According to the Ministry of Health, the most common COVID-19 symptoms include:

  • fever (temperature of 37.8°C or greater)
  • cough (that is new or worsening (e.g. continuous, more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing) 
    • Not related to other known causes or conditions (e.g., chronic obstructive pulmonary disease) •
  • shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath)
    • Not related to other known causes or conditions (e.g., chronic heart failure, asthma, chronic obstructive pulmonary disease)

Other symptoms of COVID-19 can include:

  • sore throat
  • rhinorrhea
  • nasal confestion 
  • new olfactory or taste disorder(s)
  • nausea/vomiting, diarrhea, abdominal pain

Other clinical signs of COVID-19 can include:

  • clinical or radiological evidence of pneumonia.

The Reference Document for Symptoms (version 7.0) includes additional information about atypical symptoms/ signs of COVID-19 in children, older person, and people living with a developmental disability. It provides a more detailed section on multisystem inflammatory syndrome (MIS-C) in children. 

[April 15th, 2021]

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

As of February 18, 2021, the Ontario case definitions for COVID-19 (PDF, 117 KB) 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:

Individuals with 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

Individuals who are tested with a validated Health Canada-approved point-of-care (POC) NAAT or POC antigen test for SARS-CoV-2 and the result is preliminary positive detected. 

 

[April 15, 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 healthcare exposures as outlined in Ministry guidance on cases and contacts of COVID-19

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]

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. Midwives may, however, consider testing asymptomatic clients who were recently in contact with someone with confirmed COVID-19. 

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 (PDF, 398 KB).

[December 21, 2020]

When should I screen my 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. Midwives can use this Ministry of Health screening guidance document (PDF, 96 KB) (which contains a series of screening questions) when screening their clients. 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.
  • Passive screening: signage should be posted and visible to visitors at the entrance of the clinic and at reception. Template signage for midwifery clinics is available in English (PDF, 131 KB) and French (PDF, 140 KB). 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 7 of the COVID-19 Guidance: Primary Care Providers in a Community Setting 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 in the AOM's resource, Midwives ordering testing for COVID-19 (PDF, 308 KB), as well as 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.

[November 25th, 2020]

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]

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.

For more information about testing, please see our midwives ordering testing tip sheet for COVID-19 (PDF, 398 KB).

[December 21, 2020]

How accurate are COVID-19 tests?

Testing for COVID-19 currently happens in Ontario using molecular tests for viral RNA (RT-PCR). There are some challenges with understanding the accuracy of these tests: 

  • lack of a generally accepted reference standard to compare RT-PCR tests; RT-PCR tests are often compared against future RT-PCR tests
  • lack of large, high-quality studies designed to determine the accuracy of RT-PCR testing for COVID-19
  • lack of re-testing of people who were initially negative, in order to determine accuracy of negative results. 

Public Health Ontario [PDF, 737 KB] has investigated the question of test accuracy and reports that several small studies with small sample sizes have estimated the first RT-PCR test completed as having a sensitivity of 70% to 90% for detecting SARS-CoV-2 (suggesting a 10-30% false negative rate). In a review of Ontario laboratory data of patients who were tested with nasopharyngeal swab and/or throat swab between  January 11 to April 14, Public Health Ontario found: 

  • Of 569 positive patients, 484 patients tested positive during their first test (85%), while 85 patients tested negative during their first test, and then tested positive on a subsequent test. This suggests the potential of a 15% false negative rate.

There is limited information available on the accuracy of testing in asymptomatic populations. 

The Ministry of Health [Nov 20, 2020] [PDF, 270 KB] recommends that for those who are symptomatic:

  • A single positive test is sufficient to confirm COVID-19.
  • For those with no known exposure, a single negative result is sufficient to exclude COVID-19. Repeat testing may be considered depending on the clinical scenario (persistent, new or worsening symptoms).
  • For those currently within 14 days of self-isolation as a result of exposure, a single negative result is sufficient to exclude COVID-19. However, the individual should remain in self-isolation for the remainder of their 14-day period, and if symptoms change or worsen, repeat testing.

For those who are asymptomatic:

  • A single positive test is sufficient to confirm current or prior infection with SARS-CoV-2. This could mean either:
    • Current infection that is asymptomatic or pre-symptomatic OR
    • Prior infection (with or without symptoms) as testing can remain positive for several weeks to months after infection
  • Those with a first-time positive test must be managed as if they have a current COVID-19 infection in terms of immediate isolation until cleared.
  • An asymptomatic individual who has been advised by local public health to get tested due to exposure to a case or as part of an outbreak investigation should be tested within 14 days from their last exposure. 
    • A single negative result is sufficient to exclude COVID-19 at that point in time. However, the individual must continue to follow public health advice provided to them based on their exposure risk for the rest of their 14 days from last unprotected exposure to the case, regardless of the negative result as they may still be incubating. 
    • Re-testing after an initial negative test within the quarantine period is not recommended if the individual remains asymptomatic. 
    • Re-testing should be conducted if the asymptomatic individual who initially tested negative develops symptoms. 
  • An individual that has previously had laboratory-confirmed COVID-19 AND was cleared, should generally not be re-tested due to persistent shedding. 

Midwives should use clinical judgement when interpreting negative test results and determining client management. 

[November 25th, 2020]

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

Asymptomatic infection occurs when:

  1. An individual is infected with COVID-19 but experiences no symptoms throughout their infection, or
  2. An individual is infected with COVID-19 but has not yet developed symptoms (a.k.a. a pre-symptomatic case).

There have been some case reports demonstrating COVID-19 infection amongst asymptomatic individuals who never develop symptoms (Hoehl; Tong; Bai; Hu; Zou). 

Research has demonstrated that despite having no symptoms, some asymptomatic cases may show clinical abnormalities, such as ground-glass chest found in CT scans, or stripe shadowing in the lungs. However, a smaller proportion of individuals show normal CT scans.

Asymptomatic Transmission

Although it is possible for asymptomatic individuals who never develop symptoms to transmit COVID-19, there is only limited evidence to support this. A cohort study in South Korea found that asymptomatic cases showed similar viral loads to symptomatic cases. These results may suggest the potential for similar transmission of the virus for all infected individuals, despite symptoms. However, these researchers cautioned that they are unsure of the role that molecular viral shedding plays in transmission from asymptomatic patients. Further, this cohort consisted of young (aged 22-36 years), otherwise healthy individuals and cannot be generalized to the entire population.

Evidence does exist to support that pre-symptomatic cases of COVID-19 may effectively transmit 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 (e.g. hand washing, wiping commonly used surfaces, coughing and sneezing in sleeve or tissue) to control the spread in the community.

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.

Proportion of Asymptomatic Cases

The actual proportion of confirmed asymptomatic cases is largely unknown, and likely varies by age, study setting and study methodology. Asymptomatic cases are also much less likely to be included in national reports since these individuals may never present at hospital, receive a test, or have any knowledge of their infection. Limited available data suggests that 1.2% of 72,314 cases in China (PDF, 3.41 MB) and 6.4% of 22,013 cases in Italy (PDF, 1.07 MB) have been found to be asymptomatic. According to a paediatric study in China (PDF, 1.98 MB), 12.9% of 731 confirmed cases were asymptomatic, which may suggest that asymptomatic presentation is more likely amongst children.

Asymptomatic Pregnant People

The prevalence of asymptomatic transmission in pregnant people in Canada is currently unknown; this data is expected in 2021 as part of the CANCOVID-Preg data set." (SOGC 2020) Estimates of asymptomatic rates in pregnant people differ across geographic region and are likely impacted be regional rates of infection. Where universal screening of pregnant people has been introduced, studies show the majority of those who test positive for COVID-19 are asymptomatic. In a study in New York, 215 pregnant people were tested for COVID-19. Of the 215, 33 tested positive (15.3%), four were symptomatic (12%) and 29 were asymptomatic (88%). In a study in London, UK, 129 pregnant people admitted to the hospital were universally screened for COVID-19; 9 (7%) tested positive and of these, 8 (89%) were asymptomatic. 

Guidance for Midwives

Although the estimated proportion of true asymptomatic cases remains very low, there is strong evidence that individuals may transmit the virus prior to symptom onset; midwives should be mindful of the possibility that some clients may not be aware that they have COVID-19. Using PPE for all clinical encounters when two-meters distance cannot be maintained as well as adhering to rigorous hygiene behaviours with all clients can help to decrease the risk of transmission. Midwives may also minimize the potential for asymptomatic or pre-symptomatic contact by providing virtual visits and limiting non-essential in-person care (as described in the “Antenatal and Postpartum Visits” section of this FAQ). 

[December 18th 2020]

COVID-19 Screening Using Rapid Antigen Point-of-Care Testing (POCT)

What is the COVID-19 Provincial Antigen Screening Program?

Note: These FAQs refer to “point-of-care testing (POCT)” to remain consistent with Health Canada’s terminology and classification of test types. Within the provincial (Ontario) context, it can be considered synonymous with “rapid testing.”

Midwives can now offer COVID-19 rapid antigen point-of-care testing (POCT) by participating in the Provincial Antigen Screening Program. This program, led by Ministry of Health (MoH) and supported by Public Health Ontario and Ontario Health, was piloted in 2020 and is currently being expanded to additional priority sites, including midwifery settings. The screening program involves the provision of POCT kits to enhance existing COVID-19 screening measures for asymptomatic individuals. This will allow midwives to proactively identify COVID-19 cases that may have otherwise been missed and prevent asymptomatic individuals from unknowingly spreading the virus.

[May 17th, 2021]

What is rapid antigen POCT?

A rapid antigen POCT is a COVID-19 screening tool, not a diagnostic test. It can be administered and processed anywhere (clinic, community, hospital) and does not require sending the specimen to a laboratory for processing. It is administered using one of the following methods:
•    nasopharyngeal swab
•    combined swabbing of throat and both nares
•    deep nasal swabbing
•    anterior nasal swabbing 

Results are yielded within approximately 15 minutes of specimen collection. 

Rapid antigen POCT should be used in addition to (and does not replace) public health measures such as symptom screening, physical distancing, use of PPE, and hand hygiene.

As per COVID-19 Provincial Testing Guidance on Rapid Antigen Tests, a positive antigen POCT should be considered a preliminary positive and should be followed up within 24 hours with a confirmatory laboratory-based polymerase chain reaction (PCR) test. Participation in the Provincial Antigen Screening Program does not provide participants with priority access to confirmatory lab-based PCR tests. The individual who received a positive result on the rapid antigen POCT should isolate until the PCR test result is known. 

[May 17th, 2021]

How will rapid antigen POCT be useful to midwives?

The Provincial Antigen Screening Program: Information Document (PDF, 354 MB) states, “participating employers will have significant flexibility in the implementation of rapid antigen testing within their respective workplaces.” Midwives should ensure that their program implementation adheres to the parameters of use as outlined in that document and that it complies with provincial clinical guidance. 

Midwives will determine for themselves how to implement rapid antigen POCT in their practice. Some ideas include:

  • regular screening of midwives, students, and administrative staff within the midwifery setting
  • screening clients prior to clinical encounters
  • screening clients and family members upon arrival at a home birth or home labour check (where individuals may be in close quarters for extended periods of time)
  • screening term clients (i.e., twice weekly from 37 weeks onwards)
  • additional screening for those who are unwilling or unable to wear a mask

[May 17th, 2021]

Who can administer rapid antigen POCT?

The exemption of Health Canada approved COVID-19 POCTs from the provincial regulations under the Laboratory and Specimen Collection Centre Licensing Act (“LSCCLA”) increases flexibility for implementation, including expanding who can perform the tests in accordance with the manufacturer’s label. 

As a result, a broad range of health care and non-health care professionals will be able to deliver POCT, including:

  • midwives
  • any trained individual who has the knowledge, skills, and judgment to administer the test in accordance with the manufacturer's label (e.g., administrative staff and midwifery students in midwifery settings who have reviewed training materials)

[May 17th, 2021]

Who is eligible to undergo rapid antigen POCT?

Rapid antigen POCT should only be used on asymptomatic individuals who have passed standard COVID-19 screening procedures. 

Rapid antigen POCT should not be used for symptomatic individuals, or individuals who have had close contact with known positive cases.  Laboratory-based COVID-19 PCR testing is required in these circumstances. Even if an individual suspects that they have the flu or allergies, if their symptoms are consistent with COVID-19 symptoms, a lab-based PCR test is more appropriate in this situation. 

Individuals who have received a COVID-19 vaccination, regardless of whether they have received 1 or 2 doses, can be screened using the rapid antigen test. In fact, vaccinated individuals should not be excluded from rapid antigen screening initiatives, as it is yet unknown whether they can transmit COVID-19 despite being vaccinated. 

Asymptomatic individuals previously infected with and recovered from COVID-19 should generally not undergo repeat testing, including rapid antigen POCT. This is due to the possibility of residual viral fragments causing a false positive test result. 

Rapid antigen tests should not be used in either a suspected or confirmed outbreak setting, unless under the direction and supervision of a local public health unit. 

Midwives can offer this screening test to clients and non-clients (e.g., client’s family members, support people, administrative staff in midwifery setting). 

[May 17th, 2021]

What types of rapid antigen POCTs are being offered in the Provincial Antigen Screening Program?

The Provincial Antigen Screening Program currently offers two tests:

Abbott and BD rapid antigen POCTs perform similarly by recognizing specific proteins from the COVID-19 virus to identify individuals who need further testing.  However, they have different considerations in terms of instrumentation and workflow. The key difference between the Abbott and BD rapid antigen POCT is how the test result is read:

  • The Abbott Panbio™ POCT is interpreted by looking at the test cartridge and assessing if a positive line is present to determine if the result is negative or positive.
  • The BD Veritor™ POCT requires less subjective interpretation but requires an analyzer machine to read the test cartridge and display whether the test is negative or positive. The MoH provides analyzer machines free of cost.

All rapid antigen tests can be performed using batch testing, which can help sites screen many individuals at once. 

Midwives should determine how they will be using rapid antigen POCTs (who will administer and receive test and in which setting[s]) and make requests for particular antigen test types accordingly. 

[May 17th, 2021]

How are rapid antigen specimens collected?

Midwives generally have two options for rapid antigen specimen collection:

  • combined swab of throat and both nares 
  • anterior nasal swab (both nares)

The two other specimen collection methods, nasopharyngeal (NP) swab and deep nasal swab, are considered controlled acts under the Midwifery Act 1991 and as such midwives may not administer these types of swabs under their own authority. Midwives who have a delegation arrangement to perform these swabs and who wish to offer these specimen collection methods can access more information here.

Considering that rapid antigen POCT is being offered to asymptomatic individuals with no known contact with positive COVID-19 cases, less invasive swabbing methods such as combined throat and nares and anterior nares - both which have acceptable sensitivity and specificity - may be more desirable. 

For more information about how to perform combined throat and nares and anterior nares swabs please see the following resources:

Combined throat and nares swabbing: 

Anterior nares swabbing:

[May 17th, 2021]

Can individuals self-swab?

Yes. Specimen collection for rapid antigen POCT can be done by self-swabbing if it is supervised by a trained individual.  

The provision of clear instructions for proper specimen collection is critical to the success of self-swabbing. Ontario Health recommends the deep nasal swabbing specimen collection method for self-swabbing, and provides a video tutorial (5 minutes) and a self-swabbing instruction sheet (PDF, 506 KB) regarding this method.  The Centre for Disease Control advises against nasopharyngeal and oropharyngeal (throat) specimens for self-swabbing; therefore, the combined throat and anterior nares swab is likely not an appropriate option for self-swabbing. 

Midwives may suggest anterior nares self-swabbing, a less invasive yet less sensitive method of specimen collection. Anterior nares swabbing instructions can be found here (PDF, 940 KB). 

Once the swab is collected, the trained supervising individual will process the specimen to yield a result. 

Individuals who are supervising self-swabbing must consult the self-swabbing training resources listed above and ensure they have the appropriate knowledge, skills, and judgment to provide adequate self-swabbing oversight, including PPE requirements, and how to safely dispose of biowaste.
 
Supervised self-swabbing minimizes healthcare worker exposure and conserves PPE. One trained professional could supervise multiple individuals collect their own self-swabs at one time. The Ministry of Health is not being prescriptive about how many self-swabbing individuals can be supervised at a time. Midwives can determine the best approach based on their implementation needs and workflow.

[May 17th, 2021]

How accurate is the rapid antigen test?

The rapid antigen POCT is a screening test for COVID-19. The diagnostic test for COVID-19 is the lab-based PCR test.

There is currently no direct data available on the accuracy of the two types of specimens that midwives are most likely to collect for rapid antigen POCT - combined throat and nares specimens and anterior nares specimens. In general, rapid antigen POCT has lower sensitivity and specificity than lab-based COVID-19 PCR testing. 

As per COVID-19 Provincial Testing Guidance on Rapid Antigen Tests, a positive antigen POCT should be considered a preliminary positive and should be followed up within 24 hours with a confirmatory laboratory-based PCR test. 

[May 17th, 2021]

How do I communicate rapid antigen POCT results to those being screened?

If the rapid antigen POCT result is negative:

  • Tell the individual that the result is negative, but that the result may be inaccurate. 
  • Reinforce the importance of adhering to COVID-19 infection prevention and control measures, such as appropriate distancing, use of PPE, and hand hygiene. 

If the rapid antigen POCT result is positive:

  • Tell the individual that the positive result is preliminary and that it may be inaccurate.
  • Advise the individual that they must undergo a confirmatory COVID-19 PCR test within 24 hours.
  • Tell the individual they must self-isolate and follow public health guidance until the result of the confirmatory, lab-based PCR test is known.

Report the preliminary positive rapid antigen test result to the individual’s local Public Health Unit as soon as possible.

[May 17th, 2021]

What are the reporting requirements in the case of a positive antigen POCT result?

A positive result on a rapid antigen POCT is considered a preliminary positive. The Health Protection and Promotion Act (HPPA) requires anyone performing a COVID-19 POCT to report the results to the local Public Health Unit in which the person receiving (not performing) the test resides. The individual tested is required to undergo a follow-up, confirmatory lab-based COVID-19 PCR test within 24 hours. 

In the instance that an employee (i.e., administrative staff person within a midwifery setting) who had a positive result on rapid antigen POCT through the program has also received a positive result through a confirmatory, lab-based PCR test and the infection was due to exposure at the workplace, in accordance with the Occupational Health and Safety Act 1990, the employer must give notice in writing within four days to:

Additionally, the employer must report any occupationally acquired illnesses to the Workplace Safety and Insurance Board within three days of receiving notification of the illness, in accordance with the Workplace Safety and Insurance Act 1997

Further information on what is required following a positive rapid antigen POCT can be found in COVID-19 Guidance: Considerations for Antigen Point-of-Care Testing.

[May 17th, 2021]

Can rapid antigen POCTs identify COVID-19 Variants of Concern?

It is believed that rapid antigen POCTs can detect COVID-19 caused by Variants of Concern, as they detect the nucleocapsid protein rather than the spike protein (where most variant mutations occur).  Rapid antigen test results, however, will not indicate whether an infection has been caused by a Variant of Concern. 

[May 17th, 2021]

How frequently can individuals be screened using the rapid antigen POCT?

Rapid antigen POCTs are ideally used for serial testing of asymptomatic individuals to facilitate early detection of COVID-19.  

Midwives are best able to determine the frequency at which they administer rapid antigen POCT in their own communities.  Some midwifery settings may consider regular screening of midwives and administrative staff.  

COVID-19 Guidance: Considerations for Antigen Point-of-Care Testing recommends the following testing frequency based on geographical prevalence of COVID-19:

  • For individuals in high-prevalence geographic areas (Yellow/Orange/Red/Grey zones), antigen POCT should be performed 2-3 times per week. 
  • For low prevalence geographic areas (Green zones), antigen POCT should be performed 1-2 times per week. 

[May 17th, 2021]

What are the Ministry of Health administrative requirements for those using rapid antigen POCTs?

There are two types of MoH administrative reporting requirements associated with POCTs in the province:

1. Legislative requirement to report positive COVID-19 rapid antigen POCT results to Public Health

2. Programmatic weekly reporting requirements to the MOH Health Data Collection Service

  • The MoH will be collecting data from participating sites to support the ongoing evaluation of the program and the value of rapid antigen POCTs as an effective and accurate screening tool for COVID-19.
  • Participating sites are asked to track the type and number of rapid antigen tests performed, as well as numbers of positive, negative, and invalid tests.
  • All data is reported and stored at the aggregate level; no identifiable tester data is collected.

Once accepted into the provincial screening program, midwives will be onboarded to the Health Data Collection Service and will be provided information and training (PDF, 2003 KB) on how to submit data. Data must be entered weekly by Friday at 11:59 pm EST. 

Further information on the reporting requirements and data collection associated with program participation are outlined in the Program Reporting Requirements section of Provincial Antigen Screening Program: Information Document (PDF, 354 KB). 

Ontario Health has developed COVID-19 Antigen Rapid Test Results Tracker (Excel, 77 KB) – a spreadsheet where tests performed can be tracked to facilitate weekly data reporting. 

Questions related specifically to data submission for the Provincial Antigen Screening Program can be emailed to AskHealthData@ontario.ca with the subject line ‘Antigen Testing Data Collection.’

[May 17th, 2021]

My midwifery setting is interested in offering rapid antigen POCT. What factors do we need to consider?

There are many benefits to being able to offer rapid antigen POCT, however, midwives should consider the numerous practical aspects regarding program implementation to determine their ability to offer this type of screening:

  • human resources
  • time
  • uptake
  • cost
  • space
  • equipment
  • development of policy/procedure/protocol

For more information on the practical considerations of screening program implementation, please see Midwifery Setting Considerations Regarding Implementation of COVID-19 Rapid Antigen Point-of-Care Testing (POCT) (PDF, 276 KB).

[May 17th, 2021]

How can I order rapid antigen testing kits? Do you have any tips to facilitate a smoother ordering process? 

Midwives can request participation and provision of POCT kits using these instructions (PDF, 652 KB). Refer closely to these instructions, including the screen shot examples, as they will provide the information you need to complete the order form. 

Here are some tips to facilitate a smooth ordering process for midwives:

  • Know the following information before you place an order:

  1. which kit type (Abbott Panbio™ or BD Veritor™) you would like based on your testing needs (you can order two different test types to meet the needs of different settings and populations)

  2. how many test kits you will require for one month (you can only order one month’s supply at a time)

  3. your current inventory (will only apply after placing your first order)

  4. how quickly you anticipate going through inventory (this question is asked on the order form)

  5. where you would like test kits to be shipped (if you would like to exercise the option of having them shipped outside of business hours, know contact information for person receiving delivery)

  • Orders should be placed 7-14 days before you require supply.

  • Non-emergency orders are filled Monday to Wednesday (if received Thursday to Sunday, they will be processed the following week).

  • Emergency orders can be placed at any time and will be filled within 24-48 hours.

  • When indicating the ordering organization, midwives can either select their midwifery practice group from the pre-populated pull-down menu or manually enter the name of their setting (e.g., “Six Nations Health Services Birthing Centre”). 

  • The same order form is used to order both Abbott Panbio™ and BD Veritor™ test kits. 

  • Abbott Panbio™ test kits come with either nasopharyngeal (NP) swabs or nasal swabs. Either swab kit may be distributed based on available inventory. When placing an order, there is no need to specify a particular type of swab unless NP swabs are preferred. BD Veritor™ test kits only come with nasal swabs. Both NP and nasal swabs provided in these two testing kits can be used for alternate specimen collection methods; ordering separate swabs is not necessary. 

  • Remember to order analyzer machines if you are using the BD Veritor™ test types as they are not included in the test kits.

  • You will receive a confirmation email with ticket number after placing your order. Keep this ticket number.

  • Expect to be contacted by an Ontario Health representative after placing your order, asking the following questions:

  1. Do you perform patient-facing services on a daily basis?

  2. Who do you intend to test? 

  3. How many people are you planning to test?

  4. What is the testing frequency? 

[May 17th, 2021]

Where can I access training materials and other helpful resources for the Provincial Antigen Screening Program?

Training materials:

Participation in training is not a mandatory requirement of this program but will help build confidence and competence for those performing testing and will assist your setting in understanding program logistics and implementation. 

Ontario Health offers a suite of written materials and pre-recorded training modules for Provincial Antigen Screening Program participants. Here you will find information on:

  • overview of Provincial Antigen Screening Program
  • best practices for point-of-care testing
  • collecting specimens
  • self-collection 
  • documenting and reporting results

Ontario Health’s Panbio™ COVID-19 Antigen Rapid Testing Onboarding Guide and BD Veritor™ COVID-19 Antigen Rapid Testing Onboarding Guide offer helpful information regarding the following:

  • onboarding process overview
  • clinical guidance
  • specimen collection tips
  • best practices for POCT 
  • site set-up, supplies, workflow suggestions
  • kit ordering considerations
  • information sheets for individuals being tested and for staff offering testing
  • recommended steps for implementing the screening program
  • Go Live Readiness Checklist 

Other helpful resources:

Provincial Antigen Screening Program: Information Document (PDF, 354 KB)

COVID-19 Guidance: Considerations for Antigen Point-of-Care Testing

COVID-19 Provincial Testing Guidance on Rapid Antigen Tests

Implementing a COVID-19 Rapid Antigen Screening Program

Ordering Rapid Antigen Test Kits through Ontario Health (PDF, 652 KB)

Biosafety Considerations (PDF, 924 KB)

Abbot Panbio™ website

BD Veritor™ website

[May 17th, 2021]

Who can I contact if I have questions about rapid antigen testing?

For general information about the Provincial Antigen Screening Program, please contact covid19testing@ontariohealth.ca.

Questions about ordering rapid antigen test kits can be sent to Meaghan.Boddy@ontariohealth.ca.

For information about rapid antigen training resources, please contact Sahara.Khan@ontariohealth.ca.

Questions related to data submission can be sent to AskHealthData@ontario.ca (with subject "Antigen Testing Data Collection").

[May 17th, 2021]

Self-Isolation and Physical Distancing

What are the recommendations on physical distancing?

Physical distancing means keeping our distance from one another and limiting activities outside the home. Clients and midwives can review Public Health Ontario's (PDF, 649 KB) guidance on physical distancing, or Toronto Public Health’s fact sheet (PDF, 387 KB) for helpful information on what to consider. 

[October 2, 2020]

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

According to the Government 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 some who has or is suspected to have COVID-19.
  • They have been told by public health that they may have been exposed and need to self-isolate.

Clients that meet this criteria may follow guidance from Public Health Ontario on how to properly self-isolate. 

[October 2, 2020]

 

Personal Protective Equipment

When should midwives use PPE when interacting with a client?

All healthcare 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 healthcare worker.

The AOM recommends the use of droplet/contact PPE for all clinical encounters as best practice, however, based on a PCRA, including consideration of the local context (e.g. in "hot spots"), some midwives may chose to wear N95s respirators in some settings.

The Province updated the COVID-19 Directive #5 in March to state that "if a regulated health professional determines, based on the [Point of Care Risk Assessment], and based on their professional and clinical judgement and proximity to the patient or resident, that an N95 respirator may be required in the delivery of care or services (including interactions), then the public hospital or long-term care home must provide that regulated health professional and other health care workers present for that patient or resident interaction with a fit-tested N95 respirator or approved equivalent or better protection. The public hospital or long-term care home will not deny access to a fit-tested N95 respirator or approved equivalent or better protection if determined by the PCRA."

If a midwife is working in a hospital with clients suspected, probable, or confirmed to have COVID-19 and, through the midwife's PCRA, it is determined that an N95 respirator is needed instead of a surgical/procedure mask, the hospital must provide a fit-tested N95 to the midwife to wear while interacting with the client in hospital.

Eye protection should also be considered for ALL clinical encounters (even with clients who have screened "negative") as an important part in reducing risk and breaking the cycle of transmission by limiting access to the conjunctiva.  Whether eye protection was worn or not, in addition to a surgical/procedure mask, can be the difference between what is considered a "high-risk exposure" (need to self-isolate, get tested, contacts are notified, etc.) and a "low-risk exposure" (self-monitoring) according to the provincial guidance on the management of cases and contacts.  In the interest of reducing transmission and with midwives' health and safety in mind, the AOM recommends that midwives use eye protection in all clinical encounters with close contact. 

[April 23rd 2021]

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

In the PCMCH's Maternal-Neonatal COVID-19 General Guideline, the use of droplet/contact precautions is recommended for all health-care providers at all births in Ontario. Suitable precautions may include the use of:

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

This recommendation aligns with PHO's guidance (PDF, 1.2 MB), updated as of January 29, 2021, that 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. 

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. 

PCMCH also recommends 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. 

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 15, 2021]

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

What does the update to CMOH Directive #2 mean for our MPG?

The Chief Medical Officer of Health has updated Directive #2 for health-care providers (regulated health professionals or persons who operate a group practice of regulated health professionals). This current directive acknowledges the realities and health-care strain of the 3rd wave and the variants of concern and orders all health-care providers to cease the provision of all non-urgent and emergent care.  

Directive #2 orders:

  • All non-emergent and non-urgent surgeries and procedures should be ceased.
  • Clinicians are in the best position to determine what are urgent and emergent surgeries and procedures in their specific health practice and should rely on evidence and guidance where available."
  • Clinicians should consider the following factors when deciding which procedures to postpone: proportionality, minimizing harm to patients, equity and reciprocity.

The very nature of midwifery care means that the majority of the procedures performed by midwives are of the emergent or urgent nature. However, midwives can examine how care is provided and determine if certain procedures can be delayed.

In the first wave, the cervical cancer screening program was suspended. Cancer Care Ontario has yet to announce whether this program will be suspended again. The AOM is monitoring the situation and will inform midwives of any program suspensions that could impact the provision of midwifery care in the province.

[April 22rd 2021]

What are the requirements for continuing to provide essential health services and to gradually re-start offering non-essential health services?

As per the MOH's Operational Requirements, midwives may begin the gradual restart of all non-essential services assuming the necessary precautions are met: 

Elimination

  • Consider which services to continue to offer remotely 
    • Implement a system for an initial virtual/telephone consultation to determine if an in-person visit is warranted
  • If in-person care is required, minimize the in-person time by dividing the visit into a virtual and in-person session
  • Create adaptive and flexible visitor policies that balances the need to mitigate risks to other midwives, clinical staff and clients with the mental, physical, and spiritual needs of clients. Consider a visitor policy that:
    • responds to the local COVID-19 situation
    • accounts for the visitor's role and client's circumstances
    • follows IPAC principles to minimize the risk of COVID-19 transmission

Engineering controls

  • Install barriers such as plexiglass, or other markers delineating 2 metres (for example, a line of tape on the ground and a sign that says to not come any closer) from the staff, at the reception desk to separate people
  • Minimize the need for clients to wait in the waiting room
    • Spread out appointment times, ask clients to wait in their car if able
    • Space seats in waiting area at least 2 meters apart
    • Continue to restrict access to books, toys etc.
  • Implement one-way doors or walkways, if possible
    • Add visual signage or markers to the floor to impose 2 meters of distance

Administrative controls

  • Continue with a system of active screening over the phone before appointments are schedules or upon entry to the clinic
    • Clients who screen positive should not come to the clinic
    • If screening occurs at the clinic, screeners should be behind a barrier to protect from contact/droplet spread. If a barrier is not available, screeners should remain 2 meters away and if unable should wear contact/droplet precautions
  • Promote good respiratory and hand hygiene
  • Implement regular cleaning and disinfection protocols
    • Clean and disinfect washroom facilities
    • Sanitize commonly touched surfaces (door handles, light switches, toiler handles, counters, equipment) twice a day and when visibly soiled
    • Clean and disinfect contact surfaces after every client visit

PPE

  • Only resume in-person visits with sufficient PPE 
  • Wear a surgical/procedure mask and provide a face covering to client and support people if physical distancing is not possible 
  • Source PPE through regular supply chains and/or through the Province's stockpile

[September 24th 2020]

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]

In the absence of hospital-grade disinfectants, is there anything else that midwives could be using to disinfect?

For disinfection of non-critical equipment in clinic rooms, cleaning followed by low-level hospital grade disinfectants with a drug identification number (DIN), is recommended. In light of COVID-19, Health Canada has taken interim measures so that products that may not fully meet labelling, licensing or packaging requirements are made available.

Please see Disinfectants and hand sanitizers accepted under COVID-19 interim measures for a full list of disinfectants accepted under interim measures.

In the absence of hospital grade disinfectants, regular household cleaner or soap and water can be used for cleaning, followed by a bleach/water dilution (1 part bleach: 9 parts water) in spray bottles as an alternative to available disinfectant.

[September 28th 2020]

How can I protect and disinfect my cell phone to prevent the spread of COVID-19?

Cell phones are frequently touched by hands and faces, and may easily be contaminated by droplets while speaking. Yet, for midwives they are critical pieces of equipment. Using the phone in client care settings and public spaces poses a much higher risk than only using it in your own space and performing hand hygiene.

To reduce how frequently the phone needs to be disinfected:

  • When in an environment that may be contaminated, perform hand hygiene before use to protect yourself and after use to protect clients.
  • Keep the phone out of the immediate care area, or keep it covered when not in use.
  • For temporary protection, use a plastic bag (the touch screen and buttons work while the phone is in the bag).
  • Reusable waterproof cases which can be disinfected can also be purchased.

To disinfect a phone:

  • Check the manufacturer’s web site for the latest recommendations. Some manufacturers, such as Apple, recently provided options for disinfection without voiding the warranty.
  • 70% isopropyl alcohol wipe or Clorox Disinfecting Wipes (containing quaternary ammonium compounds, not bleach) are recommended by some manufacturers. These products accelerate the  deterioration of the coating on touch screens less than bleach or hydrogen peroxide.
  • To the extent possible, follow manufacturer’s instructions for the chosen disinfectant, including wet time. This can be challenging, because the kill time for products ranges from 30 seconds for some wipes to 10 minutes for 70% alcohol.

[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 released the Maternal-Neonatal COVID-19 Pregnancy Care Guideline 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. 

 [November 25th, 2020]
 

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]

Can I still do a Pap test for my clients?

Ontario Health (Cancer Care Ontario) is now recommending health care providers gradually resume routine  cervical screening tests. For more guidance on resuming cervical cancer screening, and which clients to prioritize, please see Cancer Care Ontario’s Tip Sheet (PDF, 946 KM). 

[September 24, 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 Quick Reference Public Health Guidance on Testing and Clearance which provides detailed information on the different approaches to clearing clients.

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

[November 25th, 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

[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 November 9, 2020) 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) 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)". 

[April 23rd 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, 530 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 healthcare 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 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 is being 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. 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

[September 24, 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 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 updated on December 1st, 2020 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 October 22nd 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 18th 2020]

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 18th 2020]

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) was updated on October 22nd and now 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 there is no evidence that nitrous is an aerosol generating medical procedure (AGMP) and they support its use for labouring people.
  • 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?

Improving ventilation of indoor spaces may help to reduce the risk of aerosol transmission of COVID-19 for midwives and clients. This is particularly important in the home birth setting. Strategies to improve natural ventilation include:

  • Opening windows and doors to allow outdoor air to flow across a room, creating a cross breeze
  • Using portable air cleaning or filtration devices to filter indoor air particles
  •  Installing a window fan or pedestal fan in the window to filter the room air to the outside
  • Consider using a humidifier to maintain optimal humidity level

CAUTION: Midwives should not use portable or ceiling fans or single unit air conditioners without external ventilation to the outdoors as fans can blow infectious droplets and particles further from their source, which may contribute to some infections.

Ventilation is just one part an overall strategy to reduce the potential risk of COVID-19 transmission. Midwives can review the updated Home Birth during the COVID-19 Pandemic guidance document for additional strategies to maintain PPE and IPAC practices in the home setting during the COVID-19 pandemic.

[April 23, 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 now that colder Fall and Winter days approach. 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). 

[November 25th 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.

[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?

When COVID-19 entered our world, it was quickly clear that healthcare workers, including midwives, were at a significantly increased risk for mental illness and burnout.  We also know that the repercussions of COVID disproportionately impact women, IBPOC folks and others who play caregiving roles in their home life.   The psychological pressures associated with the pandemic for midwives are real.  Now that we are several months in, prioritizing your mental health and psychosocial well-being is more important than ever.  

“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 to consider.
 

Tips for Mental Wellness

  1. Ensure your physical needs are being met. In particular:
    • Eat good food and have nutrient dense snacks on hand for those times when you can't eat good food.
    • Sleepercise: sleep as much as you can when you can. 
  2. Move your body: stretch, dance, walk, run, jump up and down, take the stairs.
  3. Breathe: taking just 3 minutes when you are feeling overwhelmed to stop, be still, and breathe can have a positive impact on your mental wellbeing. The 4-7-8 breathing practice is one simple and rhythmic practice you can do anywhere, anytime:
    • Set a 3-minute timer
    • Breathe in for 4 seconds
    • Hold your breath for 7 seconds
    • Exhale over 8 seconds
    • Repeat
  4. Rest your mind: meditate, powernap, take a bath (without your cellphone).
  5. Acknowledge and normalize your psychological responses; it is okay to not be okay.
  6. 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 healthcare providers working during COVID-19 like this one.
  7. Connect with the people in your inner circle: your friends, family, spiritual or faith community.
  8. Continue to engage or re-engage in your spiritual practice, if you have one.
  9. 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. 

Mental Health and Wellness Resources Available to Midwives 

If adding some mental health first aid to your repertoire feels challening and/or still needs some nurturing, below we share some resources that are available to midwives. 

  1. The Ministry of Health and Ontario Health partnered with five hospitals to provide services for frontline health care workers. Individuals who meet the following criteria are eligible to self-refer for psychotherapy and psychiatric services:
    • You are a health care worker in Ontario;
    • You are impacted by stress related to COVID-19; and,
    • You require mental health and/or addictions support.
  2. BEACON provides personalized one-to-one digital therapy engagements with a registered therapist that is both private and secure.
  3. ECHO is a service offered by CAMH for both healthcare providers and health professions students who are responding to the pandemic.  Interested individuals can attend weekly virtual sessions via video-conferencing to share and learn about ways to build resilience and overall wellness.  ECHO meetings take place every Friday afternoon from 2:00-3:00pm EST.
  4. Canadian Psychological Association provides a listing of psychologists who have volunteered to provide psychological services to frontline healthcare workers. 
  5. 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:
    • 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
  6. Optima Global Health is the new employee assistance program offered to AOM midwife members and immediate family. They provide support on a variety of different work/life issues that may be impacting your mental well-being.  
  7. 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

[October 20th 2020]

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 healthcare 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]

Medication

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

There has been some debate regarding the use of Ibuprofen to treat suspected or confirmed COVID-19. 

After a review of national and international guidance and policies, as well as advice from specialists working across the UK, NICE has recommended that either paracetamol (acetaminophen) or ibuprofen may be used for symptom management. 

Health Canada has investigated and also concludes that there is no scientific evidence that links ibuprofen to worsened COVID-19 outcomes. However, the use of ibuprofen should be avoided in pregnancy > 30 weeks. 

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.

[September 10, 2020]
 

What medications are being used to treat COVID-19?

A number of antiviral, antibacterial, immunomodulatory and other medications have been investigated as potential treatments for COVID-19.  The British Columbia COVID-19 Therapeutics Committee has published recommendations on the use of various therapeutics for mildly ill, severely ill and critically ill people with COVID-19.

Clients may request these medications from their midwives, however they are not in the midwifery pharmacopeia. 

[September 30, 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 resusciation, PCMCH in their Maternal-Neonatal COVID-19 General Guideline, 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 healthcare 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.

Midwives can reassure their clients that the guidance, with regards to the routine recommended immunizations in pregnancy and for infants, has not changed during the pandemic. However, they may need to access vaccines from a different provider during this time.

[May 21st 2020]

Vaccination

Can pregnant people receive the COVID-19 vaccine?

As of April 23rd, 2021 Ontario announced that all pregnant individuals will be eligible to register for vaccination appointments under the highest risk health conditions in the Phase 2 prioritization guidance.

Pregnant individuals are eligible to receive their vaccine through Public Health Unit immunization clinics by booking an appointment through the provincial call centre at 1-888-999-6488.  Pregnant individuals who are in a PHU not using the provincial booking system will be directed to their local PHU to book an appointment.  
 
Pregnant individuals may choose to receive the vaccine at any time during their pregnancy. However, essential consideration should be made for those in the later stages of their pregnancy.
 
It is recommended, but not required, that pregnant individuals have discussion with their treating health care provider, or with a health care provider familiar with their pregnancy, that includes: 

  1. a review of the potential risks and benefits of the vaccine,
  2. a review of the risk of acquiring a COVID-19 infection during pregnancy (e.g., local epidemiology and risk of community acquisition of COVID-19 and workplace situation and risk of work-related acquisition of COVID-19)
  3. a review of the potential risks /consequences associated with a COVID-19 infection during pregnancy (e.g., individual risk for COVID-related morbidity, including consideration for comorbidities such as advanced maternal age, immunosuppressive conditions, preexisting diabetes, preexisting hypertension, obesity or chronic respiratory conditions)
  4. an acknowledgment of the limited evidence from clinical trials of COVID-19 vaccines in the pregnant population.  
  5. individual beliefs and personal risk assessment of the available data

Please see the COVID-19 Vaccination Recommendations for Special Populations for further details on COVID-19 vaccination for pregnant individuals.
 
Please Note:

  • A letter from a health care provider is not required for vaccination. 
  • The extended dose interval of 16 weeks remains appropriate for this population. 
  • The Province’s Prioritization Guidance and website will be updated in the coming days to reflect this change in prioritization for pregnant individuals, but implementation can begin immediately.

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

[May 13th 2021]

What information can I provide to help counsel clients about COVID-19 vaccination?

The Ministry of Health and the Provincial Council for Maternal and Child Health have released two documents to help clinicians counsel patients/clients about COVID-19 vaccination in pregnancy. One is aimed at clinicians and the other is a decision aid that can be used with clients.

These documents were produced prior to the Astra Zeneca vaccine being made available to Ontarians under the age of 55; as such, these documents provide guidance specific to the Pfizer and Moderna vaccines only.

Midwives can also direct clients to the COVID-19 Vaccination in Pregnancy webpage or share the "I am pregnant or breastfeeding. Should I get the COVID-19 Vaccine?" infographic to aid in discussions regarding vaccination. 

[April 23rd 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]