What effect does COVID-19 have on pregnant people?

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

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

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

[June 8th 2021] 

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

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

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

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

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

[June 8th 2021]

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) has stated 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. 

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. 

[March 18th 2021]

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

Recommendations for pregnant workers in the above question apply to those who work in health care. Additionally, health care workers should consider their duty to care and the workplace's duty to accommodate. 

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

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

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

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

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

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

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

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

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

[March 18th, 2020]

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

As of January 2022, current case definitions can be found here. 

[March 18th 2021]

When should midwives screen clients for COVID-19? 

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

• Active screening: clients should be screened at the point of entry - either the client entering the clinic or the midwife entering the home. 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. Screeners should be wearing a surgical mask (or better), eye protection, a gown, and gloves. Midwives should use the current symptom list to screen clients for COVID-19. The provincial self assessment tool has been updated to reflect this new symptom list. 
• Passive screening: signage should be posted and visible to visitors at the entrance of the clinic and at reception. Screening messaging can also be included in voicemail greeting messages and on MPG websites and social media.

When a client screens positive over the phone or before entering the clinic, 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 provide testing information or offer testing, if available. 

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 9 of the COVID-19 Guidance: Primary Care Providers in a Community Setting  (PDF, 206KB) for a full set of instructions on what to do when someone screens positive in the clinic setting.

Depending on the clinical context, the midwife might advise the client who has screened positive to go home and isolate (with a plan for follow up), to present to a Covid 19 Clinical Assessment Centre, or to go to the hospital.  If an in person assessment by the midwife is required, the client should be seen away from other clients and provided with a KN95/non-fit tested N95 mask or procedure mask.  

Midwives should don PPE for all clinical encounters, including a fitted N95 mask, eye protection, gown and gloves for any suspect or confirmed cases. 

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

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

[March 18th 2022] 

How should midwives document the results of COVID screening? 

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

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

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

Alternatively, midwives might design a table that can be placed in each client’s chart and used to document each time a covid screen is performed, such as:

We understand that this might be a new practice for some MPGs, and could cumbersome 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.

[March 18th 2022]

COVID-19 testing - what is currently within the midwifery scope of practice?

The COVID-19 tests midwives can perform and who midwives can test have changed over the course of the pandemic. The province has made emergency changes to regulations and laws to allow more health professionals to perform tests. Some of these have since been rescinded. 

Currently, midwives can do the following on their own authority (without delegation from a physician) if they have the required knowledge, skill, and judgement:

In any setting (clinics, homes, birthing centers or hospital), only for people who are pregnant, recently postpartum, or newborns:

• Order laboratory testing for COVID-19 (antigen, or PCR, or any other viral isolation test)
• Perform anterior nasal swabs and throat swabs (unlike nasopharyngeal or deep nasal swabs, these are NOT a controlled act)
•  Perform point-of-care tests to diagnose COVID-19 (e.g., rapid antigen tests)

Midwives cannot order or diagnose based on test results for people who are not pregnant, recently post-partum, or newborn unless the act is delegated to them by a regulated health care professional who has authority to provide this care in their scope of practice. If it is important to the care of the client or newborn for a family member to be tested, consider providing access to rapid antigen self-testing.

Under a provincial order under the Emergency Management and Civil Protections Act in effect until April 27, 2022,  all regulated health professionals were authorized to engage outside of their regular scope of practice in hospitals provided it was necessary for the health care professional to provide such services to respond to, prevent, or alleviate the effects of the COVID-19 outbreak. This order has been rescinded. Midwives who have been testing people who are not pregnant, in labour, postpartum, or a newborn or were performing nasal pharyngeal or deep nasal specimen collection under their own authority as requested by their hospitals can no longer do so. Care outside of scope can continue to be provided under delegation as described by the CMO on their Professional Practice Advice FAQ.   

[May 2nd 2022]

How do I test for COVID-19?

Midwives may use RAT or PCR testing, as described in the previous question. Regardless of the type of test, a single upper respiratory tract specimen for COVID-19 testing is sufficient for COVID-19 testing.  

If unable to get a medical directive to perform nasopharyngeal swab (NPS) testing, midwives can collect specimens for COVID-19 testing using the following swabs* (in the order of most to least 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 PPE, including an N95 mask when testing for COVID-19.

[March 18th 2022]

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 22nd 2022]

What PPE should I be wearing when providing midwifery care?  

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

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

Ontario's COVID-19 Guidance: Primary Care Provides in a Community Setting provides more information about PPE for the community setting. 

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

• N95 respirator (fit-tested, seal-checked). Since there is a shortage of some styles of respirators but good stock of other styles and sizes, it can be useful for midwives to be fit-tested for different styles of N95 respirators.
• Isolation gown
• Gloves
• Eye protection (goggles or face shield)
• Negative pressure room (if available)

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

[March 18th 2022] 

PPE shortages - what should midwives consider?

During the COVID-19 pandemic there have been periods of time when PPE access was severely reduced.  Thankfully, at this time in Ontario, midwives should be able to access PPE including N95 masks for use while providing clinical care.  Anyone having difficulty getting PPE should try to get access using the provincial Pandemic PPE Transitional Support (PPTS) program. To access this free PPE (including N95 respirators) as well as rapid antigen testing kits and COVID-19 swab kits, complete the appropriate request form on this page.  Midwives can also contact the AOM’s on call line for further support accessing PPE.

When working in the context of critical shortages, midwives have had to consider how to prolong the use of PPE, how to store used PPE for reuse, and when to use expired PPE.  The following questions provide information about working in a PPE shortage situation.  

[March 22nd 2022]

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

In response to shortages of masks and respirators, the Public Health Agency of Canada 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-don) 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.
6. Reprocess N95 respirators   .
   • Health Canada advises that reprocessed N95 respirators meeting safety and effectiveness requirements can be used when: when correctly fitted and used with other PPE such as gowns, face shields.
   • Medical device companies with extensive experience manufacturing the equipment used in reprocessing could be approved to safely and effectively reprocess N95s.
   • There are currently no effective measures for midwives to decontaminate n95s in the community.                                                                     

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

[March 22nd 2022]

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. 

 [March 22nd 2022]

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

In response to the 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. 

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.

[March 22nd 2022]

How can MPGs keep workers safe in the clinic setting?

The Ministry of Health outlines how to keep the clinic space as safe as possible for clients and workers (including midwives and staff) in their document, “COVID-19 Guidance: Primary Care Providers in a Community Setting.” Midwifery Practice Partners should consider the following for keeping clinic staff safe:

• All workers should actively screen themselves daily for COVID-19
• If anybody in the clinic turns out to have COVID-19 (symptoms or positive test), risk assessment should be conducted that considers potential exposures and implications. Call the AOM on Call line if you are wondering about calling clients to report possible exposure to the virus at your clinic. 
• Appropriate cleaning practices
  • routine cleaning for those who screen negative (includes wiping of anything that comes into contact with the client's skin between client visits)
  • Disinfection of all surfaces within 2 m of the client who screens positive, as well as any equipment that touched their skin 
• Common areas used by staff and midwives (e.g. kitchen, lunch room) should be arranged to ensure physical distancing and their use should be staggered to minimize the number of people at the same time, especially if unmasking. 
• Do your best to ensure appropriate ventilation and air filtration throughout the clinic.  Consider assessing the HVAC system, exhaust fans, opening windows, and/or using portable air filtration devices.  
• Minimize staff and midwives in the midwifery clinic at one time
  • Stagger staff start times, breaks and lunches as well as clinic days and appointments
  • Continue remote work or offer work hours outside of regular clinic hours, when possible
• Strive to keep 2 meters between all people
• 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
• Consider a vaccination policy or rapid test protocol for unvaccinated staff

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.

[March 22nd 2022]

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).

Additionally, consider the ventilation and filtration of the air in the clinic space. The HVAC system, exhaust fans, windows, and/or using portable air filtration devices can all play a role in improving the safety of the air. 

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.

[March 22nd 2022]

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.

[March 22nd 2022]

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

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

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

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

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

 [March 22nd 2022]
 

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 (reaffirmed February 15, 2021) 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. The PCMCH  recommends that while symptoms remain mild, it is preferable to defer routine prenatal care until the person is deemed clear through resolution of symptoms and a period of self-isolation and/or negative testing. 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 to allow access to care while implementing community mitigation efforts (SMFM, 2022) 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.  If an in-person visit is being conducted, ideally the provider assessment and any necessary investigations for both pregnant person and fetus can be performed in the same visit to avoid multiple exposures.

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. 

[April 19th 2022] 

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.  
  • Clients who had mild, moderate or no symptoms should continue antenatal care as usual.
  • Clients who experienced severe COVID-19 illness requiring hospitalization should have ongoing antenatal care 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, with further ultrasound monitoring considered on an individual basis. 
  • Clients who had severe infection should receive enhanced monitoring for hypertensive disorders of pregnancy.
• The SOGC (Canada) currently recommends:
  • Clients should be instructed to monitor for fetal movements (where appropriate based on gestational age) given unknown impacts of COVID-19 on the placenta
  • ​​​​​Clients should have 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. 

[April 14, 2022] 

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 screen positive. 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).

[March 22nd 2022]

My client missed 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 Non-Invasive Prenatal Testing (NIPT) which can be done at any time in the pregnancy 

Clients should be aware, however, that the performance of both of these alternative screening options will be impacted if they have not already had a dating ultrasound to confirm EDD and number of gestations, especially if the LMP is unknown.  

NIPT is now covered in Ontario for all twin pregnancies.  

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

[March 22nd 2022]

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

Local laboratories such as Lifelabs continue to operate and offer testing such as the Oral Glucose Challenge Test (OGCT).  Midwives who offer this test at their clinic may continue to do so, while promoting social distancing.  Adjustments to the process could 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, and then come to the clinic, with as minimal exercise as possible. 

[March 22nd 2022]

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)
     • 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.

[March 22nd 2022]

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

With the availability of PPE, midwives can continue to provide urgent clinical in-person care to clients with COVID-19.  For non-urgent care, midwives can delay or cancel in-person visits and replace them with a virtual visit.  The Ontario College of Family Physicians has released guidance to help provider determine when to conduct virtual vs in person care.  When determining when to resume in-person visits, midwives should refer to the COVID-19 Public Health Guidance on Testing and Clearance which provides detailed information on the different approaches to clearing clients.

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

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

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

These measures include:

• Keeping the client separate from other clients visiting the clinic (e.g., separate entrance or atypical time of appointment)
• 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

More information about providing care in the clinic during the pandemic can be found here.

[December 23rd, 2021]

How can midwives keep their clients safe when providing in person care at the midwifery clinic?

In order to keep the clinic as safe as possible for clients, practices should consider: 

• social distancing (PDF, 253 KB). 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
• move 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

Cleaning practices around the clinic

• routine cleaning for those who screen negative (includes wiping of anything that comes in contact with the client’s skin between client visits).  

Ventilation and air filtration 

• Do your best to ensure appropriate ventilation and air filtration throughout the clinic
• Consider assessing the HVAC system, exhaust fans, opening windows, and/or using portable air filtration devices

Contact tracing

• If anybody in the clinic turns out to have COVID-19 (symptoms or positive test), risk assessment should be conducted that considers potential exposures and implications.  Call the AOM on call line if you are wondering about calling clients to report possible exposure to the virus at your clinic.  

Midwives and staff who are sick or who have been exposed should not go to work in accordance with the latest provincial guidance.

For more information see MOH’s Covid-19 Guidance: Primary Care Providers in a Community Setting and the Ontario Family Physician’s document “Balancing In-Person and Virtual Care.”

[March 22nd 2022]

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

Ontario's Chief Medical Officer of Health announced that "Ontario will remove the mandatory masking requirement for most settings on March 21st, with the exception of select settings such as public transit, health care settings, long-term care homes and congregate care settings." Clients may be confused and question having to wear a mask for their midwifery care and midwives may need to explain how there are different measures for higher risk settings like health care.

The provincial COVID-19 Guidance: Primary Care Providers in a Community Setting (updated February 14 2022) states that “Patients and those accompanying them (if applicable), must wear a mask (unless they have a valid exemption) and perform hand hygiene while at the office/clinic.” They suggest a surgical mask, KN95 or non -fit tested N95 be provided free of charge by the clinic.

Most hospitals required masks in all areas for patients and support people, including in labour (as tolerated). The recommendation from the Provincial Council for Maternal and Child Health (PCMCH) (PDF, 399 KB) is that "pregnant patients who screen positive for signs/symptoms of COVID-19 should be treated as suspected for COVID-19, and should be given a surgical/procedure mask for all stages of labour (if tolerated), and that support people and care providers wear PPE for all labours. PCMCH has not recommended that clients who have not tested positive and have no symptoms wear masks in labour.

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)". 

[March 22nd 2022]

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.

Violence and harassment around mask refusal should not be tolerated. Under the Occupational Health and Safety Act, midwifery practice groups are required to have an Anti-Harassment and Anti-Violence policy; the AOM has produced a template (under "Midwives Safety"). 

In January 2022, the Criminal Code of Canada was amended to enhance protections for healthcare workers. The newly enacted section 423.2 makes it an offence to intimidate a health professional or a person who assists a health professional, in order to impede them in the performance of their duties. Midwives should not hesitate to contact hospital security or the police with any threat of violence

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

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

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

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

• Having a practice protocol/policy about masking that is shared with all clients on intake
• A client's decisions and understanding may change over time; a client that refuses to wear a mask at one appointment may choose to wear a mask in the future or wear one in certain circumstances (i.e. only when the midwives are within 2 metres distance)
• The safety of midwives (e.g. can the midwives wear full PPE during visits with the unmasked client, just as health-care providers caring for patients with COVID-19 do, including gowns and face shields/goggles?)
• The safety of other clients, virtual care and visit scheduling to avoid contact with other clients
• The occupational health and safety of clinic staff, avoiding or reducing contact
• Thinking ahead to birth plans: 
  • if the client is symptomatic for COVID-19 and refusing to mask, in areas of high community spread, or in other higher risk situations, consider the use of N95 respirator upon completion of a point-of-care risk assessment
  • consider creating a policy for rapid covid testing (RATs) at the beginning of a home birth for the client and support person(s)
• 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 and contact  AOM On Call. 

[March 22nd 2022]

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

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

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

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

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

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

When in-person clinical care is planned, 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

[March 22nd 2022]

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.  

[September 24, 2020]

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

In times of high transmission and low human resources, a reduced postpartum visit schedule can be adopted 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 as needed, weighing the risks and benefits of in person versus virtual care. If your client's clinical circumstances require in-person assessment (e.g., weight or feeding concerns, unwell infant, concerning jaundice or repeat jaundice screening, secondary PPH, postpartum infections, mental health concerns 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, 7252 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.

 [April 7th, 2022]
 

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. BORN has now been updated to reflect virtual care and offers "virtual home visit" and "virtual clinic appointment" options. 

Remember:

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

[March 22nd 2022]

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 Canada, International 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) reaffirmed on Feb 15th, 2021 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 case reports on COVID-19 coagulopathy in pregnancy, a critical review on this topic was published in August 2020 and can be found HERE. A second systematic review and critical analysis was published in February 2021. The findings of the systematic review suggest that haematological complications are more common in pregnant persons with COVID-19 (1.26%) than pregnant persons without COVID-19 (0.45%). 

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 LMWH 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.

[April 13th 2022]

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. 

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 guidance from the SOGC recommends cEFM should be considered for labouring people with COVID-19 under all circumstances, 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.

[April 13th 2022]

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).} 

Is nitrous oxide safe for use during the COVID-19 pandemic?

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 in case the labouring person using nitrous oxide turned out to have COVID-19. 

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 February 15 2022).
• Guidance from Ontario’s Provincial Council on Maternal and Child Health (PCMCH) (PDF, 399 KB) was updated in July 2021 and states that there is a lack of comprehensive and definitive evidence on the risk of nitrous oxide use and COVID-19. PCMCH suggests that a biomedical filter should be applied along with adequate sanitization of equipment if nitrous oxide is used during labour and delivery.  

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

• Whether in home with a clinic supplied nitrous kit or in hospital with a hospital set up, midwives should make sure they have the appropriate equipment 
• 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.
• There should be a scavenging system in place and the client should be using it appropriately (e.g., exhaling into the nitrous equipment and the scavenging system)
• Discontinue if nitrous use is inducing coughing or vomiting.
• Midwives should wear PPE including a mask when caring for a client, including when a client is using nitrous. 
• Increase ventilation of the space (consider opening windows, increasing the HVAC air flow or using a portable air filter)
• For a labouring person either choosing to wear or requiring a mask during labour, use of nitrous is not feasible.

 [March 22nd 2022]

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
• Discuss keeping distance between the midwife providing care and anyone in the home.

[March 22nd 2022]

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

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

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

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

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

[March 22nd 2022]

Should clients consider a home birth during a pandemic?

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

The guide includes:

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

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

[April 16, 2021]

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.

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?

Hydrotherapy for pain relief may be appropriate for a labouring client with COVID-19 infection or exposure, as long as there is sufficient PPE for the midwife to obtain a new set if the PPE being worn gets wet.  

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

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

[March 22nd 2022]

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

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

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

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

Mental Health and Wellness Resources Available to Midwives 

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

[March 22nd 2022]

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

Working in a pandemic over multiple years has been hard for everyone.  Midwives and health care works likely feel less resourced than usual, and this environment can contribute to conflict, stress and burnout.  As best they can, 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.
• Consider caseload plans – some midwives may prefer to reduce caseload during this time, to provide themselves with more time off or to provide a buffer in case a midwife becomes unexpectedly unable to work.
• Facilitate access to and ensure staff are aware of resources to support mental health such as the 10 Percent Happier Meditation App (free for 6 months for health-care providers), and the employee assistance program offered to AOM midwife members.

[March 23rd 2022]

What are some resources that I can provide to my clients who are seeking mental health support?

Midwives may wish to provide the following free resources to clients who are seeking mental health support:

• Wellness Together: A mental health and substance use support website created by the Canadian government, Homewood Health, Kids Help Phone and Stepped Care Solutions. Once an individual makes a profile and completes a self-assessment, they gain access to numerous resources including individual counselling, peer support, and comprehensive courses on topics such as resilience, stress and anxiety. 
• Bounce Back Ontario: A skill-building program managed by the Canadian Mental Health Association (CMHA) for people over age 15 experiencing mild to moderate anxiety or depression.  Includes telephone coaching, skill-building workshops and online videos. 
• Connex Ontario: A connection service funded by the Province of Ontario with a focus on mental health, addiction, and problem gambling.  This site does not provide counselling but maintains up to date information about availability of services across the province.
• Addiction Treatment Helplines: A list of provincial helplines for people struggling with addictions, maintained by the Canadian Centre on Substance Use and Addiction.  
• National Eating Disorder Information Centre: Website has information and resources and provides referrals and support for people struggling with eating disorders. 
• Trans Lifeline: Run by and for trans people, provides peer support including emotional and financial support to individuals in Canada and the USA.  

[March 23rd 2022]

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

In addition to the resources listed in the previous question, there are some specific services available for Indigenous people.  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. 

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.

Some of them,  such as Hope for Wellness, offer services in Ojibwe, Cree and Inuktitut.

Current resources include: 

• Hope for Wellness: Offers mental health counselling and immediate crisis intervention for all Indigenous people across Canada by phone or online chat.  Services offered in English, French, Ojibwe, Cree and Inuktitut.    
• Talk4Healing: Provides helpline support and resources for Indigenous women, by Indigenous women, across Ontario, in 14 languages. 
• NIHB Mental Health Services (see eligibility criteria): 22 hours of counselling per year offered by Psychologists, Social Workers, Psychiatric nurses or other regulated mental health providers covered under the Non-Insured Health Benefits for First Nations and Inuit (NIHB). Contact your regional office for more information.

If you are 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.

[March 23rd 2022]

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

There is no evidence of viral transmission through human milk therefore the current guidance from the Canadian Paediatric Society, World 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

[March 23rd 2022]

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. 

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.

[April 4th 2022]

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.

[March 23rd 2022]

Can I still refer my clients to outpatient bilirubin clinics?

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

[March 23rd 2022]

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

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

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

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

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

[March 23rd 2022]

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

The Better Outcomes Registry Network (BORN) Ontario has just released a fourth descriptive report on COVID-19 vaccination during pregnancy with data from Dec 14, 2020 to March 31, 2022. 

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

• among people who were pregnant in March 2022, 81.3% had received one or more doses before or during pregnancy
• BORN data has been used in a recent study that found vaccinated individuals had no increased risk of postpartum hemorrhage, chorioamnionitis or cesarean delivery, and their babies did not have higher rates of admission to neonatal intensive care unit or low newborn 5-minute Apgar score compared with those who were not vaccinated during pregnancy. There is an infographic summarizing these findings here.

Another study using BORN data from Fell et al. found no evidence of increased risk of preterm birth before 37 weeks, very preterm birth (<32 weeks), SGA at birth (<10th percentile) or stillbirth following COVID-19 vaccination in pregnancy. There is an infographic summarizing these findings here. 

The SOGC recommends all pregnant people get vaccinated, regardless of trimester or chest/breastfeeding status in their Statement on COVID-19 vaccination in pregnancy.    

People who receive the COVID-19 vaccine during pregnancy may experience the same side effects as non-pregnant people. The most common side effects include plain at injection site, fatigue, headache and muscle ache. A literature review from Badell et al. published in BMJ found that generally reactions to COVID-19 vaccination in pregnancy are mild or moderate and resolve within one to two days.

The Provincial Council for Maternal and Child Health (PCMCH) has created this resource to provide information and help decision-making for pregnant people about the COVID-19 vaccine.

[September 9th 2022]

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

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

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

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

[March 23rd 2022]

Is vaccination mandatory for health care workers?

Midwives who have hospital privileges or who do any work in hospitals will be required to comply with the COVID-19 vaccination policies of their hospitals. 
Midwives are advised to check the requirements of each hospital where they work. Hospitals can add requirements and will determine the details of implementation. For example, hospitals can require vaccination or regular rapid testing. Hospitals’ policies will determine where and when the testing will be done and if proof of off-site testing will be accepted.

[March 23rd 2022]

Do midwifery practice groups need a vaccination policy?

There is no requirement for midwifery practices to have a vaccination policy. Practices should consider the advantages of adopting a vaccination policy or protocol to ensure compliance with the hospital policies and to keep all workers and clients at the practice safe.

[March 23rd 2022]