COVID-19 Clinical FAQ

COVID-19

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

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

COVID-19 and Different Populations

What effect does COVID-19 have on pregnant people?

There is no evidence that pregnant people are at increased risk of becoming infected with COVID-19 than the general population. (RCOG 2020; RANZCOG 2020) If infected, the large majority of pregnant people will experience only mild or moderate symptoms and most will recover without the need for hospital admission. The SOGC suggests that outcomes may be correlated with degree of maternal illness.

A large meta-analysis of 86 studies including 2567 pregnancies described the outcomes of COVID-19 in pregnancy for the pregnant/birthing person. For the large majority of pregnant individuals, outcomes were good; admission to ICU occurred in approximately 7% of all pregnant individuals, intubation in 3.4%, and death occurred in just 0.9% of cases. Most deaths occurred in pregnant individuals with co-morbid conditions (Khalil et al., 2020

An emerging but still yet small body of evidence suggests that the risk of requiring ICU admission may be higher among pregnant individuals with COVID-19 compared to a non-pregnant population of similar age. A study of 427 pregnant individuals admitted to hospital with coronavirus in the UK found that about 1 in 10 required intensive care. (Knight, 2020) A second study in Sweden reported the incidence of ICU admission as 14 per 100,000 pregnant/postpartum individuals with COVID-19 compared to 2.5 per 100,000 non-pregnant individuals with COVID-19. (Collin, 2020)  Midwives should note that despite this emerging trend, ICU admission remains very rare and outcomes for pregnant and birthing people are generally good. Normal pregnancy alone, is not a risk factor for poor prognosis (SOGC, 2020)

International experience of COVID-19 in pregnancy has shown that individuals over the age of 35 and those with pre-existing medical problems, may be more at risk of becoming unwell and requiring admission to hospital.   One study comparing pregnant people in the UK, Sweden and the US confirmed that pre-existing lung disease, heart disease and diabetes were risk factors that contribute to the development of more severe COVID-19 related disease during pregnancy. This is consistent with evidence from the general population. (Molteni, 2020)

[September 1st 2020}

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

There is currently no evidence to suggest that COVID-19 causes problems with a baby’s development or causes miscarriage. (RCOG 2020; RANZCOG 2020)

A large meta-analysis of 86 studies including 2567 pregnancies described the outcomes of COVID-19 in pregnancy for the fetus/neonate.  (Khalil et al., 2020) Preterm birth, primarily iatrogenic was common, occurring in about 20% of pregnant individuals with COVID-19.  Perinatal deaths were very rare occurring in less than 1% of cases, and this is substantially lower than the current perinatal death rate in Canada (6.1%). (COVID-19 Scientific Advisory Group, 2020)

Results from a recent study of 427 pregnant people with coronavirus in the UK found similar rates of NICU admission (about 1 in 10) among newborns born at term (37 weeks or later) to people who had tested positive for COVID-19 as compared to pregnant people without the virus. (Knight, 2020)

Vertical transmission remains rare although emerging evidence suggests that transmission from a pregnant person to the baby during pregnancy or birth may be possible. In all reported cases of newborn babies developing coronavirus soon after the birth, the babies were well. (RCOG 2020; RANZCOG 2020)

[September 1st 2020}

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

Pre-existing medical conditions
Based on a review of the available evidence, the CDC has identified people who are at increased risk of severe illness from COVID-19 as those with: 

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

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

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

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

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

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

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

When reviewing the evidence it is important to remember that some of this data comes from settings with very different health systems from Ontario and this may affect COVID-19 outcomes. 

[September 2, 2020]

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

[September 2, 2020]
 

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

What effect does COVID-19 have on pregnant people?

There is no evidence that pregnant people are at increased risk of becoming infected with COVID-19 than the general population. (RCOG 2020; RANZCOG 2020) If infected, the large majority of pregnant people will experience only mild or moderate symptoms and most will recover without the need for hospital admission. The SOGC suggests that outcomes may be correlated with degree of maternal illness.

A large meta-analysis of 86 studies including 2567 pregnancies described the outcomes of COVID-19 in pregnancy for the pregnant/birthing person. For the large majority of pregnant individuals, outcomes were good; admission to ICU occurred in approximately 7% of all pregnant individuals, intubation in 3.4%, and death occurred in just 0.9% of cases. Most deaths occurred in pregnant individuals with co-morbid conditions (Khalil et al., 2020

An emerging but still yet small body of evidence suggests that the risk of requiring ICU admission may be higher among pregnant individuals with COVID-19 compared to a non-pregnant population of similar age. A study of 427 pregnant individuals admitted to hospital with coronavirus in the UK found that about 1 in 10 required intensive care. (Knight, 2020) A second study in Sweden reported the incidence of ICU admission as 14 per 100,000 pregnant/postpartum individuals with COVID-19 compared to 2.5 per 100,000 non-pregnant individuals with COVID-19. (Collin, 2020)  Midwives should note that despite this emerging trend, ICU admission remains very rare and outcomes for pregnant and birthing people are generally good. Normal pregnancy alone, is not a risk factor for poor prognosis (SOGC, 2020)

International experience of COVID-19 in pregnancy has shown that individuals over the age of 35 and those with pre-existing medical problems, may be more at risk of becoming unwell and requiring admission to hospital.   One study comparing pregnant people in the UK, Sweden and the US confirmed that pre-existing lung disease, heart disease and diabetes were risk factors that contribute to the development of more severe COVID-19 related disease during pregnancy. This is consistent with evidence from the general population. (Molteni, 2020)

[September 1st 2020}

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

There is currently no evidence to suggest that COVID-19 causes problems with a baby’s development or causes miscarriage. (RCOG 2020; RANZCOG 2020)

A large meta-analysis of 86 studies including 2567 pregnancies described the outcomes of COVID-19 in pregnancy for the fetus/neonate.  (Khalil et al., 2020) Preterm birth, primarily iatrogenic was common, occurring in about 20% of pregnant individuals with COVID-19.  Perinatal deaths were very rare occurring in less than 1% of cases, and this is substantially lower than the current perinatal death rate in Canada (6.1%). (COVID-19 Scientific Advisory Group, 2020)

Results from a recent study of 427 pregnant people with coronavirus in the UK found similar rates of NICU admission (about 1 in 10) among newborns born at term (37 weeks or later) to people who had tested positive for COVID-19 as compared to pregnant people without the virus. (Knight, 2020)

Vertical transmission remains rare although emerging evidence suggests that transmission from a pregnant person to the baby during pregnancy or birth may be possible. In all reported cases of newborn babies developing coronavirus soon after the birth, the babies were well. (RCOG 2020; RANZCOG 2020)

[September 1st 2020}

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

Current guidance for pregnant workers is varied around the world.

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

  •  Local epidemiology
  • Work-related risk of infection (e.g., type of work, exposure, access to PPE, etc.)
  •  Individual risk for COVID-19 related morbidity (e.g., health history and current status including relevant comorbidities) 

In situations where work-related exposure is substantive 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.  [June 16, 2020]

RANZCOG (Australia and New Zealand) recommends that, where possible, pregnant health care workers be allocated to patients and duties that have reduced exposure to patients with confirmed or suspected COVID-19. Consideration should also be given to reallocation to lower-risk duties, working from home, or leave of absence.  RANZCOG states that this advice can be extrapolated to other professions with a relatively high risk of exposure such as teachers or child-care workers. All personnel are advised to observe strict hygiene protocols and have full access to PPE. [March 25th 2020]

The RCOG (UK) generally recommends that pregnant workers who can work from home should continue to do so. Pregnant workers who are unable to work from home should perform an individual risk assessment with their employer to modify the working environment to limit contact with suspected or confirmed individuals with COVID-19 to minimise the risk of infection as far as possible. [August 10th 2020]

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

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

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

[September 1st 2020]

COVID-19 and Health-Care Workers

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

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

Though there is no direct evidence on social distancing at home of asymptomatic healthcare workers during COVID-19, the review notes that current evidence supports: hand hygiene, face masks (both at home and at work), adequate PPE and minimizing patient contacts to reduce the risk of transmission.  

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

[May 13th 2020]

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

What effect does COVID-19 have on pregnant people?

There is no evidence that pregnant people are at increased risk of becoming infected with COVID-19 than the general population. (RCOG 2020; RANZCOG 2020) If infected, the large majority of pregnant people will experience only mild or moderate symptoms and most will recover without the need for hospital admission. The SOGC suggests that outcomes may be correlated with degree of maternal illness.

A large meta-analysis of 86 studies including 2567 pregnancies described the outcomes of COVID-19 in pregnancy for the pregnant/birthing person. For the large majority of pregnant individuals, outcomes were good; admission to ICU occurred in approximately 7% of all pregnant individuals, intubation in 3.4%, and death occurred in just 0.9% of cases. Most deaths occurred in pregnant individuals with co-morbid conditions (Khalil et al., 2020

An emerging but still yet small body of evidence suggests that the risk of requiring ICU admission may be higher among pregnant individuals with COVID-19 compared to a non-pregnant population of similar age. A study of 427 pregnant individuals admitted to hospital with coronavirus in the UK found that about 1 in 10 required intensive care. (Knight, 2020) A second study in Sweden reported the incidence of ICU admission as 14 per 100,000 pregnant/postpartum individuals with COVID-19 compared to 2.5 per 100,000 non-pregnant individuals with COVID-19. (Collin, 2020)  Midwives should note that despite this emerging trend, ICU admission remains very rare and outcomes for pregnant and birthing people are generally good. Normal pregnancy alone, is not a risk factor for poor prognosis (SOGC, 2020)

International experience of COVID-19 in pregnancy has shown that individuals over the age of 35 and those with pre-existing medical problems, may be more at risk of becoming unwell and requiring admission to hospital.   One study comparing pregnant people in the UK, Sweden and the US confirmed that pre-existing lung disease, heart disease and diabetes were risk factors that contribute to the development of more severe COVID-19 related disease during pregnancy. This is consistent with evidence from the general population. (Molteni, 2020)

[September 1st 2020]

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

There is currently no evidence to suggest that COVID-19 causes problems with a baby’s development or causes miscarriage. (RCOG 2020; RANZCOG 2020)

A large meta-analysis of 86 studies including 2567 pregnancies described the outcomes of COVID-19 in pregnancy for the fetus/neonate.  (Khalil et al., 2020) Preterm birth, primarily iatrogenic was common, occurring in about 20% of pregnant individuals with COVID-19.  Perinatal deaths were very rare occurring in less than 1% of cases, and this is substantially lower than the current perinatal death rate in Canada (6.1%). (COVID-19 Scientific Advisory Group, 2020)

Results from a recent study of 427 pregnant people with coronavirus in the UK found similar rates of NICU admission (about 1 in 10) among newborns born at term (37 weeks or later) to people who had tested positive for COVID-19 as compared to pregnant people without the virus. (Knight, 2020)

Vertical transmission remains rare although emerging evidence suggests that transmission from a pregnant person to the baby during pregnancy or birth may be possible. In all reported cases of newborn babies developing coronavirus soon after the birth, the babies were well. (RCOG 2020; RANZCOG 2020)

[September 1st 2020]

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

Current guidance for pregnant health care workers is varied.

The SOGC states that pregnant healthcare workers can continue to work during the pandemic. They recommend that PPE should be used in situations where a worker may be exposed to a person with suspected or confirmed COVID-19; no additional PPE measures are required for pregnant healthcare workers. Where possible, avoiding unnecessary exposure to those with suspected or confirmed COVID-19 should be considered. [June 16, 2020]

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

RANZCOG recommends that, where possible, pregnant health care workers be allocated to patients and duties that have reduced exposure to patients with confirmed or suspected COVID-19. All personnel are advised to observe strict hygiene protocols and have full access to PPE. [March 25th 2020]

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

CDC guidance for pregnant heath care workers suggests that pregnant health care workers follow general risk assessment and infection control guidelines for health care providers. [March 16th 2020]

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

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

Duty to care and duty to accommodate for pregnant healthcare workers

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

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

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

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

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

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

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

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

[September 1st 2020]

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

The Ministry of Health's updated COVID-19 quick reference guidance on testing and clearance (PDF, 683 KB) replaces the previous guidance from June 25th.

This new update recommends that:

  • Health care workers (HCWs) should follow isolation and clearance with a non-test–based approach, unless they have required hospitalization during the course of their illness, in which case a test-based approach may be used at the discretion of the hospital. Some HCWs may be directed to have test-based clearance by their employer/Occupational Health and Safety.
  • Symptomatic HCWs awaiting testing results must be off work.
  • Asymptomatic HCWs awaiting testing results may continue to work using the appropriate precautions recommended by the facility, which will depend on the reason for testing (i.e. asymptomatic HCW is not on self-isolation following a high-risk exposure).

Return to Work Instructions for Midwives[August 10th 2020]

A family member has had close contact with an infected person and is awaiting test results, can I continue to work as a midwife during this time?

As Ontario continues to re-open and the start of school begins, there may be increased instances where family members are deemed at high-risk of COVID-19 exposure. If a family member has been advised to isolate or has been recommended for testing, you, as a midwife can continue to work as long as you remain symptom free with appropriate PPE as usual.

  • If your family member's test returns positive, you should be tested. While awaiting your test results:
    • If symptomatic, you must be off work
    • If asymptomatic, you may continue to work using the appropriate PPE precaution recommended by the facility
  • If you develop symptoms at the time of testing and receive a positive test:
    • You may return to work no sooner than 72 hours after symptom resolution, however, you must return to work under work self-isolation1 for 14 days from your symptom onset because you had contact with a confirmed case (e.g., your family member)
  • If you develop symptoms at the time of testing and receive a negative test:
    • You may return to work 24 hours after symptom resolution, however, you must return to work under work self-isolation1 for 14 days from symptom onset because you had contact with a confirmed case (e.g., your family member)

Work self-isolation is not recommended for any workers in non-health care settings as it can be difficult to ensure best practices in infection prevention and control are consistently and appropriately applied. 

For more information on the recommendations for health-care workers returning to work, review COVID-19 Quick Reference Public Health Guidance on Testing and Clearance

 

Footnotes

1. Work self-isolation means that while at work, the midwife should use droplet/contact precautions, adhere to universal masking recommendations, maintain physical distancing from all others except when providing direct care, and perform meticulous hand hygiene and surface disinfection to prevent possible transmission. 

[August 31, 2020]

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

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

[April 6th, 2020]

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

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

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

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

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

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

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

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

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

[March 31st 2020]

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

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

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

[May 6th 2020]

COVID-19 Testing and Transmission

What are the symptoms of COVID-19?

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

The MOH updated their COVID-19 reference document for symptoms (PDF, 50 KB) on August 6, 2020. According to the Ministry of Health, the most common COVID-19 symptoms include:

  • fever (temperature of 37.8°C or greater)
  • new or worsening cough
  • shortness of breath (dyspnea)

Other symptoms of COVID-19 can include:

  • sore throat
  • difficulty swallowing
  • new olfactory or taste disorder(s)
  • nausea/vomiting, diarrhea, abdominal pain
  • runny nose, or nasal congestion – in absence of underlying reason for these symptoms such as seasonal allergies, post nasal drip, etc.

Other clinical signs of COVID-19 can include:

  • clinical or radiological evidence of pneumonia.

The Reference Document for Symptoms (version 6.0) includes additional information about atypical symptoms/ signs of COVID-19 in children, older person, and people living with a developmental disability. It provides a more detailed section on multisystem inflammatory syndrome (MIS-C) in children. 

[August 12th 2020]

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

As of August 6th 2020, the Ontario case definitions for COVID-19 (PDF, 117 KB) are: 

Confirmed cases are:

  1. Individuals with laboratory confirmation of COVID-19 infection using a validated assay, consisting of positive nucleic acid amplification test (NAAT; e.g. real-time PCR or nucleic acid sequencing) on at least one specific genome target. Laboratory confirmation is performed at reference laboratories (e.g., The National Microbiology Laboratory or Public Health Ontario Laboratory) or non-reference laboratories (e.g., hospital or community laboratories).1 
  2. A person with a positive detection of serum/plasma immunoglobulin G (IgG) antibodies to SARS-CoV2 from a laboratory in Ontario that is licensed to conduct serology testing for clinical purposes.

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

  1. Individuals (who have not had a laboratory test) with symptoms compatible with COVID-19 AND
    • Traveled to an impacted area, including inside of Canada in the 14 days prior to symptom onset or
    • Close contact* with a confirmed case of COVID-19 or
    • Lived in or worked in a facility known to be experiencing an outbreak of COVID-19 (e.g., long-term care, prison)
  2. A person with symptoms compatible with COVID-19 AND In whom laboratory diagnosis of COVID-19 is inconclusive2,3

[August 12th 2020]

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

 

Footnotes

1. Some hospital and community laboratories have implemented COVID-19 testing in-house and report final positive results, which is sufficient for case confirmation. Other hospital and community laboratories will report positives as preliminary positive during the early phases of implementation and will require confirmatory testing at a reference laboratory (e.g. Public Health Ontario Laboratory or the National Microbiology Laboratory).
2. Inconclusive is defined as an indeterminate on a single or multiple real-time PCR target (and no positives) without sequencing confirmation, or a positive test with an assay that has limited performance data available.
3. An indeterminate result on a real-time PCR assay is defined as a late amplification signal in a real-time PCR reaction at a predetermined high cycle threshold value range (e.g. Ct >38). This may be due to low viral target quantity in the clinical specimen approaching the limit of detection of the assay, or alternatively may represent nonspecific reactivity (false signal) in the specimen. When clinically relevant, indeterminate samples should be investigated further by testing for an alternate gene target using a validated real-time PCR or nucleic acid sequencing at the community, hospital or reference laboratory that is equally or more sensitive than the initial assay or method used.

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

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

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

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

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

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

Pregnant clients and newborns should be tested if they exhibit any COVID-19 symptoms (see here (PDF, 88 KB) for an up-to-date list of symptoms)

Newborns should be tested for COVID-19 within 24 hours of birth if their birthing parent had suspected or confirmed COVID-19 at time of delivery, regardless of symptoms. 

Midwives should use their clinical judgement to determine whether to test a birthing parent in the postpartum period. The case definition and symptoms list can help to inform this decision. 

At this point in time, all specimens that are submitted for testing will be accepted. 

For more information about testing, please see our midwives ordering testing tip sheet for COVID-19 (PDF, 308 KB).

[August 31st, 2020]

When should I screen my clients for COVID-19?

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

  • Active screening: clients should be screened over the phone before their appointment and then again when entering the clinic or before the midwife goes into a client’s home for a home visit. Midwives can use this Ministry of Health screening guidance document (PDF, 96 KB) (which contains a series of screening questions) when screening their clients. Those conducting in-person screening should remain behind a barrier (such as a plexiglass barrier) or at least 2 metres away from the client as a precaution from droplet or contact spread.
  • Passive screening: signage should be posted and visible to visitors at the entrance of the clinic and at reception. Template signage for midwifery clinics is available in English (PDF, 138 KB) and French (PDF, 140 KB). Screening messaging can also be included in voicemail greeting messages and on MPG websites.

When a client screens positive:

Testing guidance may be found in our resource, Midwives ordering testing for COVID-19 (PDF, 308 KB), as well as through the Public Health Ontario and Ministry of Health websites.

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

[August 31st, 2020]

How do I test for COVID-19?

According to Public Health Ontario, midwives are only required to submit a single upper respiratory tract specimen for COVID-19 testing. This specimen can be collected through either a nasopharyngeal swab OR a viral throat swab. However, PHO states that a nasopharyngeal swab is the preferred specimen. Midwives should don droplet and contact precautions when testing for COVID-19.

For more information about testing, please see our tip sheet on midwives ordering testing for COVID-19 (PDF, 308 KB). 

[August 31st, 2020]

How accurate are COVID-19 tests?

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

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

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

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

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


The Ministry of Health [July 29, 2020] [PDF, 270 KB] recommends that for those who are symptomatic:

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

For those who are asymptomatic:

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

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


[September 10, 2020]

 

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

Asymptomatic infection occurs when:

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

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

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

[August 31st 2020]

Asymptomatic Transmission

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

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

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

[August 31st 2020]

Proportion of Asymptomatic Cases

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

[August 31st 2020]

Asymptomatic Pregnant People

Estimates of asymptomatic rates in pregnant people differ across geographic region and are likely impacted be regional rates of infection. An early Chinese study of 13 pregnant people with confirmed COVID-19, reported that one pregnant person was asymptomatic (7.6%). 

Where universal screening of pregnant people has been introduced, studies show the majority of those who test positive for COVID-19 are asymptomatic. In a study in New York, 215 pregnant people were tested for COVID-19. Of the 215, 33 tested positive (15.3%), four were symptomatic (12%) and 29 were asymptomatic (88%). In a study in London, UK, 129 pregnant people admitted to the hospital were universally screened for COVID-19; 9 (7%) tested positive and of these, 8 (89%) were asymptomatic. 

[May 11th 2020]

Guidance for Midwives

It is important to note that the majority of this research has not yet been peer-reviewed, is conducted in countries and contexts that differ significantly from Ontario, and is limited in sample size. In general, case report data cannot be used to make generalized assumptions about the likelihood of midwives encountering such cases in amongst the Ontario population.

Although the estimated proportion of asymptomatic cases remains very low, midwives should be mindful of the small possibility that some clients may not be aware if they have COVID-19. Maintaining important hygiene behaviours with all clients can help to decrease the risk of transmission. Midwives may also minimize the potential for asymptomatic or pre-symptomatic contact by providing virtual visits and limiting non-essential in-person care (as described in the “Antenatal and Postpartum Visits” section of this FAQ). Midwives may further consider wearing a mask (or potential alternatives to surgical masks such as cloth masks) for all clinical encounters if sufficient supplies are available.

[August 31st 2020]

Self-Isolation and Social Distancing

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

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

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

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

[March 18th 2020]

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

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

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

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

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

What are the current recommendations for the general public on wearing face coverings?

On May 20th 2020, the provincial and federal governments both made announcements recommending the use of face coverings by the general public.

It is recommended that individuals use a face covering (non-medical mask such as a cloth mask) to reduce the risk of transmission of COVID-19 when physical distancing and keeping a two-metre distance from others may be challenging or not possible, such as:

  • Public transit
  • Smaller grocery stores or pharmacies
  • When receiving essential services

Medical masks (surgical, medical procedure face masks and respirators like N95 masks) should be reserved for use by health-care workers and first responders.

The provincial government has information on the proper fit, use and cleaning of face coverings and has produced a downloadable poster with key messages for the public (PDF, 545 KB).

[August 28 2020]

How should I advise my client regarding social circles? 

As of Friday, June 12th, people throughout Ontario are able to establish a social "circle" of no more than 10 people who can interact and come into close contact with one another without physical distancing.  These social circles include members outside of the immediate household. 

Social circles will support the mental health and well-being of Ontarians and help reduce social isolation. Midwives may want to discuss how clients can establish social circles with family and friends to maximize the support available to them in the prenatal and postpartum period.

Check out the practical step-by-step guide to help your clients as they safely develop and join a social circle.

[June 15th 2020]

Personal Protective Equipment

When should midwives use PPE when interacting with a client?

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

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

When conducting antenatal or postpartum visits, midwives can use the antenatal or postpartum visits decision tree (PDF, 172 KB) to determine when to use PPE if client and household members are self-isolating and/or symptomatic. 

When attending home births, midwives can use the home or community birth decision tree (PDF, 556 KB) to determine when to use PPE if client and household members are self-isolating and/or symptomatic. 

[April 8th 2020]

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

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

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

This recommendation aligns with PHO's guidance (PDF, 1.2 MB), updated as of May 3rd 2020, that continues to recommend that health-care providers providing direct care to patients with suspect or confirmed COVID-19, including nasopharyngeal and oropharyngeal swab collection, should use droplet and contact precautions. 

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

PCMCH also recommends that the labouring person who is suspected or confirmed for COVID-19 should be given a surgical/procedure mask for all stages of labour, if tolerated. 

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

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

[May 8th 2020]

Where can midwives go to place orders for face shields?

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

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

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

[April 7th 2020]

How do I properly put on and remove PPE equipment?

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

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

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

To manage expected shortages of PPE, midwives can:

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

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

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

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

[September 11 2020]

How do I store PPE for reuse?

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

 

 [September 11 2020]

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

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

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

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

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

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

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

[September 11 2020]

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

Emerging evidence over the course of the pandemic has shown that face coverings such as cloth masks play an important role in slowing the spread of COVID-19 in community settings. 

Use Among Midwives

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

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

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

Use Among Clients

The Public Health Agency of Canada and the CDC are now recommending that all individuals wear non-medical masks in public settings where social distancing measures are difficult to maintain. Many Ontario regions such as Toronto, Hamilton, Ottawa, Niagara, London and Thunder Bay now require the use of face coverings in enclosed public spaces. 

A recent meta-analysis of 41 studies from the Institute of Health Metrics and Evaluation showed that individuals who wore masks reduced their risk of COVID-19 infection by 33%, providing further evidence that mask use can help slow community spread of COVID-19. 

Additional modeling forecasts suggest that increasing mask use to rates of 95% in the community could reduce the number of COVID-19 related deaths by greater than 50% in many countries including Canada. 

Some Considerations

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

When considering use of a cloth face covering or mask, the following are important:

  • Comfort and fit to avoid touching one's face; the mask should fit securely to the head and cover the nose and mouth 
  • Proper donning and doffing procedures
  • Changing masks every six hours or when they become damp or soiled
  • Use of separate clearly labeled containers for clean and dirty masks to prevent contamination
  • Regular cleaning of dirty masks with hot water and detergent. Dry completely on the hot setting.

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

[September 9th 2020]

Which materials and patterns are best for face coverings/face masks? 

Mask Material

A recent study tested 14 commonly available masks or masks alternatives to determine the efficacy of each mask to reduce the transmission of respiratory droplets during regular speech. The following mask types approached the performance of standard surgical masks:

  • 3 layer cotton-polypropylene-cotton masks
  • 2 layer polypropylene mask
  • 2 layer cotton, pleated style mask

In contrast, knitted masks, bandanas and polyester spandex neck fleeces or gaiters offer less protection. 

A small body of research investigating mask sewing with commonly available household materials suggest that single layer pillowcases, 100% cotton t-shirts or tea towels are the most suitable materials for an improvised mask given their optimal balance of particle capture and breathability. In particular, t-shirts are the preferred choice because their slight elasticity provides a better fit. While vacuum cleaner bags were found to be the most effective at capturing virus particles, they were not recommended because they are difficult to breathe through.

[September 9th 2020]

Is there a mask pattern that the AOM recommends?

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

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

[September 9th 2020]

Occupational Health and Safety

What are the 4 foundational principles for restarting the health sector?

The CMOH Directive #2 (originally issued March 19, 2020) has been amended to reflect the gradual restart of all deferred and non-essential and elective services carried out by health care providers. 

The directive states: All deferred and non-essential and elective services carried out by Health Care Providers may be gradually restarted, subject to the requirements of this Directive.  

Health Care Providers must adhere to any guidance provided by their applicable health regulatory college, and the following principles:

  • Proportionality: Decision to restart services should be proportionate to the real or anticipated capacities to provide those services.
  • Minimizing Harm to Patients: Decisions should strive to limit harm to patients wherever possible. Activities that have higher implications for morbidity/mortality if delayed too long should be prioritized over those with fewer implications for morbidity/mortality if delayed too long. This requires considering the differential benefits and burdens to patients and patient populations as well as available alternatives to relieve pain and suffering.
  • Equity: Equity requires that all persons with the same clinical needs should be treated in the same way unless relevant differences exist (e.g., different levels of clinical urgency), and that special attention is paid to actions that might further disadvantage the already disadvantaged or vulnerable.
  • Reciprocity: Certain patients and patient populations will be particularly burdened as a result of our health system’s limited capacity to restart services. Consequently, our health system has a reciprocal obligation to ensure that those who continue to be burdened have their health monitored, receive appropriate care, and be re-evaluated for emergent activities should they require them. 

[May 29th 2020]

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

As of May 26, 2020, midwives may begin the gradual restart of all non-essential services assuming the necessary precautions outlined in the MOH's Operational Requirements are met: 

Elimination

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

Engineering controls

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

Administrative controls

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

PPE

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

[June 17th 2020]

How can MPGs keep workers safe in the clinic setting?

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

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

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

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

[May 29th 2020]

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

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

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

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

[April 24th 2020]

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

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

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

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

[April 24th 2020]

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

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

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

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

[April 24th 2020]

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

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

To reduce how frequently the phone needs to be disinfected:

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

To disinfect a phone:

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

[June 15th 2020]

Routine Antenatal Testing

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

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

[August 31st, 2020]

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

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

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

[August 31st, 2020]

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

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

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

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

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

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

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

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

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

[March 18th 2020]

Can I still do a Pap test for my clients?

Ontario Health (Cancer Care Ontario) is now recommending health care providers gradually resume routine  cervical screening tests.  [June 24, 2020] 

What are alternate screening methods for GDM?

The SOGC and the Diabetes Canada Clinical Practice Guidelines Steering Committee recently 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.

[April 9th 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. The Association of Ontario Midwives is advocating for midwives to be able to order HbA1c for GDM screening.

[April 9th 2020]

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

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

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

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

[April 9th 2020]

Antenatal and Postpartum Visits

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

Midwives should delay or cancel in-person visits for clients with confirmed or suspected COVID-19 (PDF, 117 KB) until after the period of self-isolation (PDF, 508 KB) is complete. Offer a virtual visit (by phone, Skype, etc.) if applicable (when physical care is not required).

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

These measures include:

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

[March 20th 2020]

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

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

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

[March 20th 2020]

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

There is no national or provincial requirement to use face coverings in indoor public areas, but many municipalities have issued bylaws to that effect. Some municipal bylaws exempt health care spaces from the requirement to wear masks, with the understanding that there will be mask policies specific to their context and population. The provincial COVID-19 Guidance: Primary Care Providers in a Community Setting (updated September 4, 2020) states that “All patients [and visitors], regardless of screening should wear a mask and perform hand hygiene while at the office/clinic.” 


In many parts of the province, labour wards are only requiring labouring clients to wear masks if they have tested positive for COVID-19, or are symptomatic. The recommendation from the Provincial Council for Maternal and Child Health (PCMCH) is that COVID positive clients wear surgical masks during labour, as 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.

[September 16th 2020]

What if clients refuse to wear a mask?

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

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


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


Similarly, midwives need to consider the risk to this client and to other clients and staff. Consider whether the client can safely get care elsewhere; seeing the client at a time/ place so they are unlikely to encounter other people (e.g. end of the clinic day, in the community, virtual care); and having the midwives wearing full PPE during visits with the unmasked client, including gowns and face shields.

Recognize that clients’ 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.

A decision not to provide the client with care during pregnancy is not without risk. Pregnancy without care can lead to poor outcomes, and it is often not feasible for the client to get care elsewhere. 

Midwives encountering such situations may access the advice available through AOM On Call.

[September 16th 2020]

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

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

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

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

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

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

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

Topics to be covered in a virtual visit may include:

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

[March 20th 2020]

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

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

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

4. At 30-34 weeks

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

[March 27th 2020]

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

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

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

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

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, as determined by an evidence review (PDF, 217.72 KB) from Alberta Health Services. Signs of decompensation may also include a reduction in urine output and drowsiness. 

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

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

 [June 16th, 2020]
 

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

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

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

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

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

[March 25th 2020]

What should I consider when planning visits for vulnerable populations?

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 vulnerabilities.

[April 15th 2020]

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

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

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

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

Remember:

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

[April 22nd 2020]

Labour Considerations

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

Recent reports have drawn attention to an increase in coagulopathy and thrombotic complications in non-pregnant patients with severe COVID-19 infection. As a result of these reports guidance (not specific to pregnancy) was released on March 21st by the International Society on Thrombosis and Haemostasis in the UK recommending prophylactic dose Low Molecular Weight Heparin (LMWH) in all patients who require hospital admission for COVID-19 infection. Thrombosis Canada, in an expert panel presentation on April 29th, similarly recommended that all COVID-19 patients admitted to hospital receive thromboprophylaxis. 

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 updated their COVID-19 guideline on April 9th to now recommend that all pregnant people with suspected or confirmed positive COVID-19 receive prophylactic LMWH. 
 
To date there are only two case reports of what appears to be the development of COVID-19 related coagulopathy in pregnancy, one from Mount Sinai Hospital in Toronto and the other from France. In the case reports, both patients were admitted to hospital in their 35th week of pregnancy with cough and pyrexia and subsequently diagnosed with COVID-19. Laboratory markers, notably significantly elevated D-dimers, indicated progressive coagulopathy which was managed by prompt delivery by cesarean section and by LBWH treatment in the postpartum. In one case, the pregnant person had a significant PPH managed by uterine artery ligation and B-lynch compression. No morbidity in the birthing person was reported in the second case. Both cases resolved shortly in the postpartum on day 1 and day 3.

The current research on hypercoagulability in COVID-19 patients (with the exception of the case reports described above) are from non-pregnant patients with severe COVID-19 disease. Authors of a study from the Netherlands (PDF, 400 KB) on 184 (non-pregnant) ICU patients with COVID-19 remarked that excessive inflammation, hypoxia, immobilization and DIC may predispose COVID-19 patients to thromboembolism. Guidance for non-pregnant patients with COVID-19 from thrombosis organizations recommends thromboprophylaxis for patients admitted to hospital with COVID-19. Midwives should use their clinical judgment regarding the risk of coagulopathy in pregnant people with COVID-19 experiencing mild illness. For pregnant people admitted to hospital with moderate to severe COVID-19 infection, midwives should work with obstetric consultants regarding initiation of LBWH and course of treatment.

Safety of LMWH in pregnancy and the postpartum

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

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

[May 14th 2020]

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

Some hospitals are recommending the routine use of early epidurals for all birthing people diagnosed with COVID-19. This recommendation is in line with RCOG guidance stating that “epidural analgesia should be recommended before, or early in labour, to women with suspected/confirmed COVID-19 to minimise the need for general anaesthesia if urgent delivery is needed.” Of note, the SOGC, in their “COVID-19 in Pregnancy” statement updated on May 14th, 2020 does not make this recommendation. In addition COVID-19 specific guidance for birthing parents and their newborns released on April 30th by the Ontario Provincial Council for Maternal and Child Health (PCMCH), states that the use of “analgesia options (e.g. epidural, opioids) is not changed by COVID-19 positive status.”   

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

To see an analysis of the research regarding the effect of COVID-19 on the pregnant person and the fetus – see “COVID-19 and Different Populations” at the beginning of the FAQ.

COVID-19 transmission during a general anaesthetic

  • According to the WHO, a general anaesthetic requires procedures that generate aerosols such as endotracheal intubation, manual ventilation before intubation and positive pressure ventilation. Aerosol generating procedures can potentially cause airborne transmission of COVID-19 which increases the risk of transmission of the virus to health care providers, hospital staff and potentially other hospital patients. 
  • There are a number of measures and precautions that can be taken to protect against COVID-19 becoming airborne during a GA but they add time and complexity to the procedure. These additional precautions also can have an impact on the fetus as there can be a greater transfer of anesthetic agents to the fetus with the increased time required leading to cardio-respiratory depression and decreased tone in the infant. (Rollins)
  • The PCMCH COVID-19 guideline offers Ontario specific recommendations regarding appropriate precautions and use of PPE when a general anesthetic is required for a labouring person.

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

[May 11th 2020]

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

For afebrile, term clients who have mild illness associated with COVID-19 and in whom no other co-morbidities1 present, it is reasonable to offer Intermittent Auscultation (IA). An informed choice discussion with the client about the risks and benefits of EFM compared with IA should occur. Continuous EFM 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, EFM is indicated as the pregnant person is more likely to be hypoxemic, which in turn could affect fetal oxygenation in labour.  People with comorbidities who present with mild illness have a higher risk of rapid deterioration. (WHO)


While statements by RCOG and SOGC responding to the COVID-19 pandemic have recommended continuous electronic fetal monitoring (cEFM) for labouring people with COVID-19, recent guidance released on April 30th from 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.   
 
Research is still limited on the incidence of fetal compromise in birthing people with suspected or confirmed positive COVID-19 and the numbers are too small to draw definitive conclusions about this association at this time. Currently the recommendations for cEFM from the RCOG and SOGC are based on 3 case reports and one retrospective study from China. To see an analysis of this research, see “What effect does COVID-19 have on the fetus/neonate” under the heading COVID-19 and Different Populations at the beginning of our FAQ.  

[May 11th 2020]

Footnotes

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

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

There has been vague and at times conflicting information and advice about whether intrapartum use of 50:50 nitrous oxide (N20) and oxygen blend (also known as Entonox or “nitrous”) increases the risk of COVID-19 transmission. In Version 2 of the RCOG “Coronavirus (COVID-19) Infection in Pregnancy” guideline, it was suggested that the use of Entonox could potentially cause aerosolization of COVID-19 increasing the spread of the virus. However, in Version 3 and all ensuing versions to date, advice about Entonox was changed to acknowledge that there is no evidence that the use of Entonox is an aerosol generating medical procedure (AGMP), and that it could continue to be used in labour.

Many Ontario hospitals have discontinued the intrapartum use of nitrous oxide despite the lack of evidence showing that it could lead to aerosolization. This approach is supported by a statement by the Society for Obstetric Anesthesia and Perinatology (SOAP) and the Society for Maternal-Fetal Medicine that cautioned against the use of nitrous oxide and suggested its use be suspended due to the insufficient information that exists regarding the cleaning, filtering and potential aerosolization in the setting of COVID-19. The SOGC has not published any recommendation regarding intrapartum use of nitrous oxide. However Ontario’s Provincial Council on Maternal and Child Health (PCMCH) suggests that nitrous oxide use be discontinued as it could potentially increase the viral load in the environment. 

Internationally, there is variation among different organizations’ approach to use of nitrous oxide during the COVID-19 pandemic.  Some organizations have recommended against the use of nitrous and some organizations continue to support its use in labouring people. A recently published Cochrane review looking at national COVID-19 clinical practice guidelines in pregnant people and their babies did not come to consensus regarding whether or not nitrous is contraindicated due to COVID-19. While some countries, such as the UK and Turkey appear to support N2O use under any circumstances, including use in a person who is COVID-19 positive, countries such as Austria only permit its use for a labouring person who is asymptomatic and not at risk. Not included in the Cochrane review, is guidance from New Zealand’s Ministry of Health that supports the use of nitrous for pregnant people with suspected or confirmed COVID-19 as long as standard precautions are being followed and health care providers are wearing the appropriate PPE.    

What is an Aerosol Generating Medical Procedures (AGMPs)?

AGMPs are medical procedures that create aerosols (a tiny droplet or particle suspended in air) in addition to those that are created normally from breathing, coughing, sneezing and talking.

The CDC identifies a number of medical procedures as aerosol generating (CDC list), although the occupational risk these procedures pose to health-care workers is not conclusive in the scientific literature. A 2012 systematic review examined the risk of SARS infection among HCPs exposed to patients undergoing AGMPs compared to patients not undergoing AGMPs. The review found that out of 20 potential AGMPs, only the HCPs performing tracheal intubation procedures had a higher risk of disease transmission compared with unexposed workers. However the authors concluded that the studies were limited and of too low quality to establish the risk of transmission with any certainty.

Can nitrous oxide use increase transmission of COVID-19?

There is no evidence that the use of nitrous could lead to aerosolization of the COVID-19 virus or that it is an AGMP or that it contributes to an increased viral load in the environment of the labouring person. Nitrous is a sweet smelling, colourless gas that when exhaled is eliminated unchanged from the body. The 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. Filtration and scavenging is intended to protect health care providers from exposure to nitrous gas as it could potentially become an occupational health risk if health care providers have prolonged exposure. The small amount of exhaled gas that escapes filtration and scavenging, 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. There is an interplay of complex factors that determine whether aerosols can contribute to viral transmission and cause an infection. They include droplet size, viability of the virus, degree of viral shedding, infective dose, and virulence of the virus. Many of these are still to be determined for COVID-19 and could take years to definitely establish.

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.

Can nitrous oxide be used by a labouring person with suspected or confirmed positive COVID-19?

Use of nitrous oxide by a labouring person with suspected or confirmed COVID-19 should be approached with caution. There is no research on the use of nitrous oxide among COVID-19 positive people and very little about its use with active respiratory infections generally.

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

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

[May 11th 2020]

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

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

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

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

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

If possible, use one person to provide support who:

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

Discuss the following infection prevention and control considerations with clients:

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

(French - Couillard, 2020)
 
[April 21st 2020]

Home Birth

Should clients consider a home birth during a pandemic?

The home birth during the COVID-19 pandemic (PDF, 885 KB) reference guide was developed to provide information to midwives and clients engaged in complex decision-making on choice of birthplace during a pandemic.

The guide includes:

  • The latest research on birth outcomes for pregnant people with COVID-19
  • Nine considerations for offering choice of birthplace during a pandemic
  • Tips on how best to maintain PPE and IPAC practices in the home setting
  • A decision tree on when to use PPE at home births depending on the health status of the client and/or household member

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

[April 21st 2020]

Water Birth and Hydrotherapy

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

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

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

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

[March 27th 2020]

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

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

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

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

[March 27th 2020]

Mental Health

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

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

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

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

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

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

[September 14th 2020]

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

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

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

[September 14th 2020]

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

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

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

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

Resources for midwives include:

  1. BEACON provides guided digital therapy that is personalized, and enables members to receive support from a registered therapist that's always one-to-one, completely digital, private, and secure.
  2. ECHO provides virtual sessions designed for healthcare providers and residents responding to the COVID-19 pandemic. Participants are invited to join ECHO sessions using multi-point videoconference technology to share and learn about ways to build resilience and overall wellness through lectures and case-based discussions.
  3. Canadian Psychological Association provides a listing of psychologists who have volunteered to provide psychological services to frontline healthcare workers. 
  4. 10 Percent Happier Meditation App: Healthcare workers are being offered a free six-month subscriptions to the Ten Percent Happier app, no strings attached. This app allows users to follow guided meditations to support them in this trying time.
    • To access:
    • IMPORTANT: Make a note of the way you registered your account (email, Facebook, etc.) because you must log into the app using the same method you used to claim your code on the website
    • For those that do not wish to download the app, the 10 Percent Happier team also offers several free resources including podcasts and meditations on their website
  5. HumanaCare is the new employee assistance program offered to AOM midwife members and immediate family to assist with a variety of different work/life issues that may threaten their health, impair their work performance, or affect their work attendance.
  6. SSQ Insurance is offering free access to telephone counselling services for plan members only. The free COVID-19 distress hotline is a temporary service available 24 hours a day, seven days a week, at 1-877-480-2240.

    Before calling, make sure to have your certificate number ready. You will be asked to provide it when you call. Although family members on your plan are not eligible to call the hotline, they do have access to services through the Member Assistance Plan, Optima Global Health’s Health InSight Program. This includes professional, confidential assistance with mental health-related issues or workplace stress, short-term counselling, or an hour of legal or financial consultation.

  7. AOM On Call is a confidential resource for members who seek support for concerns arising from practice. You can get free support advice 24/7 from the AOM On-Call team. To reach AOM On Call, contact the AOM office at: Toll Free: 1-866-418-3773 OR Local: 416-425-997

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

[September 14th 2020]

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

Practice partners and head midwives should attempt to:

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

[September 14th 2020]

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

There is a wide range of virtual resources available to help Indigenous communities with their mental wellness. Support is available to help people cope with anxiety related to the pandemic itself as well as with stress from trying to balance cultural values with public health measures, losing a job, being at home, isolation, physical distancing, family conflict, problematic substance use, and many other issues. Counselling, cultural supports, and other forms of treatment are available through Telehealth and online platforms.

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. New online mental wellness resources related to COVID-19 are being launched daily, which has led to an overwhelming amount of information.

Here is a snapshot of current examples of resources (PDF, 240 KB) developed for First Nations, Métis, and Inuit populations from Indigenous Services Canada.

[September 14th 2020]

Medication

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

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

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

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

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

[September 10, 2020]
 

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

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

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

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

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

[March 30th 2020]

Chest/Breastfeeding

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

There has been no documentation of viral transmission through human milk. Five studies that have tested the human milk from birthing individuals with confirmed COVID-19 were all negative for SARS-CoV-2. 

One case study published on May 14th 2020 reported the only case of SARS-CoV-2 found in the human milk of a birthing parent who was positive for COVID-19. However, this birthing parent had several co-morbidities including familial neutropenia, gestational diabetes and a history of frequent bacterial infections. This individual’s immunocompromised state was likely to have contributed to the widespread dissemination of the SARS-CoV-2 virus throughout the body tissues and secretions. Despite this unique case, the presence of SARS-CoV-2 in human milk continues to be extremely rare.

[May 29th 2020]

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

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

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

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

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

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

[May 29th 2020]

Newborn Care

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

According to the WHO, clients should be enabled to remain with their infants and should be supported in the practice of skin-to-skin contact, whether or not these clients have suspected or confirmed COVID-19. [March 19th 2020] Similarly, RCOG also recommends that infants should remain with their birthing parent in the immediate postpartum unless neonatal care is required. [March 21st 2020]

Midwives should engage clients in an informed choice discussion about the risks and benefits of skin-to-skin contact in light of potential or confirmed COVID-19 infection. This discussion should include information on the importance of good handwashing and the use of a mask, if available, while engaging in newborn care. [March 19th 2020]

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.

[May 12th 2020]

Will I still be able to conduct routine newborn screening?

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

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

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

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

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

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

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

[September 21st, 2020]

Can I still refer my clients to outpatient bilirubin clinics?

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

[September 21st, 2020]

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

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

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

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

  • A distance of two meters should be kept between the neonatal resuscitation team (if applicable in addition to midwives providing care) and the birthing parent with COVID-19.
    • If the midwife who has caught the newborn is needed to assist the second midwife/attendant with newborn resuscitation, they should consider changing their gloves if feasible prior to assisting with the resuscitation.
  • If a distance of two meters can be maintained between the birthing parent and the bed in which a newborn will be resuscitated, care can be provided in the same room.
  • Newborns should be resuscitated in an adjacent room if the birthing parent requires intubation or other aerosol generating medical procedures, since the newborn cannot be protected against airborne transmission.
  • In the asymptomatic birthing parent who is COVID-19 suspect or positive, droplet/contact precautions are recommended during the initial steps of resuscitation. 
  • In the symptomatic birthing parent (any one or combination of tachypnea, cough, respiratory distress or radiography consistent with a lower respiratory tract infection with or without fever prior to the onset of labour) whether receiving respiratory support or not, it is recommended that those performing resuscitation for the newborn use enhanced droplet precautions including an N95 mask.  This recommendation is born out of concerns that those with significant illness may be capable of vertical transmission if such a route of infection does exist.  

[August 28th 2020]

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

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

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

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

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

[May 21st 2020]