Τρίτη 25 Φεβρουαρίου 2020

Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings

These infection prevention and control considerations are for healthcare facilities providing obstetric care for pregnant patients with confirmed coronavirus disease (COVID-19) or pregnant persons under investigation (PUI) in inpatient obstetric healthcare settings including obstetrical triage, labor and delivery, recovery and inpatient postpartum settings.

This information is intended to aid hospitals and clinicians in applying broader CDC interim guidance on infection control (Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings).

Since maternity and newborn care units vary in physical configuration, each facility should consider their appropriate space and staffing needs to prevent transmission of the virus that causes COVID-19. These considerations include appropriate isolation of pregnant patients who have confirmed COVID-19 or are PUIs; basic and refresher training for all healthcare personnel on those units to include correct adherence to infection control practices and personal protective equipment (PPE) use and handling; sufficient and appropriate PPE supplies positioned at all points of care; and processes to protect newborns from risk of COVID-19.

These considerations are based upon the limited evidence available to date about transmission of the virus that causes COVID-19, and knowledge of other viruses that cause severe respiratory illness including influenza, severe acute respiratory syndrome coronavirus (SARS-CoV), and Middle East Respiratory Syndrome coronavirus (MERS-CoV). The approaches outlined below are intentionally cautious until additional data become available to refine recommendations for prevention of person-to-person transmission in inpatient obstetric care settings.

Prehospital Considerations

Pregnant patients who have confirmed COVID-19 or who are PUIs should notify the obstetric unit prior to arrival so the facility can make appropriate infection control preparations (e.g., identifying the most appropriate room for labor and delivery, ensuring infection prevention and control supplies and PPE are correctly positioned, informing all healthcare personnel who will be involved in the patient’s care of infection control expectations) before the patient’s arrival.
If a pregnant patient who has confirmed COVID-19 or is a PUI is arriving via transport by emergency medical services, the driver should contact the receiving emergency department or healthcare facility and follow previously agreed-upon local or regional transport protocols. For more information refer to the Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
Healthcare providers should promptly notify infection control personnel at their facility of the anticipated arrival of a pregnant patient who has confirmed COVID-19 or is a PUI.

During Hospitalization

Healthcare facilities should ensure recommended infection control practices for hospitalized pregnant patients who have confirmed COVID-19 or are PUIs are consistent with Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.

All healthcare facilities that provide obstetric care must ensure that their personnel are correctly trained and capable of implementing recommended infection control interventions. Individual healthcare personnel should ensure they understand and can adhere to infection control requirements.
Healthcare facilities should follow the above infection control guidance on managing visitor access, including essential support persons for women in labor (e.g., spouse, partner).

Infants born to mothers with confirmed COVID-19 should be considered PUIs. As such, infants should be isolated according to the Infection Prevention and Control Guidance for PUIs.

Mother/Baby Contact

It is unknown whether newborns with COVID-19 are at increased risk for severe complications. Transmission after birth via contact with infectious respiratory secretions is a concern. To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued, as described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19. See the considerations below for temporary separation:

The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team.
A separate isolation room should be available for the infant while they remain a PUI. Healthcare facilities should consider limiting visitors, with the exception of a healthy parent or caregiver. Visitors should be instructed to wear appropriate PPE, including gown, gloves, face mask, and eye protection. If another healthy family or staff member is present to provide care (e.g., diapering, bathing) and feeding for the newborn, they should use appropriate PPE. For healthy family members, appropriate PPE includes gown, gloves, face mask, and eye protection. For healthcare personnel, recommendations for appropriate PPE are outlined in the Infection Prevention and Control Recommendations.
The decision to discontinue temporary separation of the mother from her baby Considerations to discontinue temporary separation are the same as those to discontinue transmission-based precautions for hospitalized patients with COVID-19. Please see Interim Considerations for Disposition of Hospitalized Patients with COVID-19.
If colocation (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19.

Consider using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the ill mother.
If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed COVID-19 or is a PUI should put on a facemask and practice hand hygiene¹ before each feeding or other close contact with her newborn. The facemask should remain in place during contact with the newborn. These practices should continue while the mother is on transmission-based precautions in a healthcare facility.should be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. The decision should take into account disease severity, illness signs and symptoms, and results of laboratory testing for the virus that causes COVID-19, SARS-CoV-2.

Breastfeeding

During temporary separation, mothers who intend to breastfeed should be encouraged to express their breast milk to establish and maintain milk supply. If possible, a dedicated breast pump should be provided. Prior to expressing breast milk, mothers should practice hand hygiene.¹ After each pumping session, all parts that come into contact with breast milk should be thoroughly washed and the entire pump should be appropriately disinfected per the manufacturer’s instructions. This expressed breast milk should be fed to the newborn by a healthy caregiver.
If a mother and newborn do room-in and the mother wishes to feed at the breast, she should put on a facemask and practice hand hygiene before each feeding.

Hospital Discharge

Discharge for postpartum women should follow recommendations described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19.
For infants with pending testing results or who test negative for the virus that causes COVID-19 upon hospital discharge, caretakers should take steps to reduce the risk of transmission to the infant, including following the Interim Guidance for Preventing Spread of Coronavirus Disease 2019 (COVID-19) in Homes and Residential Communities.

Footnote:

¹ Hand hygiene includes use of alcohol-based hand sanitizer that contains 60% to 95% alcohol before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Hand hygiene can also be performed by washing with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to alcohol-based hand sanitizer.