Coronavirus (SARS-CoV-2) is an infectious disease that is spread through saliva droplets or nasal discharge while coughing or sneezing (World Health Organization [WHO], 2020a). These droplets could be inhaled into the mouth or nose and, possibly, into the lungs through the air if one is close to an infected person (Centers for Disease Control and Prevention [CDC], 2020e). According to the latest guidance from RCOG (2021), pregnant women ‘do not appear more likely to contract the infection than the general population’ however, it is still probable that pregnant women can contract the virus and thus certain strategies still need to be put in place to care for them.
Preliminary reports suggest that outbreaks are more likely to occur when a person is in close contact with someone who has SARS-CoV-2 (CDC, 2020e). Physiological and anatomical changes during pregnancy increase the susceptibility to infections in general (Dashraath et al, 2020) and so there is no way to ensure that the risk of infection could be zero (CDC, 2020d). Therefore, pregnant women should be monitored in order to be diagnosed and prevent mother and baby from being infected with the virus (Yang et al, 2020).
SARS-CoV-2 is assumed to be transmitted to infants primarily through respiratory droplets in the postpartum period (CDC, 2020c). Data show that infants (<12 months) are at higher risk of contracting severe SARS-CoV-2 than babies aged older than 12 months (CDC, 2020c). Therefore, pregnant women and infants are known as a vulnerable group and need standard care in the epidemic. The purpose of this editorial is to express the standard solutions and care for mothers and babies in the COVID-19 epidemic to prevent this vulnerable group from getting the disease. According to previous data, which showed that the vulnerability scores for frontline nurses, including the scores of physiological and psychological responses, are significantly lower than those not working on the frontline, which also included surgical unit nurses (Li et al, 2020).
Pregnancy
Personal care
Pregnant women and those who live with them should take into account the risk before deciding to go out. They should pay attention to activities for which protection measures are difficult to be considered, such as those in which social distance cannot be maintained (CDC, 2020d). If they intend to carry out public activities, they must take preventive measures and bring protective equipment including a face mask, a piece of cloth, and hand sanitiser with a minimum of 60% alcohol, with them. They have to avoid those without a face mask (CDC, 2020d; WHO, 2020b) or ask others to use a mask (CDC, 2020d). Pregnant women should continue their pregnancy care visits and limit individual interactions with others as much as possible. They must also use their medications for at least 30 days (CDC, 2020d). Pregnant women with respiratory diseases should be given priority in treatment due to the increased risk of SARS-CoV-2 side effects. They should also be separated in health units from patients identified as infected with SARS-CoV-2 (UNPFA, 2020). The WHO (2020c) also recommends that pregnant women with symptoms of SARS-CoV-2 should be given priority in testing. Pregnant women should wash their hands frequently, avoid touching their eyes, nose, and mouth, and sneeze or cough at their elbow bend or in a tissue (WHO, 2020b).
Vaccination during pregnancy
The first vaccine against SARS-CoV-2 was approved for use in the UK on 2 December 2020 after a review by the Medicines and Healthcare products Regulatory Agency. Since then, other vaccines have been approved and a national vaccination programme is underway. None of the vaccines have undergone specific clinical trials in pregnant women. The Joint Committee on Vaccination and Immunisation (JCVI) published updated advice on 30 December 2020 and confirmed the available data do not indicate any safety concerns or harm to pregnancy, and vaccination in pregnancy should be considered where the risk of exposure to SARS-CoV-2 infection is high or cannot be avoided.
Furthermore, the JCVI stated that vaccination should be considered where the woman has an underlying condition that puts her at very high risk of serious complications of SARS-CoV-2. Similar advice was issued for breastfeeding women. Routine vaccines play an important role in protecting the health of people. On the other hand, receiving some vaccines during pregnancy, such as the flu vaccine and Tdap, can help mothers and children (CDC, 2020d).
During hospitalisation
Pregnant women with or suspected of having SARS-CoV-2 at the time of admission should be given priority for testing (CDC, 2020a) and should minimise the number of members that enter the room. The latest guidance from RCOG (2021) also states that ‘visitors to isolation rooms or cohort bays/ward should be kept to a minimum and follow local hospital visitor policies’. The test for pregnant women with no symptoms should be decided by the healthcare professional (CDC, 2020a).
Childbirth
Newborn babies could become infected after close contact with a person infected with SARS-CoV-2. Other problems, such as premature delivery, have been reported for mothers who have tested positive for SARS-CoV-2 (CDC, 2020d). WHO recommends that caesarean operation should be performed only if medically justified (UNPFA, 2020) and with regards to water birth, RCOG (2020) guidelines express that women who are asymptomatic of SARS-CoV-2 with presumed or confirmed SARS-CoV-2 swab are not contraindicated for water birth and, for women who are symptomatic of SARS-CoV-2, water birth is not recommended.
Healthcare providers must consider that infants suspected of having SARS-CoV-2 infection should be isolated from other healthy infants (CDC, 2020c) The staff should keep patients in care before, during and after delivery with a safe distance (at least two metres) (UNPFA, 2020). The test should be given to all infants born to mothers with or suspected of having SARS-CoV-2, regardless of any symptoms of infection (CDC, 2020c). Children with certain medical conditions, such as chronic lung disease, moderate to severe asthma, serious heart conditions, or a weakened immune system, may be at increased risk for severe SARS-CoV-2 disease (CDC, 2020d).
Recommended tests
The diagnosis should be confirmed by testing for SARS-CoV-2 RNA by reverse transcription-polymerase chain reaction. Detection of SARS-CoV-2 viral RNA can be collected using nasopharyngeal, oropharynx, or nasal swab samples. Serological testing for acute infection is not currently recommended for newborn babies (CDC, 2020c). Symptomatic and asymptomatic infants born to mothers with or suspected of SARS-CoV-2 should have tests performed within the first 24 hours of birth, regardless of the mother's symptoms. If the initial test results are negative or unavailable, the test should be repeated within the first 48 hours of the baby's birth (CDC, 2020c). In asymptomatic infants who are expected to be discharged less than 48 days after birth, a pre-discharge test is performed between 24–48 hours after birth (CDC, 2020c). Initial tests may be false-positive (for example, if the baby's nasal cavity, nasopharynx or oropharynx is contaminated with SARS-CoV-2 RNA in maternal fluids) or false-negative (eg RNA after delivery is not immediately detectable) (CDC, 2020c).
Isolation of the newborn baby
If a mother infected with SARS-CoV-2 or suspected of having the disease does not choose temporary isolation in the hospital, she should keep a distance of six feet from her baby, wash her hands and cover her face to prevent the virus from spreading to the baby. Physical barriers (eg placing the baby in an incubator) can be used (CDC, 2020d). Separating babies from mothers may make it more difficult for some new mothers to start or continue breastfeeding. Lactation by hand or pumping, ideally with a pump in the hospital, is essential during the temporary separation. Pumping every 2–3 hours (at least 8–10 times in 24 hours, including the night time), especially in the first few days, causes the breasts to react to milk production and prevents clogging of the milk ducts and breast infections. If the mother is unable to do this, they can do so with the support of a healthcare provider (CDC, 2020d). Although the ideal option for caring for a healthy baby in the hospital is in-room care, temporary separation from a suspected or SARS-CoV-2-infected mother should be done to reduce the infection risk for the baby (CDC, 2020c).
Face shields for newborn babies
The plastic face shield is not recommended for infants as it can increase the risk of sudden infant death syndrome or suffocation. Newborn babies move frequently. This can increase the risk of obstruction of the nose and mouth by a plastic face protector or its components, and also the baby's movement can cause the suffocation with a face shield (CDC, 2020d).
Safe sleep for babies during the COVID-19 pandemic
The child should be in the supine position at all times of sleep – nap-taking and night sleep – and can be kept in the mother's room.
COVID-19 and lactation
It is not yet known whether mothers with SARS-CoV-2 can transmit the virus to their infants through breastmilk but available data rule out this possibility (CDC, 2020d). Yet the following cautions are advised.
Breastfeeding care
During breastfeeding, mothers should cover their face and wash their hands with soap and water for at least 20 seconds before each feed (CDC, 2020d; 2020b). In case of breastmilk pumping, a mother who has contracted SARS-CoV-2 should use a special breast pump and before touching any of its parts or bottle, and before feeding the infant, should cover her face and wash her hands with soap and water (CDC, 2020d; 2020b). As far as possible, breastmilk should be given to the baby by a healthy caregiver without SARS-CoV-2 and not at high risk of infection, and who lives in the same house (CDC, 2020d).
If a woman with SARS-CoV-2 cannot breastfeed her baby, she can use another person's breast milk, her pumped breastmilk or dried powdered milk (WHO, 2020b). If the newborn has been fed by a mother with or suspected of having SARS-CoV-2, or has been in contact with a person suspected of having SARS-CoV-2, he or she should be suspected of having SARS-CoV-2 and the caregiver should be aware of this issue (CDC, 2020b).
Conclusion
SARS-CoV-2 is an infectious disease that continues to affect people all over the world. Among these, pregnant women are still considered high risk due to the physiological changes a pregnant women experiences which has thus caused the need for more support during this period. According to the mentioned cases, pregnant mothers should take care of themselves and their newborn babies by using the provided protocols in order to support the treatment staff more effectively during childbirth, because if the pregnant woman has SARS-CoV-2, it may affect the performance of the treatment staff which ultimately affects the mother and baby.
Key points
- Pregnant woman should be made a priority when it comes to testing for SARS-CoV-2
- Asymptomatic infected pregnant woman aren't in contrandication of water birth. However, for those women who are symptomatic of SARS-CoV-2, water birth is not recommended
- The test should be given to all infants born to mothers with or suspected of having SARS-CoV-2, regardless of any symptoms of infection
- During breastfeeding, mothers should cover their face and wash their hands with soap and water for at least 20 seconds before each feed
CPD reflective questions
- If a mother infected with SARS-CoV-2, is breastfeeding contrandicated?
- If a woman is not well enough to care for her own infant and feed him/her, what should she do?
- Is a plastic face shield a proper form of protection for infants to use during COVID-19?