standard protocols and specific measures to be followed

National Health Mission

Uttarakhand

Standard Protocols and specific measures to be followed for Antenatal, Intra natal and Post natal care in view

of COVID-19

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Contents

1- Guiding Principal………………………………………………………...2

2- Community Level Consideration…………………………………………3

3- Facility Level Consideration along with Temporary Labor Room……….4

4- Treatment Protocol……………………………………………………….9

5- Breastfeeding and the COVID-19 infected mother……………………21

6- Postnatal Care………………………………………………………….22

7- Referral Protocols………………………………………………………23

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1. Guiding Principal

This has been observed that most of the maternal deaths occurs due to

-Not getting tested at the Community Level even appearing of mild symptoms

- Denial of Admission especially Covid suspected and positive pregnant women

- Increase in Home Delivery due to fear of getting infected at the facility

- Late arrival at the Dedicated Covid facility

Considering the high morbidity and mortality due to pandemic along with resuming the MCH

services two pronged strategy is the need of the hour that is community and facility based

strategy as outlined below-

The Guiding principal for management of all Maternal Cases during Covid-19

pandemic-

No Pregnant women should be denial for hospital admission irrespective of her Covid

status

The fear in the community would be minimize so the pregnant women can visit the

facility for seeking necessary services

Proper follow up of all covid -19 positive deliver cases as well as pregnant women

Every Facility must have triage facility for all pregnant women

As far as possible every FRU/ Block Level Facility should have separate temporary

Labor Room for conducting delivery of Covid Positive even suspected

There should be dedicated covid MCH facility in each districts for the management

of any complications and serious cases

Dedicated Ambulances should be arranged for transportation of pregnant cases

ASHA & ASHA Facilitators must be aware about all pregnant women and their Covid

status. Prior information must be communicated to all facilities before any covid

pregnant women visit to facility.

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2. Community Level Consideration

The primary step for Covid-19 management for all maternal health services is that there should

be very less fear in the community about Covid-19 and they should follow all guidelines

/protocols. The Role of frontline health workers are very critical for building the faith within

the community for availing necessary maternal health services.

ROLE OF THE FRONTLINE WORKER

A) ANM-

(a) Follow up and coordination with ASHA on Delivery of quality ANC services, especially

on ANC SaMMAN Diwas

(b) Preventive and control measures including social distancing during routine ANC check-

up along with birth planning.

(c) Line Listing of all pregnant women along with Birth Planning

(d) Support Block Surveillance team for early testing of suspected pregnant women

(e) Coordination with Block MOI/c ,AWW and ASHA for conducting ANC session on

VHND day keeping Covid Appropriate Behavior

B) ASHA-

ASHA must be very watchful in this critical time of pandemic especially in case of pregnant

women as it was observed that most of the Covid pregnant cases approached the appropriate

facility only after when their condition became worst due to covid. So it is utmost important to

detect the women as early as possible. ASHA has to perform following two activities

(a) Line Listing of all pregnant women, their regular follow up and measuring of Oxygen

saturation of all suspected cases, Oxygen below 94 would be referred immediately to DCC,

all suspected cases would be referred to Block CHC/FRUs and informing the concern

ANM/AF along with State RCH Call Centre-104

(b) Follow up of all confirmed and suspected pregnant cases (In case of any alarming situation

ASHA has to contact State RCH Call centre (104)

(c) ASHA should also aware about the category of Covid illness that is asymptomatic, mild

moderate and severe cases and should refer all category to Block level facility. Any pregnant

women who is having any past history of illness such as heart, liver kidney problem and present

with Covid like symptoms should be referred immediately to FRU/DH.

(d) ASHA Facilitator will be responsible for monitoring and data reporting from all ASHAs

and provide coordination support to ASHAs. Any pregnant women who is covid positive and

detected in severe condition AFs would be answerable for late detection/ no detection.

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3. Facility Level Consideration

Following key activities are to be undertaken for facility level consideration-

The suggestive guideline for temporary covid LR are presented along with necessary items.

.Base Hospital Kotdwara and STM Haldwani are two example taken in the consideration for

established the temporary Covid LR. For any support these facility can be contacted.

3.1. Guidelines forDevelopment of Temporary Labour Room (TLR)

The decision to set up TLR would be based upon reduction in institutional deliveries, covid

positivity amongst pregnant women, space and other infrastructure at the facility level.

Moreover due to conversion of major high case load facilities into Covid Hospital and not

conducting non covid deliveries which are always in higher percentage. So to mitigate the

impact on non covid delivery cases it is suggested to those facilities to take necessary steps in

conducting non covid deliveries by setting up temporary labor room as per their

feasibility.The provision of temporary labor room is required in order to conduct the delivery

of covid positive pregnant women or any suspected cases so that the non covid pregnant

women can come to the facility without any fear of getting infected. The basic steps for

setting up temporary labor room are as under-

Identification of Space- Preferably the LR and adjacent ward should have separate entry

and exit. Any room within the hospital complex or nearby facility can be set up for

temporary LR.

The temporary LR should be labeled as Covid LR, necessary items such as Labor Table,

Radient Warmer, delivery trays, medicine trays, PPE kits must be arranged. The

Appropriate isolation of pregnant patients who have confirmed COVID-19 or are

Persons under Investigations / present with symptoms. Admit in isolated temporary

LR. Referrals would be done only after stabilize the case.

Basic and refresher training for all healthcare personnel to include correct

adherence to infection control practices, Personal Protective Equipment (PPE) use

and handling (preferably by a video presentation/ Using Safe Delivery App)

Sufficient and appropriate PPE supplies positioned at all points of care

Processes to protect new-borns from risk of COVID-19

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suggestive checklist also provided for the same.

Duty roaster of staff should be prepared for the temporary covid LR

Place appropriate waste bags in a bin. If possible, use a touch-free bin. Ensure that used

(i.e. dirty) bins remain inside the isolation rooms.

Place a puncture-proof container for sharps disposal inside the temporary LR and bio-

medical waste should be managed as per the BMWM guidelines.

Keep the patient’s personal belongings to a minimum. Keep water pitchers and cups,

tissue wipes, and all items necessary for attending to personal hygiene within the

patient’s reach.

Patient-care equipment (e.g. stethoscope, thermometer, blood pressure cuff, and

sphygmomanometer) should be dedicated for the patient, if possible. Any patient-care

equipment that is required for use by other patients should be thoroughly cleaned and

disinfected before use.

Place an appropriate container with a lid outside the door for equipment that requires

disinfection or sterilization.

Ensure that appropriate hand washing facilities and hand-hygiene supplies are

available. Stock the sink area with suitable supplies for hand washing, and with alcohol-

based hand rub, near the point of care.

Ensure adequate room ventilation in the temporary LR. If room is air-conditioned,

ensure 12 air changes/ hour and filtering of exhaust air. The principle of natural

ventilation is to allow and enhance the flow of outdoor air by natural forces such as

wind and thermal buoyancy forces from one opening to another to achieve the desirable

air change per hour.

The temporary LR should have a separate toilet with proper cleaning and supplies.

Avoid sharing of equipment, but if unavoidable, ensure that reusable equipment is

appropriately disinfected between patients.

Train all staffs including maternity, neonatal service providers in use of PPE. The safe

delivery App can be used for trainings.

In some of the facilities where due to space constraint temporary LR could not be established in that case the same

LR could be used for eminent delivery cases otherwise the case can be referred to nearby higher centre where there

is a facility of temporary Covid LR. For those facilities which cannot arranged the temporary LR needs to adhere

strictly on infection control protocols presented below-

Environmental Cleaning: Labour Room (LR)

Frequency Process / Additional guidance

Every two hours Clean floor (Phenyl or another phenolic disinfectant).

At least once daily (e.g., per 24-hour

period)

Clean with detergent and copious amounts of water

After each Spill, and as needed 1 in 5 dilution of 5% {1%} Sodium hypochlorite for 20 minutes, or

aldehyde like bacillocid for 10 mins; Mop dry and clean thoroughly

with detergent and water.

Before and after (i.e., between*) each

procedure

Wipe clean bed with detergent and water and then with available

disinfectant after each patient. Wear gloves for this procedure. Use

fresh linen for each patient.

End of the day (terminal clean) Environment and equipment should be maintained dust free.

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The indicative pictures from BH Kotdwara and STM Haldwani (These two facilities are

taken as example) is presented below for replicating the same.

Temporary Covid LR in BH Kotdwara

Temporary Covid LR in STM Haldwani

Checklist for Development of Temporary Labour Room

A. Infrastructure (Space or area to be developed or identified)

S.N Particualar Required Space Availability Remark

1

Total space for Labour room complex in

female ward & also take two photogarphs

of outer & inner area As per availability

2 Attached toilet with western commode &

washbasin

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3 NBCC Area for Radiant Warmer

4 Space for Prenatal & Postnatal care

5 Elbow tap Hand washing station for staff

6 Nursing station with storage capacity

7 Aluminium/glass partition/curtains for privacy

B. Equipments & Consumables

S.N Equipments required for LDR Required Quantity Availability Remark

1 All time weather 1.5 ton A.C Desirable

2 Labor Table 1 or 2

3 Foetal doppler 1

4 Digital BP instrument 1

5 Drum for Autoclave 1

6 Autoclave 1

7 Ambubag with 0,1 mask 2 sets

8 Pulse oxymeter 2

9 Infrared thermometer 2

10 Focus lamp 1

11 Labour Table 1 or 2

12 Kelly's Pad 2

13 Suction device 1

14 Radiant warmer 1

15 Refrigerator (Small) 1

16 Stretcher 1

17 Normal Beds with Mattress 2

18 Oxygen Cylinder/ Concentrator 2

19 Hub cutter 2

20 Wall clock 1

21 Mucus extractor 20

22 O2 mask 2

23 Crash cart trolley 1

24 Cord clamp 12

25 Exhaust fan 2 to 4

26 LED TV 1 (Desirable)

27 Side rack 3

28 Charging points in each cubicle 4

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29 Bed side locker 2

30 Sutures 12

31 3-bucket mopping trolley 1

32 Emergency Calling Bell 4

33 Cubicle curtains 4

34 PPE including face shield and N-95 respirator

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35 Hand Sanitizer 10

36 BMW bags with puncture proof container for

sharp items 1

37 Detergent and Lysol/phenolic disinfectant 1

38 IV sets 20

39 Sodium hypochlorite solution As per requirement

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4 Treatment Protocols

Letter No: GDMC/PS/2021/ Dated:31-05-2021

Recommendations of Committee constituted vide Letter No.

426/SEC-MH/2020 dated 26.5.2020 and Letter No. 430/SEC-MH/2020

dated 28.05.2020 and further letter no. 404/PS-SEC/2021 dated 17 May

2021, regarding technical inputs and decision support

(Date 31ST May, 2021)

A committee was constituted vide Letter No. 426/SEC-MH/2020 dated

26.25.2020 and Letter No. 430/SEC-MH/2020 dated 28.05.2020 and further

reconstituted vide letter no. 404/PS-SEC/2021 dated 17 May 2021, regarding

technical inputs and decision support for informed policy making for Covid-19 in

Uttarakhand State. A meeting was held on 31.05.2021 at 2.45 P.M under the

chairmanship of Prof. (Dr.) Hem Chandra, Vice Chancellor, Hemwati Nandan

Bahuguna Uttarakhand Medical Education University, and Prof. (Dr.) Ashutosh

Sayana, Principal, Govt. Doon Medical College & Coordinator of committee through

mutual discussions with following expert representatives from different

hospital/organisation of State of Uttarakhand.

1. Prof. (Dr.) M.K. Pant, Deputy Director, Medical Education

Uttarakhand.

2. Prof. (Dr.) Anurag Agarwal, Nodal Officer Covid-19, GDMC,

Dehradun.

3. Prof (Dr) Chitra Joshi, Head, Obs & Gynae Department, GDMC,

Dehradun.

4. Prof. (Dr) Debabrata Roy, Prof & Head, Community Medicine

Department GDMC, Dehradun.

5. Dr Shekhar Pal, Prof. & Head, Microbiology Department GDMC,

Dehradun.

6. Prof. Ashwani K Sood, Department of Paediatrics, HIMS

Dehradun.

7. Dr. Paramjeet Singh, Associate Prof. Department of Medicine,

8. Dr. Nidhi Uniyal, Associate Professor, Department of General

Medicine GDMC Dehradun.

9. Dr. Atul Kumar Singh, Associate Professor, Department of

Anaesthesia GDMC.

10. Dr. Sanjoy Das, Representative from HIMS, Dehradun.

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11. Dr Ritu Rakholia Associate Professor, Department of Paediatrics

DMC .

12. Dr. Pankaj Singh, State surveillance Officer IDSP

13. Dr. Pradeep Chandra Sharma, Assistant Nodal Officer, COVID-

19, GDMC, Dehradun.

14. Dr. Ashok Kumar, Associate Professor, Department of

Paediatrics, GDMC, Dehradun.

15. Dr. Vishal Kaushik, Assistant Professor, Department of

Paediatrics, GDMC, Dehradun.

16. Dr. Tanvi, Assistant Professor, Department of Paediatrics, GDMC,

Dehradun.

17. Dr. Amit Suyal, Consultant Paediatrician, Haldwani.

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Management of Obstetrics Covid-19 Patient

The recommendations regarding management of Antenatal Covid-19 Positive

Patients are formulated by following Sub-committee members on the basis of

guidelines given by ICMR, AIIMS, State Covid Protocol.

1. Prof (Dr) Jaya Chaturvedi, Head, Obs & Gynae Department AIIMS,

Rishikesh.

2. Prof (Dr) Geeta Jain Head, Obs & Gynae Department, GMC, Haldwani.

3. Prof (Dr) Vineeta Gupta Head, Obs & Gynae Department SGRR Medical

College, Dehradun.

4. Prof (Dr) Ruchira Nautiyal, Head, Obs & Gynae Department HIMS Jolly

Grant, Dehradun.

5. Prof (Dr) N.Bora, Head, Obs & Gynae Department VCSGGMS & RI, Srinagar

Garhwal.

6. Prof (Dr) Chitra Joshi Head, Obs & Gynae Department, GDMC, Dehradun.

At the outset, the committee would like to emphasize that pregnancy, though a

physiological state constitutes a very susceptible and hemodynamically unique

group of patients. Thus management of Covid-19 positive pregnant patients should

be a team work between the obstetrician neonatologist physicians and

anesthesiologists. These recommended Protocols are based on the guidelines

provided till date and may change with upcoming evidence in future. The

recommendation of sub-committee was discussed and finalised by Advisory

committee.

Recommendation -

Following four conditions should be considered while categorizing and

managing the Covid-19 positive antenatal patients:-

a) Severity of Covid19 infection.

b) Gestational age.

c) Any obstetric complaint or indication.

d) Presence and extent of any co-morbidity any medical/ surgical

condition like:-

Diabetes / other Immuno-compromising conditions

Liver diseases

Renal disease

Respiratory disease

Cardiovascular / haematological disorders

Obesity

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The infection is categorized into 4 broad categories:

Category I- Asymptomatic

I a- No Co-morbidity/ No Obstetric complaint or complication

I b- With Co-morbidity / With Obstetric complaint or complication

Category II- Mild disease

II a- No Co-morbidity/ No Obstetric complaint or complication

II b- With one or more Co-morbidity/ With Obstetric complaint or

complication.

Category III- Moderate disease

Category IV- Severe disease

Category I –Asymptomatic

Category I a - Asymptomatic/ No Co-morbidity/ No Obstetric complaint or

indication/All trimesters

Clinical features- No signs or symptoms suggestive of Influenza like illness (ILI)

Investigations-After diagnosis of Covid-19

Routine antenatal investigations only

No additional blood tests/ chest imaging are recommended.

Management- Supportive care, adequate nutrition, plenty of oral fluids to maintain

adequate hydration, routine antenatal care.

Home isolation( provided all criteria fulfilled)

Self monitoring chart to be maintained.

Tab Vitamin C 500 mg OD

Warm saline gargles, steam inhalation.

Tab. Iron and Tab. Calcium + Vitamin D.

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Routine antenatal care through telemedicine.

Report to facility – Appearance of symptoms, Obstetric complaint.

Category I b- Asymptomatic with Co-morbidity and/or Obstetric

complaint/Indication

All trimesters

Complete initial work up at the facility.

Admission and facility based care, if Laboratory or clinical parameters not within

the normal limits and/ or obstetric indication.

Management of obstetric condition as per standard obstetric guidelines.

If parameters normal and no obstetric indication then Home isolation with self

monitoring

Daily checking of monitoring chart by HCW.

Steam inhalation, warm gargles

Vitamin C 500 mg OD


Routine antenatal care through telemedicine.

Report to facility in case of appearance of symptoms/ obstetric indication.

Eligibility criteria for Home Isolation-

There should be no fast breathing/ hypoxia

Absence of all Co morbidities/ obstetric complaint.

Requisite facility for isolation is available,

Caregiver is available -to provide care on 24X7 basis

Caregiver has agreed to monitor health of the patient

Regularly inform the health authority about the same,

Patient and care-giver have filled an undertaking after understanding the

aforesaid.

If home isolation is not feasible, patient should be taken care of in a Covid-19

healthcare facilities or Hospital.

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Self monitoring chart

Day/

date

Pulse

rate

Respiratory

rate

SpO2 Temperature Feeling

of well

being

Any fresh

complaint

ASHA workers to be sensitized about importance and interpretation of

self monitoring.

Report to treating doctors in case of any problem.

Category II- Mild disease

Category II a- Mild disease / No Obstetric complaint or indication/ No Co-

morbidity

Clinical features-

Cough, malaise headache, myalgia, fatigue, sore throat, nasal symptoms fever

(>37.8), chills, loss of smell/taste, diarrhoea.

No shortness of breath or hypoxia.

Investigations*-Routine antenatal investigations + CBC, CRP (if possible)

*Additional investigations (if symptoms persist for > 5 days or the symptoms

worsen)- CRP, LFT, KET, X ray chest with abdominal shield ( as per adv of

physician)

Management- Supportive care, adequate nutrition, plenty of oral fluids to maintain

adequate hydration

Oral Paracetamol 650 mg; may be repeated every 4-6 hours.

Tab Azithromycin 500 mg OD x 5 days,



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Warm saline gargles, Betadine gargles, steam inhalation.

Other symptomatic treatment may be given accordingly.

Routine antenatal care though telemedicine.

Report to facility – Persistence of symptoms, Worsening of symptoms,

Danger symptoms and signs (specified as below) or/ and any obstetric

complaint.

Danger symptoms and signs- (ASHA workers to be sensitized)

Difficulty in breathing with RR>24

Oxygen saturation below 94% on a fingertip pulse oximeter,

A persistent fever of 100.4 or higher for more than 24 hours,

Persistent pain or pressure in the chest,

Unremitting cough,

Mental confusion or inability to wake up, slurred speech, seizures,

weakness or numbness in any limb or face,

Bluish discolouration of lips or face,

Signs of onset of any organ dysfunction such as hypotension and

drowsiness, decreased urine output.

Any obstetrical complaint such as Preterm contractions, Vaginal Bleeding

or decreased fetal movements.

Category II b- Mild Disease with Co morbidity and/ or obstetric

complaint or indication

Clinical features-

Cough, malaise headache, myalgia, fatigue, sore throat, nasal symptoms

fever (>37.8), chills, loss of smell/taste, diarrhea.

No shortness of breath or hypoxia.

Investigations*- Routine antenatal investigations + CBC, CRP (if possible)

Facility based care.

Complete initial work up at the facility.

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Supportive care, adequate nutrition, plenty of oral fluids to maintain

adequate hydration

Oral Paracetamol 650 mg; may be repeated every 4-6 hours.

Tab Azithromycin 500 mg OD x 5 days,



Warm saline gargles, Betadine gargles, steam inhalation.

Other symptomatic treatment may be given accordingly.

Management of obstetric condition as per standard obstetric guidelines.

Category III - Moderate disease

(All Trimesters)

Clinical feature-

Shortness of breath,

Pneumonia,

Loose stool, vomiting, severe headache,

Respiratory rate≥ 24/min

Saturation 90-94% on room air with no signs of severe pneumonia/ illness.

Mild disease symptoms persisting beyond 5 days.

Investigations-

CBC

Blood sugar

CRP– 48 to 72 hourly

D-dimer– 48 to 72 hourly

S. Ferritin 48-72 hourly,

LFT, KFT 24-48 hourly,

IL-6 if deteriorating ,

Chest X-ray, HRCT (With abdominal shield) in consultation with physician.

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Management-

Facility based management- Dedicated Covid Health Centre (DCHC) or

District Hospital or Medical College.

Multidisciplinary approach.

Oxygen support to maintain SpO2 >95%- Non Re breathing Masks( NRBM)

Awake proning with 2 hourly change in position.

Steroid therapy-

a) Start in consultation with physician.

b) Inj. Methyl Prednisolone 0.5 – 1 mg/kg in 2 divided doses (or Inj.

Dexamethasone)

c) Switch to oral when stable or improving.

Anti coagulation- start in consultation with physician

a) Not to be started if patient is in labour or labour is imminent in next

24 hours.

b) Rule out any blood dyscrasias.

c) Rule out – Hemorrhagic Obstetric conditions eg- APH.

Monitoring –

a) Clinical – Pulse rate, Blood Pressure, SPO2, Temperature, fetal

monitoring

b) Laboratory investigations/ imaging- as per protocol

Antivirals – As per recommendation of physician

Remdesivir – In pregnancy, the use of remdesivir has not been well tested

however, the discretion lies on the treating physician based on the severity of the

disease and the risk benefit ratio, after ruling out any other contraindication like

deranged hepatic and renal function. However, no fetal toxicity has been reported

till date.

Referral- a) Information to be sent to the referred centre

b) All the documents explaining in detail the findings, treatment given

and investigations done, to be provided to the patient.

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c) Patient to be sent with oxygen support.

d) Tab. Dexona 6 mg stat or Tab Methylprednisolone 16 mg stat or

Inj.Methyl prednisolone 0.5 to 1 mg/ kg x stat ( as per the

availability)

e) Injection Ceftriaxone 1 gram,IV stat.

Category IV- Severe Disease

Clinical Feature – Clinical signs of pneumonia with Respiratory Rate ≥ 30/min, SpO2

<90% or ARDS, Sepsis, Septic shock, MODS.

Investigations: CRP, D-dimer, S. Ferritin 48-72 hourly, CBC, LFT, KFT 24-48 hourly,

IL6 if deteriorating, Chest X-ray, HRCT with abdominal shield.

Management

Facility based care-Tertiary level healthcare facility.

Multidisciplinary approach with physician and intensivist .

Patient to be shifted on oxygen to a Covid care equipped centre.

Ensure that there is no obstetric emergency or delivery is not imminent prior to

shifting.

Give supplemental oxygen therapy to target SpO2 >94% during resuscitation

and >90% for stable and recovering patients. Choice of oxygen support HFNC,

NIV, Mechanical Ventilation as per the condition of the patient and decision of

Anaesthesiologist/ Intensivist.

Injectable antibiotics as per institutional protocol.

Steroid therapy as per protocol in consultation with physician.

Anticoagulation as per protocol in consultation with physician and intensivist

after ruling out labour/ imminent labour/ obstetric hemorrhagic conditions.

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Referral criteria:

Assess the clinical status prior to referral to a designated Covid facility.

If the patient is in active labor or any other high risk related to obstetrics that

needs to be attended on priority before referral.

Inform the facility beforehand about the transfer.

Patient with Moderate illness (RR>24, SPO2-90-95%) should be referred to

DCH/Medical College on O2 therapy.

Patient with Severe illness (RR>30, SPO2<90%) should be transferred to

DCH/Medical College on HFM on O2.

Tab. Dexona 6 mg stat or Tab Methylprednisolone 16 mg stat or Inj.Methyl

prednisolone 0.5 to 1 mg/ kg x stat ( as per the availability)

Injection Ceftriaxone 1 gram,IV stat.

Intra-partum Care:

The timing of delivery will be determined as per the clinical condition of the

mother and the standard obstetric guidelines. It is reasonable to postpone

delivery if there are no other medical or obstetrical indications for the same.

However, if indicated, decision of delivery should not be deferred just

because of Covid positive status of the patient

Once settled in an isolation room, a full maternal and fetal assessment should

be conducted to include:

a) Assessment of the severity of COVID-19 symptoms, which should

follow a multidisciplinary team approach including a physician and/or

critical care intensivist.

b) Confirmation of the onset and stage of labor, as per standard care.

c) Fetal monitoring

Maternal observations including temperature, respiratory rate & oxygen

saturation.

Hourly oxygen saturation has to be monitored during labor.

Aim to keep oxygen saturation >94%, titrating oxygen therapy accordingly.

Avoid volume overload in all stages of labor.

Electronic foetal monitoring using cardiotocograph (CTG) as per standard

protocol.

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There is currently no evidence to favour one mode of birth over another.

Mode of birth should not be influenced by the presence of COVID-19, unless

the woman’s respiratory condition demands urgent delivery. Hence the

interventions and decisions will be as per the standard obstetric guidelines.

In case of deterioration in the woman’s symptoms, make an individual

assessment regarding the risks and benefits of continuing the labor, versus

emergency caesarean birth if this is likely to assist efforts to resuscitate the

mother.

Regional anesthesia to be preferred as far as possible in case of caesarean

section as GA can be an aerosol generating procedure.

Baby Trolley should be placed 2 meter away from delivery table/ operating

area.

Delayed cord clamping should be done unless indication for early clamping.

Active management of third stage of labor (AMTSL) for all patients. Avoid

Carboprost in cases of PPH.

Breast feeding taking care of Covid appropriate precautions.

Postpartum Care:

Illness to be classified as mild, moderate and severe based on symptoms

and to be treated similar to non pregnant patients.

Breastfeeding and Rooming-in to be allowed following Covid appropriate

behavior.

Counseling for PPIUCD should be done for stable patients.

Vaccination.

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5. Breast-feeding and the COVID-19

infected mother

There is no evidence that COVID -19 is secreted in breast milk. As breast milk is the

best source of nutrition and general immunity for the infant, early initiation of breast

feeding should be done and initiated in golden hour.

In the light of the current evidence, it is advised that the benefits of breast feeding

outweigh any potential risks of transmission of the virus through breast milk.

Adherence to infection prevention and control measures essential while breast feeding

should be followed.

WHO recommends that mothers with suspected or confirmed COVID-19 should been

courage to initiate or continue to breastfeed. The main risk for infants of breast feeding

is the close contact with the mother, who is also likely to share infective air borne

droplets.

The following precautions should be taken to limit spread to the baby:

I. If the baby is roomed-in, it is better to keep the baby at a distance of more

than one metre from the mother except for the duration of breastfeeding.

II. Pregnant woman should wash her hands before and after touching her baby

III. She should wear a mask (preferably N95)

IV. She should avoid coughing or sneezing while breastfeeding

V. All surfaces should be kept clean and disinfection should be done.

VI. If a mother does not wish to feed the child directly, she can express her breast

milk by hand or by a pump. If a pump is used, it should be kept separate and

instructions on keeping it clean should be followed. The mother should follow

hand hygiene.

VII. The expressed milk should be fed to the baby by another individual who is

not infected.

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6. Post-natal Care

The various aspects of post-natal care that need to be addressed including counselling

about nutrition, perineal, breast, hand hygiene, counselling about birth spacing and

family planning and advice on early mobilization and gentle exercise. Iron and folic

acid, calcium supplementation should be provided for at least 6 months after delivery.

Tab Vit C, Multi vitamin with Zinc for 6 weeks.

A suspected/confirmed COVID-19 mother should be kept in a separate room with a

strict watch for respiratory status and symptoms. Standard practices of routine postnatal

care and hygiene maintenance should be practiced.

i. Postnatal care of the mother infected with COVID -19 should include

continued medical evaluation for respiratory status and symptoms and

standard practices of routine postnatal care.

ii. 3 months post COVID-positive and delivery, all women in the post-

partum period must be evaluated for multi-organ functioning.

iii. She should be encouraged to maintain the good practices of hygiene

related to the puerperium and hand hygiene.

iv. Advice should include management of engorged breasts when feeding has

not been established and measures to enhance breastfeeding after the

isolation period is completed.

v. She should consume a healthy, nutritious diet to recover from the

infection and build immunity.

vi. The discharge card from the maternity unit should have advice about

COVID- 19 infection in addition to the usual post-delivery instructions.

It should emphasize social distancing and need for evaluation if

symptoms of acute respiratory illness (SARI) arise after delivery.

vii. The mother who is recovering from an acute illness and/or is isolated from

the infant may be at risk for developing anxiety, postpartum depression

and other mental health issues. She should be offered counselling and

psychological support.

viii. Some women may need a psychiatrist's consultations. These interventions

can be safely provided by tele-consultation 104 Call Centre or E-

Sanjeevani. After an individual (and especially a pregnant woman)

recovers, they may face stigma of the disease. There should be widespread

community awareness of recovery and de-stigmatization campaigns.

ix. Further into the puerperium, the couple should follow contraceptive

practices as per their informed choice.

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7. Referral Protocols

I. Birth preparedness and complication readiness especially for PW in last month of

EDD and for SOS calls is the key.

II. Map referral and referring facilities

III. One person responsible for referral (preferably Nursing in-charge of the LR/OT).

IV. Ensure that complete of case records are sent with the patient and mention the

reason for referral

V. Prior to referring, the facility should telephonically contact the referral facility and

confirm the availability of resources for the management of PW with Covid-19.

Mapping of Health Facility

Name of Nodal

Person and

Contact

Number

Nearest Non

COVID health

facility

Dedicated

COVID health

centre

Dedicated

COVID

Hospital

Private Hospital

with CEmONC

facilities

standard protocols and specific measures to be followed

Documents