Coronavirus COVID-19 | Evidence Based Birth® Resource Page
A SPECIAL MESSAGE FROM DR. REBECCA DEKKER
Founder and CEO of Evidence Based Birth®
It’s Rebecca, here. I know this is an uncertain time and many are feeling a range of emotions. Our goal remains the same: to provide you with friendly, accessible, evidence based information so that you can make informed decisions
During a global pandemic, our goal is more important than ever.
At Evidence Based Birth®, we are continually monitoring the situation and our research team is examining the best available resources. We will keep this page updated with relevant information for both pregnant parents and birth professionals.
Wishing you calm and a sense of peace,
VIRTUAL DOULA SUPPORT FOR BIRTHING FAMILIES DURING COVID-19
Evidence Based Birth® has created a Virtual Doula Directory, populated by our Professional Members and Instructors. We know that birthing during a pandemic can be fraught with uncertainty, confusion, and even anxiety. We believe now, more than ever, birthing families will benefit from the support of a doula. Knowing many hospitals are restricting visitor access, the birth world has responded by increased virtual support options. We have collected some of the best of the best options for you!
Virtual Doula FAQs
What is a Virtual Doula?
A Virtual Doula provides education, comforting affirmations, and reassuring support throughout pregnancy, birth and the postpartum transition. You will be supported in a similar way as a traditional in-person doula, except services will be conducted virtually.
What does it look like to be supported by a Virtual Doula?
Virtual Doulas will likely meet for your prenatal consultations via video chat, and will still be available to answer any questions via phone, text, or email. For your birth, a virtual doula will likely use a video meeting platform and provide you with comfort measures and laboring techniques that you previously rehearsed and discussed. How virtual doula support is conducted varies from doula to doula – be sure to ask in your interview what the doula’s support package looks like!
Why would I hire a Virtual Doula?
Navigating birth during this unprecedented pandemic, having a virtual doula on your team for support is a great option for when a doula is not able to attend your birth in person.
What kinds of interview questions should I ask?
You should ask the same interview questions you would ask during a normal doula interview – including, and especially, what the virtual doula’s backup options are.
VIRTUAL CHILDBIRTH EDUCATION FOR BIRTHING FAMILIES DURING COVID-19
Evidence Based Birth® has moved its pioneering Childbirth Class completely online, taught by our Evidence Based Birth® Instructors. The best way to get enrolled in our completely online Childbirth Class is to contact your local Instructor.
The Evidence on COVID-19
Webinar Replay | Monday, March 23rd 2020
Official Public Health and Relevant Organizations
Parent and Birth Worker Advocacy
Evidence Based Birth® Communications & Resources
Research update from Monday, March 30 at 11:30AM
Numbers Update from Johns Hopkins University
As of 10 AM EDT this morning, there are 740,157 confirmed cases of COVID-19 around the world. The U.S. now has the highest number of cases at 143,532, followed by Italy, Spain, China, and Germany.
What new research has come out this week?
- There is new research showing that mother-to-baby transmission during pregnancy or birth (vertical transmission) may be possible with COVID-19. The evidence is not conclusive, and even if vertical transmission does occur, we don’t know how many pregnancies are affected or how infection during pregnancy affects the baby. An earlier case series of nine infected pregnant women in China found no evidence of mother-to-baby transmission, but researchers have continued to search for the possibility.
- Two articles came out this week in JAMA:
- A case report published March 26 describes a single mother-infant pair in Wuhan, China (Dong et al. 2020). The mother’s nasopharyngeal swab was positive for the virus. The baby was born by Cesarean in a negative-pressure isolation room (the reason for Cesarean was not reported). The mother wore an N95 mask during the Cesarean and was immediately separated from the baby without any physical contact. The baby had good Apgar scores but was quarantined in the NICU as a precaution. Results of 5 swabs from the infant were all negative for the virus. The baby did have SARS-CoV-2 Immunoglobulin G (IgG) and Immunoglobulin M (IgM) antibodies present in their blood two hours after birth. Since IgM does not typically cross the placenta, the researchers think this likely represents an immune response to in utero infection. IgG antibodies in the newborn could represent either maternal or infant infection with the virus. They think the baby was infected in utero because IgM antibodies usually do not appear until 3-7 days after infection, and the IgM antibodies in the newborn were detected in a blood sample drawn two hours after birth. The infected mother’s vaginal fluids and breast milk were tested and they were negative. There was no testing of amniotic fluid or placenta. Both mother and baby were discharged without any reported complications.
- A case series of six pregnant women with mild COVID-19 pneumonia in Wuhan, China was published March 26 (Hui Zeng et al. 2020). All six mothers had Cesareans (again, the reasons for the Cesareans were not reported). They all wore masks in negative pressure isolation rooms and the infants were isolated from their mothers immediately. All of the infants had good Apgar scores and they all tested negative for the virus. All six of the newborns had virus-specific antibodies detected in their blood at birth. Five of the infants had elevated IgG concentrations (IgG crosses the placenta) and two of the infants had elevated IgM (which is not usually transferred from mother to fetus through the placenta because of its larger structure). The authors propose two explanations for the elevated IgM: either the virus crossed the placenta leading the fetus to produce its own IgM, or, the mothers had damaged placentas and that allowed the IgM to cross to the baby. There was no information on the clinical outcomes of the infants or mothers.
- An editorial response to these two articles (also in JAMA) cautioned that “these data are not conclusive and do not prove in utero transmission” (Kimberlin and Stagno, 2020). They say that IgM is a challenging way to diagnose in utero infections because IgM tests can be prone to false-positive and false-negative results and other testing problems. So, it’s possible that the laboratory findings in the three infants with elevated IgM are not evidence of true in utero infection with SARS-CoV-2.
- A third article exploring the possibility of pregnant parent-to-baby transmission came out on March 26 in JAMA Pediatrics (Lingkong Zeng, et al. 2020).
- This article reviewed details of 33 infants born to mothers with COVID-19 pneumonia in a hospital in Wuhan, China. Unlike the other two studies, they didn’t examine virus-specific antibodies in the infants. However, they reported that three of the 33 infants tested positive for the virus on day two of life. All three of the infants who tested positive were born by Cesarean. No deaths were reported.
The reported reasons for the Cesareans were 1) meconium-stained amniotic fluid and confirmed maternal COVID-19 pneumonia; 2) confirmed maternal COVID-19 pneumonia; and 3) fetal distress and confirmed maternal COVID-19 pneumonia. The authors think it’s likely that the three newborns acquired their infections from their infected mothers during pregnancy, since strict infection control and prevention procedures were in place during the Cesarean surgeries. However, since the babies were not tested until two days after birth, it’s possible that the infections did not happen inside the womb. For example, the infants could have contracted the infection from infected health care workers.
First systematic review and meta-analysis of coronavirus infections during pregnancy
- An article published in AJOG MFM on March 25 explored pregnancy and birth outcomes of coronavirus infections occurring during pregnancy (Di Mascio et al. 2020).
- They included all reports of hospitalized pregnant people with three different confirmed coronavirus illnesses (SARS, MERS, or COVID-19). The authors note that since all of the included cases were hospitalized, they may not reflect the overall population (infected mothers with mild or no symptoms may have better pregnancy and birth outcomes compared to infected mothers who are hospitalized with their illness). Altogether 19 studies with 79 pregnant people were included: 41 pregnancies affected by COVID-19, 12 by MERS, and 26 by SARS.
- Focusing on COVID-19 (six studies, 41 hospitalized infected pregnant people):
- The rates of admission to ICU (9%), use of mechanical ventilation (5%) and maternal death (0%) were all significantly lower compared to the rates with MERS and SARS.
- The rate of preeclampsia was 14%.
- There was no data on miscarriage.
- There were no reported cases of fetal growth restriction.
- The most common poor pregnancy outcome was preterm birth <37 weeks (41% of cases). Note that it is unclear whether the infection caused early labor, or whether medical providers intervened with early birth out of concern for the mother’s health. We know that preterm prelabor rupture of membranes was reported to have occurred in 19% of cases, but the rate of Cesarean was also very high (91%). The authors advised that “…COVID-19 cannot be considered as an indication for delivery and therefore the timing and mode of delivery should be individualized according to maternal clinical conditions or obstetric factors as usual (and not COVID-19 status alone)…”
- The rate of fetal distress was 43% and 9% of newborns were admitted to the NICU.
- The rate of stillbirth or newborn death with maternal COVID-19 infection was 7% (including one stillbirth and one newborn death).
- The authors concluded that pregnancies with coronavirus infections, including COVID-19, are at increased risk of miscarriage, preterm birth, preeclampsia, Cesarean, perinatal death, and admission to the NICU, compared to the general population. However, we think it’s important to point out that the limited data specifically on COVID-19 infection in pregnancy show better outcomes compared to SARS and MERS (grouping them all together may not be appropriate and could be unnecessarily anxiety-provoking for birthing families).
Early lessons on COVID-19 and pregnancy published in AJOG MFM
- This article presents details of seven cases of confirmed COVID-19 in pregnancy at a single large New York City tertiary care hospital (Breslin et al. 2020).
- Five of the seven patients presented to the hospital with symptoms of COVID-19 including cough, fever, chest pain, muscle aches, and headache. Importantly, two of the seven patients had no symptoms—they came to the hospital for medically indicated labor inductions (the first for poorly-controlled type 2 diabetes and a liver disorder and the second for chronic hypertension). Both women started having symptoms of COVID-19 after birth and required intensive care unit admission.
- An estimated 15-20 healthcare workers were exposed to each of these two asymptomatic patients without adequate PPE prior to diagnosis with COVID-19. The authors write that, ideally, health care workers would wear N95 masks for all births, including those with unknown COVID-19 status. They also say that surgical masks should be worn at all times by patients coming to labor units and inpatient staff.
- The main takeaway from this case series is that “there is currently no easy way to clinically predict COVID-19 infection in asymptomatic people.”
Updated guidance for pregnant healthcare workers (HCWs)
- The Royal College of Obstetricians and Gynecologists (RCOG) updated their guidance for pregnant HCWs on March 26, available here (Rimmer, 2020).
- They recommend that pregnant HCWs of any gestation be offered the choice of whether or not to work directly with patients during the pandemic. Alternative duties might include remote triage, telephone consultations, or administrative roles.
- Prior to 28 weeks of pregnancy, pregnant HCWs who choose to work directly with patients should follow established methods of reducing risk of transmission (i.e. the use of appropriate PPE and risk assessments). If possible, they should avoid working with patients with confirmed or suspected COVID-19 in environments where a higher number of aerosol-generating procedures are performed (e.g. operating rooms, respiratory wards, ICUs).
- Pregnant HCWs after 28 weeks of pregnancy or with underlying health conditions such as heart or lung disease should take more precautions. It is recommended that that they stay home and avoid direct contact with all patients.
- It is worth noting that RCOG updates their guidance on COVID-19 infection in pregnancy frequently. Access Version 5 here (updated March 28).
Updated guidance on personal protective equipment (PPE)
- An expert review on “Labor and Delivery Guidance for COVID-19” was published online March 25 in AJOG MFM (Boelig et al. 2020).
- With regard to PPE, the review article recommends, “Given the risk of asymptomatic carriers and transmission, it should be the goal of every unit that every patient wear a surgical mask and every provider have a surgical mask for each patient encounter.” Obviously, this goal is limited by supply. They recommend that providers wear an N95 respirator instead of a surgical mask when they are caring for someone with suspected or confirmed COVID-19 or performing an aerosol generating procedure.
What is the difference between a surgical mask and a N95 respirator mask?
- The U.S. Centers for Disease Control (CDC) has a great infographic explaining the difference here.
- N95 means that the mask can filter out at least 95% of particles of all sizes from the air. It must fit tightly to the user’s face. A surgical mask does not protect the wearer from inhaling small airborne particles and is not considered respiratory protection. It protects the user from microorganisms in large droplets and sprays.
- A systematic review and meta-analysis published online March 13 compared the effectiveness of N95 respirators versus surgical masks against influenza (Long et al. 2020) (Note: this study was about masks and influenza, not masks and COVID-19). They included six RCTs with 9,171 participants. There was no significant difference in the risk of laboratory-confirmed influenza with N95 respirators versus surgical masks. Thus they recommend that N95 respirator masks should not be used by the general public to prevent influenza, but instead reserved for those with close contact with influenza patients or suspected patients. They state that “surgical masks are primarily designed to protect the environment from the wearer, whereas the respirators are supposed to protect the wearer from the environment.”
Boelig, R., Manuck, T., Oliver, E., et al. (2020). Labor and Delivery Guidance for COVID-19. American Journal of Obstetrics & Gynecology MFM. Click here.
Breslin, N., Baptiste, C., Miller, R., et al. (2020). COVID-19 in pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM. Click here.
Di Mascio, D., Khalil, A., Saccone, G., et al. (2020). Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM. Click here.
Dong, L., Tian, J., He, S., et al. (2020). Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA. Click here. Free full text!
Kimberlin, D. W. and Stagno, S. (2020). Can SARS-CoV-2 Infection Be Acquired In Utero? More Definitive Evidence Is Needed. JAMA. Click here. Free full text!
Long Y, Hu T, Liu L, et al. (2020). Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis [published online ahead of print, 2020 Mar 13]. J Evid Based Med. Click here.
Rimmer, A. (2020). Covid-19: doctors in final trimester of pregnancy should avoid direct patient contact. BMJ. Click here.
Zeng, H., Xu, C., Fan, J., et al. (2020). Antibodies in infants born to mothers with COVID-19 pneumonia. JAMA. Click here. Free full text!
Zeng, L., Xia, S., Yuan, W., et al. (2020). Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. Click here. Free full text!
Research update from Monday, March 23 at 9PM
SARS-CoV-2 is the 7th coronavirus known to infect humans (Mullins et al. 2020)
- 4 human coronaviruses cause the common cold
- 3 human coronaviruses cause more severe, acute illnesses; MERS-CoV causes Middle East Respiratory Syndrome (MERS), SARS-CoV causes severe acute respiratory syndrome (SARS), and SARS-CoV-2 causes COVID-19
The main way the virus spreads is person-to-person. This virus can be isolated from respiratory secretions and feces. A new study found that the virus is also stable on surfaces for up to several days. The study was conducted by scientists from the National Institutes of Health, CDC, UCLA and Princeton University and was published March 17 in The New England Journal of Medicine (van Doremalen et al. 2020).
- SARS-CoV-2 was detectable in aerosols for up to three hours, up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel.
- The results suggest that people may acquire the virus through the air and after touching contaminated objects.
A new study from Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, confirms that the median incubation period of the new virus is around 5 days, meaning that about half of the people who contract SARS-CoV-2 will start showing symptoms at that point in time.
- The study was published in the Annals of Internal Medicine on March 10. There were 181 confirmed cases with identifiable exposure and symptom onset windows to estimate the incubation period of COVID-19. The median incubation period was estimated to be 5.1 days (95% CI, 4.5 to 5.8 days), and 97.5% of those who develop symptoms will do so within 11.5 days (CI, 8.2 to 15.6 days) of infection.
How long are you contagious? A retrospective review of adult patients in China with lab-confirmed COVID-19 found the median length of viral shedding was 20 days in survivors. The longest observed duration of viral shedding was 37 days (Fei Zhou et al. 2020).
To date, no evidence of parent-to-baby transmission during pregnancy has been published. Samples of breastmilk, cord blood, placenta, and amniotic fluid from infected pregnant people have all been negative.
- An infected newborn could have acquired the infection from health care workers or the infected mother immediately after birth, not necessarily during the womb or during birth.
Johns Hopkins University has a great resource for the latest COVID-19 figures (confirmed cases, deaths, recovered) here.
Instead of large studies, we only have the details from individual reported cases at this point. Researchers are grouping these cases together to analyze the data. Mullins et al. in the U.K. published a “Rapid Review” of COVID-19 in pregnancy and birth.
- So far, there is no evidence that pregnant people are at greater risk of infection or severe illness with COVID-19 (they are only considered a ‘vulnerable group’ as precaution).
- They reviewed reports from China on 32 infected pregnant women and 30 babies (one set of twins and three ongoing pregnancies).
- There have been no reported maternal deaths.
- 7/32 mothers (22%) were asymptomatic
- 2/32 (6%) were admitted to the ICU, 1 with severe pneumonia
- 27 mothers had Cesareans, 2 had vaginal births. We don’t know why the Cesarean rate was so high among these mothers.
- Women gave birth within 13 days of onset of illness. The authors mention that fetal growth is unlikely to be affected in this time period.
- There was one stillbirth that occurred to a mother who presented at 34 weeks with a fever and sore throat; her condition worsened to severe pneumonia; she required ICU and life support (extracorporeal membrane oxygenation or ECMO). She had a stillbirth by Cesarean. (Yangli Liu)
- The one newborn death occurred when a baby died after being born at 34 weeks. The baby was admitted to ICU 30 minutes after birth with respiratory difficulties. The baby developed shock, multiple organ failure, and died at 8 days postpartum. (Zhu)
- This is not enough evidence to know if COVID-19 infection increased the risk of harm to babies. However, the high number of preterm births is concerning; it could mean tremendous pressure on newborn health services if the infection is widespread. With these case reports of preterm birth in women with COVID-19, it is unclear whether the preterm births were always because of medical intervention by Cesarean, or whether some were spontaneous preterm labors that resulted in Cesareans. Cesareans were predominantly for maternal indications related to the viral infection, although there was evidence of fetal distress in at least 7 reports (Mullins et al.) and prelabour PROM, in at least one report (Zhu et al.).
- We don’t have any data on outcomes with COVID-19 infection in the 1st trimester.
To get evidence on which treatments are most effective, WHO and its partners are organizing a large international study, called the Solidarity Trial, to compare different treatments. They announced the trial on Friday, March 20. It will be a global megatrial of the four most promising coronavirus treatments. Click here.
We recommend you watch the Royal College of Obstetricians and Gynecologists (RCOG) practice guidance on COVID-19 because they are updating it very often. The most current (fourth) version is here.
Lauer, S. A., Grantz, K. H., Bi, Q., et al. (2020). The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 [Epub ahead of print 10 March 2020]. Click here.
Mullins, E., Evans, D., Viner, R. M., et al. (2020). Coronavirus in pregnancy and delivery: rapid review [published online ahead of print, 2020 Mar 17]. Ultrasound Obstet Gynecol. Click here.
Schwartz, D. A. (2020). An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes [published online ahead of print, 2020 Mar 17]. Arch Pathol Lab Med. Click here.
van Doremalen N, Bushmaker T, Morris DH, et al. (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 [published online ahead of print, 2020 Mar 17]. N Engl J Med. Click here.
Zhou F, Yu T, Du R, et al. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published online ahead of print, 2020 Mar 11] [published correction appears in Lancet. 2020 Mar 12;:]. Lancet;S0140-6736(20)30566-3. Click here.
Research Update from Monday, March 16 at 1:57pm
Last Friday, we sent out an email with the latest research evidence on COVID-19 and pregnancy. Our research team plans to send out updates on this topic every Monday, starting today.
We also created a COVID-19 resource & pregnancy page that will include links to the most important websites, archives of our newsletters, and any other info we think you might find useful (such as resources for doulas who are encountering visitor bans). You can access that page here.
Research Update from Monday, March 16:
- According to the World Health Organization’s (WHO) most recent situation report here, there are now over 153,000 confirmed cases and 5,735 deaths globally
- The WHO published interim guidance on March 13, 2020, here.
- There is little research on the clinical presentation of COVID-19 in pregnant women and children
- There have been a few cases of infants with COVID-19 and they experienced mild illness
- So far, there is no evidence of mother-to-baby transmission, and when researchers tested women who were infected, the samples of amniotic fluid, cord blood, vaginal discharge, newborn throat swabs, and breast milk have all been negative.
- Some reports of PROM (premature rupture of membranes), fetal distress, and preterm birth have been reported when mothers became infected in the third trimester
- The mode of birth should be individualized and Cesarean used only when it is medically justified
- Standard infant feeding guidelines should be followed with appropriate precautions for infection prevention and control. These standard guidelines include initiating breastfeeding within 1 hour of birth and continuing to exclusively breastfeed for 6 months, continuing breastfeeding up to 2 years or beyond. Infected mothers who are breastfeeding or practicing skin-to-skin should wear a medical mask, perform careful hand hygiene, and clean and disinfect all surfaces. Infected mothers should still be provided with breastfeeding support. If complications prevent the infected parent from breastfeeding, they should be encouraged and supported to express milk for the infant for someone else to feed to the baby or to maintain milk supply. There should be no promotion of breastmilk substitutes (formula) or pacifiers.
- “Mothers and infants should be enabled to remain together and practice skin-to-skin contact, kangaroo mother care and to remain together and to practice rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.”
- The Centers for Disease Control and Prevention (CDC) in the Unites States (U.S.) publishes situation summaries here
- The CDC has a pregnancy/breastfeeding and COVID-19 page here
- ACOG Practice Guidelines: The American Congress of Obstetricians and Gynecologists published a practice advisory on March 13, 2020.
- ACOG has worked with the Society for Maternal Fetal Medicine to develop an algorithm that can be used to assess and manage pregnant women with suspected COVID-19.
- They encourage care providers to read and familiarize themselves with the complete list of recommendations from the CDC about inpatient obstetric facilities (see below).
- ACOG refers to the CDC guidance on breastfeeding and COVID-19 infection. They state, “Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.”
- CDC Interim Guidance on Inpatient Obstetric Healthcare
- The CDC has released interim guidance on caring for pregnant women with suspected or confirmed COVID-19 in the inpatient hospital setting.
- In contrast to the WHO, the CDC recommends separation of a newborn from a mother with confirmed or suspected COVID-19: “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.”
- The guidance goes on to say, “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.”
- UpToDate® guidance for clinicians here.
- There is very little info regarding COVID-19 during pregnancy
- Mother-to-baby transmission during pregnancy or birth has not been identified
- There have been at least two newborn cases documented
- Pregnant people are more susceptible to infectious diseases due to immune suppression during pregnancy
- Other respiratory infections—(SARS)-CoV, (MERS)-CoV, and influenza—have been shown to develop into more severe disease in pregnant people
- Out of 18 pregnant women with confirmed or suspected infection, there was no laboratory evidence of transmitting the virus to the newborn
New research on PubMed: A retrospective study reviewed the clinical and CT imaging features of 59 people in China with COVID-19. This group included 14 non-pregnant adults with lab-confirmed infection, 16 pregnant women with lab-confirmed infection, 25 pregnant women with clinically diagnosed infection, and 4 children with lab-confirmed infection (Liu et al.)
- All of the pregnant women had mild illness. None were admitted to ICU and none of the babies had abnormalities or evidence of mother-to-baby transmission.
- Compared with the non-pregnant adults, the pregnant women (both lab-confirmed and clinically diagnosed) had atypical clinical features, making early detection difficult. It was more common for pregnant people to have an initial normal temperature—only 36% to 44% had a fever. This means that fever may not be as useful of a screening tool with pregnant people.
- It was also more common for the pregnant people with infection to have leukocytosis (increase in white blood cells) and elevated neutrophil ratio (a marker of inflammation) compared to the non-pregnant people with infection.
For other research updates that we sent out last week, view our COVID-19 resource page here.
Rebecca Dekker, PhD, RN
Founder, Evidence Based Birth®
'Here's the Evidence on COVID-19 + an upcoming Relaxation session' Newsletter from Fri, Mar 13, 5:29 PM
At Evidence Based Birth®, we are continually monitoring the situation and our research team is examining the best available resources. Here is what we can share with you today:
> The latest evidence on COVID-19 and pregnancy:
- Here is the CDC’s FAQ about pregnancy and coronavirus disease. You’ll notice that a lot of the answers start with “We do not know…” It is an unfortunate reality that very little research has been published on pregnancy, birth, and COVID-19. Due to the emerging nature of the situation, I anticipate more research will arise in the coming weeks.
- The International Society of Ultrasound in Obstetrics & Gynecology issued new guidance for birth professionals on March 11, 2020 (Poon et al. 2020). This is the most recent professional guidance we were able to find today. For patients, their main recommendations were to:
- Avoid close contact with others, i.e. avoid gatherings where a distance of 1 meter between individuals can not be maintained
- Frequent hand washing or hand sanitizer (with 70% alcohol concentration)
- Seek medical attention when experiencing symptoms such as fever and cough (but call first before going in; see if telehealth is an option)
- Check out their article for detailed info about health care provider protection, suggestions on care for infected mothers and their babies, and more. They state that there is no evidence on the safety of mother-infant separation if the mother is infected. “If the mother is severely or critically ill, separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production. Precautions should be taken for the cleaning of the breast pumps. If the patient is asymptomatic or mildly affected, breastfeeding and [rooming-in] can be considered…Since the main concern is that the virus may be transmitted by respiratory droplets rather than breastmilk, breastfeeding mothers should ensure to wash their hands and wear a three-ply surgical mask before touching the baby.”
- A review article was published in the American Journal of Obstetrics and Gynecology on February 24 (Rasmussen et al. 2020). This article compares and contrasts the effects of SARS, MERS, and COVID-19 on pregnant women. They summarize the result from several small studies from China in which pregnant women with COVID-19 were followed. In one study with 9 pregnancies, 6 had intrauterine fetal distress, 7 gave birth by Cesarean , and 6 infants were born preterm. The symptoms in these women were similar to non-pregnant patients: fever, cough, muscle aches, sore throat, and fatigue.
- A case report was just published March 12 [online ahead of print] that reports the first case of COVID-19 infection in a newborn whose mother was also diagnosed with COVID-19 in China (Wang et al. 2020). The researchers are not sure how the baby caught the virus, since the baby was separated from its mother at birth and there were zero traces of the virus in breastmilk, cord blood, and the placenta. We don’t know if the virus can be transmitted through the placenta before birth. Fortunately, in this case, the illness was mild in both the mother and baby, and the baby’s prognosis was good.
- Dr. Aviva Romm, an MD specializing in integrative medicine, has posted some interesting articles on her website about pregnancy and COVID-19.
> Doula support in hospitals in light of the COVID-19 situation
Around the world, hospital visitation policies are becoming quite restrictive. It’s important to remember that doulas and partners are not visitors, rather, they are members of the health care team and their presence is critical to having safe birth outcomes. However, I know that parents are becoming anxious about the possibility of their doulas being turned away from the hospital (and doulas are worried, too!). As far as resources go…
- Birth Monopoly has an excellent article on this subject… I highly recommend absorbing the info there!
- EBB Instructor Jolynne Polichette posted a letter template for care providers to sign about doula support
- The American Association of Women’s Health and Obstetric and Neonatal Nurses has issued a statement on this subject.
We’ve heard from countless doulas, nurses, childbirth educators, expecting parents, and others that their anxiety is running high! With school and event closings, jobs being disrupted, the fear of infection, preparing to give birth or to support birthers in hospital settings, there is plenty to worry about. With that being said, I think it’s important to calm down our nervous systems and practice some intentional relaxation. I can personally attest that even though I am generally a calm person, today I felt my heart rate going up and fight/flight hormones kicking in at times. This means it’s time for me to do some deep abdominal breathing and mental relaxation techniques!
Given that many of us are in need of some anxiety-reducing techniques, I am going to lead a public relaxation session sometime this weekend. I will read a relaxation and deep breathing script for professionals, and I will also read a relaxation script for expecting parents. These sessions will take place on Instagram Live and Facebook Live. I will send out an email about 30 minutes before I go live. You’ll have to forgive me for not knowing the exact time… I will need to work it around my kids’ schedule.
> Online education
I know that childbirth education programs are being cancelled at hospitals in many places around the world. Fortunately, our EBB Childbirth Class was already 80% online, and we took steps this week to create a fully online class that EBB Instructors can use– it will be rolled out this weekend where it is needed.
So, if you’re looking for a comprehensive class that includes an emphasis on self-advocacy methods, comfort measures for labor, and evidence based care, you can check out our Events page to find an EBB Instructor near you. If social distancing is appropriate in your geographic area, then the class can be offered online. If the registration page doesn’t state whether or not the class will be offered online, feel free to email the individual Instructor to find out which method will be offered (80% online or 100% online). This is a brand new option, so registration pages might not reflect the change in method!
For those of you who don’t have a local Instructor in your geographic area, we’re hoping to have an online option open for registration in the next few weeks. This full online class will be taught by our EBB Instructors who work at EBB Headquarters. We know that people who don’t live near an Instructor have really been wanting this option, and we’re working on getting it up and running as quickly as possible!
We are also working on getting all of our other EBB Instructor Professional and Parent events and workshops online, wherever social distancing is appropriate or required.
Thanks for being part of our community, and I’ll be in touch as soon as I know what time I can lead the relaxation session! It will be recorded for those of you who can’t make it.
Rebecca Dekker, PhD, RN
Founder, Evidence Based Birth®
Author, Babies Are Not Pizzas: They’re Born, Not Delivered