C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

Standard Operating Procedure

Standard Operating Procedure for the COVID-19 testing for maternity admission, elective caesarean sections, elective

cervical cerclage & induction of labour during the COVID-19 Pandemic

CATEGORY: Standard Operating Procedure

CLASSIFICATION: Clinical

PURPOSE The aim of this standard operating procedure (SOP) is to provide a clear process for testing of all inpatient’s in maternity services.

Controlled Document Number: C140

Version Number: 1.0

Document Author: Irshad Ahmed (Labour Ward Lead)

Approved By: Medical Scientific Advisory Group (COVID-19)

Date / Time: 15/10/2020

Review Date: 30/04/2021

Distribution:

Recommended Reading for:

Clinicians, all non medical Prescribers, Pharmacists and nurses

Information for: Wards Managers, Senior Nurses, ADNs, Divisional Directors

This procedure applies to all practitioners and staff groups working within the Obstetrics and Gynaecology directorate within University Hospital Birmingham (UHB).

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

CLINICAL APPROVAL FOR:

Standard Operating Procedure

Testing maternity inpatients for COVID-19 during the current COVID-19 Pandemic

Name:

Title: Signature

Contents 1. Introduction

2. Flow chart 3

3. Who need testing & when 5

4. ‘COVID-protected’ elective pathway for elective caesarean section (C/S) 5

5. Care in labour 7

6. ‘COVID-protected’ elective pathway for induction of labour (IOL) 7

7. General Pathway for testing all maternity inpatients for COVID-19 (see flow chart) 8

8. References 8

Information Leaflet 9

Appendix 1: COVID-19 Swabbing instructions 12

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

1. Introduction

This standard operating procedure outlines the process for testing all inpatient for COVID-19.

This procedure aims to provide clear and concise instructions in regards to whom and how testing

should be carried out, how results should be obtained and how these results should be

disseminated to clinicians and the woman tested. This document has been written using the latest

Royal College of Obstetrics and Gynaecology, ‘Principles for the testing and triage of women

seeking maternity care of hospital setting, during the COVID-19 pandemic, version 1, published

29th May 2020’.

Offering testing to women who are admitted to the maternity unit will enable reduction in

nosocomial transmission. It is important that the testing process does not compromise the safety of

woman and her baby. Creation of elective caesarean section pathway with a 14-day pre-

admission self-isolation period for the woman and her household is very challenging for a variety of

reasons:

Onset of labour is unpredictable.

Some women require interventions at short notice.

Some women who are tested positive for SARS-CoV-2 pre-admission, on admission for

elective birth cannot be safely deferred to incorporate a 7-days isolation period.

Challenges for self-isolation community (children returning to school and household

members working).

Many women would require frequent access to antenatal care leading up to birth.

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

2. Flow Chart: Process of COVID-19 testing of maternity inpatients

Perform COVID-19 Swabs in all pregnant women:

Who are to be admitted as inpatient Booked for elective Caesarean section & cervix sutures Induction of labour (IOL)

Positive for COVID-19 or with suspected symptoms (see section 4)

Woman attends:

At GHH: maternity assessment unit, antenatal clinic (ANC), delivery suite At BHH: maternity day assessment unit, gynaecology assessment unit, ANC, patient assessment emergency unit,

delivery suite, Willow Suite, preterm prevention clinic At Solihull: ANC

Swabs will be done by midwife / maternity support worker (MSW).

If women decided to do home test: Provide the woman with the testing swab and instructions on how to perform test

Ensure that COVID-19 screening questions are completed on BadgerNet. Telephone pre-op for elective C/S from Mon to Fri at BHH & ensure that COVID-19 screening questions are completed on BadgerNet.

COVID-19 Swabs are performed within 72hrs prior to caesarean section, cervix suture & IOL

Community surveillance team will make frequent consultation call for 16 days if symptomatic. If continues to be symptomatic discuss with infectious diseases consultant.

Document result on Badger-Net Inform the woman, obstetrician, NNU & theatre teams. Escort woman & her birth partner to a side room (Maple/Cedar or D/S room 7 or 12) until their surgery. After surgery return to the same room Surgery done at the end of elective list

Once swab has been taken, ensure the patient details are correct and place swab and form in the courier bag provided for COVID-19 tests and send to microbiology. Document this on Badger-Net under microbiology test

Negative for COVID-19 Positive for COVID-19 or with suspected symptoms (see section 4)

Negative for COVID-19

Document result on badger-Net. Under microbiology tests- results reviewed. This creates a red flag alert Inform the woman, obstetrician, neonatal unit (NNU) and theatre teams. Escort woman & her birth partner to delivery suite room 7 or 12 at BHH) / any room on delivery suite at GHH for their IOL Postnatally Cohort all COVID-19 positive women in one bay or side rooms on the wards

Inform maternity COVID-19 maternity surveillance team who will add woman to tracker and conduct follow up telephone calls with the women post discharge.

Email address under section 7

Document result on Badger-Net Inform the woman and continue with IOL as normal

Document result on Badger-Net Inform the woman Continue with C/S list as normal

NB: Inform the neonatal team of all positive COVID-19 results.

Partners of women with positive test or women with symptoms, who have symptoms or have tested positive for COVID themselves must isolate at home and not attend the clinic

Induction of labour Elective caesarean section & Cervix suture

Delivery suite & ward midwives to check result for all women who require admission in the maternity unit

All COVID-19 swabs should be chased and followed up by the respective ward charge midwife.

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

3. Who need testing & when NHS England has recommended the following should have COVID-19 swabs done regardless of whether they have symptoms.

All women who are pregnant and admitted in the maternity unit.

All women who are having elective procedures {caesarean sections, cervical cerclage,

induction of labour (IOL)}.

Woman who has previously tested negative but subsequently becomes symptomatic of

COVID-19 must have a repeat test.

For women who tested negative on admission and stay for longer than five days in hospital

should be re-tested for COVID-19.

Women being discharged to a community care unit, e.g. mother and baby unit should be

offered a test within 48 hours prior to discharge.

It is important to be aware of:

COVID-19 testing is not compulsory thus a verbal consent must be obtained. The benefits

and implications of testing should be explained to woman and clearly documented in the

badger-net. Women who refused to have test, see section 4 under ‘For women without a

recent valid test result including women who refused test or test result un-available)’.

All women should receive Information about the SARS-CoV-2 test during her antenatal

period {via community midwife, antenatal clinic (ANC)}. This will be sent automatically via

Badgernet Maternity notes at booking, 28/40 and 36/40.

COVID-19 surveillance team should carry out daily review and communication of positive

results, including for women who are discharged.

Current COVID-19 Testing (RT-PCR) turnaround time at UHB is about 18 hours.

4. ‘COVID-protected’ elective pathway for elective caesarean section (C/S)

Women who are expected to be reviewed in the ANC between 32-34 weeks to discuss their

mode of delivery / booking of their elective caesarean section must be advised to self-

isolate including her partner for 14 days prior to their surgery if possible (see reasons

above).

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

Woman must have a COVID-19 swab taken 2-3 days before the surgery at her pre-

operative assessment together with her MRSA swabs. Pre-operative assessment (Pre-Op)

will take place in ANC at BHH & MAC (maternity assessment unit) at GHH.

All women will attend the ANC at BHH and MAC / ANC at GHH 2-3 days prior to caesarean

section. At this appointment woman should have their bloods, MRSA screening, Covid-19

screening will be done and COVID 19 triage completed via communication section of

Badgernet and Omeprazole pre-operative medication given.

Ask the woman to complete the COVID-19 test as shown in the written information.

(Appendix 1).

Please ensure that a consent form for caesarean section is completed in ANC if not

completed previously.

For women having their caesarean section on Monday or Tuesday will be asked to attend

the DAU (day assessment unit) or MAC on Saturday or Sunday, an appointment time will

be given to have their pre-op done as mentioned above.

The test result for woman should be available allowing for careful planning of the

caesarean list to accommodate the Covid-19 positive women at the end of the caesarean

list, and ensure these women are admitted to side rooms or cohosted on the postnatal

wards following surgery.

On the day of surgery:

Woman and birth partner arrives at Birmingham Heartlands Hospital at 07.30.

Maternity support worker (MSW) to check results of COVID-19 swabs.

Women and her partner to be asked about symptoms of COVID-19: via the COVID-19

triage checklist

The symptoms to ask about are:

o Recent fever

o Recent-onset persistent cough

o Loss or change in taste or smell

o Household contact with any of the above.

If woman is COVID-19 positive or suspected then admit them to one of the side room on

the Maple or Cedar ward (if unavailable then room 7 or 12 on the delivery suite) until her

surgery.

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

Women who have symptoms of COVID-19, positive COVID-19 swab or result of swab not

available should be scheduled at the end of the elective caesarean section list followed by

full postoperative theatre clean as per UHB Trust protection guidance.

Deferral of elective maternity admissions is usually not safe or appropriate. However,

where a woman receives a positive test result for SARS-CoV-2 prior to a planned

admission, deferral of the admission should be considered by a senior clinician. Measures

must be put in place to review fetal and maternal wellbeing where admission has been

deferred.

For women without a recent valid test result including women who refused test or test result un-

available): Women should be risk-assessed on their admission for their probability of COVID-

19 infection: If any of the above symptoms are present then infection is possible otherwise

infection is unlikely. In both cases schedule the surgery at the end of the list. However,

asymptomatic woman can be treated as non-COVID-19 patient and does not need isolation on

the ward.

NB: Women have remained asymptomatic during the 14 days of isolation period (if possible)

and received a negative SARS-CoV-2 test result within the 72 hours prior to admission can be

presumed ‘COVID protected’ and can be cohorted together.

For all women, appropriate PPE should be worn by staff per UHB PPE guideline.

5. Care in labour

Women who are confirmed COVID-19-positive or suspected or recent household exposure

should be treated as potentially or confirmed positive COVID-19 with regard to labour care.

Women who are risk assessed as unlikely to be currently infected with SARS-CoV-2 who

do not yet have a test result should be treated as though they do not have COVID-19 when

in labour.

6. ‘COVID-protected’ elective pathway for induction of labour (IOL)

All women who are having IOL should have COVID-19 swab taken 2-3 days before IOL.

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

Those women who are having IOL at very short notice should also have COVID-19 swab

taken as soon as possible or at admission.

Midwives on the delivery suite should check the swabs

Woman with positive result or suspected should have their IOL in dedicated labour room

(see flow chart).

7. General Pathway for testing all maternity inpatients for COVID-19 (see flow chart)

On presentation to assessment area e.g. PAER, MAC, DAU, ANC or delivery suite at Heartlands Hospital or at Good Hope Hospital the woman should be asked the SARS-CoV2 symptoms and the COVID 19 Triage questions completed on Badgernet under communication.

All women who are admitted as an inpatient must be tested, whether or not they are symptomatic for SARs-Covid2

The swab is to be given to the woman with clear instructions on how to complete the test (Appendix 1).

Once complete the midwife needs to document this under microbiology, tests on Badger-Net and the swab is to be sent in the appropriate carrier to microbiology.

All swabs taken for inpatients are to be forwarded onto the COVID-19 Surveillance Team via e-mail CovidMaternitySurveillance@heartofengland.nhs.uk

The COVID-19 Surveillance team will then follow up and communicate the results to the obstetric and midwifery staff and women via phone call.

8. References

1. Principles for the testing and triage of women seeking maternity care in hospital settings, during the COVID-19 pandemic: Royal College of Obstetricians & gynaecologist. 29 May 2020.

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

TESTING FOR COVID-19 in Pregnancy

(Patient information leaflet)

Why am I being offered screening for COVID-19?

Our priority is to keep you and your baby safe. That is why we are now testing all pregnant women who are admitted overnight to our hospitals, even if you don’t have any symptoms of COVID-19.

How is the swab taken?

The test for COVID-19 is a swab taken from your throat and nose (both nostrils).

Why do I need to have the screening test?

Knowing whether you have a positive or negative result helps us to plan the best care for you. This includes making sure you are placed in the most appropriate area for your care. It also provides you with the information so that you can protect yourself, your baby and those you live with.

If you are attending for a planned admission to hospital, self-isolate for 14 days before your admission date if possible. This will help protect you and your baby from the risk of contracting COVID-19.

However, it is still really important that you keep all of your antenatal appointments in both the hospital or with your community midwife during this self-isolation time. It is also important that you still contact the hospital and come in to be checked if you have any concerns, including concerns about your baby’s movements or any bleeding or abdominal pain.

How long does it take for the results to come back?

Results are usually ready within 18-24 hours. If you are having a planned admission for induction of labour or elective caesarean section, you will have your swab taken 2-3 days before the date of admission. You will be advised on the day of admission the result of your test.

What does it mean if I have a negative result?

It means at the time that the swab was taken, COVID-19 was not detected, and however it does not tell you if you have already had the infection. You must still take precautions to prevent infection including social distancing and regular hand washing.

What does it mean if I have a positive result?

It is unclear what the significance of a positive screening result is in the absence of any symptoms.

If you do not have any symptoms, it may mean that:

i) You have had a mild infection in the last 28 days; after the start of symptoms the test can remain positive for up to 28 days even though a person no longer has symptoms and is no longer infections.

ii) You have a current asymptomatic infection (infection without symptoms that you are aware of).

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

iii) You are currently incubating COVID-19 and will have symptoms of infection in a few days.

Unfortunately there is nothing that we can do to identify which of the above reasons apply to someone who has a positive result, which means that we have to treat anyone with a positive result as potentially infectious.

What do I need to do if I develop symptoms after the screening?

If you are incubating COVID-19 you can develop symptoms up to 14 days after the positive screening test; however most people would start to have symptoms within 1-4 days of the test. If you do develop symptoms, you must let us know, as pregnant women who have symptomatic COVID-19 have an increased chance of having a blood clot in the legs and you may be advised to have blood thinning injections.

What do I need to do if I have a positive result?

Following a positive result you will be advised to self-isolate for 7 days. This will include your baby. The other members of your household should be advised to socially distance from you and your baby as much as possible during this time. If after this time you have no symptoms you do not need to isolate any longer. However, the other people in your house should self-isolate for 14 days and if any of them develop symptoms then the Public Health England Stay at Home guidance should be followed, available on https://www.gov.uk/government/publications/COVID-19-stay-at-home-guidance

What symptoms are typical for COVID-19 infection?

The most common symptoms of COVID-19 infection are:

A new continuous cough

A high temperature

A loss of, or change in your normal sense of taste or smell (anosmia)

For most people, coronavirus will be a mild illness. However, if you develop any of the symptoms above you should self-isolate at home even if you have had a negative screening test.

What does it mean for my birth if I have a positive result?

You will be contacted by one of the midwives to discuss your admission. It may be that we can postpone it but only if it is safe to do so. The health of both you and your baby takes priority.

If you and everyone in your household have no symptoms of COVID-19 then your partner can attend with you once you are in established labour, or when you are ready to go into theatre. However, because your partner is required to self-isolate, if they do come into the hospital it is important that they travel directly from home to the hospital, ideally in their own car and not using public transport.

If anyone in the household does have symptoms, then unfortunately your partner cannot attend. Your community midwife will discuss this with you as you make preparations for your birth. Because you have tested positive, it is important for your partner to realise that they will then have been exposed to the virus and it will be necessary for them to self-isolate for 14 days following their attendance as a birth partner. We advise all birth partners who decide to attend under these circumstances that:

i) They must not leave the birth room for any reason including to vape/ smoke.

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

ii) They will be asked to wear a mask provided by the hospital, at all times

iii) They must bring their own food and drinks in with them

iv) They will not be able to go into theatre if this is required in an emergency as there is an increased chance of infection

v) They will be asked to leave the hospital once your baby is born and you transfer to the postnatal ward

This is to prevent the virus spreading within the hospital and to the wider community.

What about my baby if I have a positive result?

It is extremely rare for babies to have COVID-19. It is more likely that your baby will be well enough to be taken home. For most babies, they will not need to be screened for COVID-19. Once at home you will need to self-isolate with your baby, for 7 days from when your swab was taken. You are advised to wear a face covering when feeding your baby, and to always wash your hands before touching your baby.

If your baby needs to go the neonatal unit, you will not be able to visit your baby for 7 days from the date of your swab being taken. Your partner will not be able to visit if they live with you for 14 days. If you have had symptoms, you will be able to visit your baby 7 days after the onset of the symptoms, you feel well and have not had a high temperature for at least 48 hours (37.8 degrees and above).

The neonatal staff will discuss screening for COVID-19 for your baby with you.

Will I be screened again if I come back into hospital?

Yes but only if you have an overnight admission. The screening result is for that point in time. You may have been exposed to the virus in between admissions so you will be offered screening again. If you have had a positive test in the past you won’t need to be screened again as we know that you have been COVID positive.

HOW PRE-ADMISSION TESTING WORKS

Your midwife or doctor will arrange for you to have a pre-admission test at your booking hospital 2-3 days before your planned admission date. You will need to attend the antenatal clinic at a pre-arranged time. The test for COVID-19 is a swab taken from your throat and nose (both nostrils). Once complete you will be asked to leave the hospital.

Preparing for your admission

As well as having the test for COVID-19, you and other members of your household will be asked to self-isolate for 14 days if possible prior to your admission date. It is important that you still attend any hospital or community antenatal check-up appointments and that you let the hospital know if you have any concerns about you or your baby, for example your baby’s movements or you are bleeding or have abdominal pain.

Pre-admission testing results

Results usually take between 18-24 hours. You may be contacted by a midwife prior to your admission or you may be informed on your admission what your result is.

If you still have questions after reading this leaflet please contact your community midwife or phone our dedicated COVID-19 maternity hotline on 0121 424 2829

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C139 V1

Testing for maternity admission, elective caesarean sections, elective cervical cerclage & induction of labour during the COVID-19 Pandemic

Issued: 15/10/2020

Appendix 1: COVID-19 Swabbing instructions