Prenatal and Postnatal Care in the COVID-19 Context
Last Updated: January 18, 2021
Last reviewed: December 15, 2020
Last reviewed: January 18, 2021
Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.
This tool has has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of prenatal and postnatal care. While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.
Key takeaway
Patients still require prenatal and postnatal visits. Given that there is a need to reduce number of visits, the timing, frequency and format (in-person vs. remote) of prenatal and postnatal visits can be adjusted. In circumstances where COVID-19 has caused service disruptions, patient refusal, and/or patient self-isolation, alternative strategies for prenatal and gestational diabetes screening should be implemented.
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Prenatal and postnatal care
Remote visits should be offered where appropriate. Recent literature supports some reduction in frequency of visits in the later trimesters if the first trimester screening indicates a low-risk pregnancy (SOGC, April 6, 2020).
For additional guidance on providing prenatal and postnatal care during COVID-19, see the Royal College of Midwives/Royal College of Obstetricians & Gynaecologists Guidelines on Coronavirus (COVID-19) Infection in Pregnancy (October 14, 2020).
Putting it into practice
- At each visit, a responsible care provider must assess each woman to determine whether she is a candidate for an adjusted prenatal visit schedule as well as virtual care.
- Post-partum visits can be done remotely.
Proposed schedule for low-risk prenatal visits
11-13 week visit
In-person
- Combined dating/NT scan
- Full history and risk assessment
- Laboratory tests (including genetic screening) as needed
Tip: Can combine dating/NT to one ultrasound. There is a potential risk of being outside the window period for measuring NT if inaccurate dating by ‘Last Normal Menstrual Period.’ Earlier ultrasounds might also be needed for threatened abortion or if risk factors for an ectopic pregnancy etc. If completing initial prenatal blood work and a dating ultrasound prior to the first prenatal visit, this can be organized over the telephone.
16 week visit
Virtual/Telephone
- Discuss screening and laboratory results
- Initiate iron supplementation if needed
- Book anatomy scan for next visit
20 week visit
In-person
- Full anatomical scan
- Give requisition for glucose challenge test and CBC, Ferritin and G&S (if RH negative)
- G&S often needs to be done at lab no more than 4 weeks prior to administration of WinRho
26-28 week visit
In-person
- Coincide with T2 bloodwork
- If Rh negative, organize WinRho
Tip: For GCT, write on the requisition to allow the patient to wait in a car or in a private room in the clinic. If there are significant disruptions to lab testing and treatment due to COVID-19 and/or patient refusal, see Gestational diabetes mellitus screening.
30 week visit
Virtual/Telephone (as per AJOG MFM guideline):
- Consider remote visit if appropriate
- If remote: Review fetal movement and clinical signs of preterm labour and preeclampsia; patient to self-report BP (if accessible at home/pharmacy) and weight; consider self-symphysis fundal height3
- Book BPP/growth ultrasound for 2 weeks (if indicated)
- ADACEL
Tip: Can consider instructing patient on self-symphysis fundal height (SFH) measurement. Youtube video: How to measure your own fundus during pregnancy.
32 week visit
In-person
- Routine prenatal care
- BPP/growth ultrasound same day if indicated
- ADACEL, if not given
34 week visit
Virtual/Telephone (as per AJOG MFM guideline):
- Consider remote visit if appropriate
- If remote: Review fetal movements and clinical signs of preterm labour and preeclampsia; patient to self-report BP (if accessible at home/pharmacy) and weight; consider self-symphysis fundal height
Tip: Can consider instructing patient on self-symphysis fundal height (SFH) measurement. Youtube video: How to measure your own fundus during pregnancy.
36 week visit
In-person
- Routine prenatal care
- GBS swab
Tip: If the 36-week visit is not in person, consider coordinating with the lab for the patient to drop off a GBS self-swab if possible. Instructions to provide patient.
37-38 week visit
In-person OR virtual/telephone:
- If remote visit necessary: Review fetal movements and clinical signs of labour and preeclampsia; patient to self-report BP (if accessible at home/pharmacy) and weight
- Instruction regarding GBS management in labour
39-41 week visit
In-person
- Routine prenatal care
- Stretch and sweep
- Ultrasound as indication
When checking in on new parents, ask about their mental health and support system and connect them with local resources. For local community services and resources that you can connect your patients to, see the CEP’s Local Services Resource for:
Prenatal screening
The COVID-19 pandemic is having an impact on the delivery of prenatal screening services in Ontario:
- Some diagnostic imaging centres are not offering dating and NT ultrasounds
- Community blood collection services are being consolidated to a smaller number of labs
- Pregnant individuals in self-isolation are missing the NT ultrasound window
Putting it into practice
In situations where an NT ultrasound is not performed, the MOH is supporting the following measures (Prenatal Screening Ontario, January 12, 2021):
- Singletons: Order the second trimester MSS.
- Twins: The MOH will temporarily fund NIPT for all twin pregnancies and can be ordered by any physicians or nurse practitioner (effective April 6, 2020-June 30, 2020).
- Higher-order multiples: The only option continues to be an NT ultrasound.
Gestational diabetes mellitus (GDM) screening
The COVID-19 pandemic may cause severe disruptions to laboratory testing and treatment, and/or patient refusal for GDM screening.
Putting it into practice
In the case of sever service disruptions and/or patient refusal, this temporary alternative screening strategy for GDM should be used (SOGC & Diabetes Canada, April 8, 2020):
- All pregnant women without pre-existing diabetes will be screening with an A1c & non-fasting random plasma glucose:
- A1c of < 5.7% and a random plasma glucose <11.1 mmol/L require to further testing or treatment.
- A1c of >= 5.7% or a random plasma glucose of >= 11.1 mmol/L are identifies as having GDM.
- Postpartum screening for maternal dysglycemia should be deferred until after the COVID-19 pandemic has ended. An in-person appointment solely for an oral glucose tolerance test (OGTT) is not recommended.
Resources
These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.
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Acknowledgement and legal
The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach.
They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.
Clinical Working Group
A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:
• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CH
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP
In addition to our clinical working group the CEP also obtained feedback from others, including:
• Arun Radhakrishnan, MSC, MD, CM, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH
Thank you to everyone who supported the development of this resource.
The Prenatal and Postnatal Care in the COVID-19 Context resource is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Prenatal and Postnatal Care in the COVID-19 Context resource for commercial purposes or any modifications of the Tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: info@cep.health).
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