HMCN - Maternity and Newborn Services Response to COVID-19

7/7/2020

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This guideline has been created in collaboration between the Obstetric, Paediatric and Anaesthetic

Departments within HMCN and with assistance of the GM, DMS, DON, DDON and Infection Control

at HMCN. It is intended for use at Port Macquarie Base and Kempsey District Hospitals ONLY.

Please refer to the following sites which will provide the bulk of information:

• MNCLHD COVID-19 intranet

• NSW Health – Provides general advice regarding COVID-19 as advised by NSW health

• MNCLHD Maternity Service – provides general advice regarding maternity services

• Maternity and newborn care - Communities of practice – clearly describes essentials of

care, antenatal, intrapartum and post partum care for women at low risk of COVID – 19 and

also those with suspected / confirmed COVID - 19

Principles of care • All staff, women and visitors presenting to hospital for any reason must be screened by

having their temperature checked and asked questions approved as per NSW Health

• Visitors – as per current MNCLHD guidelines

• Staff and visitors are required to follow infection control - PPE and hand washing

appropriate to the clinical contact

• Minimise support people at AN Clinic appointments where possible – refer to MNCLHD

recommendations

• Consider where appropriate telehealth for some antenatal and post natal outpatient care

• Each Maternity Unit must have a designated isolation space for – antenatal, labour and post

natal encounters of COVID-19 positive / suspected women

• Appropriate ongoing antenatal care must be provided to COVID-19 positive/suspected

women – tailor care to the patients individual needs and risks – utilise telehealth were

appropriate

• Early discharge of women with Covid -19 is NOT to be encouraged (advice of MoH as of 23rd

April 2020). Those women who wish to be discharged early and who are suitable should

only be discharged when appropriate support at home is in place. Aim for all newborn

checks to be done prior to discharge.

Childbirth and Parenting Education As a precaution to minimise the risk of transmission of COVID-19 all face to face childbirth and

parenting education sessions have been cancelled, they will be recommenced with considered safe

to do so. Telehealth alternatives have been created.

Women may also be directed to online resourses –available on the Mothers and Babies Recourses

section of the MNCLHD public website MNCLHD Maternity Service.

Planned antenatal and outpatient post natal care All women are to be verbally screened for symptoms and risk factors for COVID-19 prior to

presentation (SMS or phone call) and screened again on arrival. They will also have temperature

checked on arrival at entry points of the hospital.

Refer to NSW Health website resources for the most up to date advice as to who is considered a

suspected case or at risk of COVID-19 and the screening questions required.

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Provide patients with resources for advice and clinical review if needed: GP, MNCLHD COVID

screening clinics, ED, Health Direct 1800 022 222 as required

• Visits will be provided as a mixture of face to face and telehealth (or a combination if

needed) as clinically appropriate in accordance with advice from NSW Health.

• Ensure COVID safe social distancing in waiting areas

• Refer to Maternity and newborn care - Communities of practice for advice regarding the

minimum requirements for antenatal care – these visits are considered essential and

additional visits should be provided where required based on the woman’s risk and the

degree of COVID-19 infection in our community.

• At time of release of the guideline visits for low risk women at will be

o Booking – face to face (unless woman requests telehealth)

o 20 weeks – face to face (telehealth would be reasonable if low risk and woman

already attended a face to face booking in visit)

o 24 – face to face – consider telehealth for low risk multiparous women

o 28 – face to face

o 32 – face to face

o 34 – face to face

o 36 – face to face

o 38 – face to face

o 39 – face to face but may be omitted if low risk multip

o 40 weeks – face to face

o Reduction in visits to the NSW Health Minimum standards (booking, 20, 38, 36, 40)

may be required in the peak of a pandemic.

• Ensure Boosterix (20 weeks onwards) and Influenza vaccination (any gestation) is offered

• Reduce face to face post natal reviews – use telehealth or refer to GP as appropriate

• Refer to flow charts at the end of this document for management of women within the

Home Midwifery Service

• Individualise care of women who are suspected / confirmed COVID-19

o Routine face to face care should NOT occur in these women until they have been

released from self isolation at the advice of the Respiratory Team at PMBH

o Use telehealth to provide care and triage to face to face care as required

o Non routine care to occur as clinically indicated – isolate & PPE precautions

• Women with respiratory symptoms / fever should not be seen in ANC, use telehealth or

rebook or review in a suitable isolation room (if review required) and advise the woman to

present to the COVID Clinic for swabbing

• Ensure women who’s care is deferred are followed up

Antenatal care/procedures for confirmed /suspected COVID-19: • If >36 weeks consider a full handover of care to Port Macquarie Base Hospital if the

woman is booked at Kempsey District Hospital. This in an attempt to keep KDH

COVID free.

• If <36 weeks resume usual antenatal care after 14 days symptom free or negative

test result and as advised by the respiratory / public health team caring for the

woman

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• Care of COVID / Suspected COVID women - remain in contact with the patient,

phone consultations, telehealth and where absolutely required face to face –

suitable location and using PPE

• Ultrasound fetal growth surveillance 14 days following resolution of acute illness.

Advice for pregnant women who are required to self-isolate at home Pregnant women who have been advised to self-isolate should stay at home and avoid contact with

others for 14 days. They should follow the same isolation recommendations as for the general

public. Advice is available on NSW Health website

Routine antenatal care and investigations should be avoided during this time – telehealth

interactions are encouraged

Review must be arranged if there is an urgent obstetric need (such as but not limited to APH, TPL,

PPROM, reduced FMF etc)

Unplanned presentations to the maternity unit – labour or acute

antenatal reviews approach to triage and care

Phone enquires: Screen all women who contact the maternity service by phone. Assess the clinical situation for

women with COVID-19 risk factors and determine if the woman requires immediate clinical

assessment and arrange review.

Verbal screening must be repeated and temperature check taken on arrival to the maternity unit.

COVID positive / suspected women should be asked to put on a surgical mask and moved to an

isolation room. All staff now required to adopt infection control measures appropriate to the clinical

exposure.

Post triage for risk of COVID-19 on arrival: If low risk for COVID-19 infection

• Utilise usual care pathways

• Avoid exposure to other known or potentially infected patients

If COVID-19 suspected or confirmed

• Utilise isolation and follow infection control protocols, ensuring correct use of PPE

• Where testing is indicated (as per https://www.health.nsw.gov.au/Infectious/covid-

19/Pages/case-definition.aspx) arrange swab - Rapid COVID swab available for women in

labour or at risk of labour in next 24 hours, refer to flow chart at end of document

• Transfer if the medical / obstetric condition allows to Port Macquarie Base Hospital if the

woman has presented to Kempsey District Hospital and has confirmed COVID-19 infection

• Manage as COVID – 19 suspected until swab results are negative or on advice of respiratory

team

Planned location of birth if COVID-19 positive • Women with confirmed COVID-19 infection are to birth at Port Macquarie Base Hospital if time

allows for a safe transfer.

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Intrapartum considerations (including induction of labour and

caesarean section) for COVID-19 positive / suspected women Refer to NSW Health website (https://www.health.nsw.gov.au/Infectious/covid-19/Pages/case-

definition.aspx) resources for the most up to date advice as to who is considered a suspected case of

or at risk of COVID-19 – this is constantly changing

There is limited evidence regarding COVID-19 and its risks of vertical transmission and risks in labour

– the risk is considered small but possible. We have taken a conservative safety first approach

regarding advice in the appendix

The following NSW Health Website provides useful information that should be reviewed in

conjunction to this document with regards to management Maternity and newborn care -

Communities of practice

Notifications: • The obstetric, paediatric & anaesthetic staff should all be notified and SCN alerted on

admission of a COVID positive / suspected woman.

PPE isolation and support people: Refer to CEC and MNCLHD COVID-19 Intranet for up to date information

• Single room, minimise face to face handovers, appropriate PPE

o All clinical staff and support person to wear appropriate PPE for the clinical

encounter

o Patient to be advised to wear a mask – but should not be forced to do so. She must

wear a mask when in transit and ideally when the door is open for staff entry / exit

• Follow MNCLHD advice regarding visitors

• Processes to allow for CTG 2nd checking and administration of drugs while minimising use of

PPE will be developed, flow charts at the end of this document

Labour: • If a swab result is not already available arrange a RAPID COVID swab

• Patients paper notes are considered ”dirty” and should not be brought out of the woman’s

room (until the patient leaves). A pack of all likely paperwork to be used for birth and

immediate post partum period will be brought into the room when the woman arrives

• FBC and IVC on admission to the Birthing Unit (risk of thrombocytopenia) – midwife collecting

the blood (donned) to label tubes and place them in a pathology bag, then the sample needs to

be double bagged with the request form in the second bag (the second bag should be held by a

“clean midwife” to minimise transmission)

• CEFM monitoring in labour

• Regular observations PLUS oxygen saturations

• Water birth and Water immersion are not recommended – as staff are not able to practice

appropriate PPE

• Individualised decision regarding shortening 2nd stage. Consider - woman’s preference,

maternal exhaustion, respiratory status, and infectious risk to those in the room.

• COVID-19 infection itself is not an indication for caesarean section – consider usual obstetric

indications plus assessment of respiratory status when making decisions.

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• Avoid Fetal Scalp Electrode and scalp blood sampling - potential risk of vertical transmission.

• Women should be made aware that the time required for staff to put on PPE may delay

decision to delivery time for instrumental birth or caesarean section

• Staff are NOT to enter the room / attend to the patient without appropriate PPE

• Midwife in the birthing room with a COVID positive/suspected woman should have constant

phone access with other staff

• Procedures will be developed to allow for CTGs to be reviewed, drugs and required equipment

to be delivered to the room – see pathway in Appendix 2

• Women who were considered low risk for COVID at the commencement of labour but who

develop respiratory symptoms or fever in labour should be reviewed by an Obstetric medical

officer and a Rapid COVID swab arranged and the woman managed as suspected COVID-19

positive until results are available (clinical judgement should be used where there is an obvious

obstetric indication for fever)

Third stage of labour: • Recommend active management of 3rd stage and avoid delayed cord clamping – to reduce risk

of PPH and may also reduce the risk of vertical transmission.

• The benefits of delayed cord clamping for preterm babies (before 32 weeks) may outweigh

risks however, paediatric advice should be sought regarding this decision.

Analgesia in labour: • Encourage early EDB for pain management (to reduce the need for general anaesthetic if an

urgent caesarean section was required). This decision will be made in discussion between the

woman, anaesthetic and medical staff considering the pros and cons and the projected

likelihood of operative delivery

• See pathway for consent and EDB in setting of COVID below in Appendix 2

• Nitrous Oxide: current advice in HMCN is to NOT to use Nitrous oxide for COVID positive /

suspected women. Use is acceptable in those women who are thought to be COVID negative

Care of the newborn immediately post birth: • Avoid placing the newborn directly on the mother’s abdomen as immediately post birth the

mother will NOT be considered to be practicing safe infection control and may expose the

newborn – wash the mother’s chest prior to skin to skin

• Regarding skin to skin ongoing contact – the known proven benefits of skin to skin contact

should be discussed together with an awareness of the small risk of transmission. Such contact

should only occur after the mother / support person have washed their hands and are wearing

face masks.

• Resuscitation of the newborn – is considered aerosol generating – all staff and support person

to wear PPE including P2 / N95 mask

Planned caesarean section if confirmed/suspected COVID-19 • Notify anaesthetics and theatres

• Book at end of list

• FBC & G+H (ensure FBC day of surgery)

• Paediatrician / registrar at birth – P2/N95 mask required

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• Patient should be made aware that the procedure will be slower than usual due to the

requirements for PPE – local agreement for HMCN that this will be P2/N95 masks for all staff

involved in a caesarean section – due to risk of conversion to GA mid procedure

• Follow advice in theatre

Anti-coagulation in COVID positive/suspected women • COVID-19 seems to be associated with a hypercoagulable state

• VTE risk assessment should occur for all women, COVID-19 infection will likely increase their

risk further

Changes to care Kempsey District Hospital for cases of confirmed /

suspected COVID-19 infection • Care will continue as normal at Kempsey District Hospital (KDH) unless a woman is

confirmed COVID-19 positive. Where this occurs they should be transferred to Port

Macquarie Base Hospital (PMBH) if safe to do so.

• Confirmed COVID -19 positive women during the antenatal period should be managed in

discussion with the respiratory team and the Obstetric consultant at PMBH

o Before 36 weeks likely ongoing care as described above via the GP Obstetricians at

KDH

o If beyond 36 weeks – ongoing antenatal and subsequent intrapartum care to be

managed via the ANC at PMBH (given that the woman will likely still be COVID-19

positive at the time of birth)

• Rapid COVID swab testing is available to speed up the diagnostic process

• Where women present to KDH with confirmed or suspected COVID-19 infection this

guideline should be used to aid management, PPE use etc. Once safe to transfer any woman

with confirmed COVID- 19 infection.

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Newborn Babies postnatal management of suspected/confirmed

COVID-19 • Refer all babies for formal review by the paediatric team, who should be notified of the

birth and asked to attend for the usual criteria

(COVID-19 along is not an indication for the paediatric team to be present for the birth)

• Routine SARS-CoV-2 testing of ASYMPTOMATIC newborn babies born to women with

suspected/confirmed COVID-19 IS NOT recommended;

• Testing IS indicated if the newborn infant becomes symptomatic within the minimum 14-

day incubation period, whether in the acute healthcare setting or at home

(combined oral / deep nasal swab – single swab kit to be used);

• Vertical transmission is considered possible, the proportion of newborns affected and

the significance to the newborn is unknown

• Wash all babies with soap and water after birth

• Give routine Hepatitis B vaccination and Vitamin K after bath

• Unless SCN admission is needed for neonatal clinical grounds the mother and infant

should be co-located and isolated together

• Babies are at risk of viral spread from a woman's respiratory secretions after birth. The

woman and support person who was present at birth should practice hand and respiratory

hygiene and wear a face mask during feeding or other close mother-baby interactions

including early skin to skin post birth, maintaining social distance of at least 1.5 metres

(cot >1.5 m from mother's bed)

• There is little evidence (but numbers of cases are limited) that the virus is carried in the

breastmilk, the main risk is close contact with the mother who is likely to share infective

droplets. Based on the current evidence breastfeeding may be encouraged with

appropriate support and education

• Women who are bottle feeding or expressing should adhere to strict sterilising

guidelines and have dedicated equipment during admission and follow hand hygiene

and PPE advice, consider non infected partner feeding baby (this may reduce but not

eliminate the risk of transmission to baby)

• Careful hygiene should continue until the woman has tested negative for SARS-CoV-2

and / or self isolation is not longer indicated based on current NSW Health advice

(currently 14 days after end of acute illness) – consult respiratory team

• Clinically well women and infants should be discharged home in the usual timeframe with

ongoing midwifery follow up in the home or a community setting – accelerated discharge

is not recommended

• Ensure ‘Blue Book’ check, SWISH hearing testing, & heel prick NBST are performed – these

are essential elements of care

• Consider providing ongoing breastfeeding and post natal support by telehealth where

available

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Appendix 1 – Port Macquarie Base Hospital Pathways

Flow chart 1 – Known COVID patient / suspected / contact in isolation who needs

clinic or outpatient review

If it’s decided they NEED a face to face visit

To access PMBH via RED ED or direct as advised by the HITH team who will be able to determine the

most appropriate location for review based on resources at the time and the patients clinical needs

Patient asked to put on surgical mask

Directed to birthing unit for review

To keep on surgical mask

Place patient in isolation room on birthing unit as available or alternate location as

advised by ED / HITH

Assessment completed

Staff droplet PPE precautions (unless labour)

If pathology or ultrasound required – bring the service to the woman

Admitted Discharged

To appropriate ward area Documentation complete

Follow up arranged

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Flow chart 2 – Antenatal care of COVID positive women or women in isolation due to contact

Once identified – careful review of antenatal record by CMC and VMO

Discuss care with the VMO during illness and after recovery

Determine if any routine / additional care is required during period of home isolation

Arrange what may be required – ensuring patient wears mask, care occurs in an isolation room at

hospital and bring care to patient (CTG, blood tests, ultrasound) as much as possible

Ensure phone call to patient each business day – hand over to on call registrar on weekend if

weekend calls are clinically indicated

Hospital in the home will be checking on woman’s general wellbeing daily also and can assist in

arranging face to face reviews if deemed clinically appropriate

Discuss care with Dr Chung / Dr Houghton regarding when patient will be able to stop isolating

Arrange face to face antenatal clinic appointment within a week of exiting isolation / recovery

in doctors clinic – ensure VMO has been notified

Arrange all outstanding antenatal care and arrange ultrasound 2 weeks after recovery (if was

confirmed COVID – ultrasound only needed on obstetric grounds if never diagnosed with COVID)

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Flow chart 3 – Woman COVID / suspected COVID / fever / respiratory symptoms

who presents for outpatient review

(non urgent obstetric concerns or non obstetric concerns)

Direct the woman to RED ED or as advised by the HITH team (who will be caring for COVID positive

women)

Consider if face to face obstetric visit is needed

To access PMBH via RED ED (or direct as above where appropriate)

Asked to put on surgical mask

Will be assessed in ED and if clinically indicated swabbed

Sent home if does not need obstetric review (ensure follow up)

OR

If obstetric review needed - directed to isolation room in birthing unit

(see flow charts 4 &5)

If admission indicated based on

COVID symptoms or non obstetric

reasons

Assessment completed

Staff droplet PPE precautions

If pathology or ultrasound required – bring the service to the woman

Admitted Discharged

(ensure obs review if has not already occurred)

To appropriate ward area Documentation complete

(may be ICU or BU or 2A or 3D) Follow up arranged

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Flow chart 4 – Women with COVID or suspected COVID who need review on BU with an urgent obstetric issue (including labour)

MW to meet woman in carpark (MW in appropriate PPE) or via RED ED if that is more appropriate

based on the clinical presentation

Woman asked to put on surgical mask

Arrange swabs if indicated (do not delay urgent obstetric care)

Placed in the assessment room in BU (if not laboring) or in Birthing room 1 if in labour

(see flow chart 6)

All staff to utilize appropriate PPE

Arrange appropriate medical and obstetric reviews

Assessment / management performed

If pathology or ultrasound required – bring the service to the woman (if possible)

Admitted Discharged

To appropriate ward area Documentation complete

(may be medical ward or ICU or BU or 2A) Follow up arranged

If in labour refer to labour pathway

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Flow chart 5: COVID-19 positive / suspected patient care in Birthing Suite – room set up

arrangements

Enters hospital via Red ED OR meet by MW (donned) in carpark - mask applied and directed to

Birthing Unit as clinically appropriate

Use of Birthing Consultation room with door closed

OR Birthing room 1 if in labour with door closed

Donning and Doffing of PPE outside room (clean area on right and dirty area on left)

Use a ‘Spotter’ Midwife when Doffing PPE to ensure correct technique of removal & discarding PPE

Barrier applied to dirty area to ensure contained within alcove

Minimal equipment kept in room (must including sharps container)

Observation equipment to be kept in room, designated battery operated CTG in room 1 at all times

Grab packs for cannulation, EDB, IDC, birthing kits, perineal repair, local, newborn vaccinations etc

Computer: WOW to be left in room if consultation room

COVID drug box in fridge

Weighing of the newborn – dedicated scales to be left in room 1

Support person: only 1 person (P2 mask) and unable to leave room until woman leaves room. Once

leaves room post birth, self -isolation as per NSW health. Meals provided for support person.

Supply information sheet to support person to explain this process

Mother – to wear mask where possible – but MUST be on if being transferred or door opened

Designated MW and Medical office as primary care providers during shift

CTG to be reviewed and counter signed by Medical Officer or midwife (if not in room – to bring CTG

machine to the open door (behind closed curtain) to allow for the CTG to be reviewed

Admitted Discharge

Woman transferred to ward wearing surgical mask Follow up as agreed with Doctor

And partner goes home Wear mask until in own car or arrive home

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Flow Chart 6 - Pathway for care of women and newborns via Home Midwifery Service in setting of

COVID-19

Women and all others who live in the home to be verbally screen prior to a visit and again at the

time of the visit for symptoms and risk factors for COVID-19

Screen negative Screen positive (visit to NOT occur at the

woman’s home)

Use telehealth consultation where possible

Ensure other home residents are Where face to face visit is needed

Screen negative D/W Paeds / O+G team as appropriate

If screen positive review options to include – ED, ward, GP

Visit as usual

Usual PPE precautions Schedule clinically appropriate time for review

Other family members in another part of AND determine most appropriate location

the house (social distancing) ensure appropriate staff available for review

Patient to access hospital via RED ED or direct (HITH

may be able to assist in arranging direct access)

Patient to put on surgical mask and patient directed

to allocated area for review in an isolation room

All staff to wear appropriate PPE

Admit to appropriate ward if required Discharged with follow up based on assessment

Mother and baby admitted together

where possible

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Pathway 7: EPAS referrals and management during COVID pandemic

Referral made by patients GP or ED or self referral as usual

Patients care triaged by EPAS Midwife and phone appointment made

Care may need to be coordinated via telephone visits until the COVID pandemic resolves

Return to face to face visits when considered reasonable based on community transmission and

social distancing advice from the DoH

If face to face visit is required arranged with on call registrar at a suitable time

COVID Negative women COVID positive / suspected women

Discuss care with on call VMO

See in EPAS and care usual / arranged Access via RED ED (HITH may assist in

arranging appropriate location for review)

Patient to wear surgical mask

Patient directed to suitable location for

review (may be Red ED, assessment room on

BU or other as per advice from ED or HITH) –

Patient not to be seen in EPAS room as too

difficult to perform terminal clean in this

room

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Rapid COVID swab testing procedures

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Appendix 2: Management of labour & post partum care for COVID

positive / suspected mothers and their babies – including anaesthetics

– this advice is relevant for PMBH and KDH (where transfer is not

possible or awaiting Rapid COVID swab result) If suspected COVID – 19 arrange RAPID COVID SWAB

Single room and notifications

• Refer to advice from MNCLHD regarding visitors / support person

• Notify – SCN, paediatrics, obstetrics and anaesthetics

• Ensure M/W in the birthing room has constant telephone contact with other staff members

Support people

• 1 support person only – must not have COVID or symptoms (fever or respiratory symptoms),

2nd support person only on compassionate grounds

• Must stay in the room with the birthing woman at all times and leaves the hospital once

birthed, must wear P2/N95 mask at all times

• Must be advised to self isolate for 14 days post (as is now a close contact) post birth

PPE

• Patient to wear mask (guidance as per MNCLHD)

• Support person (as per MNCHLD advice) should also wear a N95/P2 mask

• Staff should wear N95/P2 masks (as agreed with Executive HMCN)

• Staff safety is NOT to be compromised, use of appropriate PPE is mandatory Labour care

• FBC, IVC

• Continuous CTG in labour

• NO water birth

• LSCS for obstetric reasons

• Avoid FSE and FBS

• Encourage EDB

• NO nitrous use (local decision agreed with Executive HMCN)

• Active Mx of 3rd stage

• No delayed cord clamping (consider before 32 weeks) – local decision with Paediatricians

• All staff to wear P2/N95 masks during labour, caesarean section and resuscitation / CPAP of the newborn

Post natal care for newborn

• Do not place baby directly on maternal abdomen – wash mothers chest prior to skin to skin

• Notify Paediatrican of labouring woman, presence for birth as per usual calling criteria

• Wash baby immediately after birth prior

• Usual vaccinations (vit K and hep B) post baby bath

• Advice regarding required PPE – refer to Paediatricans / MNCLHD advice

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Procedure for Epidural in a COVID positive/suspected patient

At the time of the call for epidural ensure patient has:

● IV access ● recent FBC, GH ● epidural information sheet/consent form given

○ to reduce time in delivery suite room consider going through the epidural information over the phone with the patient

○ eg ask midwife to instruct patient to call anaesthetist on anaesthetic phone once information sheet read

Before entering the room:

● check platelets (thrombocytopenia common with COVID19) (coags only if indicated) ● anaesthetist +/- 2nd midwife to prepare all equipment and place on a separate

trolley, please refer to EDB equipment checklist ● clean EDB trolley and documentation to be left outside the room ● patient must wear surgical mask AT ALL TIMES

Go to donning area/prep trolley:

● don N95/P2 mask, head cover, eye protection ● sterile wash ● sterile gown, gloves -2 pairs

Enter the room:

● Midwife ○ open the door for anaesthetist ○ take trolley with equipment and epidural pump into the room ○ position the patient ○ ensure fluids running ○ open the packs onto the trolley

● Anaesthetist ○ perform anaesthetic assessment including airway exam ○ obtain informed consent

■ confirm patient read and understands the procedure, associated risks ■ offer to answer questions if any ■ patient signs consent on epidural information sheet

○ insert epidural ○ doff 2nd pair of gloves ○ connect the epidural to the pump ○ ensure epidural is effective ○ dispose sharps, leave the trolley in the room

After leaving the room:

● doff PPE ● wash hands ● complete clean documentation ● refer to written consent when completing epidural paperwork

Developed in consultation between Anaesthetic and O&G Departments at PMBH

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EDB equipment checklist

100mcg fentanyl

20ml 0.2% ropivacaine

2 x 5ml 1% lignocaine

4 x 10ml sterile saline plastic vials

Epidural Pack with Fenestrated sterile drape and dressing pack

Non-fenestrated sterile drape for work

20ml syringe

5ml syringe

3ml syringe

1 x sharp 22G blue needle

2 x 20G drawing up needles

1 x red filter needle

18G Tuohy epidural kit

Chlorhexidine alcohol skin prep.

Large Tegaderm

Hypafix (4 short and 1 long piece)

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Any additional equipment specific to your practice

Epidural pump

0.1% Ropivacaine/fentanyl 200ml bag

Yellow epidural tubing

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Anaesthesia For Cat 1 Caesarean Section

For COVID-19 positive/ suspected patients

EPIDURAL IN SITU?

YES NO

CONSIDER THE CLINICAL

AND THEATRE SITUATION

TO CHOOSE EITHER..

WORKING WELL?

YES NO / NOT SURE

EPIDURAL TOP UP RAPID SPINAL GA

* all don aerosol PPE

Anaes 1- don aerosol PPE,

epidural top up ASAP wherever

patient is, maternal assessment,

transfer of patient to OT

Anaes 2 prepare OT, drugs

Anaes nurse - prepare OT

Anaes Runner - – get COVID

PPH box 1

Left tilt

* all don aerosol PPE

Senior anaes - prepare spinal

Anaes nurse prepare spinal

Anaes 2 - maternal assessment,

IV access confirmation,

preparation, support,

positioning, monitoring, drugs

Anaes runner – get COVID PPH

box 1

Left tilt

* all don aerosol PPE

Proceed as per COVID

intubation checklist and

COVID intubation/extubation

procedure

expect desaturation

Anaes runner – get COVID

PPH box 1

Left tilt

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References NSW Health COVID-19 Maternity NICU SCN. Maternity and Neonatal care. Version 3, Communities of Practice - https://www.health.nsw.gov.au/Infectious/covid-19/communities-of-practice/Pages/maternity-and-newborn-care.aspx Queensland Health, Clinical Excellence Queensland. COVID-19 Guidance for Maternity Services. State-wide Maternity and Neonatal Clinical Network. Updated 29th April 2020 - https://www.health.qld.gov.au/__data/assets/pdf_file/0033/947148/g-covid-19.pdf RCOG – Coronavirus (COVID-19) Infection in Pregnancy. Information for Healthcare Professionals Version 10 - https://www.rcog.org.uk/globalassets/documents/guidelines/2020-06-04-coronavirus-covid-19-infection-in-pregnancy.pdf RANZCOG Coronavirus (COVID-19) information as available at production of this report - https://ranzcog.edu.au/statements-guidelines/covid-19-statement L Poon et al. ISUOG Interim Guidance on the novel coronavirus infection during pregnancy and puerperium information for health professionals. Ultrasound in Obstetrics and Gynaecology. 11th March 2020. https://doi/org/10.1002/uog.22013