Interim schedule for pregnant women and children during the COVID-19 pandemic
The World Health Organization (WHO) declared COVID-19 a global pandemic. Pregnant women, newborns, and children due for vaccinations still require care during the pandemic. Given that there is a need to reduce the number of visits, and women, children and their caregivers might wish to reduce exposure to others, the timing and frequency of visits can be adjusted. Many health care providers are transitioning to virtual visits whenever possible. The goal of this guideline is to propose an interim well-child and prenatal visit schedule that providers can use and adapt to their local setting.
To view and print stand-alone handout of the schedules, please click on image
Ideally, patients with symptoms suspicious for COVID-19 or exposures (travel or contact with someone who tested positive) should be separated from the rest of the practice or treated at a separate time and by a separate team (1). At St. Michael’s Hospital Family Health Team (FHT) in Toronto, Ontario, we have designated protected time slots in the morning for our more vulnerable patients, including pregnant women, newborns, and children due for vaccinations. Another goal is to schedule in-person prenatal visits to coincide with ultrasounds and other investigations to reduce the number of visits to the hospital or outpatient office.
If well-child visits are converted to virtual appointments, questionnaires such as the Rourke Baby Record (2) and Nipissing District Developmental Screen (3) can be emailed to parents prior to the appointment. Patients should be called to screen for COVID-19 symptoms or risk factors prior to attending all appointments and once again upon presenting to the hospital or clinic. Patients and families also need to be made aware of the hospital’s policy on visitors and support persons during the COVID-19 pandemic. The interim schedules below are suggestions, which can be tailored to local needs and resources. The guidance around COVID-19 is rapidly changing and therefore providers need to continue to stay up to date on new information as well as provincial and hospital policies.
Well-Child Visits
Many health care providers in Canada follow the Rourke Schedule for well-child visits (2). During the COVID-19 pandemic, if resources allow and visits can be done safely (e.g. adequate screening and physical distancing in waiting rooms), well-child visits that incorporate immunizations should be continued (4). For all other well-child visits, providers can convert to virtual appointments (i.e. telephone or e-visit) or postpone if there are no parental concerns.
Figure 1: Proposed interim schedule for well-child visits
Low-risk prenatal visits
For low-risk pregnancies, it is acceptable to adjust the routine prenatal visit schedule to align with the WHO Antenatal Care Model (2016) (7), Society of Obstetrics and Gynecologist (SOGC) COVID-19 guideline (8), Interim Nova Scotia Guideline (9), and American Journal of Obstetrics and Gynecology MFM Guidance for COVID-19 (10). Ideally, in-person prenatal visits should coincide with ultrasounds and other investigations to reduce the number of visits to the hospital or clinic. For visits after 24 weeks gestational age, perception of fetal movements can be used as a surrogate for fetal viability in lieu of doptone. For blood pressure measurement, providers can review with patients the clinical signs and symptoms of preeclampsia. If needed, providers can instruct the patient to purchase a blood pressure machine or to measure at a local pharmacy. Maternal weight can be self-reported. Postpartum visits can also be done virtually.
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.
Figure 2. Proposed interim schedule for low-risk prenatal patients
References
1. Gawande A. Keeping the Coronavirus from Infecting Health-Care Workers. The New Yorker. https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers Published 2020. Accessed March 22, 2020.
2. Li P, Rourke L, Leduc D, Arulthas S, Rezk K, Rourke J. Rourke Baby Record. Canadian Family Physician. 2019;65(3):183
3. Cairney J, Clinton J, Veldhuizen S et al. Evaluation of the revised Nipissing District Developmental Screening (NDDS) tool for use in general population samples of infants and children. BMC Pediatr. 2016;16(1). doi:10.1186/s12887-016-0577-y
4. Le Saux N. Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Current epidemiology and guidance for COVID-19 caused by SARS-CoV-2 virus in children.; 2020. https://www.cps.ca/en/documents/position/current-epidemiology-and-guidance-for-covid-19-march-2020
5. Ontario College of Family Physicians. COVID-19: Information & Resources.; 2020. https://www.ontariofamilyphysicians.ca/tools-resources/timely-trending/novel-coronavirus-2019-ncov/considerations-for-in-person-visits.pdf Accessed March 31, 2020.
6. Centers for Disease Control and Prevention. Measles Cases And Outbreaks.; 2020. https://www.cdc.gov/measles/cases-outbreaks.html Accessed March 22, 2020.
7. Word Health Organization. WHO Recommendations On Antenatal Care For A Positive Pregnancy Experience.; 2016. https://www.cdc.gov/measles/cases-outbreaks.html Accessed March 22, 2020.
8. Elwood C, Boucoiran I, VanSchalkwyk J, Money D, Yudin M, Poliquin V. Updated SOGC Committee Opinion – COVID-19 in Pregnancy. Sogc.org. https://www.sogc.org/en/-COVID-19/en/content/COVID-19/COVID-19.aspx Published 2020. Accessed March 22, 2020.
9. Reproductive Care Program of Nova Scotia, IWK Health Centre, Nova Scotia Health Authority. Interim Nova Scotia Guidance: Prenatal Care Visits For Low-Risk Women.; 2020. http://rcp.nshealth.ca/clinical-practice-guidelines/covid-19-interim-guidance-prenatal-care Accessed March 22, 2020.
10. Boelig R, Saccone G, Bellussi F, Berghella V. MFM Guidance for COVID-19. Am J Obstet Gynecol MFM. 2020:100106. doi:10.1016/j.ajogmf.2020.100106.
11. Yamamoto J, Donovan L, Feig D, Berger H. Urgent Update – Temporary Alternative
Screening
Strategy for Gestational Diabetes Screening during the COVID-19 Pandemic.; 2020.
https://www.sogc.org/en/content/featured-news/Gestational-Diabetes-Screening-During-COVID-19-Pandemic.aspx Accessed April 16, 2020.
Acknowledgements: I acknowledge the help of other members of the Family Medicine Obstetrics Group at St. Michael Hospital, Toronto, Ontario and members of the Obstetrics Department at St. Michael’s Hospital, including Dr. Filomena Meffe, Dr. Howard Berger and Dr. Eliane Shore as well as members of the Pediatrics Department at St. Michael’s Hospital, including Dr. Tony Barrozzino and Dr. Douglas Campbell. I also acknowledge the suggestions provided by members of the Family Medicine Obstetrics Group at North York General Hospital in Toronto, Ontario, including Dr. Lara Rosenberg and Dr. David Eisen as well as Dr. Allan Grill, Chief of Family Medicine at Markham Stouffville Hospital.
I want to acknowledge Orly Bogler who is a 4thyear medical student at the University of Toronto and was taken off clinical duties due to the COVID-19 pandemic. Orly helped with editing the paper and designing the interim schedules.
Dr. Tali Bogler is a staff family physician and Chair of the Family Practice Obstetrics Team at St. Michael’s Hospital in Toronto, Ontario.
https://www.cfp.ca/sites/default/files/pubfiles/PDF%20Documents/Blog/interim_schedule_apr16.pdf
