Antenatal care

Women should be advised to attend routine antenatal care, unless they meet current self-isolation guidance for individuals and households of individuals with symptoms of new continuous cough or fever. Maternity care has repeatedly been shown to be essential, and studies in the UK and internationally have shown that if women do not attend antenatal services they are at increased risk of maternal death, stillbirth and other adverse perinatal outcomes.

The recent MBRRACE Rapid Report (2020) reviews the period March–May 2020, and highlights instances of significant barriers to accessing care or in-person review due to the pandemic. While we do not yet understand the impact of these changes to the overall quality of care being delivered, a single unit in London has reported an increase in stillbirth (Khalil et al, 2020). 

• The NICE-recommended schedule of antenatal care should be offered in full wherever possible. These appointments should be offered in-person as far as possible, with particular attention to those from BAME communities or those living with medical, social or psychological conditions that make them higher risk.
• Appropriate screening for diabetes in pregnancy should be provided, following NICE guidance as far as possible, with awareness that changes in screening provision may be associated with a reduction in the detection of milder cases of GDM.
• Open access for pregnant women to day assessment and triage services should be maintained. Women should be actively encouraged to attend if they have concerns about their own or their baby’s wellbeing.
• Continuity of care should be maintained wherever possible, particularly where this is offered to women from vulnerable groups who may also be at greater risk from COVID-19.
• Where they have not already done so, services should seek to provide remote antenatal education classes. Remote antenatal classes may continue as in-person classes are reintroduced, as they may be more accessible and acceptable for some women.
• Appointments where physical examination is not required and where there are no additional risk factors are most appropriate to be conducted remotely.
• Women with identified safeguarding concerns should be encouraged to maintain face-to-face appointments in order to assess concerns and access support.
• Services should establish triage processes, to ensure that women with mental health concerns can be appropriately assessed.
• Electronic record systems should be used and, where remote access for staff or patients is an available function, this should be expedited. When seeing women face-to-face, simultaneous electronic documentation will facilitate future remote consultation.
• For women who have had symptoms, appointments can be deferred until seven days after the start of symptoms, unless symptoms (aside from persistent cough) persevere.
• Units should appoint a group of clinicians to coordinate care for women forced to miss appointments due to self-isolation. Women should be able to notify the unit of their self-isolation through telephone numbers that are already available to them. Appointments should then be reviewed for urgency, and either converted to remote appointments, attendance as appropriately advised or deferred.
• For women who are self-isolating because someone in their household has possible symptoms of COVID-19, appointments should be deferred for 14 days. 
• Women who experience a miscarriage should be cared for in accordance with local protocols, and there should be an effort to reduce in-patient admission due to COVID-19.
• Women should be advised that vaccination against influenza is safe at all gestations of pregnancy, and is recommended to protect both mother and baby from the adverse effects of a pregnant woman becoming seriously ill with flu. During the COVID-19 pandemic, it is particularly important that pregnant women take up the influenza vaccine, to reduce their risk of contracting flu and COVID-19 simultaneously.

Most women attending maternity services are healthy and are otherwise advised to maintain stringent social distancing. It is recognised that attending maternity services, particularly where located in hospitals, may cause significant anxiety about the possibility of contracting COVID-19. It is important that maternity services do all they can to protect women from contracting COVID-19 during their maternity care, by following NHS infection prevention and control guidance stringently and using appropriate PPE. 

Particular consideration should be given to the care of pregnant women with comorbidities, who are 'shielded'. These individuals are advised to be particularly stringent with social distancing measures and should be provided with a mask during hospital visits. Their status should be clearly noted at any handover; where possible, shared waiting areas should be avoided; and if admitted, they should be in a side room.