Transmission:
COVID-19 is a viral respiratory infection that is highly contagious and is primarily transmitted via large droplet respiratory person-person contact. It is most likely spread by being in close contact (within 6 feet) when an infected person coughs or sneezes. This is similar to the transmission of influenza. Recent evidence indicates that the virus may remain airborne for up to 30- minutes.
There are some data indicating that the virus can also be transmitted by touching a contaminated surface and then touching eyes, mouth or nose because the virus can live from 24 -72 hours on some surfaces. Although the virus has been identified in other body fluids it is unknown if they can transmit the virus.
The incubation period is unclear, but evidence suggests that most individuals who become symptomatic do so between 2 – 14 days after exposure, with a median incubation time of 5-days. It is believed that asymptomatic or mildly symptomatic people may also transmit the infection. It is currently unknown
if a person can be infected more than once. It is currently unknown how long a person can remain infectious.
Symptoms:
• Fever >100.4oF (38oC)
• Fatigue
• Dry cough
• Shortness of breath or difficulty breathing
• Less common – GI symptoms (loss of appetite, diarrhea, vomiting, abdominal pain)1, sore
throat, headache, runny nose
The symptoms are similar to influenza or other respiratory infection. It is possible for an infected person to have symptoms ranging from none to severe. For healthy adults this disease was thought to be mild-moderate;
however, recent CDC data indicate that 58% of patients with COVID-19 severe enough for hospital admission and 12% of those requiring ICU admission were younger than 65 years old. Older adults (65 and older) and people with comorbidities (for example, respiratory or cardiovascular disease, diabetes, autoimmune disorders, or immunosuppressive medications) are at the greatest risk for severe illness (60% of those hospitalized and 25% of ICU admissions).2
It is unclear if pregnant women fall into this high risk group or if there is vertical transmission from mother to fetus. In limited case series of infants born to mothers with COVID-19, the infants have not tested positive. 3 It is unclear if infants fall into the high risk group, but a recent study of 2000 ill children in China report nearly 6% with very severe illness, with 60% of those in children under 5-years of age.Pregnant women, due to physiologic changes in their immune and cardiovascular systems, may be more at risk for severe illness as seen in other viral respiratory infections, although has not been demonstrated in the data thus far, possibly because of very limited availability of data for pregnant individuals.
Person-to-person community transmission is occurring in the U.S. The case fatality rate of COVID-19 has been difficult to determine due, in part, to limited testing; however, the current estimate for the U.S. is around 1.6%, which is more than 10 times higher than for influenza (0.1%). There is no vaccine currently available for this virus. There is no treatment currently confirmed to lessen this virus’s virulence (such as Tamiflu for influenza), thus care is currently supportive in nature. Case-fatality rates were much higher in those over 65 compared to those under 65 (17% vs 2.6%).
Health Care Personnel
1. Hand washing is the first line of defense
a. Washing thoroughly with soap and water for at least 20-seconds is preferable to using hand sanitizer.
b. When soap and water are unavailable, use an alcohol-based sanitizer with at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry.
c. Wash hands before and after touching a client.
6. Avoid touching your eyes, nose, and mouth, especially with unwashed hands.
7. Maintain as much distance as possible from clients, do not shake hands, and touch only as essential for necessary procedures.
8. Universal precautions (as always) should be followed
9. Staff Illness
a. Screening staff for fever and other symptoms upon arrival at the office/birth center.
b. All personnel with symptoms of an URI or influenza should NOT come to work. They should self-isolate at home and check with their PCP and/or local or state health department for any needed testing and for guidance on when it is safe to return to work. Current CDC return to work recommendations for symptomatic healthcare workers not meeting criteria for COVID-19 testing are:
i. Afebrile for 72 hours without antipyretic medications AND ii. Symptoms have improved AND
iii. At least 7 days have passed since symptoms first appeared 10. Have plans in place for contingency staffing patterns if one or more staff members are exposed or become ill. Haven plans on using Apprentice Bethany Kirillov for Admin duties if Asher Belisle is unable to come to work. There is a current list of CDM providers that have agreed to cover if Bethel or Noa becomes ill or exposed.
11. Plan for how mildly ill or PUI staff can continue to work from home if they desire – chart reviews and other CQI activities, PDR data entry, telephone triage, developing client education materials, conducting PNV’s remotely, etc.
12. Modify staffing patterns to limit the number of staff working together at the same time so that an exposure does not impact your entire staff. 13. Review your sick time personnel policies. There are no salaried employees at this time so there is no paid sick leave.
14. Review infection control procedures with clinical and administrative staff. Clorox style wipes are to be used after client touches door knobs, bathrooms and common spaces. No children’s books or toys are available. No waiting in common areas, limit appointment times so no over lap of individuals.
15. Discuss with staff the level of risk you are willing to take regarding screening clients who report COVID-19 symptoms and make a plan that considers their feelings. Community screening resources should also be considered in this decision. Current signage warning symptomatic people not enter into the office- masks and hand sanitizer are available at the front desk, All women who are due are encouraged to get tested.
16. Provide staff training and discussion on how to talk with clients about COVID-19. Monthly staff meetings role play. Covid discussion is charted at each visit with emphasis on social distancing, masks and hand washing. 17. Drill and role play monthly on how staff will respond to a client who is unhappy about new procedures, such as wearing a mask, transferring to hospital birth, decreasing in-person visits, limits on support people. 18. It is important to continue usual CQI activities – chart reviews, facility checks, etc. Times of stress and increased volume provide greater potential for things to fall through the cracks and result in errors and decreased quality. 19. N-95 masks
a. If facing a situation in which it seems you should use an N-95 mask, consider referring that client out for evaluation at the hospital (following guidelines about calling first and where to send). The CDC is currently advising, because of limited supply, that N- 95 masks be reserved for aerosol generating procedures and personnel who are directly caring for known COVID-19 patients.
b. If you have the mask, they must be fit tested in order to be effective OSHA Respirator Fit Testing. Fit test kits are available online or you can use a professional fit testing service. Haven Does not have N-95 masks. c. Although not ideal, individual staff may be able to reuse N-95 mask for several days if it is not soiled by storing it in an enclosed paper or plastic bag between uses.
d. The CDC currently advises the following when interacting with clients with suspected COVID-19:
i. Regular surgical mask
ii. Fluid proof gown
iii. Gloves
iv. Eye protection
v. Surgical mask for the symptomatic client
vi. In addition, avoiding close contact to the extent possible is critical. 20. Revoked
21. The CDC just issued Strategies for Optimizing the Supply of PPE. Although intended for public health officials and other decision-makers in hospitals, they can provide some guidance for birth center administrators as well.
22. Although not optimal, in light of current shortages of surgical masks, there is evidence that cloth homemade masks provide some protection.Use of
these in lower risk situations will preserve the use of more effective masks for use when screening symptomatic clients.
Recommendations for use:
Restrict use to no more than 3-hours
Wash, dry, and sterilize after each use.
Have replacements to use while being laundered and sterilized.
Visits
Consider canceling all home visits and doing the visit remotely or having client and newborn come to the office.
Personnel doing home visits should call prior to entering the home to inquire about any household members who are symptomatic, have had COVID-19 exposure, or are under quarantine.
When possible, contact and assessment should be conducted by electronic means rather than in the home.
Asymptomatic clients can come to the office for early follow up rather than home visits if there is any concern about a symptomatic individual in the home or if staff are uneasy about doing home visits.
e. Personnel should employ universal precautions and use appropriate PPE for all home visits.
f. Consider obtaining CCHD screen prior to discharge from the birth center. There will be a higher false positive rate, but this will assure that the screening isn’t missed if a home visit cannot be done.
g. Consider performing newborn metabolic screening prior to discharge from the birth center if you are not already doing so.
24. Staff should wear clean street clothes. Consider having changing clothing prior to going home in a room that can be isolated and cleaned thoroughly (or in their garage at home). Used clothing can then be laundered separately from other birth center or family laundry. During a peak crisis, scrubs “may” be worn at Haven for births.
Prenatal appointments
1. Clients are offered telemedicine appointments for any routine Prenatal visits out side of the a)initial b) 28 week c) last month of pregnancy.
2. Telehealth visits will be made on client choice of platform. Options include a) WhatsApp b) facetime c) FB messenger d) Zoom e) telephone. These visits are only covered by insurance when a State of Emergency is declared.
3. Visits in the office will be scheduled 1 hour apart and will last for 30-40 min. There will be no waiting in the waiting room. Client will be directed to use hand sanitizer or wash their hands upon arrival. Patient room is already set up for 6 ft of social distancing. Hands on care will be less than 10 min.
4. After the visit, midwife will cleanse with a disinfected wipe every surface the client and guest came in contact with including doppler, BP cuff, tape measure. Pillow case will be changed with each visit. All door handles will be wiped.
5. During the visit, the admin will disinfect the bathroom after patient uses it, wiping the toilet, counter, sink, faucet and door handles with disinfectant wipes. Door handles into the office will also be wiped.
6. All cups, glasses or dishes used will be washed immediately upon finishing use, using warm water and dish soap.
7. Children are allowed to attend visits with the mother and 1 guest is welcome as well during a prenatal visit is allowed. All visitors must stay in the prenatal room and no toys or books are provided by Haven.
8. Hand sanitizer and face masks are available for use at the front desk. 9. All patients and guests will be screened upon arrival for fever, symptoms of COVID19. If they screen positive they will be instructed to go directly to their PCP.
10. All visa payments will be self swipe, and IPAD and attachments will be cleaned with disinfectant after use.
11. Only 1 pen will be in client use and will be wiped down after each use.
Birth Center
1. Birth center rooms will remain closed except for during a tour or for a birth.
2. No visitors are allowed to linger in the waiting room.
3. Doulas are allowed to attend.
4. Masks are available for patients but doulas need to bring their own PPE. 5. Traditional cleaning will continue as it meets void standards already. 6. NO symptomatic individuals will be allowed into the birth room. If a
client is symptomatic she will need to deliver in the hospital. 7. Masks, tissues and hand sanitizer is available in each birth room. There is no need for asymptomatic individuals (partners)to wear a mask.
Midwives and Attendants:
1. Wear outside clothes into the birth center
2. Change into a designated set of birth clothing, consider a long sleeve jacket to wear that is removable when you leave the room in order to grab a snack or use the bath room. Consider scrubs instead of street clothes.
3. Wear birth shoes only at the center.
4. Masks are provided. Eye wear is optional and provided. 5. After birth: ALWAYS Wear gloves for cleaning.
6. After all cleaning is finished, attendant will have the option of bringing street clothes into the bathroom, remove all birth clothing and place in a plastic bag. She may shower, dry with a towel, place towel in the bag and get dressed. Bagged items will be placed in the washing machine and then the attendant is free to go.
7. Midwife may repeat the clothes/shower/dressed and will wipe with disinfectant as she leaves the bathroom. She will placed her items in the washing machine and wash in hot water with bleach.
Home birth:
Attendants are encouraged to change clothes in the garage of their own home as soon as they arrive, and shower immediately after a birth. Wipe all bags down with disinfectant before placing in the car. Wash hands with sanitizer once in the car. Use disposable equipment as needed. Keep O2 and supplies in the zip up bag and only remove items as needed. Haven is considering limiting home birth options for primips in order to limit the exposure of the midwives to an increased number of people. Cleaning and Disinfecting
1. In general, the cleaning substances birth centers currently use with bactericidal and viroscidal properties are adequate for COVID-19.
2. Plan for the fact that you may have increasing difficulty obtaining these supplies. Haven currently has adequate volume of supplies.
3. This EPA list of disinfectants for use against COVID-19 shows products that are effective and contact time required for each disinfectant, including diluted household bleach and alcohol solutions with at least 70% alcohol.
4. The CDC provides these recommendations for cleaning and disinfecting.
5. The use of spray devises for cleaning may aerosolize virus on surfaces and should be not be used.
6. Proper PPE should be worn with cleaning (fluid impermeable gown, mask, disposable gloves or those dedicated to cleaning and disinfection) 7. Universal precautions should be followed, including washing hands after removing gloves.
8. If a client with symptoms is seen in the facility, that client care area should be cleaned prior to any other client encounter.
9. The client care areas such as waiting or family or class rooms should be cleaned daily.
10. Wipe down frequently touched surfaces (door knobs, cabinet handles, counters, keyboards, phones, light switches, toilets, faucets, sinks) multiple times during the course of the day. Haven does so after each client visit. 11. Clean client care equipment (such as blood pressure cuffs and dopplers) and other exam room surfaces (counters, desktop, exam table, chair arms and backs, etc.) between clients.
12. Know your inventory and supply chain. Keep in mind that there may be delays or shortages of some of your usual cleaning and medical supplies. Assess stock more frequently and order prior to stock getting too low. Plan for acceptable substitute in case you are unable to obtain something that you normally use.
13. If you are not already using, consider reusable (i.e. washable) gowns or coveralls that can be washed in hot water. Most have an indicator to track the number of washings prior to loss of impermeability.
14. If you are unable to obtain surgical masks, consider asking a client (or your mother) to make masks for you. Although they should only be used as a last resort, there is some evidence that are better than no protection at all.
15. Remove toys, reading materials, or other communal objects if they cannot be thoroughly cleaned at least daily.
16. Since it is unclear how long the virus can remain infectious on some materials, such as textiles, use universal precautions and PPE (as usual) for handling linens.
Other Planning
1. Give serious consideration to whether or not you will accept client desiring to transfer to your practice from hospital to birth center birth late in pregnancy due to fears about COVID-19 exposure in the hospital.
2. Consider the risks and benefits for your birth center and staff, capacity for a sudden increase in volume, realistic assessment of your resources to allow you to continue providing safe and high quality care.
3. If you are increasing your volume, explore how you can also increase your birth centers capacity to adjust to this – e.g. temporary credentialing of outside midwives, delegating some activities to RN’s or other clinical staff. Haven is open to usage by other providers if they maintain similar Mal practice limits as Haven.
4. Temporarily suspending some less essential aspects of your birth center program. Haven is suspending our PPD support group and moving to all support group activities online during this crisis.
Late Transfers:
Haven will accept late transfer, capping home birth to 5 per month and 10 birth center clients. Clients must be low risk and have consistent prenatal care else where. There is no reduction in fee for late transfers. If Haven needs to expand these numbers, Mary Yanagawa CDM, has agreed to do postpartum home visits so the midwives have time to recover from a run of deliveries.
COVID-19 is a viral respiratory infection that is highly contagious and is primarily transmitted via large droplet respiratory person-person contact. It is most likely spread by being in close contact (within 6 feet) when an infected person coughs or sneezes. This is similar to the transmission of influenza. Recent evidence indicates that the virus may remain airborne for up to 30- minutes.
There are some data indicating that the virus can also be transmitted by touching a contaminated surface and then touching eyes, mouth or nose because the virus can live from 24 -72 hours on some surfaces. Although the virus has been identified in other body fluids it is unknown if they can transmit the virus.
The incubation period is unclear, but evidence suggests that most individuals who become symptomatic do so between 2 – 14 days after exposure, with a median incubation time of 5-days. It is believed that asymptomatic or mildly symptomatic people may also transmit the infection. It is currently unknown
if a person can be infected more than once. It is currently unknown how long a person can remain infectious.
Symptoms:
• Fever >100.4oF (38oC)
• Fatigue
• Dry cough
• Shortness of breath or difficulty breathing
• Less common – GI symptoms (loss of appetite, diarrhea, vomiting, abdominal pain)1, sore
throat, headache, runny nose
The symptoms are similar to influenza or other respiratory infection. It is possible for an infected person to have symptoms ranging from none to severe. For healthy adults this disease was thought to be mild-moderate;
however, recent CDC data indicate that 58% of patients with COVID-19 severe enough for hospital admission and 12% of those requiring ICU admission were younger than 65 years old. Older adults (65 and older) and people with comorbidities (for example, respiratory or cardiovascular disease, diabetes, autoimmune disorders, or immunosuppressive medications) are at the greatest risk for severe illness (60% of those hospitalized and 25% of ICU admissions).2
It is unclear if pregnant women fall into this high risk group or if there is vertical transmission from mother to fetus. In limited case series of infants born to mothers with COVID-19, the infants have not tested positive. 3 It is unclear if infants fall into the high risk group, but a recent study of 2000 ill children in China report nearly 6% with very severe illness, with 60% of those in children under 5-years of age.Pregnant women, due to physiologic changes in their immune and cardiovascular systems, may be more at risk for severe illness as seen in other viral respiratory infections, although has not been demonstrated in the data thus far, possibly because of very limited availability of data for pregnant individuals.
Person-to-person community transmission is occurring in the U.S. The case fatality rate of COVID-19 has been difficult to determine due, in part, to limited testing; however, the current estimate for the U.S. is around 1.6%, which is more than 10 times higher than for influenza (0.1%). There is no vaccine currently available for this virus. There is no treatment currently confirmed to lessen this virus’s virulence (such as Tamiflu for influenza), thus care is currently supportive in nature. Case-fatality rates were much higher in those over 65 compared to those under 65 (17% vs 2.6%).
Health Care Personnel
1. Hand washing is the first line of defense
a. Washing thoroughly with soap and water for at least 20-seconds is preferable to using hand sanitizer.
b. When soap and water are unavailable, use an alcohol-based sanitizer with at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry.
c. Wash hands before and after touching a client.
6. Avoid touching your eyes, nose, and mouth, especially with unwashed hands.
7. Maintain as much distance as possible from clients, do not shake hands, and touch only as essential for necessary procedures.
8. Universal precautions (as always) should be followed
9. Staff Illness
a. Screening staff for fever and other symptoms upon arrival at the office/birth center.
b. All personnel with symptoms of an URI or influenza should NOT come to work. They should self-isolate at home and check with their PCP and/or local or state health department for any needed testing and for guidance on when it is safe to return to work. Current CDC return to work recommendations for symptomatic healthcare workers not meeting criteria for COVID-19 testing are:
i. Afebrile for 72 hours without antipyretic medications AND ii. Symptoms have improved AND
iii. At least 7 days have passed since symptoms first appeared 10. Have plans in place for contingency staffing patterns if one or more staff members are exposed or become ill. Haven plans on using Apprentice Bethany Kirillov for Admin duties if Asher Belisle is unable to come to work. There is a current list of CDM providers that have agreed to cover if Bethel or Noa becomes ill or exposed.
11. Plan for how mildly ill or PUI staff can continue to work from home if they desire – chart reviews and other CQI activities, PDR data entry, telephone triage, developing client education materials, conducting PNV’s remotely, etc.
12. Modify staffing patterns to limit the number of staff working together at the same time so that an exposure does not impact your entire staff. 13. Review your sick time personnel policies. There are no salaried employees at this time so there is no paid sick leave.
14. Review infection control procedures with clinical and administrative staff. Clorox style wipes are to be used after client touches door knobs, bathrooms and common spaces. No children’s books or toys are available. No waiting in common areas, limit appointment times so no over lap of individuals.
15. Discuss with staff the level of risk you are willing to take regarding screening clients who report COVID-19 symptoms and make a plan that considers their feelings. Community screening resources should also be considered in this decision. Current signage warning symptomatic people not enter into the office- masks and hand sanitizer are available at the front desk, All women who are due are encouraged to get tested.
16. Provide staff training and discussion on how to talk with clients about COVID-19. Monthly staff meetings role play. Covid discussion is charted at each visit with emphasis on social distancing, masks and hand washing. 17. Drill and role play monthly on how staff will respond to a client who is unhappy about new procedures, such as wearing a mask, transferring to hospital birth, decreasing in-person visits, limits on support people. 18. It is important to continue usual CQI activities – chart reviews, facility checks, etc. Times of stress and increased volume provide greater potential for things to fall through the cracks and result in errors and decreased quality. 19. N-95 masks
a. If facing a situation in which it seems you should use an N-95 mask, consider referring that client out for evaluation at the hospital (following guidelines about calling first and where to send). The CDC is currently advising, because of limited supply, that N- 95 masks be reserved for aerosol generating procedures and personnel who are directly caring for known COVID-19 patients.
b. If you have the mask, they must be fit tested in order to be effective OSHA Respirator Fit Testing. Fit test kits are available online or you can use a professional fit testing service. Haven Does not have N-95 masks. c. Although not ideal, individual staff may be able to reuse N-95 mask for several days if it is not soiled by storing it in an enclosed paper or plastic bag between uses.
d. The CDC currently advises the following when interacting with clients with suspected COVID-19:
i. Regular surgical mask
ii. Fluid proof gown
iii. Gloves
iv. Eye protection
v. Surgical mask for the symptomatic client
vi. In addition, avoiding close contact to the extent possible is critical. 20. Revoked
21. The CDC just issued Strategies for Optimizing the Supply of PPE. Although intended for public health officials and other decision-makers in hospitals, they can provide some guidance for birth center administrators as well.
22. Although not optimal, in light of current shortages of surgical masks, there is evidence that cloth homemade masks provide some protection.Use of
these in lower risk situations will preserve the use of more effective masks for use when screening symptomatic clients.
Recommendations for use:
Restrict use to no more than 3-hours
Wash, dry, and sterilize after each use.
Have replacements to use while being laundered and sterilized.
Visits
Consider canceling all home visits and doing the visit remotely or having client and newborn come to the office.
Personnel doing home visits should call prior to entering the home to inquire about any household members who are symptomatic, have had COVID-19 exposure, or are under quarantine.
When possible, contact and assessment should be conducted by electronic means rather than in the home.
Asymptomatic clients can come to the office for early follow up rather than home visits if there is any concern about a symptomatic individual in the home or if staff are uneasy about doing home visits.
e. Personnel should employ universal precautions and use appropriate PPE for all home visits.
f. Consider obtaining CCHD screen prior to discharge from the birth center. There will be a higher false positive rate, but this will assure that the screening isn’t missed if a home visit cannot be done.
g. Consider performing newborn metabolic screening prior to discharge from the birth center if you are not already doing so.
24. Staff should wear clean street clothes. Consider having changing clothing prior to going home in a room that can be isolated and cleaned thoroughly (or in their garage at home). Used clothing can then be laundered separately from other birth center or family laundry. During a peak crisis, scrubs “may” be worn at Haven for births.
Prenatal appointments
1. Clients are offered telemedicine appointments for any routine Prenatal visits out side of the a)initial b) 28 week c) last month of pregnancy.
2. Telehealth visits will be made on client choice of platform. Options include a) WhatsApp b) facetime c) FB messenger d) Zoom e) telephone. These visits are only covered by insurance when a State of Emergency is declared.
3. Visits in the office will be scheduled 1 hour apart and will last for 30-40 min. There will be no waiting in the waiting room. Client will be directed to use hand sanitizer or wash their hands upon arrival. Patient room is already set up for 6 ft of social distancing. Hands on care will be less than 10 min.
4. After the visit, midwife will cleanse with a disinfected wipe every surface the client and guest came in contact with including doppler, BP cuff, tape measure. Pillow case will be changed with each visit. All door handles will be wiped.
5. During the visit, the admin will disinfect the bathroom after patient uses it, wiping the toilet, counter, sink, faucet and door handles with disinfectant wipes. Door handles into the office will also be wiped.
6. All cups, glasses or dishes used will be washed immediately upon finishing use, using warm water and dish soap.
7. Children are allowed to attend visits with the mother and 1 guest is welcome as well during a prenatal visit is allowed. All visitors must stay in the prenatal room and no toys or books are provided by Haven.
8. Hand sanitizer and face masks are available for use at the front desk. 9. All patients and guests will be screened upon arrival for fever, symptoms of COVID19. If they screen positive they will be instructed to go directly to their PCP.
10. All visa payments will be self swipe, and IPAD and attachments will be cleaned with disinfectant after use.
11. Only 1 pen will be in client use and will be wiped down after each use.
Birth Center
1. Birth center rooms will remain closed except for during a tour or for a birth.
2. No visitors are allowed to linger in the waiting room.
3. Doulas are allowed to attend.
4. Masks are available for patients but doulas need to bring their own PPE. 5. Traditional cleaning will continue as it meets void standards already. 6. NO symptomatic individuals will be allowed into the birth room. If a
client is symptomatic she will need to deliver in the hospital. 7. Masks, tissues and hand sanitizer is available in each birth room. There is no need for asymptomatic individuals (partners)to wear a mask.
Midwives and Attendants:
1. Wear outside clothes into the birth center
2. Change into a designated set of birth clothing, consider a long sleeve jacket to wear that is removable when you leave the room in order to grab a snack or use the bath room. Consider scrubs instead of street clothes.
3. Wear birth shoes only at the center.
4. Masks are provided. Eye wear is optional and provided. 5. After birth: ALWAYS Wear gloves for cleaning.
6. After all cleaning is finished, attendant will have the option of bringing street clothes into the bathroom, remove all birth clothing and place in a plastic bag. She may shower, dry with a towel, place towel in the bag and get dressed. Bagged items will be placed in the washing machine and then the attendant is free to go.
7. Midwife may repeat the clothes/shower/dressed and will wipe with disinfectant as she leaves the bathroom. She will placed her items in the washing machine and wash in hot water with bleach.
Home birth:
Attendants are encouraged to change clothes in the garage of their own home as soon as they arrive, and shower immediately after a birth. Wipe all bags down with disinfectant before placing in the car. Wash hands with sanitizer once in the car. Use disposable equipment as needed. Keep O2 and supplies in the zip up bag and only remove items as needed. Haven is considering limiting home birth options for primips in order to limit the exposure of the midwives to an increased number of people. Cleaning and Disinfecting
1. In general, the cleaning substances birth centers currently use with bactericidal and viroscidal properties are adequate for COVID-19.
2. Plan for the fact that you may have increasing difficulty obtaining these supplies. Haven currently has adequate volume of supplies.
3. This EPA list of disinfectants for use against COVID-19 shows products that are effective and contact time required for each disinfectant, including diluted household bleach and alcohol solutions with at least 70% alcohol.
4. The CDC provides these recommendations for cleaning and disinfecting.
5. The use of spray devises for cleaning may aerosolize virus on surfaces and should be not be used.
6. Proper PPE should be worn with cleaning (fluid impermeable gown, mask, disposable gloves or those dedicated to cleaning and disinfection) 7. Universal precautions should be followed, including washing hands after removing gloves.
8. If a client with symptoms is seen in the facility, that client care area should be cleaned prior to any other client encounter.
9. The client care areas such as waiting or family or class rooms should be cleaned daily.
10. Wipe down frequently touched surfaces (door knobs, cabinet handles, counters, keyboards, phones, light switches, toilets, faucets, sinks) multiple times during the course of the day. Haven does so after each client visit. 11. Clean client care equipment (such as blood pressure cuffs and dopplers) and other exam room surfaces (counters, desktop, exam table, chair arms and backs, etc.) between clients.
12. Know your inventory and supply chain. Keep in mind that there may be delays or shortages of some of your usual cleaning and medical supplies. Assess stock more frequently and order prior to stock getting too low. Plan for acceptable substitute in case you are unable to obtain something that you normally use.
13. If you are not already using, consider reusable (i.e. washable) gowns or coveralls that can be washed in hot water. Most have an indicator to track the number of washings prior to loss of impermeability.
14. If you are unable to obtain surgical masks, consider asking a client (or your mother) to make masks for you. Although they should only be used as a last resort, there is some evidence that are better than no protection at all.
15. Remove toys, reading materials, or other communal objects if they cannot be thoroughly cleaned at least daily.
16. Since it is unclear how long the virus can remain infectious on some materials, such as textiles, use universal precautions and PPE (as usual) for handling linens.
Other Planning
1. Give serious consideration to whether or not you will accept client desiring to transfer to your practice from hospital to birth center birth late in pregnancy due to fears about COVID-19 exposure in the hospital.
2. Consider the risks and benefits for your birth center and staff, capacity for a sudden increase in volume, realistic assessment of your resources to allow you to continue providing safe and high quality care.
3. If you are increasing your volume, explore how you can also increase your birth centers capacity to adjust to this – e.g. temporary credentialing of outside midwives, delegating some activities to RN’s or other clinical staff. Haven is open to usage by other providers if they maintain similar Mal practice limits as Haven.
4. Temporarily suspending some less essential aspects of your birth center program. Haven is suspending our PPD support group and moving to all support group activities online during this crisis.
Late Transfers:
Haven will accept late transfer, capping home birth to 5 per month and 10 birth center clients. Clients must be low risk and have consistent prenatal care else where. There is no reduction in fee for late transfers. If Haven needs to expand these numbers, Mary Yanagawa CDM, has agreed to do postpartum home visits so the midwives have time to recover from a run of deliveries.