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COVID 19
​Haven Midwifery and Birth Center and Haven Birth Protocols

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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.  


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He will cover you with His feathers, and under His wings you will find refuge; His faithfulness will be your shield and rampart. -Psalms 91:4

What Our Clients Are Saying:

​“Having you for midwives has been a divine intervention in
our lives. You are some of the most caring and loving
people we have ever met. This entire journey has been
wonderful and we thank you for always being there to help
us! This birth was perfect and there is no one I could
trust more.” Mariann

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