This information was last updated on 17 October 2020, and we will keep it under review as the situation develops. The links were checked at that time but webpages are sometimes moved. If a link appears to be broken please let us know by emailing firstname.lastname@example.org. You should still be able to find the page by entering the title in your browser.
For information about what AIMS is doing to campaign for what women are telling us they want please see here.
We appreciate that it is going to be very stressful to be pregnant or a new parent at this time. It can help to be as clear as possible on ways to keep yourself and your family as safe as possible.
Here is the latest information about the implications of coronavirus for pregnant women, and the guidance that has been given to the maternity services.
Coronavirus infection in pregnancy: information for healthcare professionals published 14 October 2020 by The Royal College of Obstetricians (RCOG), Royal College of Midwives (RCM), Royal College of Paediatrics and Child Health, Public Health England and Health Protection Scotland. This is the guidance for healthcare professionals.
There is an accompanying Q and A Factsheet for pregnant women and their families drawn from the clinical guidance
The RCM website has Advice for pregnant women
The NHS has published a set of recommendations “Clinical guide for the temporary reorganisation of intrapartum maternity care during the coronavirus pandemic” 9 April Version 1
RCM and RCOG have jointly published “Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic” Version 2.2 published 10 July
RCM and RCOG have jointly published Guidance for antenatal and postnatal services in the evolving coronavirus pandemic Version 2.2 10th July
NHS England has published a Framework to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services on 8 September 2020
You should have a contact number to contact your midwife, but you can also contact one of the following depending where you live.
The maternity services are under huge stress with the Covid-19 pandemic. This is causing women to be given mixed messages about the services available, with different NHS Trusts making different decisions. The AIMS Helpline volunteers are working as normal to offer support to maternity service users. Please contact us by email email@example.com or by phone on 0300 365 0663.
The AIMS Helpline does not offer medical advice, but we can provide information and support to help you navigate the maternity system, to know your rights and to listen to your concerns. We will be regularly reviewing the issues brought to us on the Helpline, so we offer the best information and most effective support that we can.
AIMS is receiving question from women about a variety of concerns and we try to answer some of those below. Different Trusts seem to be adopting different strategies, so you will need to check with your midwife about what is happening locally. There may also be information on your NHS Trust's website or Facebook page.
There has been a concern that changes to the immune system which happen during pregnancy mean that in theory pregnant women could be more likely that other healthy women to be seriously affected by COVID-19, but there is no evidence that this is happening. In fact, according to the latest RCM/RCOG guidance pregnant women do not in general appear more likely to contract the infection than the rest of the population and most pregnant women who are infected will experience only mild or moderate symptoms. As many as three quarters of pregnant women who are infected may have no symptoms. Because many questions remain it is still considered 'prudent' for pregnant women to observe strict social distancing, especially from 28 weeks of pregnancy.
A UK study (Docherty 2020) which looked at 16,749 people hospitalised with COVID-19 found that the percentage of pregnant women (6%) was no greater than in the general population, and that pregnant women did not have a higher risk of dying from the infection.
Another large study (the UKOSS study) is currently in progress in the UK and so far has analysed data on 427 pregnant women admitted to hospital with a confirmed coronavirus infection between 1 March and 14 April 2020. This corresponds to 4.9 out of every 1000 pregnancies. Of those admitted to hospital 9% required admission to intensive care and 1.2% died, but we don't know how many of those deaths were directly due to COVID-19. This is equivalent to 5.6 deaths for every 100,000 pregnant women who were admitted to hospital and tested positive for coronavirus, For comparison, the usual figure is that 9.2 out of every 100,000 pregnant women die from any cause during pregnancy.
Maternal COVID-19 infection is associated about a three times higher risk of premature birth but most of these are due to a decision to bring forward the birth by induction of labour or a caesarean because of concerns about the mother and/or baby's wellbeing.
The UKOSS study found that (in common with what seems to be the case for the general population) pregnant women admitted to hospital with COVID-19 are four to five times more likely to be of black, asian or minority ethnic heritage. Other risk factors were being overweight or obese, being over 35 years old or having pre-existing health problems such as diabetes.
As a result of these findings women of BAME heritage are being advised to seek to seek advice without delay if they have a concern about their health, and doctors are advised to apply a lower threshold for reviewing or admitting to hospital such women if they display symptoms of COVID-19. Remote consultations are generally favoured where appropriate, to reduce the risk of infection, However, Trusts are reminded that face-to-face consultations may be more effective especially if an interpreter is required. The RCOG Q&A for women and families has a advice for women who are at higher risk of illness, including those of BAME heritage, and there is a video on the topic at the top of the webpage.
There is some evidence that people with Vitamin D deficiency may be at greater risk of severe breathing problems if they develop COVID-19. Pregnant women and individuals of BAME heritage are already advised to take a Vitamin D supplement, but this may be particularly important for those of BAME heritage who are pregnant.
The RCM/RCOG guidance reports that the majority of babies born to mothers diagnosed with COVID-19 have been born in good condition. So far there is no evidence that a COVID-19 infection increases the risk of stillbirth, death of a baby shortly after birth or a birth defect. It's considered possible that ian infection could be associated with the baby's growth being restricted, as that was the case with the similar SARS virus. However there is no evidence that this is happening with COVID-19.
The UK Obstetric Surveillance System (UKOSS) survey now underway to look at the impact of COVID-19 in pregnancy found that 27% of those admitted to hospital gave birth prematurely. Two thirds of these were deliberate early births due to concerns over mother or baby's well-being.
There is some evidence which suggests it is possible for the virus to be transmitted to babies in the womb but that it is uncommon for this to happen. A summary of the findings of 49 studies, with a total of 666 babies born to mothers with a confirmed infection found that only 4% tested positive (Walker et al 2020). There was no difference in the risk whether the baby was were born vaginally or by caesarean . The UKOSS study found that between 1 March and 14 April out of 247 babies born to mothers who had been hospitalised with COVID-19 only six (2.5%) tested positive for coronavirus in the first 12 hours after birth, and only one required admission to a neonatal unit.
On the evidence so far it seems that the infection can be passed to babies in the womb, but most babies are unaffected and any infection is likely to be mild.
The guidance on this is now different in the four nations of the UK.
AIMS has drafted a template letter which you can adapt to your own situation if your Trust/Board is not currently allowing partners or other supporters to be present at antenatal appointments or scans and you want to request them to allow it in your case.
If you attend any medical appointment you are legally entitled to make an audio or visual recording for your own use, and share it with your partner or other supporters, as this article from the British Medical Association confirms. In the article it says "Information disclosed during a consultation is confidential to the patient. Therefore, patients do not need doctors’ permission to make an audio or visual recording of a consultation". AIMS believes that the same legal principle would apply to appointments with other healthcare staff and therefore to all antenatal appointments and scans. You might, as a courtesy, like to explain that you are making a recording and why, but you do not have to do so.
Although the article does not cover phone or video calls specifically, AIMS believes that you should also be able to have a call in progress with your partner or other supporter using your own smartphone or tablet, so that at least they can hear and take part in any discussions at your appointment or scan.
Some Trusts are stating that recordings or calls are "not permitted" during scans so you might want to ask them what the legal basis is for placing this restriction on your use of your own personal data. If a healthcare professional were to refuse to continue with an appointment or scan unless you ended the recording or call, they could be considered to have breached their duty of care to you, as this article from the Medical Defense Union indicates would be the case for a doctor who refused to continue to treat a patient who was recording the consultation.
In England revised guidance from NHS England on visiting in-patient settings, updated on 13th October says that "all providers of maternity services are asked to follow" the specific guidance for maternity services outlined in the Framework to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services (published on 8 September). This encourages Trusts to "tailor your policies to your local situation and be innovative in the way you reintroduce visiting" and to take "a stepwise approach, following a meaningful and documented risk assessment," Unfortunately this means that we are likely to still see a 'post-code lottery' with some Trusts going further than others in allowing support at antenatal appointments and scans.
The framework distinguishes between 'essential visitors' (by which it means "supportive individuals required by women with specific communication or care needs, eg a carer or interpreter") and and 'birth partners' chosen by the woman to accompany her during labour and birth.
A briefing from the Royal College of Midwives (RCM) on reintroduction of visitors to maternity units, published in 15 July, noted that "restrictions on visiting and support at appointments has had a disproportionate impact on some groups" including those with mental health problems , those with a learning disability, hearing or visual impairment, those for whom English is not their first language and those who have experienced a previous pregnancy loss or bereavement. AIMS welcomes the RCM recommendation that when Trusts are considering lifting visitor restrictions "Any risk assessment should be accompanied by an Equality Impact Assessment (EqIA). This is a vital tool to ensure new policies and practices are fair and do not have unintended consequences for some groups."
The first step of the NHS England framework for maternity outpatient services is for Trusts to allow essential visitors to be present to meet women's communication or care needs "AND single adults attending where a woman requires familiar support for consultations which may cause her distress." AIMS hopes that Trusts will recognise that all the groups listed in the RCM briefing are likely to need to be accompanied to antenatal appointments and scans, and be prepared to consider this on a case by case basis.
We also hope that Trusts will move swiftly to put in place practical measures to reduce the risk of transmission and move to the next step of the reintroduction framework. This would allow all women and birthing people to be accompanied by one adult to "specific appointments where social distancing can be achieved, such as antenatal, screening ultrasound scans, early pregnancy, antenatal or postnatal complications, birth planning, unscheduled attendances to maternity triage." The third step would allow one accompanying person at "any appointments where social distancing can be achieved."
However, this research shows that many Trusts in England plan to reimpose restrictions in the event of an increase in cases locally or nationally, so check the latest information for your local Trust.
In Scotland "women can identify one supportive person to accompany them to antenatal or postnatal appointments and scans, provided that person is not ill or showing any symptoms of coronavirus. Where women require additional support, for example of a carer, advocate or translator, or in the case of a minor, a parent, this person can be in addition to the supportive person."
In Wales women can be accompanied by "her partner/nominated other" at least for a 12-week pregnancy dating scan, early pregnancy clinic, anomaly scan and attendance at a Fetal Medicine Department, and possibly for other appointments at the Trust's discretion.
In Northern Ireland a woman can be accompanied by her partner or nominated other when attending a 12-week pregnancy dating scan, early pregnancy clinic, anomaly scan and attendance at Fetal Medicine Department, or while an in-patient on the antenatal ward. There may still be occasions when individual Trusts decide that they need to limit this, especially if there is an increase in cases of COVID-19 locally.
The latest guidance from the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists (RCM/RCOG) suggests that the normal schedule of antenatal appointments should be offered in full wherever possible. Ideally these should be carried out face to face, especially for "those from BAME communities, those with communication difficulties or those living with medical, social or psychological conditions that put them at higher risk of complications, or adverse outcomes, during pregnancy." In cases where it is thought necessary to offer 'virtual' appointments (e.g. during a local lockdown) they recommend the use of teleconferencing and videoconferencing - which would have the advantage of allowing your partner or supporter to be present and participate if you wish.
We are aware that some hospitals have been restricting the number of people who can accompany women and pregnant people in labour or visit/stay with them postnatally. Some have been insisting that a birth partner must be from the same household or even banning birth supporters altogether.
The guidance from the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists RCM/RCOG has been updated to say that “Support and encourage women to have birth partners present with them during active labour and birth if they wish to do so, in accordance with local or national hospital policies." This is in recognition of the evidence that "having a trusted birth partner present throughout labour is known to make a significant difference to the safety and well-being of women in childbirth. It also says that partners who have no symptoms and are not required to self-isolate should be allowed "to stay with the woman through labour and birth, unless the birth occurs under general anaesthetic. Further guidance about access to maternity services for birth partners and other supportive adults has been published by the NHS and should be followed as far as possible." (This is referreing the guidance from NHS ENgland discussed below.)
There are now differences in the guidance in place in the four nations of the UK, and all allow for "local discretion". Trusts/Boards seem to be varying in their practice, so do check arrangements locally.
National guidance from NHS England Framework to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services encourages Trusts to "tailor your policies to your local situation and be innovative in the way you reintroduce visiting" and to take "a stepwise approach, following a meaningful and documented risk assessment," Unfortunately this means that we are likely to still see a 'post-code lottery' with some Trusts going further than others in allowing birth supporters into maternity units.
The framework distinguishes between 'essential visitors' (by which it means "supportive individuals required by women with specific communication or care needs, eg a carer or interpreter")and 'birth partners' chosen by the woman to accompany her during labour and birth.
For women with suspected or confirmed COVID-19 it says that "only essential visitors (and when in labour, a single birth partner from the same household) should be permitted." This clearly implies that this is the minimum that should be permitted for everyone, and that therefore that someone with particular Communication or care needs should be allowed another 'essential visitor' during labour in addition to their birth partner.
A briefing from the Royal College of Midwives (RCM) on reintroduction of visitors to maternity units, published in 15 July, noted that "restrictions on visiting and support at appointments has had a disproportionate impact on some groups" including those with mental health problems , those with a learning disability, hearing or visual impairment, those for whom English is not their first language and those who have experienced a previous pregnancy loss or bereavement. AIMS welcomes the RCM recommendation that when Trusts are considering lifting visitor restrictions "Any risk assessment should be accompanied by an Equality Impact Assessment (EqIA). This is a vital tool to ensure new policies and practices are fair and do not have unintended consequences for some groups." AIMS believes that all those listed in the RCM briefing may be in need of additional support, including those with mental health or anxiety issues as well as those with communication or care needs. We therefore hope that Trusts will consider on a case by case basis whether an individual can be accompanied by an appropriate supporter throughout their time in hospital, as well as by their chosen birth supporter during labour.
We also hope that Trusts will move swiftly to put in place practical measures to reduce the risk of transmission and move to the next steps of the reintroduction framework. This would allow all women and birthing people to be accompanied by "essential visitors AND a maximum of two birth partners in labour (observing national guidance on social distancing)", and by one or two "other designated/nominated visitors" in addition to essential visitors when they are in an antenatal or postnatal ward.
In Scotland "women in labour can be accompanied by a birth partner (as an essential visitor) and by a second birth partner if requested". In hospitals and birth centres this is "subject to the need to maintain physical distancing" - which the guidance notes may not always be practicable, especially in older facilities. It is worth noting that the guidance also says that if someone needs support from a carer, advocate or translator that person should not be counted as a visitor - implying that in these cases a women should be able to have a support person as well as a birth partner present.
For homebirths there can be two birth partners but if they are from different households they must follow "indoor physical distancing."
One designated person in addition to the birth partner is permitted to visit on the postnatal ward, subject to a local risk assessment.
In Wales the guidance allows for "a birthing partner for women in labour, preferably from the same household or part of an extended household" but does not mention support on the postnatal ward.
In Northern Ireland "women can be accompanied by their partner or nominated other" for the "duration of labour and birth". There may still be occasions when individual Trusts decide that they need to limit this. It's possible to nominate another person in addition to the nominated birth partner who will be allowed to visit for up to one hour while on the antenatal or postnatal ward.
AIMS hopes that all Trusts and Boards will now change their policies to allow more than one birth supporter, or at the very least to consider on a case-by-case basis requests for a second birth partner, which may be critical to some people’s mental well-being or other needs e.g. due to disability or being non-English speakers.
Birth partners won't be admitted if they have had symptoms within the last ten days which suggest COVID-19, so you may want to have someone else on stand-by to support you. One option for this would be to employ a doula (paid birth supporter). You can find out more about this and look for doulas in your area on the website of Doula UK. Not all doulas are members of this organisation, so try social media, word of mouth and search online as well.
Some Trusts and Boards have been refusing to allow birth partners who are from a different household. However, the latest version of the RCM/RCOG Q&A for pregnant women and their families says that "We know that for some women, their chosen birth partner may be from a different household due to their individual circumstances. You should be supported to have them with you, unless they are unwell with coronavirus symptoms or have tested positive for coronavirus." This means that single parents, or those whose partners are unable for any reason to support them in labour and birth, should be able to have a birth supporter of their choice, as long as that person has no signs of having COVID-19.
Birthrights have expressed the view in their statement www.birthrights.org.uk/2020/03/12/coronovirus-how-will-it-affect-my-rights-to-maternity-care/ that “Trusts that restrict a woman’s right to choose who will be present at her birth, for example by restricting birth partners to one, will need to be very clear that this response is proportionate to the additional threat of infection, and be prepared to look at exceptions on an individual basis. Birthrights does not believe that banning all birth partners can be justified as a proportionate response to the current pandemic.”
If your Trust or Board is refusing to permit any birth partners, limiting you to one or insisting that they must be from your husehold you may want to challenge this and refer them to the relevant national and RCM/RCOG guidelines, especially if there are exceptional circumstances which mean that you need more than one person for support. You may want to ask them to give you their justification for the decision. AIMS has drafted a set of template letters which you can adapt to your own situation to request the support you want for your birth.
As with the general guidance on birth partners in labour, there are now differences between the four nations of the UK on access for partners/supporters in the antenatal ward. The rules remain subject to local discretion by trusts and other NHS bodies so please check with your maternity team for their policy.
On 8th September NHS England published a new framework for Trusts to reintroduce access for partners, visitors and other supporters [see the previous section for details of what this says]. The first step of the framework allows 'essential visitors' for women with specific communication or care needs while on the antenatal ward, which should include during the early stages of induction. The second step allows for essential visitors AND one other designated/nominated visitor observing national guidance on social distancing.
In Scotland "a partner can accompany a woman when she is being induced if it is possible to maintain a reasonable level of physical distancing from other patients. Home induction should be considered where possible" Also, "where a women requires an operative birth, partners should be accommodated, except when a general anaesthetic is needed." It is worth noting that the guidance also says that if someone needs support from a carer, advocate or translator that person should not be counted as a visitor - implying that in these cases a women should be able to have a support person as well as a birth partner present.
In Northern Ireland the wording is that "women can be accompanied by their partner or nominated other for the duration of labour and birth" as well as when an "in-patient on antenatal wards" - so that ought to mean during induction as well, though it isn't explicitly stated. The Welsh guidelines do not seem to say anything about this.
The RCM/RCOG Q&A for pregnant women and their families says "At least on birth partner without symptoms should be able to attend your induction of labour where that is in a single room (e.g. on the maternity suite). Whether a partner can visit you if the induction takes place in a bay on a main ward, will be dependent on the local NHS Trust/Board assessment of safety, including whether it is possible to maintain the necessary social distancing measures." Some hospitals will only allow your birth partners in once you have been admitted to a birth room in active labour. However, some are willing to be flexible about this for those who have a specific need to have a supporter with them during the early stages of induction or while waiting to be admitted to a birth room. It is worth seeing if you can negotiate to have your needs met.
AIMS has suggested that the guidance should encourage local Trusts to explore options to enable birth partners to be present throughout an induction. It may be worth asking whether your hospital has facilities for you to be in a separate room from the start of the induction, especially if your circumstances mean that you have a particular need to have the support of a birth partner throughout. AIMS has drafted a template letter which you can adapt to your own situation to request the support you want for your birth.
Some doulas are offering virtual support for women in early labour, including the early stages of an induction. You may be able to find someone offering this service here doula.org.uk/find-a-doula but not all doulas are members of this organisation, so try social media, word of mouth and search online as well.
The RCM/RCOG guidelines for antenatal care suggest that Trusts "Consider offering outpatient induction of labour for low-risk women." This means going home in early stages of an induction once a slow-release pessary or mechanical dilation device has been inserted, after waiting a short period to check that there are no problems. You would then return to hospital 24 hours later, or sooner if labour has started. If you are planning an induction you may want to ask your midwife or doctor about doing this.
If you are having a caesarean, unless this is being done under general anaesthetic, the RCM/RCOG information says "everything will be done by the clinical staff – midwives, obstetricians and anaesthetists – to keep your birth partner with you" but "there will be some occasions when there is a need for an urgent emergency birth with epidural or spinal anaesthetic, and it is not possible for your partner to be present. " However "your maternity team will explain this to you and will do everything they can to ensure that your partner can see you and your baby as soon as possible after the birth." This is a clear expectation that staff should be enabling birth partners to be present during a caesarean unless it really is an emergency.
Many women are asking about whether they and their babies would be safer if they stayed at home for the birth. The evidence about the safety of homebirth can be found in the "Your Choice - where to have your baby" leaflets for first time mothers and for those having a subsequent baby which your midwife should already have given you at antenatal appointment early in your pregnancy. You will also need to take into account any specific issues that might affect your birth, as well as the chance of catching Covid-19.
Article 8 of the Human Rights Act protects your right to birth where you choose. In normal circumstances if you made the decision to birth at home, you should be able to expect NHS care for the birth. However in the current circumstances there may be situations where this in not possible. This does not mean that you can be legally required to birth in hospital, but that you may not be guaranteed medical support if you decide to birth at home.
RCM/RCOG’s “Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic” recognises that “Continuation of as near normal care for women should be supported, as it is recognised to prevent poor outcomes.” It also says that “The positive impact of midwife-led birth settings is well documented, including reductions in the need for a range of medical interventions. These positive impacts remain of significant importance to prevent avoidable harm, and availability of midwife-led care settings for birth should therefore be continued as far as is possible during the pandemic.” The guidance notes that “Emerging evidence from European settings supports continuing to strengthen community services in order to enable social distancing and minimise spread in healthcare settings.”
Many Trusts seem to be justifying withdrawing support for all home-births on the grounds that they have insufficient midwifery staff and/or that local ambulance services cannot guarantee timely transfer in the event of an emergency. However, many others have put arrangements in place to ensure that women wishing to have a homebirth can be supported to do so.
In fact, the RCM/RCOG guidance recommends that Trusts take a phased approach based on levels of midwifery shortage and how the ambulance service is running. They indicate that if the midwifery shortage is under 20% and the ambulance service is running as usual, all places of birth should continue to be available. The calculation of available midwifery resources should include " additional midwives from the NMC emergency register, independent midwives, those previously in non-clinical roles or year-3 student midwives."
Before moving to restrict homebirths this guidance says that Trusts should consider adapting the usual policy of having two midwives at a homebirth “to include senior student midwives, returning registered non-clinical midwives, returning recently retired midwives or appropriately prepared maternity support workers to attend as the second member of the team for low-risk home births.” They should also consider a combined rota for community midwives and those at freestanding birth centres “so as to maximise the spread of resources and maintain the full range of maternity settings for as long as sustainable staffing allows.”
Even with a midwifery shortage of over 30% and/or ambulance service experiencing severe delays either an alongside midwife-led unit or allocated midwife-led rooms on obstetric units should still be available, if Trusts feel unable to offer support for homebirths.
Trusts should review the constraints on a daily basis and follow a corresponding ‘de-escalation plan’, reinstating services as midwifery shortages reduce.
If you are planning a homebirth, you will need to check the situation in your local area. You may want to check whether your Trust has followed the escalation/de-escalation plan which RCM/RCOG recommend, and the current state of midwifery staffing levels and ambulance services.
If your local Trust is one of those that has said that they will not support homebirths, you could try writing to your local Head/Director of Midwifery asking them to consider the solutions adopted elsewhere to enable support to be provided for homebirths. AIMS has drafted a template letter which you may like to adapt to your own situation. You can find it here www.aims.org.uk/information/item/booking-a-home-birth .
You may also want to find out whether you could go to a birth centre or a midwife-led room in the hospital instead, as in line with the RCM/RCOG guidance at least one of these should be an option. Another option for some families could be to hire an independent midwife. Independent midwives work separately to the NHS and so can offer support for a homebirth even when the NHS will not, or there is a threat of withdrawal. Some Independent Midwives can be found on the IMUK website but not all midwives are part of IMUK so try social media, word of mouth and search online.
If neither of these is an option for you, and your Trust continues to decline support for a homebirth, you will need to decide whether to go to hospital or birth at home without medical support. If you are considering remaining at home for the birth even if a midwife may not be available please see the section "Can I birth at home without a midwife?" below.
See "What are my birth choices if I have tested positive or have symptoms of coronavirus?" for how this might affect your ability to access a birth centre.
Many women feel that this would be the option they would prefer because they feel it would be safer for them, their baby and their family. You should have already been given information about birth outside an obstetric unit, but you can also find it here: "Your Choice - where to have your baby" leaflet for first time mothers and for those having a subsequent baby. Your midwives should be able to answer any questions that you have. You will also need to take into account any specific issues that might affect your birth, as well as the chance of catching Covid-19.
Please see the section “Will I be able to have my baby at home?” for details of guidance from RCM/RCOG on maintaining midwife-led care settings for birth, depending on the levels of midwifery shortage and how the ambulance service is running. If there are problems with these, the guidelines say that Alongside Midwifery units (AMUs) may be prioritised over Freestanding Midwifery units (FMUs) where a Trust has both. If a Trust decides that it needs to close an FMU, then an AMU should still be available. If there is no AMU then they should arrange for “allocated midwife-led rooms on obstetric units”.
Confusingly, Trusts around the country seem to be taking different approaches to the use of birth centres. We are aware that in some areas efforts are being made to support more birth centre births, as this may help to reduce the transmission of coronavirus and relieve pressure on staff in the obstetric unit. You may even find that you are encouraged to consider this option even if you were previously planning to have your baby in hospital. In other areas, birth centres are being closed for birth, in order to concentrate staff in the obstetric unit or so they can be used for providing other care. If this is the case in your area and you had planned to birth there, you may want to discuss the option of a homebirth.
If you wish to use a Birth centre and have tested positive but have no symptoms of COVID-19 the RCM/RCOG guidelines say "it is recommended that an informed discussion takes place with the midwife, consistent with local policies." It also says that continuous monitoring should not be recommened if the only factor is that someone has tested positive. This means that if a birth centre is available in your area, you should not be prevented from using it on the grounds that you need continuos monitoring, if there is no other reason why you might choose yo have it.
We are receiving increasing numbers of contacts from women who tell us that they are now considering remaining at home to give birth even though a midwife may not be available to come out to them. A planned birth without the presence of a health professional is known as a freebirth. It is your right to birth without a midwife or doctor present.
We would hope that women who are planning a homebirth and want a midwife present will not be forced into a choice between leaving their home to birth elsewhere or having to birth without that support, but in the current situation we know this is happening. If you are in this position you will need to weigh up the risks and benefits of remaining at home without medical support compared to going into hospital.
Recent guidance from the RCM suggests that maternity services should seek to build a dialogue with women considering a freebirth. This should include a chance to “share what is important to her in relation to her psychological and physical safety”, time to “explore why she wants to have an unassisted birth” and the offer of support for previous birth trauma. AIMS hopes that this means that midwives will listen to such women with empathy.
It is important for midwives to give objective, factual evidence about the risks of all of a mother’s birthplace options in order to enable her to make an informed decision. However, mothers have the right to decline further discussion for any reason, including if they feel that they are being subjected to unwanted repetition of the risks of freebirth.
The RCM guidance suggests asking the woman “what plan for the birth would feel safe and acceptable to her” and that “The senior midwifery management team should then assess what individualised, flexibility of service provision might be possible to avoid an unassisted birth as far as possible.” AIMS hopes that this would include the option of providing support for a homebirth if this is the only way in which a woman can feel safe and/or able to protect her mental well-being.
It is not acceptable, and could be illegal, for anyone to coerce you, or threaten to refer you to Child Services if you decide to remain at home to birth your baby unattended by a midwife. Anyone who tries to do so should be reminded that this is not a valid reason for referral and that it goes against the code of practice for both doctors and midwives, and could lead to a complaint not only to their employer, but to the General Medical Council (GMC) or Nursing and Midwifery Council (NMC). The RCM guidance reminds midwives that “It is not illegal for a woman to give birth unattended by a midwife or healthcare professional” and that “It is not appropriate for healthcare professionals to refer a woman to social services with concerns about the unborn baby, solely on the basis that she has declined medical support, as she is legally entitled to do."
If you are considering a freebirth we would suggest gathering as much information and emotional and practical support as possible in order to prepare for a birth without a doctor or midwife present. There is more information about Freebirth on the following AIMS Birth information page Freebirth, Unassisted Childbirth and Unassisted Pregnancy which addresses rights and other things you need to know and where you can find support.
The RCM/RCOG guidelines say that if you have recovered from COVID-19 but did not require hospital treatment and have completed the necessary period of self-isolation there should be no change to your planned care or birth choices. You should therefore be able to have midwifery support for a homebirth, go to a birth centre or use a birth pool as long as these options are available in your area.
If you were admitted to hospital with severe COVID-19 and have recovered the guidelines say "place of birth should be discussed and planned with the woman, her family, if she wishes." The plan should take account of your baby's growth and your choices.
If you have tested positive within 10 days of going into labour but have no symptoms and wish to give birth at home or in a birth centre "it is recommended that an informed discussion around place of birth takes place with the midwife." Note, however, that the decision whether to birth at home is yours - you do not need 'permission' to do this. It also says that continuous monitoring of your baby's heartrate "is not recommended" just vbecause of the positive test. This means that you should not be offered this unless there is some other reason for suggesting it (but see our Birth Information page "Monitoring your baby's heartbeat during labour".) This is because there is no evidence that a mother having an infection without symptoms puts her baby at any increased risk of problems.
If you have mild COVID-19 symptom the guidelines say you should be encouraged to remain at home (self-isolating) in early labour, and if you do go to the maternity unit in early labour but all is well with you and your baby , you should be encouraged to go home again until your labour is more established (assuming you have your own transport to do so). The guidelines recommend that any mother with symptoms should give birth in a hospital obstetric unit rather than at home or in a birth centre, and be offered continuous monitoring of her baby's heartrate. The guidelines say "Although the data in this area are poor, it appears prudent to use fetal monitoring for maternal systemic infection including COVID-19" In other words, there isn't any evidence to say whether a baby whose mother has mild symptoms is at increased risk, or that continuous monitoring would help if they are, but the guideline authors feel it's better to be on the safe side. However, you still have the right to birth at home if you choose and to decline continuous monitoring if you do not want it.
There is no evidence to favour a caesarean over a vaginal birth for women with COVID-19, unless the mother's condition is worsening and she needs urgent treatment. Of the small number of babies found to be infected within 12 hours of birth in the UKOSS study of pregnant women with COVID-19, two had been born vginally and four by caesarean. You might be recommended to have an epidural put in during early labour, so that if you were to need a caesarean very urgently you would not need to be put under a general anaesthetic. However this is just being recommended as a precaution. So far there is no evidence to show whether women with suspected/confirmed COVID-19 are significantly more likely to need a very urgent caesarean where there would not be enough time to set up an epidural or spinal block. It is up to you whether you want to have an epidural for this reason, if you were not otherwise intending to use it to manage your labour, and your doctor or midwife should discuss the benefits and risks so that you can make an informed decision.
AIMS has heard that some women have been told that they will not or may not be able to use Gas and Air (Entonox) during their birth because of a concern about transmission of Coronavirus. However, the latest RCM/RCOG guidance states "Entonox can be used with a single-patient microbiological filter. There is no evidence that the use of Entonox is an aerosol-generating procedure." The use of single-patient filters is standard practice. RCOG's information for women says "there is no reason you cannot use this in labour." This means you should not be denied access to Gas and Air because of concerns about you contracting Coronavirus or because you might pass it on to others.
The availability of birth-pools varies. In some NHS Trusts there are one or more pool rooms within the main hospital obstetric unit, but in others they are only available in midwife-led units (birth centres). In that case, if the midwife-led units have been suspended, then there probably won’t be a birth-pool available unless the Trust has, for example, installed a portable birth-pool in the obstetric unit. Unfortunately, you do not have a right to insist on a water-birth so you may need to negotiate for this. If homebirth is an option for you then you can hire your own birth-pool.
Some Trusts have decided to suspend the use of birth-pools even though these are available in an obstetric unit and/or in a midwife-led unit which remains open. The RCM/RCOG guidance guidance recognises that labour and birth in water "may confer benefits" and makes it clear that those who have no symptoms and have tested negative or can be presumed not to be infected with COVID-19 should be able to use a birth-pool "providing adequate PPE can be worn by those providing care." AIMS hopes that this will mean that Trusts cease to impose blanket bans on waterbirths.
The guidance goes on to say that while there is evidence that coronavirus may be present in faeces (poo) there is no direct evidence that it can be caught from a birthpool, It notes that there is a "small theoretical risk" of the virus being transmitted to a baby or the staff caring for a woman in water but "this risk also applies when caring for a woman during labour out of water." Despite the fact that there is no evidence of a higher risk of transmission when birthing in water compared wih birthing on land, the UK Infection Prevention and Control Cell have decided to recommend that women who, within 10 days of birth, test positive for, or have symptoms of, COVID-19 "should not be offered to birth in water".
RCM/RCOG feel that those with symptoms such as fever, coughing or breathing difficulties, or who feel on well, need careful monitoring so their care is better managed on land. For those who have tested positive but have no symptoms they simply say "there is inadequate evidence" about the risk - which leaves the situation rather confused.
The guidance no longer quotes the research on the potential risk of disease transmission through faeces [poo], but previously they gave two references. One (Wang 2020) is a report of live virus being detected in stool samples from some COVID-19 patients in China, but the number of patients tested was very small so we don't know how common that is. The other (Amirian 2020) is a review of published reports where viral RNA (the genetic materialof the coronavirus) has been detected in the faeces of some COVID-19 patients. The authors of this review point out that the presence of viral genetic material in a stool does not necessarily mean that it contains infectious virus particles, nor prove that the virus can be spread by this route, but it is possible that it is. They recommend that "additional precautions for preventing potential fecal transmission should be strongly considered until future studies can establish whether this is a plausible (and if so, frequent) mode of transmission for SARS-CoV-2" (the scientific name for this strain of coronavirus). They are mainly talking about things like sewage exposure, food preparation or infections in care homes and do not mention birthpools.
The guidance is therefore erring on the side of caution in recommending against the use of birthpools for women with suspected or confirmed COVID-19.
This briefing from the Royal College of Midwives (RCM) concludes that “The current evidence does not suggest that there should be a blanket cessation on the use of water in labour or waterbirth for all women.” It does go on to say that “Individualised risk assessment about the appropriateness of providing labour or birth care in the pool room should be undertaken for each woman by the midwifery team providing care, based on the woman’s individual presentation and the pool environment within the labour setting.” This would still allow a Trust to say that their pool room is not suitable.
A paper from Oxford Brookes University water immersion during labour and waterbirth - COVID-19 context makes the case for waterbirth being a potentially safer option for women who do not have suspected or confirmed symptoms of COVID-19 “because it promotes the use of social distancing without interrupting normal midwifery care” and that the water should dilute any potential contamination from respiratory droplets or faeces.
RCOG has suggested that Trusts should identify areas where services could be 'rationalised' giving as an example "reducing induction of labour for indications where this is not ‘medically indicated’." This means that you may not be offered an induction if your doctor thinks the risk of continuing your pregnancy is low. You should be able to discuss this with your doctor, and if you are not happy with the recommendation you can ask for a second opinion. Although they do not mention it, it's possible that some hospitals will also try to reduce or delay planned caesareans.
For women who are self-isolating because they or someone in their househol has suspected COVID-19 the RCM/RCOG guidance is that "an individual assessment should be made to determine whether it is safe to delay" a planned caesarean or induction. Again, you can ask for a second opinion if you are unhappy with the decision.
There is little evidence about the risk of a baby catching COVID-19 from an infected mother. For now the Royal College of Paediatrics and Child Health (RCPCH) advises ""Well babies born to suspected/confirmed COVID-19 mothers and who do not require medical intervention should remain with their mother in their designated room. The RCM/RCOG guidance also says that in this situation you should be "supported and enabled" to remain with your baby, practice skin-to-skin ('kangaroo care') and to breastfeed if you wish.
RCPCH also says that "Well babies born to suspected/confirmed COVID-19 mothers and who require additional care (e.g. intravenous antibiotics) should be assessed in the labour ward and a decision made as to whether additional care can safely be provided at the mother’s bedside. Avoid NNU [neonatal unit] admission if possible and safe."
If you have suspected or conformed COVID-19 and your baby needs to be cared for in a neonatal unit then RCM/RCOG recommend a preciationary approach" to reduce the risk of giving the infection to your baby, but you should still be involved in decisions about your babies care, and be supported to breastfeed if you wish
If you have given birth and have questions about infant feeding, it is important to know that the best way to protect your baby from infection is to breastfeed and maintain close contact/skin to skin contact with your baby even if you are ill. You may choose to wear a mask when you are in close contact with your baby, or when you are feeding them.
The latest guidance from RSPCH confirms that even women with a suspected or confirmed COVID-19 infection should be enabled to have skin-to-skin contact and breastfeed their baby if that is their choice. They say " Viral RNA has not, to date, been detected in breast milk of COVID-19 confirmed mothers" and so, though the sample is small, they consider that "for well babies of COVID-19 suspected or confirmed mothers is that the benefits of breast feeding outweigh any theoretical risks.." They suggest care with hand washing and wearing a fluid-resistant (Type IIR) surgical mask (FRSM) while handling the baby.
The RCM/RCOG guidance says that if you are unwell or otherwise unable to breastfeed your baby directly, you should be supported to express your breastmilk, or be offered donor milk for your baby.
Getting breastfeeding support may be more difficult right now due to the closures of face to face breastfeeding drop ins, however, most of those groups will have moved online and be offering video call support to parents. Search Facebook for your local group.
Breastfeeding Counsellors, Lactation Consultants and doulas are making themselves available for video consultations so do reach out if you need support.
All the breastfeeding helplines are still open:
Breastfeeding Support organisations
If you are formula feeding your baby it is even more important than usual to make sure you are carefully sterilising all the equipment you use and minimising the number of people who hold and feed the baby.
Should you encounter any issues obtaining formula for your baby please do not ring the ‘careline’ number on the packaging - the rumour that the companies are sending out free supplies to mothers is not true. If you are running short of formula and unable to find any in the shops, please inform your pharmacy or GP surgery, who can order in stocks for you.
Many parents worry about their baby not taking the recommended amount of milk, and during this time where they may be a lack of support you may be concerned about this. In which case you may find the ‘Paced Bottle-Feeding’ method may be useful and information can be found here https://feedsleepbond.com/lactation-consultants-guide-bottle-feeding.
For information about what AIMS is campaigning for during this crisis please see here.
AIMS Helpline Team Latest update 17th October 2020
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email firstname.lastname@example.org or ring 0300 365 0663.
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