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Adapting obstetric and neonatal services during the COVID-19 pandemic: a scoping review



The provision of care to pregnant persons and neonates must continue through pandemics. To maintain quality of care, while minimizing physical contact during the Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV2) pandemic, hospitals and international organizations issued recommendations on maternity and neonatal care delivery and restructuring of clinical and academic services. Early in the pandemic, recommendations relied on expert opinion, and offered a one-size-fits-all set of guidelines. Our aim was to examine these recommendations and provide the rationale and context to guide clinicians, administrators, educators, and researchers, on how to adapt maternity and neonatal services during the pandemic, regardless of jurisdiction.


Our initial database search used Medical subject headings and free-text search terms related to coronavirus infections, pregnancy and neonatology, and summarized relevant recommendations from international society guidelines. Subsequent targeted searches to December 30, 2020, included relevant publications in general medical and obstetric journals, and updated society recommendations.


We identified 846 titles and abstracts, of which 105 English-language publications fulfilled eligibility criteria and were included in our study. A multidisciplinary team representing clinicians from various disciplines, academics, administrators and training program directors critically appraised the literature to collate recommendations by multiple jurisdictions, including a quaternary care Canadian hospital, to provide context and rationale for viable options.


There are different schools of thought regarding effective practices in obstetric and neonatal services. Our critical review presents the rationale to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability.

Peer Review reports


Quality care throughout pregnancy, childbirth and the postnatal period is considered an essential service. The disciplines of obstetrics/midwifery and neonatology, collectively termed perinatology, have decreased maternal and neonatal mortality and morbidity worldwide [1], but the COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome-related Coronavirus 2 (SARS-CoV-2), challenged the safe provision of care [2]. Some early estimates predicted COVID-19 to be the indirect cause of an increase in maternal (8.3–38.6%) and child deaths (9.8–44.7%) in low- and middle-income countries alone [3].

Changes in the provision of care during the pandemic restricted unnecessary physical contact amongst pregnant persons, infants, and healthcare providers and adapts to changing information. Although many academic institutions and national organizations made recommendations on the delivery of perinatal services early in the pandemic, these did not provide enough information for individual institutions to build their own policies, and were made in the absence of strong evidence [4,5,6,7]. These limitations made it difficult for clinicians and policy-makers to determine how best to modify their own perinatal services. The objective of this paper is to review the literature, and draw from expert experience at a quaternary care centre, to synthesize and present published recommendations, and where guidelines conflict, provide rationale for selecting the most centre-appropriate modifications.


We conducted a scoping review to address our objectives, the checklist of which is presented as Supplementary Data 1. Since the international register for systematic reviews does not register scoping reviews, the protocol was not registered or published. We initially searched Medline, Embase, the Cochrane databases, CINAHL and Scopus from inception until May 14, 2020 using medical subject headings and free-text search terms related to coronavirus infections and pregnancy, and summarized clinical practice recommendations from guidelines of international societies. Prior to submission, we updated targeted searches of general medical and obstetric journals, as well as recommendations from national societies published until December 30, 2020. Our search strategy is presented as Supplementary data 2. Data was charted on forms tested by the research team. One member extracted the data and a second cross-checked for accuracy. In cases of discrepancies, a third investigator independently adjudicated. A list of all data items is presented as Supplementary data 3. We drew upon the expert advice from our hospital, Sinai Health System (SHS), a quaternary referral centre in Toronto, Canada, which was well placed to address the novel coronavirus, based on the experience and lessons learned from the SARS outbreak of 2003, where Toronto was the hardest hit centre outside Asia.

Results and interpretation

We identified 846 titles and abstracts of which 105 fulfilled eligibility criteria (Supplementary Data 4). These papers mostly included descriptive studies including guidelines, commentaries, expert opinions and committee statements and have been included in our reference list. Since all studies were descriptive, and their scope is clearly outlined in the study titles, study characteristics are not presented separately, but include the entire reference list of this paper. Study findings have been summarized related to organization of services, followed by considerations specific to healthcare providers (HCPs) and health service users (HSUs).


Leadership and planning

Clear and up-to-date communication from one leadership source at an academic institution is essential to effective implementation of change. Ideally an infectious disease physician and a clinical co-lead should chair the implementation team which includes representation from all clinical and non-clinical departments [8, 9]. In addition to providing oversight and clinical recommendations within the academic setting, the leadership team should liaise with other academic and community hospitals and federal and provincial agencies, to obtain up-to-date evidence and local, context-specific recommendations. Management decisions at the institutional level should be based on local disease prevalence, phase of the pandemic and availability of resources [10]. Within the departments of perinatology, a Steering Committee which includes representation of all HCPs should have virtual meetings as required, to synthesize information, formulate recommendations and disseminate guidance. Early institutional planning is vital and should not await government directives (Fig. 1).

Fig. 1
figure 1

Timeline depicting global events and local response in Toronto with regard to planning for the pandemic

Staffing and training considerations


Options for staff scheduling changes, based on the phase of the pandemic, local prevalence of cases, and resource availability, include: (1) no change, (2) a formal back-up system (across hospitals, if feasible), in the event of a surge in admissions or reduced staffing from HCPs requiring self-isolation [11, 12], (3) creating HCPs teams always working together and caring for all patients [13], or (4) designating ‘COVID-19 teams’, solely responsible for the care of COVID-19 positive or suspected persons [9, 12, 14,15,16,17,18]. High prevalence areas may benefit from designated care teams/cohorting [19]. HCPs with health or other concerns, should be offered the option of working in lower-risk areas or taking temporary leave [20, 21].


Perinatology services that are critically necessary at all times should exempt HCPs from redeployment to intensive care units (ICU)s and infectious disease wards [22]. Cancellation of elective gynaecologic procedures allows increased inpatient capacity [23], and staff availability.

Training of staff

Current evidence supports the view that the SARS-CoV-2 virus primarily spreads via droplets, but may be transmitted during aerosol-generating medical procedures (AGMPs) [24]. Training on appropriate donning and doffing of PPE is essential, and most effective through simulation [9, 25]. With adequate PPE and infection control measures, the risk of acquiring an infection within the healthcare setting is low [26].

Medical education and residency/fellowship training

Depending on the phase of the pandemic and the ability of healthcare systems to safely cope with increased volumes of extremely high-risk patients, it was suggested that medical students should be removed from clinical care ADDIN EN.CITE [27,28,29]. This also helped prevent unnecessary exposure of medical students to COVID-19 and conserve PPE. In order to to minimize impact on their education, medical students in several jurisdictions were provided access to print materials and virtual learning tools [27,28,29]. It may be necessary to suspend subspecialty rotations and deploy trainees to cover emergency perinatology [30], or other emergency services. Reducing trainee work hours could facilitate the creation of a backup pool supporting trainees who are ill or self-isolating. In-person educational activities and non-essential clinical activities should be cancelled [30, 31] or moved online [32, 33]. Fellowship training programs that recruit post-residency trainees could continue with minimal changes, with fellows providing virtual and in-person clinics, in-house team call, and clinical service on the wards.

Health care professionals’ (HCPs) wellness

Universal screening of HCPs at the hospital/clinic entrance should be considered; those screening positive should be tested and self-isolate until results are available or for 14-days. Monitoring symptoms of COVID-19 [34] include measuring temperatures twice daily, having a dedicated clinic to assess HCPs with symptoms [35], and ensuring 14-days of self-isolation for those exposed to COVID-19 without adequate PPE [34, 36, 37]. HCPs are also at increased risk for psychological distress and mental health problems during pandemics [38]. Recommendations for promoting psychosocial wellness include recognition of efforts, creating back-up schedules to avoid fatigue [9], providing discussion forums to raise concerns [38], and the availability of dedicated psychiatrists and counsellors to provide resilience coaching and support.

Care of the pregnant person

Screening and testing

Universal screening via telephone, for symptoms and risk factors the day prior to appointments, and again upon entry into a clinical setting, is an effective risk-reduction method [4, 9, 28, 29, 34, 39,40,41,42]. If deferral of appointments for screen-positive persons is not possible, protocols as described in Supplementary Data 5 should be implemented. Testing policies could vary from universal testing of all HSUs to testing only those that are screen-positive, depending on community prevalence of COVID-19, testing capacity, turnaround time for test results and the availability of PPE for all HSUs and HCPs under investigation while awaiting results [43,44,45,46].

Antenatal care – ambulatory settings

Centres should have systems that limit physical exposure between and among HSUs and HCPs. Telephone and videoconferencing can effectively limit the number of in-person visits, and can be scheduled to coincide with routine blood or ultrasound tests [4, 28, 36, 42, 47,48,49,50,51,52,53,54]. Any modifications to care, as illustrated in Fig. 2, should consider limitations of virtual care, which include barriers to access, language skills, and impaired HSU-HCP relationships [53]. A summary of COVID-specific considerations at in-person antenatal visits for low-risk pregnancies is presented in Table 1. Basic principles for the management of high-risk pregnancies include individualization of care plans and 24-h access to a telephone line in case of emergencies and specific considerations are discussed in Table 2. Specialized Ambulatory Units such as obstetrical day units, which provide non-urgent in-person services including administration of antenatal corticosteroids, blood pressure assessments, blood work and non-stress tests; and obstetrical triage may continue to offer services, and possibly expand their scope to limit hospitalization, with strict protocols/algorithms (Fig. 3) and designated rooms for screen-positive persons. Risk-reduction strategies during in-person visits include diligent hand and surface hygiene and wearing of surgical masks by HCPs [34, 36, 39, 55] and symptomatic [9, 20, 28, 34, 40] or all HSUs [28, 39, 53, 55, 56]. Screen-positive HSUs should wear a mask, wait in a designated area prior to assessment [9, 40], and enter an assessment room along a designated route guided by a HCP in full droplet- and contact PPE [53]. Paper charts should be avoided in the assessment room, and there should be clear signage describing the necessary cleaning protocols. Strategies to minimize contact between and among HSUs and HCPs include assessment of vital signs by physicians in physician-led units to avoid additional contact with a nurse at each visit [40], creation of distanced waiting areas [50], and increasing time between appointments [29]. Physical space modifications include ensuring that triage/screening areas are separate and well-ventilated, incorporating plexiglass barriers to triage settings, placing chairs in waiting rooms six feet apart, and providing hand hygiene stations [9, 28, 29, 40, 55]. Special clinics/ hospitals could be designated for providing antenatal care to COVID-19-positive or suspected persons in high-prevalence areas [11, 39, 50, 57]. Centres should have contingency plans if case numbers increase (Supplementary data 6). Decisions regarding the presence of partners/ support persons during antepartum appointments should be based on the patient volume at each centre, the ability to follow physical distancing protocols, while safely providing in-person care to the birthing parent and emerging evidence on the impact of restrictions on maternal physical and mental health, preterm birth and stillbirths [58,59,60,61]. Pregnancy and parenting education classes could be conducted online, if possible. While making these decisions, the human impact of these restrictions need to be considered.

Fig. 2
figure 2

Modifications to the low-risk prenatal clinic schedule during the COVID-19 pandemic

Table 1 Considerations at in-person antenatal visits for low-risk pregnancies
Table 2 Considerations at in-person antenatal visits for high-risk pregnancies during the pandemic
Fig. 3
figure 3

Algorithm for the management of persons with suspected or confirmed COVID-19 infection in pregnancy in the outpatient setting

Antenatal care - inpatient settings

A positive COVID-19 result is not an indication for hospital admission or transfer to a higher centre; inpatient management should only be considered when medically indicated [21, 42, 71]. Those admitted for COVID-unrelated concerns, should be monitored daily for development of COVID-19 symptoms, and those admitted with suspected or confirmed COVID-19 should be systematically assessed for disease progression using algorithms such as the one presented in Fig. 4. In high-prevalence areas, sequestration of HSUs with suspected and confirmed COVID-19 in isolated wards [11, 28, 34, 37, 39, 72], management by specific HCPs [9], or redirection to designated hospitals may be considered [39, 57]. These policies need regional cooperation. In addition to structural modifications to inpatient units, measures to limit HSU-HCP contact include limiting blood-draws and avoidable assessments, care by the senior-most and fewest numbers of HCPs, and using virtual platforms for handovers. An evidence-based approach to the use of routine and experimental medications is described elsewhere [73, 74].

Fig. 4
figure 4

Algorithm for the management of persons with suspected or confirmed COVID-19 infection in pregnancy in the inpatient setting

Intrapartum care

COVID-19 is not an indication for inducing labour or performing a caesarean [4, 6, 13,14,15, 21, 34, 36, 39, 41, 42, 50, 75,76,77]. Scheduled births may be delayed in COVID-19 positive and suspected HSUs to enable confirmatory testing [15], allow time for recovery, optimize one’s respiratory status [78] and reduce the risk to themselves, HCPs and neonates [4, 6, 41]. Timing of birth must consider the HSU’s clinical status, gestational age and fetal condition [4, 6, 34, 41, 42]. While medically-indicated labour inductions should continue uninterrupted [15, 36, 78], decisions on non-urgent indications must be based on a risk-benefit assessment that includes duration of hospitalization, contact with HCPs, resource utilization and the perceived risk of continuing the pregnancy. Outpatient cervical ripening is safe and effective [79], and has the advantage of reducing the length of hospital stay [15]. Telephone-screening for symptoms the day before scheduled inductions or planned caesareans, as well as upon arrival, is recommended. While hospital-births are considered safest for those with confirmed or suspected COVID-19, decisions regarding homebirths for non-infected individuals, to minimize contact with HCPs should depend on locally-available infrastructure and regional/cultural acceptance [53]. Suggested modifications to protocols for hospital births including visitor policies are presented in Table 3. Decisions around labour analgesia are often personal, with considerable regional variation. Regional (epidural) analgesia has been recommended early in labour to avoid exacerbation of respiratory symptoms secondary to labour pain [15, 17, 25, 34,35,36, 76, 80, 81], and the need for general anaesthesia in case of an emergency caesarean. Neuraxial anaesthesia (spinal or epidural) is the preferred modality for caesareans [11, 15, 25, 34, 35]. Widespread use of epidurals could increase the incidence and severity of intrapartum pyrexia, which could result in designating a HSU as a suspected case of COVID-19, requiring increased use of PPE [80]. Some organizations have advocated for suspending the use of nitrous oxide for labour analgesia, because of possible aerosolization [15, 36, 56, 81], while others suggest its use may be acceptable with precautions such as a single-use microbiological filter [13, 25, 35]. Hydrotherapy (water births) was disallowed by certain groups due to possible presence of SARS-Cov-2 in feces [34, 42, 53].

Table 3 Modifications to protocols for labour and childbirth

Postpartum care

Multiple transfers between birthing and recovery units should be avoided and the duration of postpartum hospitalization should be reduced where possible [15, 50, 78, 81].

Although not ideal, depending on a local risk-benefit assessment, group breastfeeding and discharge classes may be replaced by instructive videos. One-on-one care should be provided for those that require additional breastfeeding support prior to discharge. For those that meet pre-specified criteria (Supplementary data 7), early discharge and screening at home within 24–36 h of birth by midwives should be considered [9, 15, 57]. Those requiring blood draws or wound care could be assessed in Postnatal Ambulatory Care clinics and the scheduled six-week postpartum visit may be conducted virtually.

Care of the critically ill pregnant person

Pregnant persons with COVID-19 are at risk of life-threatening complications, particularly acute respiratory failure, shock and thromboembolic disease, requiring review by a critical care rapid response team and sometimes ICU admission [91]. Early warning scores can indicate escalation through detection of worsening oxygen saturation, increasing respiratory rate, and decreased level of alertness [92]. The ICU should have equipment and drugs for vaginal or caesarean birth and for neonatal resuscitation. A nearby location should be identified for potential neonatal resuscitation, allowing airborne precautions. Although ICU management is not different in the pregnant person, and there are no data to suggest an alteration to usual ventilatory approaches, airway management requires a higher degree of skill and prone positioning may be more difficult [93]. Although delivery may not always result in significant improvement of respiratory distress [94, 95], this may improve maternal oxygenation when conservative measures have failed [13, 14, 21, 34, 36, 50, 75, 76].

Health service user’s (HSU) wellness

There has been a considerable increase in self-reported depression and anxiety during the pandemic [96], possibly due to isolation, job and financial insecurity, intimate partner violence and reduction in support systems [42, 53, 88]. HCPs should ask about HSU’s mental health during every encounter [4, 53]. At our centre, referral to a perinatal mental health team, composed of social workers and perinatal psychiatrists, can be made for any mental health concerns in pregnancy. Our obstetric and psychiatry teams developed weekly interactive pregnancy-specific webinars to discuss adaptations to care and mental health topics.


Pregnant women were initially excluded from vaccine trials and safety data was therefore limited. Therefore, the UK had initially recommended against vaccination in pregnant persons or those planning to conceive within 3 months, but did not describe vaccination as an indication for termination [5]. The US and Canada, cautiously supported vaccination, particularly for those at high risk of infection and/or morbidity [7, 97]. Now, it is universally recommended by all national organizations for all pregnant persons to be vaccinated by COVID-19 during pregnant women [4,5,6,7]. Although vaccine-elicited SARS-CoV-2 antibodies have been isolated in neonatal cord blood and in breast milk, however, the degree of passive immunity is not confirmed [53].

Neonatal care

Care for infants during the COVID-19 pandemic must carefully balance the risk of COVID-19 exposure with the benefits of infant-parent bonding. The contentious issues that influence care of the neonate are described in Table 4. In addition, examples of modified clinical care pathways for management of symptomatic neonates or those born to mothers with confirmed or suspected COVID-19 are detailed in Fig. 5. In the absence of adequate PPE and individual rooms for neonates, physical changes to the Neonatal Intensive Care Unit include moving monitors to doorways of high-risk infant rooms or using central monitoring, and using long-tubing intravenous lines [14]. Neonatal follow-up after discharge from hospital should be conducted using virtual platforms wherever possible.

Table 4 Neonatal care policies (after Chandrasekaran et al) [77]
Fig. 5
figure 5

Neonatal Unit Algorithms


Physical distancing recommendations require the suspension of many clinical and basic science research activities [30], in favour of COVID-19-related research in diagnostic, therapeutic and preventative approaches, and their effects on pregnancy and the neonatal period [60, 112]. Resumption of routine research activity should include careful planning, staggered work hours, smaller research teams and virtual lab meetings [30]. While data on maternal and fetal effects from COVID-19 are being gathered by registries, pregnant persons continue to be excluded from clinical trials, which could result in their failure to receive treatments due to unsubstantiated concerns [112].


The provision of high quality and evidence-based perinatal care must remain a priority, even in the face of a pandemic. Despite the limitations, which include reliance on descriptive studies and a lack of high-quality evidence, our scoping review presents a practical framework that can guide clinicians, administrators, educators, and researchers in their efforts to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability. Although the provision of a detailed critical analysis of each recommendation was out of reach of this scoping review; it provides the available options, rationale behind them, and implementation strategies to individualize an institution’s pandemic response. As with any guidance, these recommendations need to be considered in the light of their impact on the short- and long-term physical and psychological wellness of families, society, medical students, trainees and healthcare providers. At each stage of the pandemic, policymakers should perform risk-benefit analyses to determine the appropriateness of recommendations, while considering the evolving evidence and feedback.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.


  1. WHO. Millennial development goals. World Health Organization; 2020. Accessed 29 Sept 2020.

  2. O'Callaghan KP, Blatz AM, Offit PA. Developing a SARS-CoV-2 vaccine at warp speed. JAMA. 2020;324(5):437–438. doi:10.1001/jama.2020.12190

  3. Roberton T, Carter ED, Chou VB, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(7):e901–8.

    Article  PubMed  PubMed Central  Google Scholar 

  4. ACOG. COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics. 2020. Accessed 10 Oct 2020.

  5. RCOG. Coronavirus infection and pregnancy. 2020.,not%20to%20have%20the%20vaccine. Accessed 3 Oct 2020.

  6. SMFM. Society for Maternal-Fetal Medicine management considerations for pregnant patients with COVID-19. 2020. Accessed 10 Oct 2020.

  7. SOGC. SOGC Statement on COVID-19 vaccination in pregnancy. 2020. Accessed 3 Oct 2020.

  8. Zarzaur BL, Stahl CC, Greenberg JA, Savage SA, Minter RM. Blueprint for restructuring a Department of Surgery in concert with the health care system during a pandemic: the University of Wisconsin experience. JAMA Surg. 2020;155(7):628–35.

    Article  PubMed  Google Scholar 

  9. London V, McLaren R Jr, Stein J, et al. Caring for pregnant patients with COVID-19: practical tips getting from policy to practice. Am J Perinatol. 2020;37(8):850–3.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Fischhoff B. Making decisions in a COVID-19 world. JAMA. 2020;324(2):139–40.

    Article  CAS  PubMed  Google Scholar 

  11. Bauer ME, Bernstein K, Dinges E, et al. Obstetric anesthesia during the COVID-19 pandemic. Anesth Analg. 2020;131(1):7–15.

    Article  CAS  PubMed  Google Scholar 

  12. Chua M, Lee J, Sulaiman S, Tan HK. From the frontline of COVID-19 - how prepared are we as obstetricians? A commentary. BJOG. 2020;127(7):786–8.

    Article  CAS  PubMed  Google Scholar 

  13. Dashraath P, Wong JLJ, Lim MXK, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol. 2020;222(6):521–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Ng PC. Infection control measures for COVID-19 in the labour suite and neonatal unit. Neonatology. 2020;117(2):141-3.

  15. Boelig RC, Manuck T, Oliver EA, et al. Labor and delivery guidance for COVID-19. Am J Obstet Gynecol MFM. 2020;2(2):100110.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kang Y, Deng L, Zhang D, et al. A practice of anesthesia scenario design for emergency cesarean section in patients with COVID-19 infection based on the role of standard patient. Biosci Trends. 2020;14(3):222–6.

    Article  CAS  PubMed  Google Scholar 

  17. Rasmussen SA, Jamieson DJ. Caring for women who are planning a pregnancy, pregnant, or postpartum during the COVID-19 pandemic. JAMA. 2020;324(2):190–1.

    Article  CAS  PubMed  Google Scholar 

  18. Ranganathan R, Khan A, Chhabra P. Antenatal care, care at birth, and breastfeeding during the coronavirus (COVID-19) pandemic: a review. Indian J Comm Health. 2020;32(1):17–20.

    Article  Google Scholar 

  19. Toronto Co. COVID-19: status of cases in Toronto. 2020. Accessed 17 July 2020.

  20. Abramowicz JS, Basseal JM, Brezinka C, et al. ISUOG safety committee position statement on use of personal protective equipment and hazard mitigation in relation to SARS-CoV-2 for practitioners undertaking obstetric and gynecological ultrasound. Ultrasound Obstet Gynecol. 2020;55(6):886–91.

    Article  CAS  PubMed  Google Scholar 

  21. Marim F, Karadogan D, Eyuboglu TS, et al. Lessons learned so far from the pandemic: a review on pregnants and neonates with COVID-19. Eurasian J Med. 2020;52(2):202–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Grunebaum A, Dudenhausen J, McCullough LB, Chervenak FA. Women and children first: the need for ringfencing during the COVID-19 pandemic. J Perinat Med. 2020.

  23. Schull MJ, Stukel TA, Vermeulen MJ, et al. Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome. CMAJ. 2007;176(13):1827–32.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Klompas M, Baker MA, Rhee C. Airborne transmission of SARS-CoV-2: theoretical considerations and available evidence. JAMA. 2020;324(5):441–2.

    Article  CAS  PubMed  Google Scholar 

  25. Morau E, Bouvet L, Keita H, et al. Anaesthesia and intensive care in obstetrics during the COVID-19 pandemic. Anaesth Crit Care Pain Med. 2020;39(3):345–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Steensels D, Oris E, Coninx L, et al. Hospital-wide SARS-CoV-2 antibody screening in 3056 staff in a tertiary center in Belgium. JAMA. 2020;324(2):195–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. AAMC. Guidance on medical students’ participation in direct patient contact activities. 2020. Accessed 10 Oct 2020.

  28. Saccone G. Get your obstetric inpatient and outpatient units ready for COVID-19. Minerva Ginecol. 2020;72(4):185–6.

    Article  PubMed  Google Scholar 

  29. Kagan KO, Chaoui R. Ultraschall in der Schwangerschaft wahrend der Corona-Virus Pandemie: Ein praktisches Vorgehen. Ultraschall Med. 2020;41(3):237–43.

    PubMed  Google Scholar 

  30. Alvarez RD, Goff BA, Chelmow D, Griffin TR, Norwitz ER, Lancey JO. Re-engineering academic departments of obstetrics and gynecology to operate in a pandemic world and beyond - a joint AGOS/CUCOG statement. Am J Obstet Gynecol. 2020;223(3):383.e1–7.

    Article  Google Scholar 

  31. Daodu O, Panda N, Lopushinsky S, Varghese TK Jr, Brindle M. COVID-19 - considerations and implications for surgical learners. Ann Surg. 2020;272(1):e22–3.

    Article  PubMed  Google Scholar 

  32. Lee JSE, Chan JJI, Ithnin F, Goy RWL, Sng BL. Resilience of the restructured obstetric anaesthesia training program during the COVID-19 outbreak in Singapore. Int J Obstet Anesth. 2020;43:89–90.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Kiely DJ, Posner GD, Sansregret A. Health care team training and simulation-based education in obstetrics during the COVID-19 pandemic. J Obstet Gynaecol Can. 2020;42(8):1017–20.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Poon LC, Yang H, Dumont S, et al. ISUOG interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium: information for healthcare professionals - an update. Ultrasound Obstet Gynecol. 2020;55(6):848–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Lee JSE, Goy RWL, Sng BL, Lew E. Considerations and strategies in the organisation of obstetric anaesthesia care during the 2019 COVID-19 outbreak in Singapore. Int J Obstet Anesth. 2020;43:114–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Donders F, Lonnee-Hoffmann R, Tsiakalos A, et al. ISIDOG recommendations concerning COVID-19 and pregnancy. Diagnostics (Basel). 2020;10(4):243.

    Article  CAS  Google Scholar 

  37. Poon LC, Yang H, Lee JCS, et al. ISUOG interim guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals. Ultrasound Obstet Gynecol. 2020;55(5):700–8.

    Article  CAS  PubMed  Google Scholar 

  38. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ. 2020;368:m1211.

    Article  PubMed  Google Scholar 

  39. Chen D, Yang H, Cao Y, et al. Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection. Int J Gynaecol Obstet. 2020;149(2):130–6.

    Article  CAS  PubMed  Google Scholar 

  40. Jamieson DJ, Steinberg JP, Martinello RA, Perl TM, Rasmussen SA. Obstetricians on the coronavirus disease 2019 (COVID-19) front lines and the confusing world of personal protective equipment. Obstet Gynecol. 2020;135(6):1257–63.

    Article  CAS  PubMed  Google Scholar 

  41. SMFM. Management considerations for pregnant patients with COVID-19. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  42. Poon LC, Yang H, Kapur A, et al. Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. Int J Gynaecol Obstet. 2020;149(3):273–86.

    Article  CAS  PubMed  Google Scholar 

  43. RCOG. Principles for the testing and triage of women seeking maternity care in hospital settings, during the COVID-19 pandemic. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  44. Sutton D, Fuchs K, D'Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020;382(22):2163–4.

    Article  PubMed  Google Scholar 

  45. Campbell KH, Tornatore JM, Lawrence KE, et al. Prevalence of SARS-CoV-2 among patients admitted for childbirth in southern Connecticut. JAMA. 2020;323(24):2520–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. CDC. Coronavirus disease 2019 care for pregnant women. 2020. Accessed 10 Oct 2020.

  47. Barton JR, Saade GR, Sibai BM. A proposed plan for prenatal care to minimize risks of COVID-19 to patients and providers: focus on hypertensive disorders of pregnancy. Am J Perinatol. 2020;37(8):837–44.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Chen Y, Li Z, Zhang YY, Zhao WH, Yu ZY. Maternal health care management during the outbreak of coronavirus disease 2019. J Med Virol. 2020;92(7):731–9.

    Article  CAS  PubMed  Google Scholar 

  49. Turrentine M, Ramirez M, Monga M, et al. Rapid deployment of a drive-through prenatal care model in response to the coronavirus disease 2019 (COVID-19) pandemic. Obstet Gynecol. 2020;136(1):29–32.

    Article  CAS  PubMed  Google Scholar 

  50. Dotters-Katz SK, Hughes BL. Considerations for obstetric care during the COVID-19 pandemic. Am J Perinatol. 2020;37(8):773–9.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Abu-Rustum RS, Akolekar R, Sotiriadis A, et al. ISUOG consensus statement on organization of routine and specialist obstetric ultrasound services in context of COVID-19. Ultrasound Obstet Gynecol. 2020;55(6):863–70.

    Article  CAS  PubMed  Google Scholar 

  52. Bogler T, Bogler O. Interim schedule for pregnant women and children during the COVID-19 pandemic. Can Fam Physician. 2020;66(5):e155–61.

    PubMed  PubMed Central  Google Scholar 

  53. RCOG. Coronavirus (COVID-19) infection in pregnancy. 2020. Accessed.

    Google Scholar 

  54. Richens Y, Wilkinson M, Connor D. Guidance for the provision of antenatal services during the COVID-19 pandemic. Br J Midwifery. 2020;28(5):324–7.

    Article  Google Scholar 

  55. Borowski D, Sieroszewski P, Czuba B, et al. Polish Society of Gynecology and Obstetrics statement on safety measures and performance of ultrasound examinations in obstetrics and gynecology during the SARS-CoV-2 pandemic. Ginekol Pol. 2020;91(4):231–4.

    Article  PubMed  Google Scholar 

  56. Sichitiu J, Desseauve D. Intrapartum care of women with COVID-19: a practical approach. Eur J Obstet Gynecol Reprod Biol. 2020;249:94–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Giannubilo SR, Giannella L, Delli Carpini G, Carnielli VP, Ciavattini A, Regional Operative Group for the Health E. Obstetric network reorganization during the COVID-19 pandemic: suggestions from an Italian regional model. Eur J Obstet Gynecol Reprod Biol. 2020;249:103–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Iyengar U, Jaiprakash B, Haitsuka H, Kim S. One year into the pandemic: a systematic review of perinatal mental health outcomes during COVID-19. Front Psychiatry. 2021;12:674194.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Conde-Agudelo A, Romero R. SARS-CoV-2 infection during pregnancy and risk of preeclampsia: a systematic review and meta-analysis. Am J Obstet Gynecol. 2022;226(1):68-89.e3.

  60. Yang J, D'Souza R, Kharrat A, et al. Coronavirus disease 2019 pandemic and pregnancy and neonatal outcomes in general population: a living systematic review and meta-analysis (updated Aug 14, 2021). Acta Obstet Gynecol Scand. 2022;101(1):7-24.

  61. Yang J, D'Souza R, Kharrat A, et al. COVID-19 pandemic and population-level pregnancy and neonatal outcomes: a living systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2021;100(10):1756–70.

    Article  CAS  PubMed  Google Scholar 

  62. SOGC. Prenatal screening update during the COVID-19 pandemic. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  63. SOGC. Urgent update – temporary alternative screening strategy for gestational diabetes screening during the COVID-19 pandemic. 2020. Accessed 10 Oct 2020.

  64. Benton SJ, McCowan LM, Heazell AE, et al. Placental growth factor as a marker of fetal growth restriction caused by placental dysfunction. Placenta. 2016;42:1–8.

    Article  CAS  PubMed  Google Scholar 

  65. Deprest J, Choolani M, Chervenak F, et al. Fetal diagnosis and therapy during the COVID-19 pandemic: guidance on behalf of the international fetal medicine and surgery society. Fetal Diagn Ther. 2020;47(9):689-98.

  66. Bahtiyar MO, Baschat A, Deprest J, et al. Fetal interventions in the setting of the coronavirus disease 2019 pandemic: statement from the North American Fetal Therapy Network. Am J Obstet Gynecol. 2020;223(2):281–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Deprest J, Van Ranst M, Lannoo L, et al. SARS-CoV2 (COVID-19) infection: is fetal surgery in times of national disasters reasonable? Prenat Diagn. 2020;40(13):1755–8.

    Article  CAS  PubMed  Google Scholar 

  68. Weber LeBrun EE, Moawad NS, Rosenberg EI, et al. Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and obstetrics. Am J Obstet Gynecol. 2020;223(1):85.e1–85.e19.

    Article  CAS  Google Scholar 

  69. Centre OF. About us. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  70. ACOG. Joint statement on abortion access during the COVID-19 outbreak. 2020. Accessed.

  71. Pierce-Williams RAM, Burd J, Felder L, et al. Clinical course of severe and critical COVID-19 in hospitalized pregnancies: a US cohort study. Am J Obstet Gynecol MFM. 2020;2(3):100134.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Ferrazzi EM, Frigerio L, Cetin I, et al. COVID-19 obstetrics task force, Lombardy, Italy: executive management summary and short report of outcome. Int J Gynaecol Obstet. 2020;149(3):377–8.

    Article  CAS  PubMed  Google Scholar 

  73. D'Souza R, Ashraf R, Rowe H, et al. Pregnancy and COVID-19: pharmacologic considerations. Ultrasound Obstet Gynecol. 2021;57(2):195–203.

    Article  CAS  PubMed  Google Scholar 

  74. D'Souza R, Malhame I, Teshler L, Acharya G, Hunt BJ, McLintock C. A critical review of the pathophysiology of thrombotic complications and clinical practice recommendations for thromboprophylaxis in pregnant patients with COVID-19. Acta Obstet Gynecol Scand. 2020;99(9):1110–20.

    Article  CAS  PubMed  Google Scholar 

  75. Pacheco LD, Saad AF, Saade G. Early acute respiratory support for pregnant patients with coronavirus disease 2019 (COVID-19) infection. Obstet Gynecol. 2020;136(1):42–5.

    Article  CAS  PubMed  Google Scholar 

  76. Qi H, Luo X, Zheng Y, et al. Safe delivery for pregnancies affected by COVID-19. BJOG. 2020;127(8):927–9.

    Article  CAS  PubMed  Google Scholar 

  77. Chandrasekharan P, Vento M, Trevisanuto D, et al. Neonatal resuscitation and postresuscitation care of infants born to mothers with suspected or confirmed SARS-CoV-2 infection. Am J Perinatol. 2020;37(8):813–24.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Stephens AJ, Barton JR, Bentum NA, Blackwell SC, Sibai BM. General guidelines in the management of an obstetrical patient on the labor and delivery unit during the COVID-19 pandemic. Am J Perinatol. 2020;37(8):829–36.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Dong S, Khan M, Hashimi F, Chamy C, D'Souza R. Inpatient versus outpatient induction of labour: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2020;20(1):382.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Mullington CJ, Kua J, Malhotra S. The timing of labor epidurals in COVID-19 parturients: a balance of risk and benefit. Anesth Analg. 2020;131(2):e131–2.

    Article  PubMed  Google Scholar 

  81. Ashokka B, Loh MH, Tan CH, et al. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel. Am J Obstet Gynecol. 2020;223(1):66–74.e3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  82. Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: what clinical recommendations to follow? Acta Obstet Gynecol Scand. 2020;99(4):439–42.

    Article  CAS  PubMed  Google Scholar 

  83. Hermann A, Deligiannidis KM, Bergink V, et al. Response to SARS-Covid-19-related visitor restrictions on labor and delivery wards in New York City. Arch Womens Ment Health. 2020.

  84. Davis-Floyd R, Gutschow K, Schwartz DA. Pregnancy, birth and the COVID-19 pandemic in the United States. Med Anthropol. 2020;39(5):413–27.

    Article  PubMed  Google Scholar 

  85. Arora KS, Mauch JT, Gibson KS. Labor and delivery visitor policies during the COVID-19 pandemic: balancing risks and benefits. JAMA. 2020;323(24):2468–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  86. Munshi L, Evans G, Razak F. The case for relaxing no-visitor policies in hospitals during the ongoing COVID-19 pandemic. CMAJ. 2021;193(4):E135-7.

  87. CDC. COVID-19 personal protective equipment (PPE) for healthcare personnel. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  88. SOGC. Committee Opinion No. 400 – COVID-19 in pregnancy (updated May 14, 2020). 2020. Accessed 10 Oct 2020.

  89. Palatnik A, McIntosh JJ. Protecting labor and delivery personnel from COVID-19 during the second stage of labor. Am J Perinatol. 2020;37(8):854–6.

    Article  PubMed  PubMed Central  Google Scholar 

  90. CDC. Clinical questions about COVID-19: questions and answers. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  91. Team CC-R. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) - United States, February 12-march 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(12):343–6.

    Article  Google Scholar 

  92. Knight M, Bunch K, Cairns A, et al. Saving lives, improving mothers’ care rapid report: learning from SARS-CoV-2-related and associated maternal deaths in the UK March – May 2020. MBRRACE-UK: National Perinatal Epidemiology Unit, University of Oxford; 2020. Accessed 1 Oct 2020.

  93. Tolcher MC, McKinney JR, Eppes CS, et al. Prone positioning for pregnant women with hypoxemia due to coronavirus disease 2019 (COVID-19). Obstet Gynecol. 2020;136(2):259–61.

    Article  CAS  PubMed  Google Scholar 

  94. Lapinsky SE, Rojas-Suarez JA, Crozier TM, et al. Mechanical ventilation in critically-ill pregnant women: a case series. Int J Obstet Anesth. 2015;24(4):323–8.

    Article  CAS  PubMed  Google Scholar 

  95. McLaren RA Jr, London V, Atallah F, et al. Delivery for respiratory compromise among pregnant women with coronavirus disease 2019. Am J Obstet Gynecol. 2020;223(3):451–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  96. Davenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms are not OK: COVID-19 and maternal mental health. Front Glob Womens Health. 2020;1:1.

    Article  PubMed  PubMed Central  Google Scholar 

  97. ACOG. COVID-19 vaccines and pregnancy. 2020.

    Google Scholar 

  98. Lamouroux A, Attie-Bitach T, Martinovic J, Leruez-Ville M, Ville Y. Evidence for and against vertical transmission for SARS-CoV-2 (COVID-19). Am J Obstet Gynecol. 2020;223(1):91.e1–4.

    Article  CAS  Google Scholar 

  99. Huntley BJF, Huntley ES, Di Mascio D, Chen T, Berghella V, Chauhan SP. Rates of maternal and perinatal mortality and vertical transmission in pregnancies complicated by severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) infection: a systematic review. Obstet Gynecol. 2020;136(2):303–12.

    Article  CAS  PubMed  Google Scholar 

  100. Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during pregnancy and possible vertical transmission. Am J Perinatol. 2020;37(8):861–5.

    Article  PubMed  PubMed Central  Google Scholar 

  101. Dong L, Tian J, He S, et al. Possible vertical transmission of SARS-CoV-2 from an infected mother to her newborn. JAMA. 2020;323(18):1846–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  102. Kirtsman M, Diambomba Y, Poutanen SM, et al. Probable congenital SARS-CoV-2 infection in a neonate born to a woman with active SARS-CoV-2 infection. CMAJ. 2020;192(24):E647–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  103. Committee on Obstetric P. Committee opinion no. 684: delayed umbilical cord clamping after birth. Obstet Gynecol. 2017;129(1):e5–e10.

    Article  Google Scholar 

  104. CDC. Coronavirus disease 2019 (COVID-19) caring for newborns. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  105. WHO. COVID-19 and breastfeeding position paper. 2020. Accessed 10 Oct 2020.

  106. AAP. AAP issues guidance on breastfeeding during COVID-19 pandemic. 2020. Accessed 10 Oct 2020.

    Google Scholar 

  107. Davanzo R. Breast feeding at the time of COVID-19: do not forget expressed mother's milk, please. Arch Dis Child Fetal Neonatal Ed. 2020;105(4):455.

    Article  PubMed  Google Scholar 

  108. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020;222(5):415–26.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  109. CDC. Evaluation and management considerations for neonates at risk for COVID-19. 2020. Accessed 10 Oct 2020.

  110. Cavicchiolo ME, Lolli E, Trevisanuto D, Baraldi E. Managing a tertiary-level NICU in the time of COVID-19: lessons learned from a high-risk zone. Pediatr Pulmonol. 2020;55(6):1308–10.

    Article  PubMed  PubMed Central  Google Scholar 

  111. AAP. AAP updates guidance on newborns whose mothers have suspected or confirmed COVID-19. 2020. Accessed 10 Oct 2020.

  112. Malhame I, D'Souza R, Cheng MP. The moral imperative to include pregnant women in clinical trials of interventions for COVID-19. Ann Intern Med. 2020;173(10):836–7.

    Article  PubMed  Google Scholar 

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We would like to acknowledge Ms. Helen Robson for her contribution in formatting, editing and submission of the manuscript.


This study was not funded. Costs involved in preparing the manuscript and open access publication were covered by the department of Obstetrics & Gynaecology at Mount Sinai Hospital, Toronto, Canada.

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Each author contributed equally in providing intellectual content in their areas of expertise (including input relating to organization, planning, execution, research, training, quality improvement and clinical care.), reviewing their sections and the document. R.D: Study conception and design, literature review, analysis and interpretation, figures and protocols, drafting of manuscript. S.G and L.C: Data collection, analysis and interpretation, drafting of manuscript. Y. D, P. S, J. J, W. W, M. S, N. A, C. A, A. B, D.C, M.C, M. F, T. F, M.J, J. K, J. KD, J.M, S.L, M.P, G.R, A.S, C.S, J.S, N.W and B.Y and C.M: Content expertise in their areas of expertise, data collection and interpretation C.C: Literature Search. R.A: Screening of articles and reviewing final draft. All authors reviewed the final manuscript. The author(s) read and approved the final manuscript.

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Correspondence to Rohan D’Souza.

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Supplementary Information

Additional file 1: Supplement 1.

Prisma Scoping Review Checklist. Supplement 2. Search Strategy. Supplement 3. List of Data Items. Supplement 4. Prisma Flow chart. Supplement 5. Ambulatory Visit of a Confirmed or Suspected Case of COVID-19. Supplement 6. COVID-19 Antenatal Care Clinic. Supplement 7. Low-Risk Inclusion Criteria for Early Discharge, less than 24 h after birth.

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Gold, S., Clarfield, L., Johnstone, J. et al. Adapting obstetric and neonatal services during the COVID-19 pandemic: a scoping review. BMC Pregnancy Childbirth 22, 119 (2022).

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  • COVID-19
  • Pandemics
  • Coronavirus
  • Severe acute respiratory syndrome-related coronavirus 2
  • SARS-CoV-2
  • Pregnancy
  • Postnatal care
  • Neonatology
  • Perinatology
  • Perinatal care
  • Obstetrics
  • Obstetrical
  • Maternity
  • Clinical protocols
  • Patient care planning
  • Algorithms
  • Hospital restructuring
  • Hospital planning
  • Health planning guidelines
  • Quality improvement
  • Ambulatory care
  • Simulation training
  • Personnel management
  • Medical staff
  • Medical education
  • Residency training
  • Anaesthesia
  • Ultrasonography