key: cord-0818091-h2ec7g57
authors: Patrick, Nancy A.; Johnson, Teresa S.
title: Maintaining Maternal-Newborn Safety During the COVID-19 Pandemic
date: 2021-03-22
journal: Nurs Womens Health
DOI: 10.1016/j.nwh.2021.03.003
sha: 2232ba9c95980b1c9cd5f0455b20e94eebd5ffb0
doc_id: 818091
cord_uid: h2ec7g57

COVID-19, the disease caused by the SARS-CoV-2 virus, was declared a global pandemic by the World Health Organization on March 11, 2020. In addition to the elderly and individuals with underlying chronic health conditions, maternal and newborn populations were also identified as high risk. It became critical for hospitals and clinicians to maintain safety of individuals in the facility and minimize transmission of COVID-19 while continuing to strive for optimized outcomes by providing family centered care. Rapid change during the pandemic made it appropriate to use the plan-do-study-act (PDSA) cycle to continually evaluate proposed and standard practices. Our team established an obstetric COVID-19 unit for women and newborns, developed guidelines for visitation and for use of personal protective equipment, initiated universal COVID-19 testing, and provided health education to emphasize shared decision-making.

Precis Being prepared for rapid change is essential for nurses and other clinicians caring for the maternal-newborn population during a pandemic.

• During a time of uncertainty and rapid change, such as a global pandemic with a novel virus, clinicians must continually read and synthesize new information and practice guidance from various organizations.

• Health records should be reviewed to ensure that routine tests have not been overlooked with the advent of limited prenatal visits caused by the pandemic.

•

Health education should be focused on how to function in an environment that includes COVID-19; think adaptation versus avoidance to maintain an individual's safety during hospitalization and after discharge.

• Briefs, huddles, and debriefs can improve communication within multidisciplinary teams; consider using PDSA cycles to assist with rapid change.

•

Revised visitor guidelines should be standardized and implemented to decrease chance of exposure and to ensure consistent care.

When a pandemic was declared in March 2020, we needed to rapidly adapt our care practices to maintain and promote safety for the maternal-newborn population Information changed so rapidly that it was, and continues to be, difficult to keep up with the guidelines The hospital initiated an "Incident Command Center" staffed by hospital leaders, and daily emails were sent with the latest information as it evolved J o u r n a l P r e -p r o o f

The outbreak of COVID-19 was declared a pandemic on March 11, 2020 by the World Health Organization (WHO, 2020) . In addition to the elderly and individuals with underlying chronic health conditions, maternal and newborn populations were also identified as high-risk. It is critical that clinicians caring for childbearing families and newborns are informed on best practice regarding how to care for individuals who are deemed persons under investigation (PUI) or positive for the SARS-CoV-2 virus. Additionally, it is essential to provide information at discharge to help prevent maternal and newborn infection and/or to manage COVID-19 (CDC, 2020) .

The Centers for Disease Control and Prevention (CDC) has been a leader in distributing information regarding COVID-19. However, information changed so rapidly that it was, and continues to be, difficult to keep up with the guidelines. Often by the time guidelines were distributed to health care providers they were already changed. The CDC shared interim considerations for infection prevention in inpatient maternity health care settings (CDC, 2020), yet they were based on limited evidence available about transmission of the virus that causes COVID-19. Additionally, guidelines had to be adapted to individual health care sites because resources including personnel, equipment, and supplies varied greatly. At the same time, teams at hospitals and health care systems were challenged to collaborate with others in their region to 

Limited reports in the literature have raised concern about possible vertical transmission of COVID-19 between mother and newborn prior to birth, but the extent and clinical significance of vertical transmission, which appears to be rare, is unclear (CDC, 2020). In one study a single case was reviewed that showed potential vertical transmission, but results were inconclusive (Alzamora et al., 2020) . In two additional studies, 9 cases and 3 cases, respectively, were reviewed with the authors concluding there was no evidence of vertical transmission (Chen et al., 2020a; Liu et al, 2020) . Additional reviews have not detected vertical transmission but reinforce the need for further studies (Mardani & Pourkaveh, 2020; Mimouni et al, 2020; Rasmussen, 2020; Dotters-Katz & Hughes, 2020) . At the time of this writing, there is not enough evidence to prove or disprove vertical transmission of COVID-19 from mother to newborn prior to birth.

Various precautions have been recommended because of the COVID-19 pandemic. One recommendation identified by Boelig et al. (2020) was to suspend the use of nitrous oxide for J o u r n a l P r e -p r o o f labor pain management. Nitrous oxide is an inhalant of 50% nitrous, 50% oxygen concentration used as a pain management option self-administered by individuals in labor. It provides antianxiety and dissociation effects that reduce labor pain (Stewart & Collins, 2012) . Boelig et al. (2020) explained that because nitrous oxide is aerosolized when administered, it is theorized that it could cause transmission of COVID-19 (Boelig et al., 2020) . Also, because it is not the standard to dismantle the valve on the nitrous oxide tank and thoroughly sterilize it between uses, this might cause retained particles to spread the COVID-19 virus to the next user. Boelig et al. (2020) identified the second stage of labor as period of potential contagion. In an update on its website dated April 20, 2020, AWHONN recommended that all health care personnel caring for women during the second stage of labor wear appropriate PPE, including N95 masks. It stated that until universal testing is available, health care personnel should have the option to wear N95 masks when caring for any woman in the second stage of labor (AWHONN, 2020).

Another concern is acute coagulopathy in pregnancy. In pregnant women, some COVID-19-related laboratory abnormalities (hemolysis, elevated liver enzyme levels, thrombocytopenia) have been noted to be the same as those that occur in preeclampsia with severe features and HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. These diagnoses should also be considered when such laboratory changes occur and may coexist with COVID-19 (Berghella, 2020) . Covid-19 may be reminiscent of HELLP syndrome without the increased blood pressure or proteinuria. Thus, it is important for health care providers to have a heightened awareness to screen and assess for comorbidities related to HELLP syndrome (Koumoutsea et al., 2020) .

J o u r n a l P r e -p r o o f Authors of studies conducted in New York and China have suggested that there is not an increased severity of COVID-19 disease in pregnancy, in contrast to what has been observed with influenza Chen et al., 2020b; Zaigham & Andersson, 2020) . reported that 86% of maternal cases of COVID-19 are mild, 9.3% are severe, and 4.7% are critical, which is similar to results in non-pregnant adults. It is still important to maintain awareness that there been maternal morbidity and fetal deaths observed with COVID-19, so careful monitoring of pregnancies with COVID-19 is warranted (Zaigham & Andersson, 2020) . Ellington et al. (2020) reported that in adolescents and women ages 15-44 years with COVID-19, pregnancy is associated with increased risk for ICU admission and receipt of mechanical ventilation, but it is not associated with increased risk for mortality. The authors also highlight the need for more complete data to fully understand the risk for severe COVID-19 illness among pregnant women and their infants (Ellington et al., 2020) .

With all surgical procedures, universal respiratory precautions with N95 masks were recommended (Gonzalez-Brown et al., 2020; Livingston, 2020) . Intubation promotes aerosolization and the need for use of N95 masks. During all surgical procedures including cesarean birth and obstetric surgeries, even with regional anesthesia, there is the potential to progress to intubation with general anesthesia.

Multiple professional organizations provided guidance regarding separation of women who are COVID-19 PUI or positive from their newborns. The CDC provided guidance on prehospital, hospital, maternal/newborn contact, breastfeeding, and hospital discharge care for J o u r n a l P r e -p r o o f infection prevention and control of COVID-19 (CDC, 2020). Initially CDC recommended separation of mother and newborn if a mother was PUI/positive and if space and personnel allowed for it. The CDC recommendation was also cited by SMFM, ACOG, SOAP, and AAP.

Soon after, on May 12, 2020, the WHO advised that women positive for the virus could share a room with their newborn and breastfeed but should practice "respiratory hygiene" to include, washing their hands, and wearing a mask (WHO, 2020). The ABM emphasized women's choice and noted that breastfeeding and rooming-in were reasonable choices (ABM, 2020). AWHONN did not issue a specific recommendation separate from the other organizations. Bartick (2020) concluded that there were insufficient data to support separating women and newborns routinely and that it should be considered on a case-by-case basis. For example, if a woman required extensive care on a medical unit for COVID-19, temporary separation would be recommended.

As was the case with many recommendations surrounding COVID-19, they were continually evolving. In a press release dated June 12, 2020, the WHO advised that the health benefits of breastfeeding outweighed any potential risks of transmission of COVID-19 (WHO, 2020). This announcement reinforced the positive effects of breastfeeding as more beneficial than separation.

All statements support and emphasize the importance of a shared-decision-making model between women and their health care team to determine the need for postpartum separation of the maternal-newborn dyad (National Perinatal Association & National Association of Neonatal Nurses, 2020).

Universal testing is not a simple issue. It brings up questions of accessibility, timing, and costs of tests, as well as accuracy of results. Molecular tests (also called PCR tests, viral RNA tests, or nucleic acid tests), which are highly sensitive, can come back negative if tested right J o u r n a l P r e -p r o o f after exposure, before the virus has built up to detectable levels. Antigen tests produce results more quickly, but do not amplify the protein signal, so they are inherently less sensitive. Their false negative rate is anywhere between 50% and 90% which also may be related to collection, transport, and storage of samples (Association of American Medical Colleges, 2020). , recommended universal testing of pregnant women admitted for labor and birth. They completed a retrospective review of electronic health records over 15 days in two affiliated New York hospitals. They identified both symptomatic and asymptomatic pregnant women. Because pregnant women may be asymptomatic but still carry the virus, universal testing was recommended to rule out asymptomatic women, in order to protect women, their infants, and health care providers . Bianco et al. (2020) completed an observational study, within the Mount Sinai Health system in New York, in which all women who were scheduled for a planned delivery from April 4, 2020 to April 15, 2020 were contacted to undergo COVID-19 testing 1 day before coming in for scheduled birth. They found that 15.5% of asymptomatic maternity patients tested positive for SARS-CoV-2 infection despite a negative phone screening, and 58% of their asymptomatic screen-negative support persons also tested positive. Bianco et al. (2020) proposed that universal testing of women and support persons in high-prevalence areas would inform obstetric and newborn care practices as well as help ensure the safety of the health care professionals caring for them.

When reviewing universal testing from a more global perspective, Tanacan et al. (2020) concluded from their prospective cohort study conducted in Turkey that health professionals should be cautious during the labor and childbirth of high-risk pregnant women during the pandemic period and that universal testing for COVID-19 should be considered in selected populations (Tanacan et al., 2020) . Overall, universal testing for SARS-CoV-2 in pregnant J o u r n a l P r e -p r o o f women admitted for birth identified many women with viral infection who would have been missed with symptom screening. Universal testing needs to be balanced with declining resources and cost for testing as well as the potential for false positive or false negative tests. It is not a panacea for identification, but rather one element of a multipronged approach to reduce the risk of transmission (Goldfarb et al., 2020; Blitz et al., 2020) .

Many of the journals articles we reviewed referenced the CDC's "Interim considerations for infection prevention and control of coronavirus disease 2019 (COVID-19) in inpatient obstetric healthcare settings" (CDC, 2020). If the authors of these articles disagreed with the CDC recommendations, they often provided rationale for consideration. Since the information was changing so rapidly, the gap identified was the accuracy of the information. By the time articles were published, or made available to the public, they often contained obsolete information.

Our project to adapt our practice during the COVID-19 pandemic had three objectives: a)

To maintain safety for women and neonates in the perinatal period; b) To minimize transmission of COVID-19 to pregnant women and neonates; and c) To optimize maternal satisfaction with outcomes in the perinatal period while providing family centered care. We considered each of these objectives critical to obtaining positive health care outcomes.

We used a cause-and-effect diagram, also known as a fishbone diagram, as a schematic means to organize the contributing causes of risk to maintenance of maternal newborn safety during COVID-19. It helped to prioritize, select, and improve the sources of the problem as described by Kelly et al. (2013) . The fishbone diagram usually has several organizing categories that provide a guide to identifying problems (Johnson, 2017) . In this case all six categories were J o u r n a l P r e -p r o o f applicable. It helped us to sort ideas into useful categories for further investigation (see Figure   1 ).

Our setting is a tertiary care center in South Central Wisconsin that serves a high-risk obstetrics population and has multiple outpatient clinic sites including a Maternal-Fetal Medicine (MFM) clinic. It has 2,000 to 2,300 births annually.

A unit-based binder was created for updated protocols, algorithms, and guidelines on each of the four Women & Children's units and was initially updated daily to maintain safety by using the most current research-based practices. Although emails were sent daily to staff, they needed the most current unit-specific information available immediately to provide the best direct care.

One example of unit-specific information is an algorithm of the COVID-19 Newborn Workflow that defined the care plan post-birth (see Supplemental Materials).

As weeks passed, the binders became less important and daily rounding was used to provide updates to staff or answer questions as a more effective use of time and resources. The hospital initiated an "Incident Command Center" staffed by hospital leaders, and daily emails were sent with the latest information as it evolved. Information specific to care of the maternalnewborn dyad was developed by a maternal-newborn team at the system level, with input from each hospital's maternal-newborn team. This information was included in the daily emails and these emails were printed and posted for staff members who were not able to access email and but regularly used the unit-specific binder.

Another way maternal safety was maintained and promoted was through multidisciplinary J o u r n a l P r e -p r o o f briefs, huddles, and debriefing sessions, which included the obstetrician, anesthesiologist, charge nurse, primary nurse, clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse-midwife (CNM). Often the obstetrics manager or administrative director would be included as well as the neonatologist, neonatal nurse practitioner (NNP), and obstetrics technician, depending on the circumstances.

Briefs were held before the woman arrived when it was known in advance. There were planning sessions for workflow, a review of how supplies would be limited, caregiver protection, and a review of maternal and visitor preferences to coordinate family centered care while maintaining safety. Huddles often occurred after admission to update the plan for individuals who were PUI or positive for the virus. This provided the team with an opportunity to evaluate the rapidly changing evidence. Debriefing sessions occurred as a review of what went well, what did not go well, and what needed to be changed. Assignments were given to team members for changes that needed to be made, which was critical to promote teamwork and communication to improve outcomes. In a debrief after a cesarean birth by a woman who was positive for the virus, it was identified that the negative-pressure operating room did not have adequate supplies for a birth. The supplies had been decreased significantly to eliminate waste, since all supplies not contained in closed areas needed to be disposed of after a patient with COVID-19 was in the room. The supplies were limited so much that the team members had to continuously leave the room to obtain what they needed. After the debrief the physician, nurse and OB technician reviewed the supply list and made recommendations for improvement. The OB technician stocked a cart with additional supplies and positioned it in the anteroom outside of the operating room, but within the negative-pressure area. A runner easily obtained additional supplies and the process was coordinated and efficient.

The main intervention to minimize the transmission of COVID-19 to pregnant women and newborns was the design and implementation of a COVID-19 unit to cluster all the women who were COVID-19 PUI/positive in one area. This action was recommended by SMFM and SOAP to limit exposure of unaffected individuals as well as staff (SMFM, 2020). The need for this unit was identified after visiting a similar unit in the Emergency Department for all individuals who presented to the hospital and were COVID-19 PUI/positive. It became clear that separating women with the virus from those negative for the virus was essential to effectively provide appropriate care while simultaneously protecting the health care team. The rooms on the designated unit were identified and prepared for specific purposes depending on individual need to include triage of laboring women through delivery of postpartum care. If a woman had significant illness due to COVID-19 she was admitted to the ICU specific for those with COVID-19 and labor personnel were sent to the ICU to monitor her for obstetric concerns.

On the OB COVID-19 unit the staff wore PPE including a surgical mask, face shield, gown, and gloves when caring for PUI/positive women. Women admitted to the unit and visitors were also expected to wear masks. It was challenging for staffing when only one maternalnewborn dyad was on the unit. The unit was staffed with two staff members for safety since it was in a secluded wing of the hospital. As weeks passed, if there were only one laboring PUI/positive woman, she was assigned to the one negative-pressure labor room on the labor unit and went to a separate hall on the postpartum unit following birth, to allow for better staffing ratios. One nurse instead of two could be assigned to the dyad since additional staff members were immediately available for emergencies down the adjacent hallway. The COVID-19 unit continued to be used but most often it was for women admitted from the MFM clinic, when a J o u r n a l P r e -p r o o f process was set up with the on-site MFM clinic. When a pregnant woman who was PUI or positive came for an appointment, a single staff member in full PPE directed her to the OB COVID-19 unit to complete an ultrasound and/or prenatal appointment. At the culmination of her visit the patient left the facility without exposing other women who were high-risk or additional staff members in the MFM clinic.

The second intervention to minimize transmission was securing appropriate PPE for all health care personnel. This included N-95 mask fit testing and education about how to use Powered Air Purifying Respirators (PAPRs) for all staff who could potentially be exposed to an aerosolizing procedure with a patient PUI or positive for the virus. Since there was potential for a limited supply of PPE, it was secured in a locked area to be accessed only by charge nurses, managers, and the CNS. Staff members were given the required PPE at the beginning of each shift by the charge nurse. If additional PPE was required during the shift, due to contamination or damage, staff would request it from the charge nurse, manager, or CNS.

As a third intervention, visitor guidelines specific to the maternity unit were developed and vetted through the Hospital Incident Command Center (see Supplemental Materials). The visitor guidelines limited the number of people coming into the hospital and outlined the process to monitor the visitors to ensure that they remained healthy while visiting.

Hospital staff conducted a review of rooms and assigned paired rooms to women and newborns. If a PUI/positive woman was accompanied by a healthy visitor who was designated to care for the newborn, the woman could have a room for recovery that was separate from the room for the newborn. This allowed time for the woman to recover and maintain separation from her newborn while at highest risk to pass on the virus by droplet transmission. Breastfeeding was J o u r n a l P r e -p r o o f encouraged, and individual breast pumps were secured along with a basin to wash supplies before and after each pumping session. Guidelines were also provided for women about how to breastfeed with safety precautions. Many of the recommendations described above regarding breastfeeding and maternal newborn separation quickly changed. Although health care providers were concerned about viral spread, there were also concerned about risks to the dyad from separation. Breastfeeding is the safest, most reliable method of feeding in an emergency, and there were widespread reports of shortages of retail supplies of infant formula due to hoarding (Bartick, 2020) . Breastfeeding is associated with reduced risk for ear infections and diarrhea, thus reducing the chance that a newborn and their caregiver would need to leave their homes to seek medical attention and expose themselves to the virus (Bartick, 2020) . Also, breastfeeding may be protective because it often contains antibodies to pathogens to which women have been exposed (Bartick, 2020; WHO, 2020) .

Discharge instructions were developed at the hospital system level and provided for use by each hospital location. Women and their support persons were instructed on how to care for themselves and their newborns after discharge. Teaching was initiated immediately after birth with the mother and support person as part of family centered care.

The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change--by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning (Institute for Healthcare Improvement, 2020). Rapid change during the pandemic continually made it necessary to use the PDSA method to trial and evaluate different practices. Because the PDSA cycle allowed for continual adjustments, this example J o u r n a l P r e -p r o o f demonstrates how practices were developed and adjusted based on both standards and guidelines as well as patient input to maintain patient and family centered care over time (see Supplemental Materials).

During this time of rapid change, the CNS and nursing leadership, as part of the health care team, were required to continually review and synthesize information for childbearing women, newborns, and the staff who cares for them. Review of health records to check for missed appointments because of changing outpatient procedures was necessary to identify and screen for unanticipated risks. Standardization of hospital visitor guidelines helped guide care.

Regular communication that included multidisciplinary care conferences were essential to update healthcare providers in order to provide the best patient care. The use of briefs before a woman arrives, huddles during episodes of care and debriefs after procedures or discharge, helped leaders with situational monitoring to form a shared mental model of care. Finally, the use of PDSA cycles helped define the model of care to allow staff to adapt to a rapidly changing clinical environment as new evidence and research became available.

To monitor maintenance and promotion of safety for women and neonates in the perinatal period, we reviewed event reports and identified an increase in the number of events related to COVID-19 testing. This provided the opportunity to educate staff on how to effectively resolve issues through adjustments to the process and communication. The resource binder, daily emails, briefs, huddles, and debriefs became important communication techniques to help maintain patient safety based on the events.

To minimize transmission of COVID-19 to pregnant women and neonates, we used three methods. First, visitor guidelines were developed to limit the number of people coming into the J o u r n a l P r e -p r o o f hospital, which included information on screening visitors daily. Each pregnant woman was allowed one visitor who could stay overnight but was screened by the nurse each morning.

Screening included recording the woman's temperature and her answers to questions about symptoms. A colored sticker was given daily to indicate negative screening. In the course of screening, one visitor who tested negative on initial check subsequently developed a fever and symptoms and was asked to leave. He willingly left to help minimize any exposure to for his family or the health care team. Second, we created an OB COVID-19 unit in the hospital to allow for separation of individuals who were PUI/positive with COVID-19 from the rest of the maternal-newborn population. We logged an average of two to three women per week who were PUI/positive who used the OB COVID-19 unit for ultrasound procedures. They never entered the high-risk MFM clinic during their potentially infectious stage, thus eliminating the potential for exposing other high-risk pregnant women and health care staff. A neonatal measure used to track both vertical transmission and early neonatal exposure to COVID-19 was tracking how many neonates tested positive for COVID-19. All newborns of women who were PUI or positive were tested at 24 hours and/or at 48 hours of age. From March 2020 through December of 2020 no neonates tested positive for COVID-19.

To measure maternal satisfaction with outcomes in the perinatal period while providing family centered care, we used Press Ganey patient surveys. The "Patient Needs Report:

Inpatient" is a report based on three key correlates including response to concerns/complaints, staff worked together to care for you, and staff includes you in decisions related to treatment.

The percentage of responses of "very good" (9 or 10 on a 0-10 Likert scale) were tracked and calculated. A goal was set at 77.8% for 2020. The actual score was 66% in quarter 4 of 2019, which was below that from quarter 3 and something to focus on for improvement, but in quarter J o u r n a l P r e -p r o o f 1 of 2020 it was 84.7% and 88.4% in quarter 2 of 2020. In this time of uncertainty and decreased number of visitors allowed in the hospital, patient satisfaction scores were expected to decline.

The fact that they were higher than observed in 2019 was an unexpected positive result (see Figure 2) .

Breastfeeding experience success was also considered to have improved based on anecdotal feedback from lactation staff. The staff members credit improved breastfeeding with having fewer visitors and women being able to spend more one-on-one time with their neonates. Lactation staff members were also able to spend more uninterrupted time with maternal-newborn couplets.

When a pandemic was declared in March 2020, we needed to rapidly adapt our care practices to maintain and promote safety for the maternal-newborn population. Safety of women and newborns was maintained with clear communication through unit information binders and emails based on hospital, regional, and system best practices using the most current guidelines available. Teamwork that was essential to collaborative care was promoted by briefs, huddles, and debriefs with the health care team to ensure a shared mental model for individualized patient care. Minimizing the transmission of COVID-19 was realized by creating a COVID-19 obstetrics unit for triage of women in labor through postpartum and newborn care of those individuals identified as positive for COVID-19. Securing appropriate PPE and maintaining clear visitor guidelines also aided in minimizing transmission. Optimizing the outcomes for women and newborns was achieved through repeated PDSA cycles in practice. This not only promoted evidence-based practice but helped promote safe, family centered care by identifying factors that affected family bonding and positive effects of breastfeeding.

J o u r n a l P r e -p r o o f There were and continue to be unintended consequences, both positive and negative, that occur as circumstances continue to change during the pandemic. One unfortunate consequence occurred when a woman did not have her 36-week routine prenatal visit related to COVID-19 clinic restrictions. At the 36-week visit, a Group B Strep (GBS) culture would routinely be obtained, but without in-person visits, a GBS culture was not obtained. When the woman in question reached 37 weeks she was diagnosed with cholestasis and was admitted for induction of labor. Her GBS culture was unknown. Although the culture was obtained on admission, based on ACOG criteria she was not given prophylactic antibiotics during induction since she was not considered high risk for GBS. It was her first pregnancy, she had no history of GBS, no substantial risk of preterm birth, no preterm pre-labor rupture of membranes or rupture of membranes for > 18 hours or presentation with intrapartum fever, with temp > 100.4. She gave birth vaginally before the culture results were available. At birth, the neonate had respiratory distress and was admitted to the NICU. The neonate's GBS culture status was positive and diagnosed as the reason for admission to the NICU. The mother's GBS status was positive; if the mother's test had been performed and came back positive at 36 weeks, she would have been treated with antibiotics in labor that could have possibly prevented the baby's GBS infection. In this case the baby responded well and was discharged home without complications.

Reproducibility of this project is limited by the rapidly changing rules, standards, and guidelines related to COVID-19 recommendations. The parts of this project that are applicable in another facility or with another viral outbreak are the basic principles of identifying specific aims, drafting a fishbone diagram to outline the process, using PDSA cycles of change and utilizing briefs, huddles, and debriefs for teamwork and communication with multidisciplinary teams.

J o u r n a l P r e -p r o o f Conclusion Maintaining safe care for women and newborns during the COVID-19 pandemic was critical. Rapid action by nursing leadership to coordinate with maternity and newborn care providers helped create an atmosphere conducive to best practices. Collaboration of multidisciplinary teams helped promote consistency amidst the chaos of continually changing guidelines and information during a global pandemic with a novel virus. 

ABM statement on coronavirus 2019

Severe COVID-19 during pregnancy and possible vertical transmission

Association of American Medical Colleges (AAMC) (2020). Your COVID-19 testing questions answered

COVID-19: Separating infected mothers from newborns: weighing the risks and benefits

Coronavirus disease 2019 (COVID-19): Pregnancy issues

Testing of patients and support persons for coronavirus disease 2019 (COVID-19) infection before scheduled deliveries

Universal testing for coronavirus disease 2019 in pregnant women admitted for delivery: healthcare system

Labor and delivery guidance for COVID-19

COVID-19 in pregnancy: Early lessons

COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City Hospitals

Interim considerations of infection prevention and control of coronavirus disease 2019 (COVID-19) in inpatient obstetric healthcare settings

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in J o u r n a l P r e -p r o o f nine pregnant women: A retrospective review of medical records

Clinical characteristics of pregnant women with COVID-19 in

Considerations for obstetric care during the COVID-19 pandemic

Characteristics of women of reproductive age with laboratory-confirmed SARS-COV-2 infection by pregnancy status-United States

Universal SARS-CoV-2 testing on admission to the labor and delivery unit: Low prevalence among asymptomatic obstetric patients

Operating room guide for confirmed or suspected COVID-19 pregnant patients requiring cesarean delivery

Institute for Healthcare Improvement (IHI) (2020)

Quality Improvement

Mclaughlin and Kaluzny's continuous quality improvement in health care

COVID19 and acute coagulopathy in pregnancy

Coronavirus disease 2019

Surgery in a time of uncertainty: A need for universal respiratory precautions in the operating room

A controversial debate: Vertical transmission of COVID-19 in pregnancy. Archives of Clinical Infectious Disease

Perinatal aspects on the COVID-19 pandemic: A practical resource for perinatal

National Perinatal Association & National Association of Neonatal Nurses. (2020, May). Mothers with COVID-19 and their newborn infants

Coronavirus disease 2019 (COVID-19) and pregnancy: What obstetricians need to know

Labor and delivery COVID-19 considerations

Nitrous oxide as labor analgesia: Clinical implications for nurses. Nursing for Women's Health

The rate of SARS-CoV-2 positivity in asymptomatic pregnant women admitted to hospital for delivery: Experience of a pandemic center in Turkey

on COVID-19

WHO Director-General's opening remarks at the media briefing on COVID-19 -12

Frequently asked questions: Breastfeeding and COVID-19 for health care workers

Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies