key: cord-0911886-r428y2j9 authors: Vivanti, Alexandre J.; Deruelle, Philippe; Picone, Olivier; Guillaume, Sophie; Roze, Jean-Christophe; Mulin, Blandine; Kochert, Fabienne; De Beco, Isabelle; Mahu, Sophie; Gantois, Adrien; Barasinski, Chloé; Petitprez, Karine; Pauchet-Traversat, Anne-Françoise; Droy, Alcyone; Benachi, Alexandra title: Post-natal follow-up for women and neonates during the COVID-19 pandemic: French National Authority for Health recommendations date: 2020-05-11 journal: J Gynecol Obstet Hum Reprod DOI: 10.1016/j.jogoh.2020.101805 sha: 94547bd572ff038afd8e38c7aa317b67199be7f9 doc_id: 911886 cord_uid: r428y2j9 INTRODUCTION: In the context of the stage 3 SARS-Cov-2 epidemic situation, it is necessary to put forward a method of rapid response for an HAS position statement in order to answer to the requests from the French Ministry of Solidarity and Health, healthcare professionals and/or health system users’ associations, concerning post-natal follow-up for women and neonates during the COVID-19 pandemic. METHODS: A simplified 7-step process that favours HAS collaboration with experts (healthcare professionals, health system users’ associations, scientific societies etc.), the restrictive selection of available evidence and the use of digital means of communication. A short and specific dissemination format, which can be quickly updated in view of the changes in available data has been chosen. In the context of the stage 3 SARS-Cov-2 epidemic situation, it is necessary to put forward a method of rapid response for a HAS position statement in order to answer to the requests from the French Ministry of Solidarity and Health, healthcare professionals and/or health system users' associations. A simplified 7-step process that favours HAS collaboration with experts (healthcare professionals, health system users' associations, scientific societies etc.), the restrictive selection of available evidence and the use of digital means of communication. A short and specific dissemination format, which can be quickly updated in view of changes in available data has been chosen. Step 1) Selection of requests and identification of issues requiring a rapid response by the President of the HAS College. Step 2) Data selection and analysis by the HAS teams in close collaboration with experts named by the National Professional Councils (Conseils Nationaux Professionnels -CNP) and French scientific societies. Data selection has been restricted to the best levels of evidence and in descending order: Step 3) Drafting of provisional rapid responses by a select working group: HAS team, previously appointed experts and patient associations Step 4) Review and consultation / information of stakeholders. This step includes a panel of designated healthcare professionals as well as representatives of the French institutions (French General Health Directorate, High Council for Public Health). These reviews are carried out electronically and allow a response within a short time frame. Step 5) Finalization of the rapid responses by the previously appointed working group. Step 6) Validation and dissemination of the rapid responses by the HAS. The texts are then published in a short format on the website of the HAS, scientific societies and associations involved. A warning is included in the text: "These recommendations, drawn up on the basis of the knowledge available at the date of their publication, are subject to change and are likely to be updated in light of new available data". The experts' ties of interest are analysed by the HAS ethics officer and the legal department, on the basis of the information available in the "DPI-HEALTH and TRANSPARENCY-HEALTH" databases, and are provided to the members of the HAS College for their information Step 7) Regular update of the rapid responses taking into account the developments in the scientific literature and the recommendations from scientific societies. Before any early discharge from the maternity ward, the newborn is examined by a paediatrician according to the situations mentioned above: before 48 hours, at 48 hours of life and after 96 hours. -It is advisable that a post-natal care consultant accompanies women, particularly those in precarious situations or those in vulnerable psychological or social situations, in order to: -Carry out screening, prevent complications and identify them early in order to refer the patient to another professional if necessary -Identify a need for follow-up or additional assistance or referral via the appropriate channels. -Newborns of a COVID+ mother should be considered carriers of the virus. - The American Academy of Pediatrics (AAP) and Society of Obstetricians and Gynecologists (SOGC) recommend that newborns of a COVID+ mother be considered suspect for COVID-19. The authors suggest that the value of a screening test is to organize postpartum J o u r n a l P r e -p r o o f care and to provide close monitoring of the newborn 7, 8 . In the French context, the HAS considers it more prudent to consider any newborn of a COVID+ mother as a carrier of the virus. Testing the newborn is therefore not justified. The precautions to be taken are to stay confined at home with the child, to avoid too close contact with family members (especially siblings and people at risk), to wear a surgical mask and to have strict hand hygiene. Temperature and appearance of symptoms of respiratory infection should be monitored in both mother and child. Current data, feedback from professionals in the field on the impact of carrying out screening tests on maternity practices, the conditions of return home and findings on child health do not make it possible to systematically recommend a screening test for children. If the mother's COVID status is known, that of the newborn must in fact be considered to be identical. In case of the slightest symptom, both mother and child should be tested. The conditions and organization of the return home follow the HAS recommendations while adapting to the context of the epidemic 6 . J o u r n a l P r e -p r o o f -A first routine visit is carried out by a midwife ideally within 24 hours after leaving the maternity unit. The mother leaves the maternity unit with this appointment. -A second visit can be scheduled if decided by the midwife, by remote consultation or faceto-face depending on the situation. If necessary, she will contact the obstetrician and/or the paediatrician and/or the general practitioner. -Other visits can be planned according to the medical aspects to be monitored, the mother's vulnerabilities or social or psychological context, and/or if the mother or the couple feel they need them; they can be carried out by remote consultation. For at-risk women, if hospitalization at home is indicated, it should be preferred depending on the resources available locally 11 . The first health certificate "to be drawn up within the first eight days of life" is systematically issued by a doctor (paediatrician or general practitioner). It can be filled in when leaving the maternity unit. Given the shorter length of stay in the maternity unit, it is recommended that a newborn child be examined in person between the 6 th and 10 th day after the birth, preferably by a paediatrician or a general practitioner. The newborn's visit planned during the second week (close medical supervision of the infant) is left, during an outbreak of COVID-19, to the decision of the paediatrician or general practitioner who examined the child between the 6 th and 10 th day postpartum. -Bleeding, infectious, thromboembolic, urinary, digestive, scarring and pain risk concern about their maternal capacity 11 ; situation of domestic violence in the context of lockdown 12 . Psychological support may be necessary. -Breastfeeding difficulties, adapted response to newborn crying. -Risk of child abuse, especially Shaken Baby Syndrome: the quality of support from family and friends is essential, as is recourse to psychological support 13 . -In a context of lockdown and family isolation, it is essential to reinforce postnatal monitoring by remote consultation, particularly for monitoring breastfeeding 14 -Communication and town/hospital organization is essential for the appropriate care of the mother and child. -Early examination of the newborn by the paediatrician in the maternity ward before discharge in the same way as for discharge at 48 hours has to be considered, as well as early and rapid follow-up by the midwife at home. Monitoring by bilirubinometer should take place after 24h according to the local organization. The results of neonatal screening tests should be routinely recorded in the child's health record. -Systematic neonatal screening for metabolic diseases: In view of the lockdown measures taken by the post office, which have an impact on the delivery of "blotting paper" tests to neonatal screening reference centres, discharge from the maternity ward after 48h will ensure that neonatal screening can be carried out in good conditions. The implementation of these rapid responses implies essential support for the care offer, which is currently below standard in the context of the COVID The general practitioner and all home-visiting healthcare professionals must be informed of the mother's infection. Newborns without comorbidities can stay with their COVID-19+ mother and be breastfed (unless the mother asks to be separated from her child). Group (GPIP) do not currently recommend separation of mother and child and do not contraindicate breastfeeding 10 . A mother with COVID-19 and her child are monitored by their general practitioner and, if necessary, the paediatrician for the newborn. At the same time, the midwife can ensure postnatal supervision of the mother and the child in liaison with the referring obstetrical team. Any woman or child with signs of severe COVID-19 or aggravating comorbidities should be taken to a health care facility. -Active monitoring of her temperature and onset of symptoms of respiratory infection (fever, cough, breathing difficulty, sensation of suffocation etc.). -Strict lockdown with the child. -Too close contact with family members should be avoided. -A mask (surgical mask) should be worn. -Strict hand hygiene: hands should be washed before taking care of the child. J o u r n a l P r e -p r o o f -The general practitioner or the nurse should contact the mother every 24h to follow-up on the infection (tracing the results to be recovered and calls made), giving priority to remote consultation or remote care when possible. -Postnatal monitoring of mother and child by the midwife in liaison with the referring obstetrical team. -Exit from isolation after recovery as in the general population. 15 -Consultation with a doctor three weeks after discharge. -Active monitoring of temperature and the onset of symptoms of respiratory infection (fever, cough, breathing difficulties, etc.), diarrhoea. -Strict lockdown with the mother. -It is not recommended for newborns to wear masks -First consultation within 24 hours of arrival at home with the midwife, then a consultation between the 6 th and 10 th day postpartum, preferably at the paediatrician's or general practitioner's practice, in accordance with the safety protocol in place (for example at the end of a consultation with a paediatrician at a special clinic for newborns or small infants). Although compulsory, in the event of a COVID-19 epidemic, examination of the newborn planned during the second week (close medical supervision of the infant) is decided by the paediatrician or general practitioner who examined the child between the 6 th and 10 th postpartum. -Any symptoms in the newborn should be reported to the health care professional who looks after the child and should give rise to a consultation, and determine the frequency of follow-up. -In case of emergency: go to the paediatric emergency department of the reference hospital having first called the emergency services. -No data are available on the impact of early maternal infection during pregnancy on child development: close monitoring of the child at each visit 16, 17 . J o u r n a l P r e -p r o o f As with any person confirmed to be COVID-19+, self-isolation at home for 14 days after the onset of the first symptoms is recommended and special precautions should be taken. The precautions applicable to women with COVID-19 are the same as for the general population (barrier measures, social distancing, lockdown) to reduce the risk of transmission. Specific recommendations also apply. Monitoring instructions and hygiene precautions to be observed must be given and explained to the woman or couple before leaving the maternity unit. Mother and child organisation at home after leaving the maternity unit -At home, the mother is advised to isolate with the child, if possible, in a separate room, avoiding contact with the other occupants, and to air the room regularly. A hotel room is available if the mother prefers (COVISAN system in Paris, or equivalent elsewhere). -The cot should be placed about six feet from the mother's bed or chair. -All occupants should wash their hands frequently after using the bathroom and toilet, which must be cleaned regularly with bleach or disinfectant. -Surfaces touched regularly (door handles, mobile phones, etc.) are cleaned daily and disinfected). -It is not advisable to receive visits unless they are essential, such as visits from a midwife, nurse, childcare worker or home help. Studies show that the viral genome is not found in the breast milk of COVID-19- J o u r n a l P r e -p r o o f During examination or care of the newborn, during the first month of life, it is recommended to wear a mask and to wash hands beforehand (using soap or had sanitizer) The newborn must be seen again for the first month visit in person. Mandatory vaccinations must be administered at two months of life (possible from 6 weeks). Have a physical examination of the newborn between the 6 th and 10 th day after birth carried out by a paediatrician or a general practitioner within the framework of an organized care system. : Propose follow-up by remote consultation or face-to-face based on the assessment of the clinical situation, but also on the woman's social and psychological context. Ensure the physical and mental well-being of the mother, maintain psychological support for women, including remotely, and accompany the mother or couple in their parenting practices The jaundice risk assessment must be integrated into the reasoning leading up to the decision for discharge from the maternity unit. For each child, compilation of a jaundice profile based on the normogram 23 , combined with the recognition of risk factors for severe hyperbilirubinemia, ensures that the child is discharged in optimal safety conditions and thus reduces the risk of readmission to hospital for hyperbilirubinemia. Jaundice follow-up procedures should: be effective within 24 hours of early discharge from the maternity unit. enable quantification of jaundice. enable physical evaluation of the child (weighing) and breastfeeding (observation of a feed). identify a possible return route (if necessary) to a care facility. Parents must be informed of the warning signs and of who to contact in the event of an emergency prior to discharge 24 . It is recommended that jaundice data be recorded in the child's health record, or that this information (risk factors, profile outcome, diagnosis and test results) be mentioned on the immediate post-partum liaison sheet for the professional(s) providing follow-up 6 . In practice, if the midwife does not have a bilirubinometer, she should be able to arrange for a bilirubin test at the maternity ward. As part of early discharge during the COVID-19 pandemic, it is important to monitor clinical signs and arrange for bilirubin monitoring at a private practice or at the hospital if necessary. In the event of jaundice, phototherapy must be organized via secure channels in the maternity unit where the woman gave birth. The authors declare no competing interests J o u r n a l P r e -p r o o f Avis du 31 mars 2020 relatif à la prévention et à la prise en charge des patients à risque de formes graves de COVID-19 ainsi qu'à la priorisation des tests diagnostiques Clinical Characteristics of Pregnant Women with Covid-19 in Wuhan Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. 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Management of Infants Born to Mothers with COVID-19 Covid 19 pendant la grossesse Pregnancy outcomes, Newborn complications and Maternal-Fetal Transmission of SARS-CoV-2 in women with COVID-19: A systematic review Propositions de la société française de néonatalogie et de la société française de pédiatrie concernant les nouveau-nés dans le contexte d'épidémie à covid-19 Situations pathologiques pouvant relever de l'hospitalisation à domicile au cours de l'ante et du post-partum Repérage des femmes victimes de violences au sein du couple Saint-Denis Syndrome du bébé secoué ou traumatisme crânien non accidentel par secouement Le guide de l'allaitement maternel Sortie de maternité après accouchement : conditions et organisation du retour à domicile des mères et de leurs nouveau-nés American College of Obstetricians and Gynecologists. Covid-19 Obstetric preparedness manual Maternal and Perinatal Outcomes with COVID-19: a systematic review of 108 pregnancies Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know Experience of Clinical Management for Pregnant Women and Newborns with Novel Coronavirus Pneumonia in Tongji Hospital, China Centers for Disease Control and Prevention. Pregnancy and breastfeeding. Information about Coronavirus Disease Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies. Maternal & Child Nutrition World Health Organization Réginal Office for Europe. COVID-19 and breastfeeding Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation We would like to extend our thanks to Mrs Madeleine Akrich, France Artzner, Anne Evrard from the Collectif Interassociatif Autour de la Naissance (CIANE) who read the recommendations.