Please check the Ministry of Health (MOH) COVID-19 website regularly for updates to this document, mental health resources, and other information. - The latest 'COVID-19 Reference Document for Symptoms' and 'Case Definition' are available and updated on the MOH COVID-19 website. - Please check the Directives, Memorandums and Other Resources page regularly for the most up to date directives. - For detailed clinical care recommendations regarding labour and delivery procedures, please see Maternal Newborn COVID-19 General Guidelines published by the Provincial Council for Maternal and Child Health.# General
Timing and Location 1. Regardless of whether a woman is a suspected or confirmed case of COVID-19, her place of birth should continue to be informed by obstetrical factors and the woman's birth place preferences. Women should deliver in a care environment that can meet both their needs and the needs of the newborn while receiving care for COVID-19.
Movement within and between facilities should be minimized. COVID-19 alone should not be an indication for transfer but may be a consideration.
- Timing of delivery should be determined by obstetrical indications. Suspected or confirmed COVID-19 status alone is not a sufficient indication for induction or caesarean delivery.
Delivery for suspected or confirmed COVID-19 pregnant women may be expedited for fetal reasons, or if it is felt that delivery will help maternal resuscitation. If delivery is required, maternal stabilization should be the priority. for risk of droplet and contact transmission during labour, delivery, and newborn care. Suitable precautions may include: gloves, gown, a surgical/procedure mask, and eye protection (goggles or face shield).
Acute care settings should define the minimum team required to provide a safe caesarean section and aim to eliminate unnecessary HCWs in the operating room (OR).
Only essential OR staff should be in the room for administration of general anesthesia for a caesarian section, such staff should follow Airborne precautions (including appropriately fitted N95 mask). Once intubation is complete, other HCWs may enter the room and use Droplet/Contact precautions.
All staff present in the operating room for caesarean section under regional anesthesia should use Droplet/Contact precautions. In the event that regional anesthesia is not sufficient and the procedure needs to be converted to general 
HCWs should screen all pregnant women upon entry and admission to triage area for labour and delivery for symptoms and exposure history, even if they have been screened upon entry to the hospital.
HCWs conducting screening on site should ideally be behind a barrier to protect from Contact/Droplet spread. A plexiglass barrier can protect staff from sneezing/coughing patients. If a plexiglass barrier is not available, staff should maintain a 2-metre distance from the patient. HCWs who do not have a barrier and cannot maintain a 2-metre distance should use Contact/Droplet precautions. This includes the following PPE -gloves, gown, a surgical/procedure mask, and eye protection (goggles or face shield).
Positive Screening: What to do 13. Pregnant patients who screen positive for signs/symptoms of COVID-19 should be treated as suspected for COVID-19, should be given a surgical/procedure mask for all stages of labour (if tolerated) and be advised to perform hand hygiene. As soon as the reception staff is aware that the patient has screened positive, the patient should be placed in a room with the door closed (do not cohort with other patients), where possible, to avoid contact with other patients in common areas of the floor (e.g., waiting rooms).
Mothers with suspected or confirmed COVID-19 should be counseled using a patient-centred approach regarding the risks and benefits of keeping mother and baby together, including strategies to reduce risk of spread if mother and baby remain together (see bullet #22) versus separated (see bullet #23). o The ability to ensure that the support person remains compliant with physical distancing and infection control instructions.

# Institutions may also want to consider that:
- Differing policies may be appropriate for women who are suspected or confirmed COVID-19 than for asymptomatic women.
- If the support person is to accompany a pregnant patient, the same recommendations on PPE precautions must be taken.
- Movement through and between care environments by the support person should be minimized.
- In and Out privileges should be discouraged and supports may be required to remain in the patient room at all times.
- Where in-person support is not possible, virtual and/or alternative options for support should be provided. When distance support is given, practical physical support should be provided.

# Testing of Babies
- Newborns born to mothers with confirmed COVID-19 at the time of birth should be tested for COVID-19 within 24 hours of delivery, regardless of symptoms.
- If maternal testing is pending at the time of mother-baby dyad discharge then follow-up must be ensured such that if maternal testing is positive the baby is tested in a timely manner. If bringing the baby back for testing is impractical, the baby should be tested prior to discharge.
The recommended neonatal sample is a nasopharyngeal swab (NPS) placed in universal transport medium (UTM) for PCR testing. Laboratory investigation of symptomatic newborns may be more extensive, including addition of COVID-19 PCR testing of placental swab or tissue, umbilical cord blood and/or neonatal blood. The decision for expanded testing would be made by the clinical team.
Any symptomatic newborns should also be assessed for other causes of clinical disease according to the clinical findings.
A positive COVID-19 test in a newborn should be discussed with a paediatric infectious disease consultant.

# Care of Babies Born to Suspected or Confirmed

# COVID-19 Mothers
- Given the low risk of vertical transmission and the low risk of aerosol exposure from neonatal resuscitation, Droplet/Contact precautions are suitable for the initial resuscitation of newborns, even those born to suspected or confirmed COVID-19 mothers.
Babies can stay in the mother's postpartum room, though several safety precautions are recommended, where possible, including:
- a private room o mother wearing a mask o hand hygiene before all care of baby o skin hygiene before breastfeeding, and o keeping infant two meters from mother when not providing direct care, including use of a barrier (such as a curtain or incubator) to protect against droplets due to coughing 23. If possible, a separate newborn care area with caregiver should be made available for women who are unable to care for their infants due to symptoms or upon request of the mother/family to prevent COVID-19 transmission to the baby.
Well babies should be discharged early if possible, after proper risk assessment has occurred.
HCWs should provide clear instructions for mothers with confirmed COVID-19 (or who are being assessed for COVID-19) and their infants to continue to follow-up with their primary care provider(s) until 2 weeks postpartum. HCWs should provide advice to the mother on how to self-isolate, and to call ahead to their primary care provider(s) to ensure they can plan for their visit.

# Breastfeeding
Mothers who are confirmed or suspected COVID-19 patients should:
- Wash hands when touching their infant, bottles, breast pump, etc.;
- Be masked while holding or feeding their infant;
- Cough or sneeze away from their infant while holding or feeding;
- Follow breast and skin cleansing hygiene before holding or feeding;
- Ensure pumps and bottles are cleaned according to the institution's Infection Protection and Control policies.

# Care and Testing of Babies in Neonatal Intensive
Care Unit (NICU) and Special Care Nursery (SCN)