COVID-19 TREATMENT GUIDELINEIN TANZANIA, MARCH 2021
Posted by ULY CLINIC
25 Machi 2021 06:04:13
The guidance is based on proper case management aspects intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen frontline clinical management and the public health response.
NOTE. THIS GUIDELINE IS THE POPERTY OF MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN
14. MATERNAL AND CHILD HEALTH SERVICES DURIGN COVID-19 PANDEMIC
Most women attending RMNCAH services are healthy and are advised to maintain stringent physical distancing. It is recognized that women may have significant anxiety about the possibility of contracting COVID-19 by attending RMNCAH services. Similarly, health workers may be worried that they acquire an infection from their clients. Therefore, health facilities should ensure that women are protected from contracting COVID-19 while receiving services by putting strict infection prevention and control guidance and reinforcing appropriate use of PPE. Particular consideration should be given while providing care to women with co-morbidities. Women should be encouraged to wear a mask during hospital visits. Patient status should clearly have communicated during any handover, shared waiting areas should be avoided and if admitted they should be in a side room.
i. Standard infection control precautions
These are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agents from both recognized and un-recognized sources. Sources include blood and other body fluids, secretions and excretions (excluding sweat), non-intact skin or mucous, membranes, and any equipment or items in the care environment.
ii. Guidance to health care workers:
Transmission Based Precautions (TBPs) definition
TBPs are applied when SICPs alone are insufficient to prevent cross transmission of an infectious agent. TBPs are additional infection control precautions required when providing care to a patient with or suspected to have infectious agent. In the context of COVID-19 TBP include droplet, airborne and contact precautions:
Principles below are listed as a hierarchy of infection prevention and control measures at a health facility /ward level. (Note that this list is not exhaustive but includes key principles and illustrates a useful approach to preventing and controlling COVID-19).
The hierarchy of control measures is:
a. Early recognition or reporting of cases
b. Early assessment or triaging of cases
c. Implementing control measures, including
• Maintaining separation in space and or time between suspected and confirmed COVID-19 patients
• Educating staff, patients and visitors about standard precautions and TBPs
• Prompt implementation of TBPs to limit transmission
• Restricting access of ill visitors to the facility, generally minimize visitors to a facility
• Instructing staff members with symptoms to stay at home and not come to work until symptoms resolve
• Isolation rooms or ward bays should ideally have a defined area for staff to put on and remove PPE, and suitable bathroom facilities.
• Only essential staff should enter the room and visitors should be kept to a minimum.
• All non-essential items from the clinic/scan room should be removed prior to the woman’s arrival.
• All clinical areas used must be cleaned after use, as per national IPC guidelines.
A. MIDWIFERY CARE
• Continuity of care models of midwifery care will reduce the number of caregivers in contact with the woman and her birth partner and decrease the chances of COVID-19 spread in hospitals. Continuity of midwifery care should be encouraged and provided.
• Midwives have the right to full access for all personal protective equipment (PPE), sanitation and a safe and respectful working environment.
• Midwives, whether based in the community or in hospitals, are essential health workers providing a critical service to childbearing women and their babies.
• Deploying midwives away from maternity services to work in public health or general medical areas during COVDI-19 pandemic is likely to increase poor maternal and newborn outcomes hence preparation in advance is paramount.
• Maternity services shall continue to be prioritized as an essential core health service.
B. ANTENATAL CARE (ANC) IN COVID-19
• There is no evidence that pregnant women present with increased risk of severe illness or fetal compromise. However, due to changes in their bodies and immune systems, pregnant women can be badly affected by some respiratory infections. Therefore, it is important to take precautions to protect themselves against COVID-19 and report any symptoms to the disease to healthcare worker. It is not known if a pregnant woman with COVID-19 can pass the virus to her fetus or baby during pregnancy or delivery. To date, the virus has not been found in samples of amniotic fluid or breast milk
• WHO 2020 COVID-19 operational guidance recommends that all women should have access to safe, high-quality Antenatal Care (ANC) including Malaria in Pregnancy (MiP) services
• The aim of ANC guidance is to ensure providers can deliver respectful and individualized ANC services that promote the safety of a woman and her fetus, families and health care workers (HCW) during the Covid-19 pandemic.
• All pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth. (World Health Organization, 2020)’.
• Health facility staff should collaborate with Community Health Workers (CHWs) to ensure messaging to the community highlights the need to continue with routine preventive care services, such as ANC, childhood immunizations, Family Planning, facility delivery, Postnatal care (PNC), male engagement, availability of friendly services to adolescents and youths and increased risks of gender-based violence in the context of COVID-19 and the agency to report the incidences.
• CHW may be instrumental when the COVID-19 becomes so severe that community has restricted movement to the extent going to health facility to none-ill person practically impossible. In such situation CHW may assist client screening at home for any problem and escort to neighbor health facility if needed, provide essential supplies at home and commodities such as condom and oral contraceptive pills.
• Depending on the situation and in order to decongest clinics, ANC visits for mothers without clinical problems may be adjusted, instead of coming monthly, clients may be given appointment for a spacing of 2 month or more while connected CHW for regular checkup at home including ensuring adequate ANC such as SP, FeFo, LLINs, Mebendazole/ Albendazole.
C. CARE DURING PREGNANCY
During pregnancy it is advised to:
• Minimize face-to-face contacts with provider and 4 virtual contacts
• Schedule for low risk women, where face-to-face appointments can be replaced with remote assessments are detailed in table 2. As far as possible, scans, preventive measures, ANC assessments and laboratory investigations should be provided within a single visit, involving as few staff as possible.
• Provide ANC medicine packages such as SP, FEFO, mebendazole, etc by use of no hand touching techniques.
• Consider scheduling the post-dates appointment on a day where induction of labour can be commenced (after 41+0, in line with National guidelines).
• As many as 50% of ANC clients may have conditions that necessitate additional appointments or multi- disciplinary care. All contacts that do not require additional interventions like laboratory, radiological or others should be provided remotely via CHW or when available via mobile phone.
• All pregnant women should be screened for danger sign (by quick check) followed by screening and triage for COVID-19.
• Must bear in mind that malaria can present along with COVID-19,all pregnant women should be routinely screened for malaria.
• Provide information to danger signs, signs of labor, birth preparedness, and complication readiness plans.
• If risk assessment identifies potential or actual complications more frequent contacts need to occur and these may need to be face-to-face.
• Health care providers should provide information and education to pregnant women to address fears/rumors/misconceptions around COVID-19.
Health care provider should identify and make inquiry on GBV using GBV standard protocols and provide first line support to GBV survivors;
• Listen closely without judgement,
• Enquire about needs and concerns,
• Validate experience,
• Support them to connect with additional services,
• In case of rape, provide minimum package of post rape management as per protocol.
D. INTRAPARTUM CARE IN THE CONTEXT OF COVID 19
Generic screening and triage should be used for every client on the first ANC clinic visit, labour and delivery wards (refer screening and triage flow).
Labor Room Preparedness
• Majority of women presenting in labor will have no respiratory symptoms, and labor room shall keep normal provision of services. However, the labor rooms must keep readiness to IPC practices by:
• Have sufficient supplies of all PPE supplies (masks, gloves, goggles, gowns, hand sanitizer, soap and water, cleaning supplies).
• All surfaces should be cleaned thoroughly with chlorine 0.5%.
Staff should follow regular hand hygiene practices by hand washing before and after any procedure.
For all women
• Triage and screening needs to take place for all women and their birth companion before entering the health facility as outlined in previous sections.
• Routine IPC precautions needs to be instituted to every labor and birth conducted.
• In obstetric and newborn emergencies, care of the mother or newborn should not be delayed.
• Women should to be encouraged to delivery at the health facility and inform the HCW at maternity for any respiratory or other COVID-19 related symptoms.
• All women should be managed in line with National Guideline for Gender and Respectful Maternity Care Mainstreaming and Integration Across RMNCAH Services.
Intrapartum patients suspected or confirmed to have COVID-19 infection
• If patient is not having danger signs, and birth not eminent and transport exists, consider transfer of patient to the maternity unit at the designated COVID-19 treatment unit.
• If patient is in the second stage of labor with symptoms and signs suggestive of COVID- 19 infection or if confirmed to be COVID-19 positive and transfer to HIDTU not possible, it is important for her and the baby to be isolated. In this case the newborn should be treated as high risk.
• All women suspected or confirmed to have COVID 19 infection in labor and delivery shall wear mask to prevent spread of infection via nasal - droplets.
• Health care workers assisting women in labor and delivery suspected or confirmed to have COVID 19 infected shall wear PPE as recommended by the Guidelines.
• Mode of delivery needs to be individualized based on obstetric indications and not be influenced by the presence of COVID-19
• Management of women suspected or confirmed to have COVID-19 infection shall be conducted in isolation room for the entire stay of the patient.
• Where women do not have access to a single room, it is still essential to find a way of separating sick women from not infected women to reduce the risk of virus transmission.
• Only designated staff should be allowed to attend the client.
• Women with moderate-severe symptoms of COVID-19 should be monitored using hourly fluid input-output charts in order to avoid the risk of fluid overload.
• If a newborn born to a COVID-19 suspected or confirmed mother fails to establish spontaneous breathing, health care providers should use separate set of equipment to resuscitate the baby.
• If an infected woman requires a caesarian section all staff in theatre should wear full PPE as recommended by COVID-19 IPC Guidelines.
• Mothers and babies have the right to remain together at all times, even if the baby is born small, premature or with medical conditions that require extra care.
• There is no evidence to suggest that steroids for antenatal corticosteroids given to mothers to prepare for preterm delivery cause any harm in the context of COVID-19.
• Breastfeeding women confirmed or suspected to have COVID-19 should not be separated from their newborns, as there is no evidence to show vertical transmission of the virus.
• Do not promote breast milk substitutes, feeding bottles, teats, pacifiers or dummies in any part of your facilities, or by any of your staff.
• Support women, with or without COVID-19 Infection to breastfeed, with appropriate counseling and instructions for IPC measures, including hand hygiene and wearing face masks.
• Enable mothers and infants to remain together and practice skin-to-skin contact, and rooming-in throughout the day and night, especially straight after birth during establishment of breastfeeding, whether or not the mother or child has suspected or confirmed COVID-19.
• Symptomatic mothers well enough to breastfeed should wear a mask when near their newborn (including during feeding), wash hands before and after contact, clean and disinfect all close contaminated surfaces.
• If a mother is too ill to breastfeed, she should be encouraged and assisted to express breast milk that can be given to the newborn via a clean cup or spoon. Wearing of a mask, strict hand hygiene and disinfecting of all expressing equipment and hard surfaces after expressing breast milk is essential.
• Expressed breast milk can be labeled and stored for later use if not immediately given to the infant.
Referral in labour for COVID 19 patient
• Prepare transport equipment and drugs in anticipation of medical emergencies that may occur on the route, such as sudden cardiovascular collapse or hypotension.
• All staff transporting the patient should be on PPE as recommended by COVID 19 Guidelines.
• Ensure that the patient is wearing mask during transport.
• If a bag valve mask (BMV) is required during transport, provide only gently bagging to reduce aerosolization in the event of worsening hypoxia.
• Avoid unnecessary breathing circuit disconnection during transport.
EXPECTING NORMAL DELIVERY
• If possible, put the woman in isolation room equipped for managing patients who test positive for COVID-19
• Monitor labor as per guideline using partograph
• Ensure vacuum extraction equipment at hand in case of maternal distress (respiratory) during second stage of labor
• Tell the mother to wash her hand and the breast with soap and water and start skin-to-skin and breast feeding practices while putting on mask
• Provide psychosocial support to a woman in labor and companion specifically through providing facts related to COVID-19 and available services
DELIVERING BY CAESAREAN SECTION
• Obtain an informed consent
• Observe normal preparations for caesarean delivery
• Patient must have face mask in the theatre
• HCWs should wear PPEs
• Spinal anesthesia is preferred unless there are contraindicated
• When intubation and general anesthesia is required, rapid induction, using short acting muscle relaxant preceded by generous oxygenation, and by passing need for bag and mask to minimize aerosol generation.
F. POSTNATAL CARE IN THE CONTEXT OF COVID 19
• Generic screening and triage should be used to every client on the first contact in postnatal ward and clinic
• Postnatal care (PNC) should be individualized according to the woman and newborn’s needs.
F. i. Discharge after delivery
• For normal delivery with no any complication to the mother and newborn, discharge is recommended to be given after 6 hours.
• For normal delivery with no any complication to the mother and newborn, but living far away from the facility, consider discharge after 12 hours.
• For caesarean section deliveries and complicated births, the decision for discharge shall be individualized.
• Additional discharge counselling in the setting of COVID-19 infected mother includes:
o Take basic IPC precautions to protect themselves such as hand washing with soap or sanitizer.
o Delay discharge up to 24 hours due to risk of thromboembolism in pregnancy which may complicated the COVID 19 infection.
o Seek medical care in case of symptoms of COVID-19
Advise on signs and symptoms.
Advise on COVID 19 prevention/home care/ and home remedies.
Advise on signs of severe COVID-19 and how and where to seek medical care.
If possible – take the phone number of all patients and facility develop a system (assign a nurse with phone budget to call all patients and follow up every three days and document findings).
F. ii. Ambulatory postnatal care
• The minimum recommended number of contacts is three: at day 1, day 5 and day 10.
• Prioritize face to face visiting for women with:
o Known psycho-social vulnerabilities
o Operative birth
o Premature/low birthweight baby
o Other medical or neonatal complications including post COVID-19
• Where continuity models of care are in place PNC visit after 10 days can take care at home by CHWs or phone calls and attend for routine care for the baby at 6 weeks
• If the pandemic progresses to worse situation consider to institute home visits by using electronic solutions or CHWs to reach women at home.
25 Machi 2021 06:04:39
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