This is a descriptive study proposing guidance and recommendations based on a literature review and a group of expert’s opinions about the topic.
Development of the recommendations and consensus approach
A group of experts that are members of the Brazilian Association of Physiotherapy in Women's Health (ABRAFISM), came together to rapidly prepare a clinical recommendation for physiotherapy management to pregnant women, women during childbirth and, postpartum women in times of COVID-19.
A literature review was conducted from inception to June 09 2020 in the following databases: Pubmed, PEDro, Web of Science collection and, Embase. All searches were restricted to English and Portuguese languages. For all topics, we sought existing systematic reviews and clinical trial studies. We have also consulted the guidelines of international associations and entities, such as the World Confederation for Physical Therapy (WCPT), WHO, American College of Obstetricians and Gynecologists (CCOG), Royal College of Obstetricians and Gynaecologists (RCOG), Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO), Brazilian Ministry of Health (MS) and Cochrane Pregnancy and Childbirth.
The terms used in the search strategy in all database were: (“physiotherapy” OR “physical therapy” OR “rehabilitation”) AND (“pregnant” OR “pregnancy” OR “pregnant women” OR “antenatal woman” OR “postnatal women” OR “childbirth” OR “labor” OR “delivery” OR “vaginal delivery” OR “cesarean section” OR "birth" OR “puerperium” OR “postpartum” OR “episiotomy” OR “lumbopelvic pain” OR “urinary incontinence” OR “exercise” OR “pelvic floor” OR incontinence OR “labour pain” OR “birth ball” OR “non-pharmacological” OR “transcutaneous electrical nerve stimulation” “massage” OR “painful nipples” OR “breastfeeding” OR “lactation” OR “mobile app" OR “digital health” OR telemedicine OR “tele rehabilitation" OR telehealth OR “telephone-delivered care” OR “telephone health” OR “home treatment” OR “home-based” OR “COVID-19” OR “COVID 19” OR “COVID” OR “coronavirus”).
It was decided to develop consensus recommendations. Two independent reviewers (ACRP) and (CHJF) performed the selection process of studies through titles, abstracts, and full-text reading based on the previously described proposed inclusion criteria. The reference lists of included studies were screened independently to identify possible studies not retrieved by the electronic search. Any disagreements during the selection process were resolved discussion until a consensus was reached by the group of specialists. On 23 June 2020, the lead author distributed draft recommendations to all authors. The lead author organized all comments for further discussion in the group. Each recommendation was discussed until a consensus was reached and they were, therefore, grouped according to their similarities and allocated into categories.
Subsequently, the working group approved the recommendations.
Twenty-one people participated in the development process. The recommendations were distributed to all the Physiotherapists members of the ABRAFISM on the website on 04 June 2020.
What are the risks of the COVID-19 to pregnant women?
The hormonal state and the reduced chest expansion increase pregnant women’s risk of respiratory infections . Additionally, data concerning the COVID-19 epidemic, demonstrated that pregnant women and their neonates are exposed to a higher risk of poor outcomes . Little is known about the impact of COVID-19 on pregnancies, perinatal, and neonatal outcomes . The risk of being admitted to intensive care units (ICU) may be higher in pregnant and postpartum women with laboratory-confirmed SARS-CoV-2, compared with non-pregnant women of similar age. Pregnant women may be more susceptible to COVID-19 complications, but with adequate and timely intensive care the survival rate could be similar to non-pregnant women .
Normally, pregnant women with COVID-19 presented with mild symptoms, mostly fever and cough, a considerable number of patients stayed asymptomatic, and only a few cases developed dyspnea requiring oxygen therapy or admission in ICU for intensive treatment. It is feasible to hypothesize that the worse neonatal outcome was related to the poor clinical conditions of the mother during pregnancy and delivery, rather than being caused by vertical transmission of the infection. However, until now, data are limited .
The data from Brazil, Iran, and Mexico, raising the possibility of an increased risk of maternal death from COVID-19. The high birth rates and limited resources for healthcare provision in Brazil will uncover the increased risk for maternal death because of COVID-19 and highlight the need for corrective measures for adequate prenatal and postnatal care. It was hypothesized that higher birth rates, worse population health status, and poor quality of obstetrics care, caused by the management of the pandemic, would cause a rise in the number of deaths and also the case fatality rate [26, 27].
Pregnant patients with comorbidities such as obesity and gestational diabetes may be at an even higher risk for severe illness consistent with the general population with similar comorbidities . The other important factor is the highest rate of cesarean sections, which increased the risk of postoperative morbidity and mortality for patients with COVID‐19 undergoing surgery .
The COVID-19 can cause serious adverse outcomes during pregnancy, such as fetal distress and preterm delivery . It is not clear that these outcomes were related to maternal infection, and at this time the risk of adverse infant outcomes is not known. There is limited evidence about the vertical transmission, prevalence and, clinical features of COVID-19 during pregnancy, birth, and the postnatal period. . The general recommendation concerning pregnancy and the postpartum period during the COVID-19 pandemic are present in Box 1.
Physiotherapeutic assistance in pregnant, parturient, and postpartum women during the pandemic.
Face-to-face care should be avoided to the maximum during the COVID-19 pandemic. Modifying the care approach is appropriate when the risk of exposure to COVID-19 is high and health resources for outpatient care are reduced. A pre-appointment phone screening should be done before any essential face-to-face consultation to verify the existence of comorbidities or COVID-19 symptoms.
Regarding the presence of the physiotherapist in the maternity hospital teams, due to the risk of exposure to COVID-19 by the health team and patients, it may be necessary to modify the policies according to the specificities and norms of each institution. However, the WHO emphasizes that all women have the right to have a positive and safe experience in labor, regardless of the status of COVID-19. Therefore, continuing to follow the precepts of the humanization of care is essential. According to the WHO, strategies for pain relief and mobility during labor should be maintained .
Work-related care in only one health institution should also be adopted whenever possible, as well as the organization of the schedule of the physiotherapists, exclusively in the sectors destined to attend in labor and postpartum women with or without COVID-19. Box 2 presents a summary of physiotherapy care in obstetrics and the recommendations regarding personal protective equipment (PPE).
Outpatient clinics, clinics, and homes
The recommendations regarding the practice of the physiotherapist at the outpatient level, physiotherapy clinics and, at pregnant women’s home were classified and presented: the safety of the care environment [Box 3]; general aspects of care to pregnant women without symptoms of COVID-19 [Box 4]; specific aspects of care to pregnant women without symptoms of COVID-19 [Box 5]; care to pregnant women with COVID-19 [Box 6] and the practice of physical exercise in pregnant and postpartum women during the pandemic [Box 7].
Recommendations related to specific physiotherapy guidelines for pregnant women with COVID-19 should be interpreted with caution since there are no specific studies. These recommendations were based on the opinion of a group of experts.
The assistance of the physiotherapist in maternity hospitals
In some countries, the physiotherapist works in maternity hospitals assessing women in labor to prescribe, apply, and guide, the use of physiotherapeutic resources for pain relief and the progression of labor. The work of the physiotherapist involves also a specific knowledge about the body and pelvis biomechanics in labor and delivery, respecting the time and preferences of each woman in the process of labor, and the global aspects of her health and evolution in labor [8-10]. The role of the physiotherapist encompasses the immediate postpartum period, seeking to prevent deep vein thrombosis, to improve the respiratory, cardiac, gastrointestinal, locomotor, postural, urinary functions, among others, encouraging the bond between mother and the newborn. Also, it seeks to relieve pain related to perineal trauma and cesarean section favoring the healing processes [12-15].
The instructions related to the late and remote postpartum are often initiated by the physiotherapist during the period when the postpartum women are still hospitalized. The physiotherapists aim to familiarize the postpartum woman with the rehabilitation process to help in the return of her body to the pre-gestational condition and optimizing its functionality, treating the discomforts and dysfunctions that may have persisted or arisen, due to pregnancy and childbirth. The above recommendations in general are also applicable to outpatient care in maternity hospitals.
Studies have shown beneficial effects of early prone positioning for acute respiratory distress syndrome, including decreased mortality. Though, pregnant women were excluded from the trials. A current report has also found that prone positioning to be particularly helpful for patients with COVID-19 with the moderate or severe respiratory disease . However, data are limited, case reports and expert experience recommend that pregnant women may be safely prone and that prone positioning may be particularly beneficial in these patients owing to its ability to relieve both diaphragmatic compression from abdominal contents and aortocaval compression from the gravid uterus if performed correctly .
A randomized, controlled trial analyzed the influence of lying in a prone position on a specially designed stretcher on the maternal-fetal hemodynamic parameters and comfort of pregnant women. The authors created a special prototype stretcher for pregnant women. They concluded that the prone position was considered safe and comfortable and could be advantageous for improving oxygen saturation and reducing the systolic blood pressure and respiratory rate .
Prone positioning during pregnancy requires particular considerations. Routine indications and contraindications apply, with additional caution for patients within 2 days postoperative from cesarean delivery owing to concerns for incisional complications and pain in the immediate postoperative period. Prone positioning for patients at 34 weeks of gestation or more may be more technically difficult owing to the large gravid uterus at advanced gestational ages, and the risks and benefits of delivery before prone positioning should be considered . More recommendations about the physiotherapist's assistance in the maternity hospital with parturients and postpartum women can be seen in Box 8.