671 PROFESSIONAL ARTICLE Reorganization of the working process in Ljubljana Maternity Hospital during SARS-CoV-2 pandemic Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia Correspondence/ Korespondenca: Vita Andreja Mesarič, e: vita. mesaric@gmail.com Key words: SARS-CoV-2; COVID-19; reorganization; maternity hospital; labour; pregnancy Ključne besede: virus SARS-CoV-2; covid-19; reorganizacija; porodnišnica; porod; nosečnost Received: 26. 5. 2020 Accepted: 24. 7. 2020 eng slo element en article-lang 10.6016/ZdravVestn.3098 doi 26.5.2020 date-received 24.7.2020 date-accepted Human reproduction Reprodukcija človeka discipline Professional article Strokovni članek article-type Reorganization of the working process in Lju- bljana Maternity Hospital during SARS-CoV-2 pandemic Reorganizacija dela v Porodnišnici Ljubljana v času izrednih razmer zaradi pandemije virusa SARS-CoV-2 article-title Reorganization of the working process in Lju- bljana Maternity Hospital during SARS-CoV-2 pandemic Reorganizacija dela v Porodnišnici Ljubljana v času izrednih razmer zaradi pandemije virusa SARS-CoV-2 alt-title SARS-CoV-2, COVID-19, reorganization, mater- nity hospital, labour, pregnancy virus SARS-CoV-2, covid-19, reorganizacija, porod- nišnica, porod, nosečnost kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2020 89 11 12 671 679 name surname aff email Vita Andreja Mesarič 1 vita.mesaric@gmail.com name surname aff Renata Košir Pogačnik 1 Gorazd Kavšek 1 Andreja Trojner Bregar 1 Lili Steblovnik 1 Mirjam Druškovič 1 eng slo aff-id Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia Klinični oddelek za perinatologijo, Ginekološka klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija 1 Reorganization of the working process in Ljubljana Maternity Hospital during SARS- CoV-2 pandemic Reorganizacija dela v Porodnišnici Ljubljana v času izrednih razmer zaradi pandemije virusa SARS-CoV-2 Vita Andreja Mesarič, Renata Košir Pogačnik, Gorazd Kavšek, Andreja Trojner Bregar, Lili Steblovnik, Mirjam Druškovič Abstract In December 2019, a new strain of coronavirus SARS-CoV-2 that causes COVID-19 appeared in Wuhan, China. The signs and symptoms of COVID-19 include cough, dyspnea, fever and muscle aches, as well as loss of taste and smell. Experience from the outbreaks of other human coronavi- ruses (Severe Acute Respiratory Syndrome Coronavirus - SARS-CoV and Middle East Respiratory Syndrome Coronavirus - MERS-CoV) places pregnant women and their fetuses at high risk for severe form of the disease, but surprisingly according to the current knowledge pregnant wom- en are not at risk for severe COVID-19. In March 2020 a global pandemic was declared, and strict measures had to be undertaken in order to limit the spread of the virus. As a result, all aspects of life have changed dramatically. The working process in hospitals had to be strongly adapted to the existing situation. After the announcement of the SARS-CoV-2 pandemic, Ljubljana Maternity Hospital developed clinical guidelines for the treatment of pregnant and laboring women during the pandemic. Due to the nature of the work, the scope of activities could not be significantly reduced, so we had to prepare for the admission of potentially or confirmed SARS-CoV-2-positive pregnant women in an extremely short time. The maternity ward was divided into three zones: the white zone for healthy pregnant women, the grey zone for pregnant women with suspected but not yet confirmed SARS-CoV-2 infection, and the red zone, where we treated SARS-CoV-2 pos- itive pregnant women. Until the end of May 2020, two SARS-CoV-2 positive women and 3 women who had had SARS-CoV-2 during pregnancy, but were already negative, gave birth. None of them had severe symptoms of COVID-19, and no intensive therapy was required. Izvleček Decembra 2019 se je v Wuhanu na Kitajskem pojavil novi sev koronavirusa SARS-CoV-2, ki povzroča bolezen covid-19. Ta se kaže s simptomi in znaki prizadetosti zgornjih dihal: s kašljem, dispnejo, povišano telesno temperaturo, prisotne pa so lahko bolečine v mišicah, prebavne teža- ve, izguba vonja in okusa. Znanje, pridobljeno na podlagi izbruhov ostalih človeških koronaviru- sov (angl. Severe Acute Respiratory Syndrome Coronavirus - SARS-CoV in Middle East Respirato- ry Syndrome Coronavirus - MERS-CoV), uvršča nosečnice in njihove plodove v ranljivo skupino, vendar pa trenutno velja, da nosečnice niso bolj ogrožene za težak potek bolezni covid-19. Po razglasitvi pandemije so sledili ostri ukrepi, katerih cilj je bil omejiti širjenje virusa. Zato se je življenje na vseh področjih korenito spremenilo. Tudi delovanje bolnišnic se je moralo prilagoditi na obstoječe razmere. V Porodnišnici Ljubljana smo se po razglasitvi pandemije covida-19 zave- dali, da bo treba za optimalno oskrbo vseh nosečnic oblikovati smernice oz. kliničnih poti za vse zaposlene. Zaradi narave dela obsega dejavnosti ni bilo mogoče bistveno zmanjšati, zato smo se Slovenian Medical Journal 672 HUMAN REPRODUCTION Zdrav Vestn | November – December 2020 | Volume 89 | https://doi.org/10.6016/ZdravVestn.3098 1 Introduction This article was written during the first wave of the SARS-CoV-2 pandemic. It presents the adjustments that were im- plemented in the period between March and May 2020 and does not fully reflect the current conditions at the Ljubljana Maternity Hospital. The clinical pathway is constantly changing according to the conditions and national and international recommendations. In December 2019 a new strain of coronavirus appeared in China. The vi- ruses from this group cause diseases of the upper respiratory tract, as well as the severe acute respiratory syndrome, which gives the virus its name Severe Acute Re- spiratory Syndrome Coronavirus (SARS- CoV). SARS-CoV-2 is transmitted from person to person via droplets, which re- quires a close contact with an infected person, it can also be transmitted indi- rectly through infested surfaces or objects (1). The virus is highly contagious. One infected person on average infects 2.5 healthy people. It causes the COVID-19 disease, symptoms of which include fever, cough, muscle pain, dyspnea, headache, loss of smell and taste, diarrhea (2). In just a few months, the SARS-CoV-2 vi- rus has spread across the globe, and the na sprejem morebitno ali potrjeno okuženih nosečnic morali pripraviti v izjemno kratkem času. Porodnišnico smo razdelili na tri območja po zgledu urgentnega bloka Univerzitetnega klinične- ga centra Ljubljana: belo območje za zdrave nosečnice, sivo območje za nosečnice, pri katerih smo sumili na okužbo s SARS-CoV-2, vendar ta še ni bila potrjena, in rdeče območje, kjer smo obravnavali dokazano pozitivne nosečnice. Do konca maja 2020 sta v Ljubljanski porodnišnici rodili dve porodnici z dokazano okužbo z virusom SARS-CoV-2 in tri porodnice po preboleli okuž- bi z virusom SARS-CoV-2. Nobena od njih ni imela hujših simptomov bolezni covid-19, zato tudi intenzivno zdravljenje ni bilo potrebno. Cite as/Citirajte kot: Mesarič VA, Košir Pogačnik R, Kavšek G, Trojner Bregar A, Steblovnik L, Druškovič M. Reorganization of the working process in Ljubljana Maternity Hospital during SARS-CoV-2 pandemic. Zdrav Vestn. 2020;89(11–12):671–9. DOI: https://doi.org/10.6016/ZdravVestn.3098 Copyright (c) 2020 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. World Health Organization declared the global pandemic on March 11th 2020 (3). By the end of May 2020, more than 5.5 million people have become infected, with approximately 350,000 of those who had fallen ill, have also died (4). The experience obtained from the outbreaks of other human coronavirus- es (Severe Acute Respiratory Syndrome Coronavirus, SARS-CoV in Middle East Respiratory Syndrome Coronavirus, MERS-CoV), puts pregnant women and their fetuses in a high-risk group, as oth- er outbreaks had been connected with a high rate of maternal mortality (25% for SARS-CoV-1, 35% for MERS-CoV), neo- natal mortality (27% for MERS-CoV), miscarriage in the first trimester and in- trauterine growth restriction in the sec- ond and third trimester of pregnancy (5,6). However, based on the experience from the past epidemics of human coro- naviruses, we cannot reliably predict the course of infection with SARS-CoV-2 in pregnant women and neonates. Current- ly, it is believed that pregnant women are no more endangered for a severe course of the disease and the symptoms in preg- nant women do not differ from those in the general population. Approximately 673 PROFESSIONAL ARTICLE Reorganization of the working process in Ljubljana Maternity Hospital during SARS-CoV-2 pandemic 5% have severe symptoms that require in- tensive care (1). Vertical transmission of SARS-CoV-2 from the pregnant woman to the fetus is probable; however, it has yet to be proven. There were two published case studies in which IgM antibodies against the SARS- CoV-2 were discovered in the neonate’s serum. Because IgM antibodies are not passed through the placenta, it is likely that they were created as a response to the infection of the fetus with SARS-CoV-2 in the womb (7,8). So far SARS-CoV-2 has not been found in the placenta, vag- inal discharge, mother’s milk, placenta, umbilical blood, and in the nasopharyn- geal space of a newborn (1). According to the current data, it appears that SARS- CoV-2 is not teratogenic and does not af- fect the rate of early miscarriages or pre- mature births (8,9). All the data is based on a small sample of examined women in retrospective analyses. The pandemic is ongoing and we expect that this informa- tion will change in the future. After the pandemic had been de- clared, strict measures were implemented with the objective of limiting the spread of the virus, which thoroughly changed our lives. The activity of the hospitals had to adapt significantly to the exist- ing conditions. Hospitals had to provide high-quality care for those who needed it, while also protecting both the healthcare workers and other patients from poten- tial infection with the novel coronavirus. Limiting the spread among healthcare workers was crucial, as a higher number of infected among those employed at hos- pitals could lead to severe limitations in providing healthcare. Maternity hospitals could not limit the scope of their work. Compared to the previous months, the number of births was not significantly reduced due to the pandemic. Safe working conditions re- quired a reorganization of work across all levels of perinatal care. After SARS-CoV-2 pandemic was declared, we in Ljubljana Maternity Hospital were also aware that in order to ensure optimal care for all pregnant women, we had to prepare guidelines and clinical pathways for employees. The objective of the clinical pathway is a de- tailed definition of organization of the working process for healthcare workers who participate in the treatment of preg- nant women. Writing clinical pathways in an emergency situation is difficult, as it is important to first define the criteria for entry, the course of treatment and any and all derogations that may occur during the treatment in spite of the uncertain- ties related to the pandemic . The clinical pathway must be designed according to the organization of work, which is spe- cific to each maternity hospital and each working environment. Pregnant women have to be treated as a vulnerable group if infected with SARS-CoV-2, therefore the goal of the healthcare personnel must be to set di- agnosis on time and quickly, monitoring the condition of the pregnant woman and the fetus, and an optimal organization of labor, postnatal period, and the protec- tion of healthy pregnant women and the healthcare staff from the spread of the vi- rus within the maternity hospital. 2 Adjustments at the Ljubljana Maternity Hospital At Ljubljana Maternity Hospital, one of two tertiary centers in the country, we deal with healthy pregnant women and we also treat high risk pregnancies. Ap- proximately 5,500 women give birth at the Ljubljana Maternity Hospital every year, the ward for pathological pregnancy has the capacity for 15–20 pregnant women, and every day up to 100 pregnant wom- en are examined at the hospital. Nearly all extremely premature children are born here, and also the majority of all prema- ture children from entire Slovenia. 17 ob- stetricians, specially trained for handling the most complicated pregnancies and deliveries, 9 neonatologists, 45 midwives, 674 HUMAN REPRODUCTION Zdrav Vestn | November – December 2020 | Volume 89 | https://doi.org/10.6016/ZdravVestn.3098 and 4 anesthesiologists, who are focused on anesthesia in obstetrics are employed at Ljubljana Maternity Hospital. Due to the nature of work, it was not possible to significantly reduce the scope of activi- ties, so we had to prepare for admitting potentially infected pregnant women and those with confirmed infection in a very short time. Work conditions changed for all employees; physicians, midwives, nurses, anesthesiologists, pediatricians, technicians, administrators, security guards. When adopting and customizing the measures, we adhered to the recom- mendations of the National Institute for Public Health (NIPH), the World Health Organization (WHO), the Service for managing and preventing hospital infec- tions of the Ljubljana University Medical Centre, and foreign associations of gyne- cologists and obstetricians. 2.1 Employees at the Maternity Hospital When arriving to work, all employees had to measure their body temperature, and list their medical condition into a special form. When working with pa- tients, we wore surgical masks, gloves, protective coats and glasses. We took care of hand hygiene even more than usually. Doctors were divided into two groups; one worked for a week and the other stayed at home, waiting to jump in in case an infection occurred among staff. In the delivery room, colleagues from the Department of Human Reproduction also assisted, as they were not perform- ing their full scope of work during the pandemic. 2.2 Areas of work The Maternity Hospital was divided into three zones similar to the Emergency Department of the Ljubljana University Medical Centre: white zone for healthy pregnant women, grey zone for pregnant women with suspected infection with the SARS-CoV-2 virus that has not been confirmed, and the red zone, where we treated the pregnant women who were proven positive. We defined the condi- tions for entry, the organization of the space, the equipment used by the staff when working with a pregnant woman and the course of work for the midwife, the obstetrician, and the technician for each of the zones. These are described in detail in the document Clinical path- way for treating pregnant woman mother with COVID-19 (Klinična pot obravnave nosečnice/otročnice z okužbo covid-19). 2.3 Entering the Maternity Hospital We organized the so-called pre-triage at the entrance of the maternity hospital, where a resident and a nurse or a midwife, with the assistance of a security guard, asked a pregnant woman about her health condition before she was allowed to enter the building. If there was no suspicion of her being infected with SARS-CoV-2 vi- rus, we informed the pregnant woman of the importance of regularly disinfecting her hands, she received a protective mask and was allowed to attend the examina- tion. Her treatment followed established procedures, while adhering to the gen- eral recommendations of avoiding social contacts. We made sure that in the wait- ing rooms there was appropriate safety distance between patients (> 1.5 m). The partners were not permitted to attend the examination and had to wait outside the maternity hospital. 2.4 Planned admittance to the Maternity Hospital All pregnant women who were re- ferred for admission (for labor induction, planned cesarean section, planned ad- mission to the department) were referred for the swab of the nasopharyngeal space a day before planned admission. They were treated according to the test results, 675 PROFESSIONAL ARTICLE Reorganization of the working process in Ljubljana Maternity Hospital during SARS-CoV-2 pandemic and if symptoms occurred during hospi- talization, we performed another swab, according to the clinical indications. 2.5 Suspected infection If a pregnant woman manifested symp- toms and signs that are characteristic for a disease of the upper respiratory tract at the arrival to the hospital, we assessed whether she has an acute obstetric condi- tion that requires immediate treatment or the obstetric examination is non-urgent. In the latter case, we referred the patient to her general physician for the treatment of the respiratory disease, and only after admitted her to the maternity hospital. If the pregnant woman needed an im- mediate examination, we referred her to the separate entrance from Zaloška cesta, which was off limits for patients without respiratory tract infection symptoms and employees of the maternity hospital. She had to wear a surgical mask, and the staff that was in contact with her was dressed in an appropriate protective personal equipment (PPE). In a specially refitted, so-called isolating examination room, a physician and a midwife treated the preg- nant woman according to accepted clin- ical practice. The examination room is equipped with standard amenities, such as CTG, ultrasound etc. If the pregnant woman needed to be admitted to the maternity clinic, we also took a swab of her nasopharyngeal space to test for the SARS-CoV-2 virus. If the pregnant woman needed to be admitted to a hospital because of the start of labor, we admitted her into a special part of the delivery ward, in a room that was located in the grey area. Pregnant women who needed to be admitted to the Department for pathological preg- nancy waited in the grey area, which was organized in front of the isolation triage, or were admitted to the Department for pathological pregnancy’s grey zone. If the SARS-CoV-2 test was negative, we kept the patient in isolation and later moved her to the white zone and treated her ac- cording to the established clinical prac- tice. If the result was positive, confirming the presence of the SARS-CoV-2 virus, we moved the patient to the red zone of the delivery ward or the red zone of the department for intensive perinatal medicine depending on the reason for her admission (contractions, rupture of membranes, hemorrhaging, suspicious/ pathologic CTG). For transferring potentially infect- ed pregnant women, we used a sepa- rate elevator and appropriate protective equipment. 2.6 Confirmed infection Asymptomatic pregnant women, who tested positive for SARS-CoV-2, and needed a routine examination, were treat- ed at the Outpatient clinic for pathological pregnancy for COVID-19. The premises of the Outpatient clinic for pathologi- cal pregnancy were temporarily rear- ranged, and the regime of examinations was adjusted. The outpatient clinic for COVID-19 patients operates every Friday after noon. The regular examination of an infected pregnant woman is undertaken by two teams (physician, nurse), so that the work is performed safely and effec- tively. Pregnant women were examined in the suitable PPE. In order to access the outpatient clinic, we used the entrance from Zaloška cesta, as it does not cross pathways with the pathways of healthy pregnant women. Work equipment at the outpatient clinic (computer, ultrasound device, examination table) was protected appropriately. We conducted comprehen- sive examinations, including ultrasound, and drew blood and urine samples for laboratory tests. In April and May, we conducted 1 to 4 exams of pregnant wom- en who were positive for the SARS-CoV-2 virus, but showed no symptoms per week. 676 HUMAN REPRODUCTION Zdrav Vestn | November – December 2020 | Volume 89 | https://doi.org/10.6016/ZdravVestn.3098 2.7 Delivery ward The delivery ward was divided into three separate working areas. A part of the delivery ward (the COVID-19 area) was dedicated to treating patients with a suspected infection with the SARS- CoV-2 virus (grey zone) or a confirmed infection with the novel coronavirus (red zone). After an infected laboring woman was admitted, this part of the delivery ward was completely separated from the rest of the delivery ward, as we erected additional barrier walls and doors that could be closed and locked if needed. There are three delivery rooms in the COVID-19 zone – one is rearranged and equipped as an operating theater, the sec- ond one is for vaginal delivery, and in the third one we treat pregnant women who have a suspected, but not yet confirmed infection. This is the grey zone, which can change into a red zone, if the swab results come back positive. We also provide clear markings for this separation. Rooms are equipped with essential equipment need- ed for safe labor. During labor, one of the midwives was with the woman in labor the whole time. She was dressed in personal protec- tive equipment and communicated with the obstetrician and other midwives in the delivery ward using a predesignated phone. During labor, we minimized the number of people present in the delivery room. The biggest challenge was working in PPE, as it is physically more demand- ing. One of the biggest issues was with the protective eyewear steaming up, which we successfully resolved in collaboration with the Department for Infectious Dis- eases, as they lent us a positive pressure protective suit, and later we also obtained two of our own. The procedures during labor did not differ from standard labor practice. In order to limit the spread of the virus with aerosol, we did not provide analgesia with nitrous oxide and remifen- tanil; however, we did ease the pain during labor with pethidine and epidural analgesia (Figure 1). For research purposes, we took a sam- ple of blood from the woman in labor and umbilical blood for serology for the SARS-CoV-2 virus. We took a swab from the vagina and a piece of the placenta, as we wanted to verify whether the virus is found in these tissues. To limit the spread of infection, the presence of the companion during labor and delivery was not permitted, which caused additional stress to most women in labor, as well as an additional burden for the medical staff who had to pay extra attention to the woman in labor. 2.8 Postpartum care After the delivery, the mother and the newborn were moved into the red zone on the ward. International guidelines rec- ommend the newborn is fed with breast milk. In some countries, e.g., the US and China, the newborn is separated from the mother, who pumps her milk, and the medical staff then feed the baby with the breast milk (10,11). In the UK, the breast- feeding is recommended while adhering to strict hygienic measures, which is al- so what we did at the Ljubljana Materni- ty Hospital (1). When using a protective mask and adhering to the rules for hand hygiene, the risk for transmitting the vi- rus from the mother to the newborn is very low, and certainly does not outweigh the benefits of breastfeeding and room- ing-in. We released both the mother and the child into home care as soon as it was safe for both of them. 3 Discussion The COVID-19 pandemic in the first half of 2020 brought enormous chang- es to all aspects of life. Institutions such as maternity hospitals, which could not reduce the scope of their work, had to adapt to the new circumstances practical- ly overnight. All employees of the Mater- nity Hospital were included in the work Fi gu re 1 : T re at m en t o f w om en in la bo ur d ur in g th e SA RS -C oV -2 p an de m ic . A sy m p to m a ti c p re g n a n t w o m e n A N D n e g a ti v e e p id e m io lo g ic a l h is to ry O R n e g a ti v e s w a b r e su lt s fo r S A R S -C o V -2 . W h it e z o n e o f th e d e li v e ry w a rd (r o o m s 5 , 6 , 7 , 8 , 9 , 1 0 , 1 1 ). E st a b li sh e d c li n ic a l p ra ct ic e . T h e p re g n a n t w o m a n r e ce iv e s a s u rg ic a l m a sk . R e d z o n e o f th e d e li ve ry w a rd : r o o m 3 o r O P . M id w if e 1 p u ts o n P P E . N o ti fi e s th e o b st e tr ic ia n , a n a e st h e si o lo g is t, p a e d ia tr ic ia n . C o m m u n ic a ti o n is c o n d u ct e d t h ro u g h D E C T, d o cu m e n ta ti o n in t h e r o o m is in a p la st ic s le e ve . H a n d h y g ie n e , m in im u m n o . o f st a  . M o n it o ri n g t h e p re g n a n t w o m a n : R R , b o d y te m p ., O 2 s a t. , b re a th in g r a te , p o te n ti a ll y a ls o in g e st in g li q u id a n d d iu re si s. W it h s e ve re s ym p to m s, c o n su lt in fe ct io u s d is e a se s p e ci a li st . M o n it o ri n g t h e f o e tu s: c o n ti n u e d C T G . A d h e ri n g t o e st a b li sh e d c li n ic a l p ra ct ic e w h e n m a n a g in g t h e la b o u r. A n a lg e si a : p e th id in e , E D K . C o n fi rm e d in fe ct io n w it h S A R S -C o V -2 . C A E S S A R IA N O p e ra ti n g r o o m in t h e C O V ID -1 9 z o n e . A n a e st h e si o lo g ic t e a m in P P E 1 . S p in a l b lo ck : s u rg e o n a n d m id w if e 2 in P P E 2 . S E A : s u rg e o n a n d m id w if e 2 in P P E 1 . M id w if e 1 a ss is ts t h e n u rs e w it h in st ru m e n ts . S P O N T A N E O U S L A B O U R M id w if e 2 p u ts o n P P E 2 a n d a ss is ts m id w if e 1 . T h e m id w if e in d e p e n d e n tl y ch e ck s th e b ir th ca n a l a n d t h e p la ce n ta . M id w if e 2 r e m a in s w it h t h e w o m a n f o r 3 h o u rs a  e r d e li ve ry t o c h e ck t h e c o n tr a ct io n o f th e w o m b a n d b le e d in g . A D M IS S IO N T O T H E D E L IV E R Y W A R D C o n tr a ct io n s, r u p tu re o f m e m b ra n e , v a g in a l b le e d in g , u n re a su ri n g C T G , l a b o r in d u ct io n , e le ct iv e c e sa re a n se ct io n . S y m p to m a ti c p re g n a n w o m e n ( u n e x p la in e d f e ve r > 3 7 ºC , co u g h , s o re t h ro a t, lo ss o f ta st e a n d s m e ll ). A sy m p to m a ti c p re g n a n t w o m e n w it h c lo se c o n ta ct w it h a S A R S -C o V -2 -p o si ti ve p e rs o n in t h e ir fa m il y (f o r o th e r ty p e o f co n ta ct , c o n ta ct e p id e m io lo g is t) . T h e p re g n a n t w o m a n r e ce iv e s a s u rg ic a l m a sk . G re y zo n e o f th e d e li ve ry w a rd : r o o m 4 . M id w if e 1 a n d o b st e tr ic ia n p u t o n P P E 1 . A s w a b o f th e n a so p h a ry n x f o r S A R S -C o V -2 is t a ke n , i f it h a d n o t a lr e a d y b e e n t a ke n in is o la ti o n t ri a g e , o r if it is p ru d e n t to r e ta ke t h e s w a b . U n ti l t h e s w a b r e su lt s a re in , t h e p re g n a n t w o m a n is tr e a te d a s if s h e w a s S A R S -C o V -2 -p o si ti ve . I f th e s w a b re su lt is p o si ti ve , t h e g re y a re a is c h a n g e d in to r e d , a n d t h e tr e a tm e n t is c o n ti n u e d . T a k in g s a m p le s fr o m in fe ct e d t is su e s. B e fo re la b o u r: C B C , b lo o d d i e re n ti a l, C R P, P C T, b io ch e m is tr y, li ve r fu n ct io n , I L- 6 , f e rr it in , c o a g u la ti o n t e st , tr o p o n in , s e ro lo g y fo r S A R S -C o V -2 , v a g in a l s w a b ( a m n io ti c fl u id ) fo r S A R S -C o V -2 . A  e r la b o u r: c o rd b lo o d f o r se ro lo g y fo r S A R S -C o V -2 , p ie ce o f p la ce n ta ( IM I) , p la ce n ta w it h u m b il ic a l c o rd ( H P ). M E D IC A L LY G U ID E D L A B O U R V a cu u m d e li ve ry , p e ri n e a l r u p tu re s, a d h e re n t o r d e fe ct iv e p la ce n ta . M id w if e 2 p u ts o n P P E 2 , a ss is ts m id w if e 1 , a n d r e m a in s w it h t h e w o m a n f o r 3 h o u rs a  e r d e li ve ry t o c h e ck t h e co n tr a ct io n o f th e w o m b , b le e d in g a n d m o n it o r h e r vi ta l fu n ct io n s. S p e ci a li st o b st e tr ic ia n , d re ss e d in P P E 1 o r 2 . C o m p le te s th e b ir th , c h e ck s th e p la ce n ta , p o te n ti a ll y re m o ve s a d h e re n t p la ce n ta , s u tu re s p e ri n ea l r u p tu re s o r e p is io to m y. P P E r e m o v e d a cc o rd in g t o in st ru ct io n s a n d u n d e r su p e rv is io n , fo ll o w e d b y o b li g a to ry s h o w e r. T h e r o o m is f ir st a ir e d f o r 2 h o u rs , fo ll o w e d b y g e n e ra l cl e a n in g . Transfer to the white zone. Negative swab. 677 PROFESSIONAL ARTICLE Reorganization of the working process in Ljubljana Maternity Hospital during SARS-CoV-2 pandemic analgesia (Figure 1). For research purposes, we took a sam- ple of blood from the woman in labor and umbilical blood for serology for the SARS-CoV-2 virus. We took a swab from the vagina and a piece of the placenta, as we wanted to verify whether the virus is found in these tissues. To limit the spread of infection, the presence of the companion during labor and delivery was not permitted, which caused additional stress to most women in labor, as well as an additional burden for the medical staff who had to pay extra attention to the woman in labor. 2.8 Postpartum care After the delivery, the mother and the newborn were moved into the red zone on the ward. International guidelines rec- ommend the newborn is fed with breast milk. In some countries, e.g., the US and China, the newborn is separated from the mother, who pumps her milk, and the medical staff then feed the baby with the breast milk (10,11). In the UK, the breast- feeding is recommended while adhering to strict hygienic measures, which is al- so what we did at the Ljubljana Materni- ty Hospital (1). When using a protective mask and adhering to the rules for hand hygiene, the risk for transmitting the vi- rus from the mother to the newborn is very low, and certainly does not outweigh the benefits of breastfeeding and room- ing-in. We released both the mother and the child into home care as soon as it was safe for both of them. 3 Discussion The COVID-19 pandemic in the first half of 2020 brought enormous chang- es to all aspects of life. Institutions such as maternity hospitals, which could not reduce the scope of their work, had to adapt to the new circumstances practical- ly overnight. All employees of the Mater- nity Hospital were included in the work Fi gu re 1 : T re at m en t o f w om en in la bo ur d ur in g th e SA RS -C oV -2 p an de m ic . A sy m p to m a ti c p re g n a n t w o m e n A N D n e g a ti v e e p id e m io lo g ic a l h is to ry O R n e g a ti v e s w a b r e su lt s fo r S A R S -C o V -2 . W h it e z o n e o f th e d e li v e ry w a rd (r o o m s 5 , 6 , 7 , 8 , 9 , 1 0 , 1 1 ). E st a b li sh e d c li n ic a l p ra ct ic e . T h e p re g n a n t w o m a n r e ce iv e s a s u rg ic a l m a sk . R e d z o n e o f th e d e li ve ry w a rd : r o o m 3 o r O P . M id w if e 1 p u ts o n P P E . N o ti fi e s th e o b st e tr ic ia n , a n a e st h e si o lo g is t, p a e d ia tr ic ia n . C o m m u n ic a ti o n is c o n d u ct e d t h ro u g h D E C T, d o cu m e n ta ti o n in t h e r o o m is in a p la st ic s le e ve . H a n d h y g ie n e , m in im u m n o . o f st a  . M o n it o ri n g t h e p re g n a n t w o m a n : R R , b o d y te m p ., O 2 s a t. , b re a th in g r a te , p o te n ti a ll y a ls o in g e st in g li q u id a n d d iu re si s. W it h s e ve re s ym p to m s, c o n su lt in fe ct io u s d is e a se s p e ci a li st . M o n it o ri n g t h e f o e tu s: c o n ti n u e d C T G . A d h e ri n g t o e st a b li sh e d c li n ic a l p ra ct ic e w h e n m a n a g in g t h e la b o u r. A n a lg e si a : p e th id in e , E D K . C o n fi rm e d in fe ct io n w it h S A R S -C o V -2 . C A E S S A R IA N O p e ra ti n g r o o m in t h e C O V ID -1 9 z o n e . A n a e st h e si o lo g ic t e a m in P P E 1 . S p in a l b lo ck : s u rg e o n a n d m id w if e 2 in P P E 2 . S E A : s u rg e o n a n d m id w if e 2 in P P E 1 . M id w if e 1 a ss is ts t h e n u rs e w it h in st ru m e n ts . S P O N T A N E O U S L A B O U R M id w if e 2 p u ts o n P P E 2 a n d a ss is ts m id w if e 1 . T h e m id w if e in d e p e n d e n tl y ch e ck s th e b ir th ca n a l a n d t h e p la ce n ta . M id w if e 2 r e m a in s w it h t h e w o m a n f o r 3 h o u rs a  e r d e li ve ry t o c h e ck t h e c o n tr a ct io n o f th e w o m b a n d b le e d in g . A D M IS S IO N T O T H E D E L IV E R Y W A R D C o n tr a ct io n s, r u p tu re o f m e m b ra n e , v a g in a l b le e d in g , u n re a su ri n g C T G , l a b o r in d u ct io n , e le ct iv e c e sa re a n se ct io n . S y m p to m a ti c p re g n a n w o m e n ( u n e x p la in e d f e ve r > 3 7 ºC , co u g h , s o re t h ro a t, lo ss o f ta st e a n d s m e ll ). A sy m p to m a ti c p re g n a n t w o m e n w it h c lo se c o n ta ct w it h a S A R S -C o V -2 -p o si ti ve p e rs o n in t h e ir fa m il y (f o r o th e r ty p e o f co n ta ct , c o n ta ct e p id e m io lo g is t) . T h e p re g n a n t w o m a n r e ce iv e s a s u rg ic a l m a sk . G re y zo n e o f th e d e li ve ry w a rd : r o o m 4 . M id w if e 1 a n d o b st e tr ic ia n p u t o n P P E 1 . A s w a b o f th e n a so p h a ry n x f o r S A R S -C o V -2 is t a ke n , i f it h a d n o t a lr e a d y b e e n t a ke n in is o la ti o n t ri a g e , o r if it is p ru d e n t to r e ta ke t h e s w a b . U n ti l t h e s w a b r e su lt s a re in , t h e p re g n a n t w o m a n is tr e a te d a s if s h e w a s S A R S -C o V -2 -p o si ti ve . I f th e s w a b re su lt is p o si ti ve , t h e g re y a re a is c h a n g e d in to r e d , a n d t h e tr e a tm e n t is c o n ti n u e d . T a k in g s a m p le s fr o m in fe ct e d t is su e s. B e fo re la b o u r: C B C , b lo o d d i e re n ti a l, C R P, P C T, b io ch e m is tr y, li ve r fu n ct io n , I L- 6 , f e rr it in , c o a g u la ti o n t e st , tr o p o n in , s e ro lo g y fo r S A R S -C o V -2 , v a g in a l s w a b ( a m n io ti c fl u id ) fo r S A R S -C o V -2 . A  e r la b o u r: c o rd b lo o d f o r se ro lo g y fo r S A R S -C o V -2 , p ie ce o f p la ce n ta ( IM I) , p la ce n ta w it h u m b il ic a l c o rd ( H P ). M E D IC A L LY G U ID E D L A B O U R V a cu u m d e li ve ry , p e ri n e a l r u p tu re s, a d h e re n t o r d e fe ct iv e p la ce n ta . M id w if e 2 p u ts o n P P E 2 , a ss is ts m id w if e 1 , a n d r e m a in s w it h t h e w o m a n f o r 3 h o u rs a  e r d e li ve ry t o c h e ck t h e co n tr a ct io n o f th e w o m b , b le e d in g a n d m o n it o r h e r vi ta l fu n ct io n s. S p e ci a li st o b st e tr ic ia n , d re ss e d in P P E 1 o r 2 . C o m p le te s th e b ir th , c h e ck s th e p la ce n ta , p o te n ti a ll y re m o ve s a d h e re n t p la ce n ta , s u tu re s p e ri n ea l r u p tu re s o r e p is io to m y. P P E r e m o v e d a cc o rd in g t o in st ru ct io n s a n d u n d e r su p e rv is io n , fo ll o w e d b y o b li g a to ry s h o w e r. T h e r o o m is f ir st a ir e d f o r 2 h o u rs , fo ll o w e d b y g e n e ra l cl e a n in g . Transfer to the white zone. Negative swab. 678 HUMAN REPRODUCTION Zdrav Vestn | November – December 2020 | Volume 89 | https://doi.org/10.6016/ZdravVestn.3098 reorganization. Even during emergency conditions, the standard of perinatal care had to be kept at the highest level, mak- ing the procedure of adaptation even more difficult. At the Ljubljana Mater- nity Hospital, we adhered to the expert recommendations on COVID-19, and in cooperation with Service for manag- ing and preventing hospital infections of the Ljubljana University Medical Centre created the clinical pathway for treating pregnant women during the COVID-19 epidemic. Ljubljana Maternity Hospital was divided into three work zones: red for infected pregnant women, white for healthy ones, and grey zone, where we treated those with suspected, but uncon- firmed infection. We faced problems be- cause of the lack of space, as the design of the maternity hospital does not sup- port the need for the separation of the pathways for infected and non-infected patients. Along with the organization of work zones, we needed to ensure ap- propriate personal protective equipment for all employees and a sufficient supply of surgical masks for employees and pa- tients in a very short time. The spaces at the maternity ward, which is not adapted to treat both the infected and the healthy patients, had to be separated by work areas and equipped appropriately. We limited entry to the hospital, limited the number of pregnant women who had ap- pointments for examinations, increased the time intervals between examinations, so that in the waiting rooms there were as few people as possible. We prohibited fathers from being present at birth. Emer- gency conditions presented an additional stress factor for pregnant women, so they needed additional support of the medical personnel. These new conditions were also psychologically and physically de- manding for medical professionals. Even though adapting to the new re- ality was at first demanding both for healthcare workers and for pregnant women and those giving birth, we believe that at the Ljubljana Maternity Hospital we managed to organize ourselves quick- ly and effectively. Some may believe that the measures we adopted were excessive, as we treated only a few infected pregnant women, and because of that, the treat- ment of healthy patients was hindered. The presence of a birth partner was not permitted during labor or examinations, and the movement in the maternity hos- pital was limited, while the number of examinations, especially at the primary level, was reduced. During the first wave of the epidemic, we did not have any un- controlled infections or virus transmis- sions between the patients, even though we treated healthy ones, those infected and those with symptoms. Therefore, we assess that our adaptation was successful. 4 Conclusion At the Ljubljana Maternity Hospital, we treated a few patients, who were in- fected with the SARS-CoV-2. By the end of May 2020, two women with a proven infection and three who had gotten over the infection with the SARS-CoV-2 gave birth. None of them had any severe symp- toms of the COVID-19. Intensive care treatment was not necessary. There were no labor complications with any of them. The all gave vaginal births. The mothers and the newborns are in home care and feel well. The newborns are breastfed. According to the latest data, the number of people, who recovered from COVID-19, is between 2 and 4 % of the population, which means that there is a high probability of the second wave of the pandemic (12). At the Ljubljana Ma- ternity Hospital, we successfully adapted the level of our professional work to the changed needs during the epidemic. We introduced an adjusted regime of treating infected pregnant women, mothers and newborns. Based on the result, we assess that we are prepared for a potential new wave of infection with the clinical path- way and work protocols. Successfully combating the new wave of COVID-19 679 PROFESSIONAL ARTICLE Reorganization of the working process in Ljubljana Maternity Hospital during SARS-CoV-2 pandemic References 1. 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Available from: https://covid19.biolab.si/. will largely also depend on the availabil- ity of protective masks and other per- sonal protection equipment, since we as healthcare workers have to first and fore- most protect ourselves in order to be able to care for others.