Dear Colleagues

We are in the early days of what is expected to become a national medical emergency that will place an enormous strain on our already struggling health infrastructure and our economy. It is of importance that we prepare as well as is possible for the difficult time ahead and that we all play our part in our hospitals, our communities and importantly, our inner circles. These roles and priorities may at times become conflicting and may put our own health at risk.

Our first responsibility is to help prevent the rapid spread of infection, in order to increase our ability to provide appropriate care to those who will need assisted ventilation for viral pneumonia. During coming weeks this will mean strict social distancing and preventing all unnecessary travelling and interpersonal contact. These measures will no doubt have an immediate and serious economic impact but are nevertheless essential.

Secondly, we have a responsibility to assist our hospitals to prepare for the coming epidemic and manage patients during the crisis time. This includes drafting policies and strategies, gaining all necessary information and training, wisely using scarce consumables and protective wear, and freeing up essential hospital space. We may be called upon to perform duties outside of our usual scope of practice if staff deficits develop.

Thirdly, we remain responsible for the continued obstetric and gynaecologic care of our patients. Urgent care and consultations should be provided and access to after-hour emergency medical care must be available. Antenatal assessment of mother and foetus must continue, as must the assessment and management of all gynaecologic emergencies.

Last, but not least is our responsibility towards ourselves and our staff, to ensure our own safety, and by doing so, the safety of our immediate families.  It is only by ensuring our own safety, that we will be able to fulfill all the duties listed above. It is therefore essential that we take all the precautions available to us – including taking care of our nutritional status, our psychologic and emotional health, rest and our immunity.

President Ramaphosa announced a nationwide lockdown allowing only essential services to remain functional. How exactly this will work and be implemented, remains to be seen, but this is how the measures and the needs of the epidemic are interpreted by the SASOG leadership. These guidelines may have to be updated as events unfold.

RECOMMENDATIONS

Consultations:

• It is recommended that urgent and emergency consultations should continue; that all surfaces and equipment be cleaned between patients, including ultrasound equipment; that patients are screened before entering; and that potentially infected patients be seen separately in a designated area.
• All measures that can decrease contact and increase social distancing should be implemented, including: spacing of visits to limit the number of patients in waiting rooms; telephonic follow-up consultations; limiting consulting hours to the essential; and, having administrative staff working from home where possible.
• Waiting room and nursing staff who are considered essential for consulting services may continue working, but are not obliged to do so. We must explain and reinforce the importance of the above safety measures to all patients and staff, do risk assessment and do our utmost to ensure the safety of everyone.

Obstetric Care:

• Ante-natal care is known to improve pregnancy outcomes and must continue, especially for high risk patients. Important visits should not be postponed and antenatal admissions must continue as indicated and essential.
• Suspected or confirmed CoVid-19 cases should self-isolate and NOT attend for normal care; these patients should be screened or consulted telephonically or face-to-face wearing PPE and in a dedicated area.
• Safety during obstetric admissions, delivery and care of neonates must be prioritized and separation between infected and uninfected cases must be practiced.
• Protocols for vaginal and caesarian delivery of women with known or suspected infection and/or pneumonia should be developed in collaboration with hospitals, made available and followed by all.
• These should probably include oxygen administration to a saturation of around 94%, routine analgesics and epidural or spinal anaesthesia, continuous electronic fetal monitoring, and the use of PPE at delivery

Feto-Maternal Care:

• Assessment and management of suspected fetal anomalies is time-sensitive and cannot be postponed, but screening and care of low risk patients may be of less importance when resources become very strained.
• Information on CoVid-19 disease during pregnancy is scarce, but it is expected that some pregnant women may become severely ill with respiratory, renal and other sequelae and will need specialized care by multidisciplinary teams.
• Maternal well-being must be priority; steroids are considered safe for lung-maturity, mode of delivery should not be determined by the infection, unless in extreme cases.

Gynaecology Care:

• Comprehensive routine care must be provided for gynaecologic emergencies, and “time-sensitive conditions” including all pregnancy associated conditions, contraception, termination of pregnancy, and urgent oncology, including palliation.
• Elective surgery that cannot be postponed for 3 or more weeks, should be considered urgent and should be offered, provided a separate safe area in the hospital can be ensured.
• Non-urgent elective gynaecology surgery and all surgery which may result in relatively lengthy hospital stays, should be postponed.

Infertility Care:

• Give priority to completing assisted reproduction treatment cycles for those who have started, provided this can be done safely.

Uro-Gynaecology:

• Priority should be given to non-invasive and medical treatments and where possible surgery should be postponed, especially in patients older than 60 years.

Oncology Care:

• Postpone cancer surgery for non-urgent cases, most pre-cancers, and for the frail, elderly and immune-compromised.
• Radiation and chemotherapy should not be interrupted, and chemotherapy should be initiated for curable new cases like gestational trophoblastic malignancy.
• Home care as well as symptomatic treatment, palliative care and analgesia must be prioritised.

Let us join hands to help protect the health and lives of our people in solidarity and with compassion, focussing not on ourselves but on the greater good.

Wishing you, and your loved ones, and your staff, and all our patients, good health during these testing times.

SASOG Executive Committee

Dated: 23 March 2020