Clinical Practice Resources

The Nova Scotia Vaccine Expert Panel has updated resources for care providers to use with pregnant and breastfeeding individuals to guide discussion about COVID-19 vaccination. This information is specific to adult immunization.

In addition to these documents, the IWK has produced a video to help individuals make an informed choice about whether to get the COVID vaccine while they are pregnant, trying to get pregnant or breastfeeding. The video is hosted on the IWK public website: https://www.iwk.nshealth.ca/COVID-19/vaccine-info-for-pregnant-or-breastfeeding

For more resources related to the care of pregnant patients and their newborns affected by COVID-19, please refer to our COVID-19 Resources page.

This guideline presents care and investigative options for childbearing persons (and their relatives) who experience intrauterine fetal demise (IUFD) or stillbirth. Material is grouped into standard and selective investigations classified by pregnancy timing and type of investigation: childbearing person (maternal), fetal/infant, or placental. The process for individual and family informed decision-making is outlined.

According to the Nova Scotia Atlee Perinatal Database (2020), the provincial stillbirth rate has remained virtually unchanged since 1988.

Syphilis and Screening in NS for Pregnant Persons and Newborns

The rate of syphilis in Canada has been steadily rising in recent years, becoming a significant public health concern. A surge in syphilis infection among women of childbearing age has led to more cases of congenital syphilis (transmission from the pregnant person to the fetus during pregnancy), which can result in severe health outcomes or death in newborns. An infographic created by the Public Health Agency of Canada provides a visual aid depicting the increase in syphilis rates in Canada. Cases of syphilis in pregnancy and confirmed cases of syphilitic stillbirth are reportable to Public Health. The rise in cases has led to national research exploring strategies to address infectious and congenital syphilis in Canada. 

Screening

Screening recommendations for syphilis during the antenatal and postpartum periods, and for newborns are provided below.  These recommendations have been in place since 2020, were adapted from national guidelines, and remain in place until further notice. See the letter to care providers from January 2020 for additional practice guidance regarding consultation, testing and treatment.
Perform syphilis serology:

• Early in pregnancy for all pregnant persons.
• Repeat for all pregnant persons at 24 -28 weeks gestation.
  • For patients considered at high risk for syphilis, repeat syphilis serology at the time of birth.
• For patients considered at high risk for syphilis, repeat syphilis serology at the time of birth.
• In pregnant persons who experience a stillbirth from 20 weeks gestation onward.
• In pregnant persons who have NOT had the recommended syphilis serology during pregnancy, complete the screening prior to discharge following birth.
• In infants presenting with symptoms or signs compatible with early congenital syphilis even if the parent was seronegative at birth, due to the possibility of a very recent parental infection. 

Provincial Syphilis Outbreak: Recommendations for pregnant persons and newborns

As of January 20, 2020, the Office of the Chief Medical Officer of Health for Nova Scotia has declared a provincial syphilis outbreak. Across Canada syphilis outbreaks have been declared in most provinces/territories, due to increasing rates of infection. Changes to recommendations for pregnant women and newborns are outlined in the documents below:

The Canadian Paediatric Society (CPS) has recommended moving from universal newborn ocular prophylaxis, to universal prenatal screening for Neisseriae gonorrhoeae (GC) and Chlamydia trachomatis (CT) and treatment of those with positive results in order to eradicate infection and prevent intrapartum transmission to the newborn.

As universal ocular prophylaxis is eliminated from routine newborn care, functions of the health system must be optimized and synchronized to prevent ON. RCP has partnered with clinical experts and stakeholders from across NS to produce these resources, which are designed to offer guidance for the prevention of ON:

RCP has created this clinical resource to guide health professionals’ use of medication to alleviate pain in the labour and birth setting. It includes a review of the dimensions of pain and how they contribute to the labour experience, and differentiating between pain and suffering. Pharmacological options described in this resource include opioids (morphine, hydromorphone, and fentanyl) as well as nitrous oxide.

This resource is to be used in conjuction with the content in RCP’s two-part education module Supportive Care in Labour

Because of the potential for adverse effects, particularly related to IV Fentanyl use, Registered Nurses, midwives, and physicians must demonstrate competency in its safe administration.  Special considerations for the use of Fentanyl have been revised and clarified. RCP acknowledges that all policies and procedures are approved by the appropriate processes within each facility in Nova Scotia, or across the Nova Scotia Health Authority. Practice may differ across facilities, depending on available resources and prescriber preference; however, RCP recommends that the content of this clinical resource be considered in revisions to policy, procedures, and practice to ensure optimal safety and competence.

The aim of this practice resources is to provide guidance for providing antibiotics for GBS prophylaxis and with preterm prelabour rupture of membranes. The document combines recommendations from SOGC Clinical Practice Guideline No.233 – Antibiotic Therapy in Preterm Premature Rupture of the Membranes (Reaffirmed September 2017), and No.298 – The Prevention of Early-Onset Neonatal Group B Streptococcal Disease (Reaffirmed August 2018). The SOGC guidelines reflect the available evidence and professional opinion at the time of publication and are subject to change. Amendments made to the SOGC guidelines at a local level should be well documented to illustrate the basis for clinical decision-making in the course of care.

The resource entitled ‘Discussing Birth Options Following Cesarean Section in Nova Scotia: Vaginal Birth after Cesarean (VBAC) or Elective Repeat Cesarean Section’  (March 2015), and the accompanying two-page summary, are available to assist health professionals in discussions with women with a history of cesarean section as they consider their options for birth.

Small numbers have been removed from the posted versions for privacy reasons. Hard copy versions of the original resources are available by contacting RCP. Please note, these materials are intended for provider use.

RCP is revising the comprehensive clinical resource: Working with Pain in Labour. In the meantime, we are providing the attached table of recommended dosages for commonly used medications. For further information, including references, consult our clinical resource Working with Pain in Labour: Systemic Medications and our two-part education module Supportive Care in Labour

From April 2007 to January 2009, the Reproductive Care Program of Nova Scotia conducted a series of quality assessment reviews on induction of labour in 3 District Health Authorities and at the IWK Health Centre. This report summarizes findings from these reviews and from the literature. Data from the Nova Scotia Atlee Perinatal Database is presented.

Between 1970 and 2006 the cesarean section rate in Canada more than quadrupled from 6% to 26%. Similar increases have occurred in every province, including Nova Scotia where the cesarean section rate in 2006 was 27%. As part of an effort to understand the reasons for increased interventions in childbirth in our province, the Reproductive Care Program of Nova Scotia conducted quality assessment reviews in four different centres. This report outlines the collective findings from these reviews, describes the factors that appear to support best practices in maternity care with respect to cesarean sections in Nova Scotia, and presents recommendations for local and provincial action.