- Inductions in asymptomatic patients should not be rescheduled unless extreme healthcare system burden.
- Induction can be conducted as usual (Foley catheter and misoprostol or oxytocin infusion)
- Foley ripening can be done in an outpatient setting in low risk pregnancies.
- Hospital births are preferred to homebirths when infection status is positive or unknown.
- Universal nasopharyngeal testing for all parturients admitted may be beneficial to guide infection control practices because many are asymptomatic on admission.
- Timing of delivery should be individualized in infected pregnancies. Obstetric indications come first regardless of infection status. In the absence of these indications, early delivery is to be considered if the infection is refractory to treatment or severe/critical in order to improve maternal oxygenation. It is not yet known if a mild/common infection justifies early delivery in the third trimester. It may be advised because the course of the infection tends to worsen in the second week.
- The delivery method is based on obstetrical indications.
- Vaginal delivery is not contraindicated in suspected or confirmed cases.
- Indications for Caesarean should be more permissive particularly in a setting of prolonged latent phase to shorten in-patient stays and reduce exposure to medical workers and other patients among other reasons. However, emergency Caesarean section is to be avoided as much as possible to minimize usage of general anesthesia.
- Periodic evaluation of maternal and fetal health is necessary to assess the risks of prolonged labour versus those of Caesarean delivery (Vital signs, pulse oximetry ≥ 95%, input/output).
- In cases of hypoxia or increasing O2 needs, arterial blood gas and clinical evaluations will determine subsequent care and the necessity of mechanical ventilation. Early intubation is recommended to avoid emergent situations.
- Consultation with a multidisciplinary team is important for fetal assessment and delivery ensuing mechanical ventilation.
First stage of labour
- Earlier amniotomy and oxytocin are recommended for slow labour.
- Oxygen therapy is not recommended for fetal resuscitation, regardless of patient’s COVID-19 status. Recent meta-analysis has demonstrated that intrapartum oxygen has no fetal benefit and may cause harm. Handling of such equipment is at higher risk of contamination/exposure between patient and provider.
- Use of nitrous oxide is a procedure that involves risk of aerosolization; some recommend eliminating nitrous oxide use during COVID-19 pandemic.
Second stage of labour
- Deliveries should be performed in a negative pressure isolation ward by minimal medical staff practicing rigorous protection measures. Patient transfers should be organized to reduce spread of infection.
- Though not recognized as an aerosol generating procedure, there may be indication for N95 respirators given the contact with patients who are often exhaling hard.
- Operative vaginal delivery to expedite the second stage of labour may be considered.
Third stage of labour
- There are concerns regarding resources for blood transfusion. Precautions should be taken to limit the need for blood transfusions.
- In addition to standard oxytocin, consideration should be made for prophylactic tranexamic acid and misoprostol.
- Recommendations are inconsistent regarding delayed cord clamping and skin-to-skin contact.
- Newborns should be tested at birth no matter the gestational age at which the infection occurred.
- Triple biohazard bags should be used for the placenta. Placenta should be disposed in the OR in cases of Caesarean section.
Ashokka et al. provide recommendations and algorithms on various aspects of obstetric care including labour and delivery. Bauer et al. emit recommendations and expert opinions on obstetric themes such as monitoring during labour. Boelig et al. wrote an expert review regarding various steps of the labour and delivery process. Elwood et al. (Infectious Disease Committee SOGC) wrote an opinion providing recommendations for antepartum, intrapartum and postpartum care. Palatnik et al. explain their stance on the use of N-95 masks among labour and delivery personnel in a short communication article. Poon et al. issued recommendations on several aspects regarding the care of infected pregnant women from the International Federation of Gynecology and Obstetrics (FIGO) and other organizations. Sutton et al. explain, in a letter to the editor, that universal testing of parturients may be beneficial based on a study of 215 pregnant women who delivered between March 22, 2020 and April 4, 2020 in two different New York hospitals. The results showed that 87.9% of the COVID-19 parturients were asymptomatic on admission. Qi et al provided a consensus of experienced obstetricians in Wuhan, China who have managed deliveries in pregnant women with confirmed or suspected COVID-19.
Ashokka B., Loh M-H., Tan C.H. Et al. (April 10, 2020). Care of the Pregnant Woman with COVID-10 in Labor and Delivery: Anesthesia, Emergency cesarean delivery, Differential diagnosis in the acutely ill parturient, Care of the newborn, and Protection of the healthcare personnel. American Journal of Obstetrics and Gynecology. https://doi.org/10.1016/j.ajog.2020.04.005
Boelig R.C., Manuck T., Oliver E.A. et al. (March 25, 2020). Labor and Delivery Guidance for COVID-19. American Journal of Obstetrics and Gynecology MFM https://doi.org/10.1016/j.ajogmf.2020.100110
Elwood C., Boucoiran I., VanSchalkwyk J. et al. (April 2, 2020). Updated SOGC Committee Opinion – COVID-19 in Pregnancy. Retrieved from: https://www.sogc.org/en/content/featured-news/Updated-SOGC-Committee-Opinion__COVID-19-in-Pregnancy.aspx
Palatnik, A., McIntosh J.J. (April 10, 2020). Protecting Labor and Delivery Personnel from COVID-19 during the Second Stage of Labor. American Journal of Perinatology. https://doi.org/10.1055/s-0040-1709689
Poon L.C., Yang H., Kapur A. et al. (April 4, 2020). Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: Information for healthcare professionals. International Journal of Gynecology & Obstetrics. https://doi.org/10.1002/ijgo.13156
Sutton D., Fuchs K., D’Alton M, Goffman D. (April 13, 2020). Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. The New England Journal of Medicine. https://doi.org/10.1056/NEJMc2009316