Since December 2019, the Severe Acute Respiratory Syndrome Coronavirus
2(SARS-CoV-2)has swept 200 countries and regions
worldwide1 and has become a ”Public Health Emergency
of International Concern” (PHEIC). Pregnant women are susceptible to
COVID-19 due to the changes in their physiology and the adaptability of
their immune system2. During the outbreak of COVID-19,
prenatal examinations may be postponed, however, delivery cannot be
delayed, and the delivery room should work as usual. During this period,
it is particularly important to quickly identify high-risk groups and to
provide appropriate protection for childbirth and the puerperium. In
accord with experience in China (Guidelines for the Prevention and
Control of New Coronavirus Infections in Medical Institutions issued by
the National Health Commission ), we strongly recommend that during the
outbreak of COVID-19, all medical institutions should
conduct
graded,
staged,
comprehensive and continuous training of all staff, based on the
particular epidemic prevention and control needs of for of different
positions, to constantly improve
staff’s
awareness of the prevention and control of COVID-19. To strengthen staff
comprehension of the necessary precautions during a COVID-19 epidemic,
an assessment method that combines theory with scenario testing should
also be applied 3,4. At the same time, based on our
experience of delivery room management, we recommend a delivery room
processing flow (Fig.1) and graded protection 5 (Table
1) for pregnant women with different infection risks,as detailed below:
(1) Primary screening of all
women
(First level protective equipment should be applied): Check the axillary
temperature and the fetal heart rate, and enquire whether there is
fever, respiratory symptoms (cough, chest tightness, etc.),
gastrointestinal symptoms (vomiting, diarrhea, etc.) and other symptoms
before allowing women to sit in the maternity waiting area. Ask whether
there is increased risk of contact with a COVID-19 positive patient
(fever of any family member within two weeks, a history of traveling to
the epidemic area or contact with a suspected or confirmed patient). Any
positive history of the above indicates ‘potential risk’ status.
(2) Pregnant women with potential-risk and/or suspected infection merit
further screening (Second level protective equipment should be applied):
attending staff should immediately apply second or third level of
protective equipment, screening tests (which include respiratory
pathogens tests like adenovirus, respiratory syncytial virus, influenza
A virus, influenza B virus and parainfluenza virus, Mycoplasma
pneumoniae and Chlamydia pneumoniae, blood routine tests, and C-reactive
protein) should be undertaken and the new coronavirus nucleic acid test
for pregnant women with potential-risk/suspected infection should be
performed. A chest CT scan with informed consent to observe the lungs
should be performed if signs or symptoms provide any indication (inform
the patients about the necessity of chest CT and ask them to cover their
abdomen properly). Obstetric management should not be delayed by testing
for COVID-19.
(3) Delivery room management (for vaginal delivery): ① Pregnant women
suspected to be COVID-19 positive should be immediately transferred to
an isolated delivery room (avoiding contact with other patients) or
negative pressure delivery room and be required to wear surgical
mask6. Accompanying family must not be permitted.
Patients should be managed by
specific experienced senior medical
specialists, and third level protective equipment must be applied to
avoid cross-infection; ② pregnant women at potential risk of infection:
Accompanying family should not be allowed. Patients are recommended to
wear surgical masks6 and should be transferred to
isolated delivery rooms, with management/supervision by specific
experienced senior medical specialists. Second level protective
equipment should be applied to prevent cross-infection, if availability
of protective materials is adequate. ③ low-risk pregnant women (those
without any history of epidemiological exposure or clinical symptoms)
should be transferred to an ordinary delivery room for delivery
(avoiding contact with other patients). Second level protective
equipment should be applied. It is recommended that these women wear
disposable medical masks 6. Only family members who
have no history of epidemiological contact and clinical symptoms within
the past 2 weeks are allowed to attend the childbirth, and accompanying
family members are also required to wear disposable medical masks.
As fetal compromise is relatively common in pregnancies complicated by
COVID-19 infection, continuous electronic fetal monitoring in labor is
recommended for all women suspected with COVID-19, following transfer to
the appropriate delivery room.7
We advocate attempts to deliver vaginally without undue obstetric
intervention and recommend caution regarding procedures such as
episiotomy and ventouse/forceps delivery. Currently, we do not recommend
water deliveries for pregnant women with suspected infection. There is
no evidence that epidural analgesia or spinal anesthesia is
contraindicated, therefore, epidural analgesia should be recommended to
pregnant women suspected of COVID-19 infection before or in early labor
to minimize the need for general anesthesia in emergency situations7.
(4) Emergency caesarean section treatment:Suspected COVID-19 infection
is not an indication for cesarean section, unless the woman’s
respiratory condition demands urgent delivery, or pregnant women have
other indications. Multi-disciplinary consultation involving
anaesthetists, neonatologists, obstetricians, and infectious disease
physicians is required before deciding to deliver prematurely in cases
of suspected infection, and if Caesarean section is indicated, the
procedure should be performed in a negative pressure isolation operating
room (third level protective equipment should be applied). The choice of
anesthetic mode is determined by the anaesthetist, based on the
patient’s respiratory function. For pregnant women with potential
infection (potential-risk), their pregnancy can be terminated in the
isolated operating room (second level protective equipment should be
applied) if properly protected. First level protective equipment is
recommended when performing cesarean section for pregnant women with
low-risk infection.
(5) Postpartum management: postpartum vital signs, uterine contractions,
maternal mental health and other conditions of the mother should be
monitored, and attention paid to the prevention of postpartum
hemorrhage, thrombosis, etc. For pregnant women with suspected
infection, the neonatologist should be notified at least half an hour
before delivery to take appropriate measures to isolate the newborn.
Delayed cord clamping is still recommended given a lack of evidence to
the contrary, unless there are other contraindications7. 14 days of isolation for newborns is recommended8; there is currently no evidence to support the
suspension of breastfeeding in pregnant women with suspected infection,
indeed, we advocate breastfeeding, as the wider benefits outweigh the
potential risks of transmission through breastmilk 7.
Isolation and preventive measures should be undertaken if referral is
needed 5. If there are no abnormal signs/symptoms
within two hours after delivery, mothers with suspected infection can be
transferred to an isolation ward for further observation;
‘potential-risk’ pregnant women can be transferred to the isolation ward
(avoiding contact with other patients) and low-risk mothers managed
according to conventional procedures. Pregnant woman with suspected or
potential infection should undergo diagnostic testing immediately. If
infection is confirmed, the corresponding management should follow the
previous guidelines for dealing with confirmed cases of COVID-192.
(6) After-delivery protection procedures: After the mother was
transferred to the ward, routine cleaning should be undertaken. The
surfaces of the equipment (including the obstetric table, ultrasound
machine, and neonatal warm bed) in the isolation delivery room and the
negative-pressure delivery room need to be wiped and disinfected
immediately, preferably with 1000 mg/L chlorine-containing disinfectant;
75% ethanol can be used for the non-corrosion resistance instruments7,9. Spraying is not a recommended method of
disinfecting the equipment as this can affect the components. Dedicated
cleaning tools are required to avoid cross contamination. The inspection
room should be disinfected with ultraviolet light, ≥60 min each time,
once or twice a day, with at least 30 min ventilation after irradiation.
The ultrasound probe should be protected with a dark cloth during the
irradiation. The room should be vacated when ultraviolet lamps are used.
(7) Medical waste disposal: Protective supplies used by medical
personnel and all patient waste should be regarded as infectious medical
waste, which requires double-layer sealing, clear labeling, and airtight
transport 10. If testing of the placenta and/or
amniotic fluid is required, strict sampling and sealing should be
carried out to avoid contamination of the surface of the container and
the spread of infection. The surface of the container should be
disinfected before sample inspection to further avoid infection of any
personnel.