2. Experimental Section
- Prenatal and antepartum care (See Table 2): Reviewed guidelines support some form of screening of pregnant patients depending on symptoms and exposure, use of telehealth is encouraged for prenatal visits, while limiting face to face visits and ultrasounds only to those that are medically necessary. Prenatal appointments, lab work, and ultrasounds should be scheduled on the same day if possible. All ultrasound equipment and patient rooms should be appropriately cleaned after each use. The use of antenatal corticosteroids for fetal lung maturation can be continued till 34 weeks gestation, but the use of steroids in the late preterm period, >34 0/7 weeks gestation remains controversial.
- Intrapartum care (See Table 3): Reviewed guidelines recommend a designated area within the unit to care for SARS-CoV-2 positive pregnant patients or Person under investigation (PUI). Timing and mode of delivery should follow routine obstetric indications. Cesarean section (CS) should be reserved for obstetric indications only; infection with SARS-CoV-2 is not an indication for cesarean delivery unless there is acute decompensation of mother or fetus. Only one consistent asymptomatic support person is allowed to be present at time of delivery. Patients and healthcare workers should be appropriately gowned, gloved, and have protective face masks; specifically, N95 should be used for aerosol generating procedures such as forceful expiration during pushing, use of oxygen for intrauterine resuscitation, or intubation. Use of operative delivery to shorten the second stage of labor can be considered for routine obstetric indications. There is no contraindication to regional or general anesthesia if indicated, but appropriate personal protective equipment (PPE) use is encouraged.
- Postpartum care (See Table 4): Reviewed guidelines encourage early discharge from the hospital, one day for vaginal delivery and two days for cesarean delivery. This limits face to face exposure and increases bed availability. Separation of mother and baby or discouraging breastfeeding are not advised, unless the mother is acutely ill. However, mothers are encouraged to (1) practice respiratory hygiene during feeding, (2) wear a mask, (3) wash hands before and after touching the baby, and (4) routinely clean and disinfect surfaces they have touched. If breastpumping is used, all equipment should be cleaned thoroughly before and after each use. Postpartum visits should be performed over telehealth, unless face to face visit is essential to management.
Conflicts of Interest
- Director-General’s opening remarks at the media briefing on COVID-19. Available online: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19 (accessed on 11 March 2020).
- Boelig, R.C.; Manuck, T.; Oliver, E.A.; Di Mascio, D.; Saccone, G.; Bellussi, F.; Berghella, V. Labor and Delivery Guidance for COVID-19. Am. J. Obstet. Gynecol. MFM 2020. [Google Scholar] [CrossRef]
- Boelig, R.C.; Saccone, G.; Bellussi, F.; Berghella, V. MFM Guidance for COVID-19. Am. J. Obstet. Gynecol. 2020. [Google Scholar] [CrossRef] [PubMed]
- Coronavirus COVID-19, a practice advisory. Available online: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019 (accessed on 11 March 2020).
- COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics. Available online: https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics (accessed on 11 March 2020).
- Coronavirus (COVID-19) infection in pregnancy: Information for healthcare professionals. Available online: https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdf (accessed on 11 March 2020).
- Poon, L.C.; Yang, H.; Lee, J.C.S.; Copel, J.A.; Leung, T.Y.; Zhang, Y.; Chen, D.; Prefumo, F. ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: Information for healthcare professionals. Ultrasound Obstet. Gynecol. 2020. [Google Scholar] [CrossRef] [PubMed]
- Pregnany and Breastfeeding. Available online: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html (accessed on 11 March 2020).
- Information for Healthcare Providers: COVID-19 and Pregnant Women. Available online: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pregnant-women-faq.html (accessed on 11 March 2020).
- Q&A on COVID-19, pregnancy, childbirth and breastfeeding. Available online: https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-pregnancy-childbirth-and-breastfeeding (accessed on 11 March 2020).
- Peyronnet, V.; Sibiude, J.; Deruelle, P.; Huissoud, C.; Lescure, X.; Lucet, J.C.; Mandelbrot, L.; Nisand, I.; Vayssière, C.; Yazpandanah, Y.; et al. Infection par le SARS-CoV-2 chez les femmes enceintes: État des connaissances et proposition de prise en charge par CNGOF. Gynécologie Obs. Fertil. Sénologie 2020, 48, 436–443. [Google Scholar] [CrossRef] [PubMed]
- ISS, Rational use of individual protection devices in the assistance of Covid-19 patients. Available online: https://www.iss.it/coronavirus (accessed on 11 March 2020).
- Guia d’actuació enfront de casos d’infecció pel nou coronavirus SARS-CoV-2 en dones embarassades i nadons. Available online: https://canalsalut.gencat.cat/web/.content/_A-Z/C/coronavirus-2019-ncov/material-divulgatiu/guia-actuacio-embarassades.pdf (accessed on 11 March 2020).
- Salut, C. Informació per a professionals. Available online: https://canalsalut.gencat.cat/ca/salut-a-z/c/coronavirus-2019-ncov/professionals/consulta/?cat=8460bdf4-691a-11ea-88fa-005056924a59&submit=true (accessed on 18 May 2020).
|Journal/Website||Professional Society/Institution||Publication Title||Publication Date|
|Superior Institute of Health||Educational course on Health Emergency on novel Coronavirus||28 February 2020|
|ISUOG (International Society)||ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals||12 March 2020|
|ACOG (United States)||Novel Coronavirus 2019- Practice advisory||13 March 2020|
|CDC (United States)||Information for Healthcare Providers: COVID-19 and Pregnant women||16 March 2020|
|WHO (International Society)||Q&A on COVID-19, pregnancy, childbirth, and breastfeeding||18 March 2020|
|SMFM (United States)||MFM Guidance for COVID-19||19 March 2020|
|CNGOF (France)||SARS-CoV-2 infection during pregnancy. Information and proposal of management care. CNGOF||19 March 2020|
|CatSalut (Barcelona)||SARS-CoV-2 coronavirus infection|
Information for pregnant women and their families.
|20 March 2020|
|ACOG (United States)||COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics||23 March 2020|
|SMFM (United States)||Labor and Delivery Guidance for COVID-19||25 March 2020|
|Superior Institute of Health (Italy)||Rational use of individual protection devices in the assistance of Covid-19 patients||28 March 2020|
|Italian Society for Ultrasound in Obstetrics and Gynecology (Italy)||SARS-Cov-2 Pandemic: Information and Recommendation||29 March 2020|
|CDC (United States)||COVID-19: Pregnancy and breastfeeding||3 April 2020|
|CatSalut (Barcelona)||Clinical guideline for new cases of SARS-CoV-2 coronavirus infection in pregnant women and infants||6 April 2020|
|RCOG (United Kingdom)||COVID-19 infection in pregnancy||17 April 2020|
|PRENATAL CARE AND ANTEPARTUM||Infection|
|Set up triage screening area. All outpatients should be assessed and screened for TOCC and symptoms. All HCW should wear appropriate PPE. All suspected cases should be screened with qRT-PCR. Repeat testing in 24 hr if negative, but still high suspicion. Chest CT should be considered, if high suspicion||Set up triage screening area|
Patients should be provided with a surgical mask at the entrance (and is not to be removed until the patient is isolated in a suitable room). All outpatients should be assessed and screened for TOCC and symptoms. All HCW should wear appropriate PPE. All suspected cases should be screened with qRT-PCR. Symptomatic patients should be treated as positive till results are back
Patients with suspected COVID-19 who present with obstetric emergency should be transferred immediately to an isolation room by HCW using appropriate PPE. Obstetric management should not be delayed for COVID-19 testing
|Routine screening before appointment, if suspicious. If symptomatic, initiate testing and notify health department, mark patient as PUI. Screening algorithm https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/clinical-guidance/practice-advisory/covid-19-algorithm.pdf. All HCW should wear PPE (Face mask, Eye protection, gloves, and gown)||Triage symptomatic patients via telehealth. Test anyone with new flu-like symptoms, especially older, immune-compromised, advanced HIV, homeless, hemodialysis. Utilize drive through or standalone testing area. Symptomatic patients should be treated as positive till results are back||Patients should be provided with a surgical mask at the entrance (and is not to be removed until the patient is isolated in a suitable room). Screen all patients presenting to maternity unit. Patients who meet criteria (see guideline for details) for potential COVID-19should have a full blood count evaluation; if lymphopenia is identified, COVID-19 testing should be arranged. Patients with suspected COVID-19 who present with obstetric emergency should be transferred immediately to an isolation room by HCW using appropriate PPE. Obstetric management should not be delayed for COVID-19 testing|
Symptomatic patients should be treated as positive till results are back
|-Testing protocols and eligibility vary depending on where you live. Symptomatic and high risk patients should get screening priority. HCW should maintain hand hygiene, and appropriate use of protective clothing like gloves, gown, and medical mask.||Same as general population||Women are asked to phone prior to antenatal visit. All women should take preventive measures when attending health care settings. Screen women with symptoms presenting to antenatal clinic. Symptomatic patients should be treated as positive till negative results are back||Telephone triage. Screen with symptoms|
Asymptomatic mothers: respect hygiene measures, social distancing. PPE not required. Symptomatic mothers: individual PPE required for mothers and HCW. Symptomatic mothers are tested for SARS-CoV-2 using nasopharyngeal swabs and isolation in a dedicated room. Public Hygiene Service should be informed.
|Place of care||Negative pressure or single isolation rooms in tertiary care center. Reserve ICU for critical patients||Isolation room for patients with suspected/confirmed COVID-19 for whom care cannot be safely delayed for self-isolation||N/A||Designated COVID-19 area within the facility||Isolation room for patients with suspected/confirmed COVID-19 for whom care cannot be safely delayed for self-isolation||−N/A||Same as general population||Same as general population.|
If hospital admission is needed, women are referred to one reference hospital in the Region
|Asymptomatic: delivery at General Hospitals. Stable symptomatic mothers delivery at General hospital with designated area within the facility. Delivery in isolated room. Mothers, medical staff and a single accompanying person must wear PPE. Room ventilation at least with 60 L/s. Mothers & babies are kept in isolated room. Unstable symptomatic mothers delivery at tertiary care center with ICU facilities|
|Prenatal appointment||Postpone by 14 days if positive or until 2 negative results||Elective and non-urgent appointments should be postponed or completed by telehealth. Encourage use of telehealth for all visits–HCW meetings should all be virtual/audio. Keep some providers at home. No support persona at outpatient visit||If, after screening, the patient reports symptoms of or exposure to a person with COVID-19, that patient should be instructed not to come to the health care facility for their appointment and health care clinicians should contact the local or state health department to report the patient as a possible person under investigation (PUI)||Elective and non-urgent appointments should be postponed or completed by telehealth. Encourage use of telehealth for all visits. HCW meetings should all be virtual/audio. Keep some providers at home. No support persona at outpatient visit. Labs and US at the same appointment. Provide patient with ambulatory BP cuff/machine. F2F visits at 11-13,20,28,36 weeks and weekly after 37 weeks||-Routine appointments for women with suspected/confirmed COVID 19 should be delayed until after the recommender period of self-isolation. For symptomatic patients, defer appointments until 7 days after symptom onset; defer appointments for 14 days for patients with symptomatic household contacts. Encourage the use of telephone for non-urgent consultation/enquiries||N/A||N/A||Encourage use of telehealth for all visits||Routine antenatal care appointment monthly for asymptomatic mothers. Planned visit @ at maternity unit at 37-38 weeks and then at 40 weeks, if physiologic pregnancy. Symptomatic mothers: delay appointments for several days according to symptoms, recommend GP consultation and keep telephone contacts|
|Ultrasound frequency||Suspected, asymptomatic confirmed and recovering patients: US q 2–4 weeks for Fetal growth and AFI, UA dopplers if indicated||Continue US as medically indicated when possible.||Continue US as medically indicated when possible. Elective US should not be performed. Postpone or cancel testing or examinations if the risk of exposure and infection within the community outweighs the benefit of testing.||Combine dating and NT in 1st trimester. Anatomy scan at 20–22 weeks. Consider stopping serial CL after anatomy|
US if TVUS CL ≥35 mm, prior preterm birth at >34 Weeks. BMI >40: schedule at 22 weeks to reduce risk of suboptimal
views/need for follow up. Single growth F/U at 32 weeks. Low lying placenta F/U 34–36 wks. Refer to primary publication for disease specific US frequency
|In addition to routine ultrasound surveillance, fetal growth restriction surveillance is recommended 14 days after resolution of acute illness due to theoretical risk of growth restriction.||N/A||N/A||Continue US as medically indicated when possible||Asymptomatic mothers: continue US assessment as routine. Symptomatic mothers: following 14 days of isolations and resolution of symptoms, general clinical examination and ultrasound assessment for fetal growth every 3–4 weeks|
|Ultrasound Equipment/patient rooms||Must be cleaned with disinfectant per manufacturer guidelines after EVERY use|
Deep clean of all instruments and room in case of positive patient
|Must be cleaned with disinfectant per manufacturer guidelines after EVERY use||N/A||Wipe down patient rooms after every visit of suspected SARS-COV-2 patients||-Decontaminate after use on suspected or confirmed SARS-CoV-2 patients||N/A||N/A||Deep clean of all instruments and room in case of positive patient||Deep clean of all instruments and room ventilation every 10 min|
|Avoid in critically ill patient; risk of worsening disease||Should continue if <34 weeks, even if tested positive for SARS-CoV-2||Should continue if <34 weeks, even if tested positive for COVID-19|
Controversial for 34 0/7–36 6/7 Weeks
Other modifications should be individualized
|Judicious use <34 weeks|
Avoid >34 weeks
|Administer for routine indications|
No evidence to suggest harm in the context of SARS-CoV-2 infection
|N/A||N/A||Administer for routine indications||N/A|
|GBS screening||Delay by 14days in patients with TOCC risk factors||As indicated between, 36 0/7–37 6/7 weeks gestation.||As indicated between, 36 0/7–37 6/7 weeks gestation.|
Patients can self-collect with proper instructions if the resources and infrastructure allow
|Routine screening at 36wks||N/A||−N/A||N/A||Routine screening||Routine screening|
|Antenatal surveillance (BPP, NST)||N/A||Daily NST if patient hospitalized||Reserve for medically indicated screening|
During acute illness, fetal management should be similar to that provided to any ill pregnant person.
|Limit NSTs if <32 wks|
Twice weekly NST only for FGR with abnormal UA Doppler studies
If patient needs US, perform BPP instead of NST
Kick counts instead of NST for low risk patients
|INTRAPARTUM CARE||Pre-Delivery preparation||Social distancing||Social distancing||Obstetric, pediatric or family medicine, and anesthesia teams should be notified in order to facilitate care.||Social distancing and off work for 2 weeks prior to anticipated delivery (start at ~37wks). Screen patient and partner on phone day before admission. Institution should run simulations||Minimum staffing and social distancing. Screen patient and partner at maternity unit. Partners with symptoms less than 7 days prior should be instructed to self-isolate and not be allowed into the maternity unit. Women with suspected or confirmed COVID19 should be encouraged to remain at home during early labor; women in active labor should be admitted to an isolation room. Dry run simulations for elective/emergency procedures||If COVID19 is suspected or confirmed, health workers should take all appropriate precautions to reduce risks of infection to themselves and others, including hand hygiene, and appropriate use of protective clothing like gloves, gown and medical mask.||N/A||Screen women with symptoms at maternity unit|
Respectful care must be always considered
minimum number of professionals attending women. Only one partner allowed for companionship during labor and delivery.
|Screen women with symptoms at maternity unit. Asymptomatic: as per routine care. Stable Symptomatic patients admit to hospital. Unstable symptomatic patients: refer to hospitals with ICU facility|
|Delivery Time||Based on routine obstetric indications|
Early delivery should be considered for critically ill patients
|If infection in early pregnancy with recovery, No alterations in delivery time.|
Based on routine obstetric indications
Early delivery should be considered for critically ill patients
|If infection in early pregnancy with recovery, No alterations in delivery time.|
If infection in late pregnancy and recovery, postpone delivery (if no other medical indications arise) until a negative testing result is obtained or quarantine status is lifted in an attempt to avoid transmission to the neonate.
COVID-19 is not an indication of delivery.
|Based on routine indications. No contraindication to induction of labor unless beds are limited. For term COVID-19 patients, consider delivery because symptoms peak in 1–2 weeks after onset||Based on routine indications||N/A||N/A||PPE in all cases. Continuous fetal electronic monitoring.||Per routine Obstetric indications|
|Delivery location||Designated negative pressure isolation room||Designated isolation room, for suspected or confirmed cases of COVID-19||N/A||Designated delivery and operating rooms||Designated isolation room, for suspected or confirmed cases||N/A||N/A||Designed isolation room for suspected or confirmed cases of COVID-19. Designed negative pressure isolation room for CS||Designated isolated room for suspected or confirmed cases|
|Mode of Delivery||Based on routine obstetric indications|
Infection is NOT an indication for CS. Expedite delivery by CS in setting of fetal distress or maternal deterioration. Water birth should be avoided
|Based on routine obstetric indications|
Infection is NOT an indication for CS. Expedite delivery by CS in setting of fetal distress or maternal deterioration
|Per routine obstetric indications.|
No specific recommendations for CS. Operative vaginal delivery is not indicated for suspected or confirmed cases alone, but can be used as routinely indicated
|Based on routine obstetric indications. Infection is NOT an indication for CS||Based on routine obstetric indications unless maternal respiratory condition demands early delivery. Water birth should be avoided.||As clinically indicated||N/A||Based on routine obstetric indications. Infection is not an indication for CS||Routine obstetric indications. Infection is not an indication for CS|
|Support person||Limit visitors, no clear number specified||No visitor||Allowed one consistent asymptomatic support person||Allowed one consistent support person. No children <16–18 y/o||Allowed one consistent asymptomatic support person who should be restricted to the patient’s bedside.||N/A||N/A||Companionship by one person relative to the women is encouraged during all the labor and delivery||Single accompanying asymptomatic person|
|Obstetric Analgesia and Anesthesia||Regional anesthesia and GA can be considered||Regional anesthesia and GA can be considered||N/A||Avoid use of nitrous oxide||NO evidence against regional or GA. Epidural analgesia is recommended in suspected or confirmed cases, to minimize the need for GA if urgent delivery is needed.||N/A||N/A||Epidural analgesia is recommended to women with suspected or confirmed COVID-19 to minimize the need for GA if urgent delivery is needed.||Regional and GA can be considered|
|Second Stage of Labor||Consider shortening with operative delivery to minimize aerosolization and maternal respiratory effort||N/A||N/A||Do not delay pushing. Considered aerosolizing, N95 should be worn by HCW and patients||Consider shortening with operative vaginal delivery in symptomatic women who become exhausted or hypoxic||N/A||N/A||N/A||N/A|
|Third stage of Labor||N/A||N/A||Active management to reduce blood loss (national blood shortage)||N/A||N/A||N/A||Active management in all cases||Per routine|
|Oxygen supplementation||N/A||N/A||N/A||Considered aerosolizing, HCW must wear appropriate PPE. Do not use O2 for intrauterine resuscitation||Hourly O2 sat measurements (in addition to routine maternal-fetal observations) for women with suspected/confirmed COVID-19. Aim to keep o2 sat >94%, titrating O2 therapy accordingly.||N/A||N/A||N/A||N/A|
|Umbilical cord clamping||Avoid delayed cord clamping in confirmed and suspected cases||N/A||No recommendations against delayed clamping of Umbilical cord.||Avoid delayed cord clamping||Delayed cord clamping is still recommended in the absence of contraindications||N/A||N/A||Delayed cord clamping is still recommended in the absence of contraindications||General rule|
|PPE use||N/A||N/A||Asymptomatic or negative patients Patient and provider wear surgical mask. Aerosolizing procedures-N95 for patient and N95, gown, gloves, face shield for provider||Level of PPE should be based on the risk of requiring GA.|
Aerosolizing procedures-use FFP3 mask
|N/A||Same as general population||N/A||Symptomatic with stable or unstable condition: Mothers, medical staff and accompanying person must wear all protection devices. Masks should be FFP2/FFP3 type.|
|Elective Cesarean delivery/induction of labor (IOL)||N/A||N/A||No contraindication to IOL unless there is limited beds||For suspected/confirmed cases, consider delay of elective CD or IOL if safely feasible to||N/A||N/A||N/A||N/A|
|POSTPARTUM CARE||Placental or fetal tissue||Should be handled as infectious tissue in positive patients|
Consider qRT-PCR on placenta
|Length of stay||N/A||N/A||Expedited discharge should be considered.|
|Expedited discharge should be considered.|
|N/A||N/A||Same as general population||Expedited discharge should be considered||Asymptomatic→2 days|
Okay for asymptomatic patients, mothers should use masks and wash hands
Separation and breast pumping suggested in critically ill patients
|Limited evidence to advise against breastfeeding. Advise patients to: wash hands before handling baby, touching pumps or bottle; avoid coughing while baby is feeding; consider wearing face mask while feeding or handling baby;||N/A||Advice patients to: wash hands before handling baby, touching pumps or bottle; avoid coughing while baby is feeding; consider wearing face mask while feeding or handling baby; if breast pump us used, clean properly after each use; consider asking someone who is well to feed baby.||No contradictions|
Advice patients to: wash hands before handling baby, touching pumps or bottle; avoid coughing while baby is feeding; consider wearing face mask while feeding or handling baby; if breast pump us used, clean properly after each use; consider asking someone who is well to feed baby.
|Women with COVID-19 can breastfeed if they wish to do so.|
(1) Practice respiratory hygiene during feeding
(2) wear a mask
(3) Wash hands before and after touching the baby
(4) Routinely clean and disinfect surfaces they have touched.
|During separation encourage dedicated breast pump. Mother should use a facemask and practice hand hygiene after each feeding|| Encourage breastfeeding support|
(1) Practice respiratory hygiene during breastfeeding.
(2) wear a mask
(3) hands and tissues hygiene before and after breastfeeding
| Encourage breastfeeding support. Symptomatic:|
(1) hands and tissue hygiene
(2) wear a surgical mask
|Skin to skin||Can be considered with appropriate PPE use for asymptomatic patients||N/A||N/A||N/A||Routine precautionary separation of a healthy baby and mother is not advised at this point.|| Allow with precautions and good hygiene|
|N/A||Individualize according to the conditions of the mother and the baby||N/A|
|Postpartum pain control||N/A||N/A||N/A||No contraindication to NSAID use||N/A||N/A||N/A||N/A||N/A|
|Postpartum visit||N/A||Encourage telehealth for postpartum visit||Encourage telehealth for postpartum visit. Delay comprehensive face to face postpartum visit to 12 weeks. Use telehealth before 12 weeks.||Encourage telehealth for postpartum visit||Encourage telehealth for postpartum visit||N/A||N/A||Stay at home policy and encourage of telehealth postpartum visits|
home visit by health professional (midwife) between 48–72 h after discharge
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