Influence of COVID-19 on Delivery and Inpatient Postpartum Care

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Because data are sparse, the care of SARS-CoV-2 infected pregnant women and their newborns is predominantly guided by society recommendations and expert opinion. To summarize current practices, Anjali J. Kaimal, MD, MAS, director of the Deborah Kelly Center for Clinical Research, Ilona Goldfarb, MD, maternal-fetal medicine specialist, Lauren Hanley, MD, medical director of the Lactation Clinic in the Massachusetts General Hospital Department of Obstetrics and Gynecology, and Megan Aurora, MD, associate medical director of the Neonatal Intensive Care Unit at MassGeneral Hospital for Children, posted a fast literature update on May 16, 2020.

Severe COVID-19 and Delivery

The team suggests that the timing of delivery should be determined by maternal disease course and trajectory, and maternal safety, as well as the usual obstetric indications. If COVID-19 is not improved by treatment (time, medications, other supportive measures), then delivery may be considered even in the absence of obstetric indications. Although controversial, a short course of antenatal corticosteroids for fetal benefit may be considered if delivery prior to 34 weeks' gestation is anticipated. There is no specific indication for cesarean delivery, so decisions on delivery mode should be based on standard obstetric indications.

Transmission

To date, there is no definitive evidence for the transmission of SARS-CoV-2 across the placenta. However, one study detected the virus in the blood and stool of infected women, which infants are often exposed to during delivery.

The American Academy of Pediatrics (AAP) recommends routine SARS-CoV-2 testing of infants born to infected mothers at 24 hours of life and at 48 hours if still inpatient.

Mother and Newborn Location

The AAP and CDC state that separation of mothers and newborns is the best way to ensure the infant is protected from infection. However, case reports have described infants acquiring SARS-CoV-2 despite full separation from their infected mothers.

If no SARS-CoV-2–negative, non-exposed adult is available to care for the infant full-time after discharge, separation from the mother while inpatient is discouraged. Among other reasons, molecular testing of the mother often remains positive for several weeks, and timing of reunification is difficult to determine even in the absence of symptoms.

The AAP/CDC provide guidelines on alternative methods of decreasing the risk of infection, including distancing within the room, mask-wearing and physical barriers such as drapes and isolettes. An infant requiring more than level 1 (routine newborn) care should be admitted to a single room (preferably negative pressure if receiving aerosol-generating procedures) on enhanced respiratory precautions until cleared through molecular testing.

Breastfeeding

No data suggest SARS-CoV-2 infection should influence a mother's decision about feeding strategy. Breastmilk is the healthiest form of nutrition for almost all infants and there are very few contraindications. Thus far, in peer-reviewed, published studies, all breastmilk samples tested via PCR for the presence of the virus have been negative. There is, therefore, general agreement that the breastmilk itself is not a vector of transmission. However, respiratory droplets remain the main concern and thus it is recommended that women who directly breastfeed or express milk from a pump use hand and respiratory hygiene while doing so to prevent the spread of the virus via droplets.

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