INTRA-PARTUM CARE OF WOMEN WITH COVID-19 INFECTION
COVID-19 itself is not an indication for delivery.19However, the advice for the timing of delivery and the intra-partum care of women with COVID-19 infection should be determined by their clinical status.19 RCOG recommend that if the symptoms are mild then standard practice guidelines prevail regarding the management of the latent phase of labour at home.7
In the existing literature, the caesarean section rate in pregnant women with COVID-19 infection is between 69.4 and 91 percent.10, 11, 13, 20 The indications, where reported, are mostly due to maternal condition, premature rupture of membranes, preeclampsia, fetal distress or unknown risk of intra-partum vertical transmission with vaginal delivery.10, 13, 20Despite this, all guidelines agree that vaginal delivery is not contra-indicated in women with COVID-19 infection and that caesarean section should only be performed for the usual indications.7-9 ISUOG and FIGO state that there should be a lower threshold for expediting delivery because of the risk of fetal distress and deterioration in maternal condition.8, 9
Continuous fetal monitoring is recommended by all clinical guidelines. Evidence from case series and two systematic reviews suggest a rate of up to 43 percent of intrauterine fetal distress occurring during the active labour in women with COVID-19 infection.10, 12, 13 The place of birth is recommended to be a negative pressure isolation room as per FIGO and ISUOG guidelines or, in the absence of a negative pressure ventilation system, an isolation room as per RCOG guidelines.7-9
For healthcare professionals caring for all women with COVID-19 infection in the second or third stage of labour, ISUOG and FIGO advise on the use of a fit-tested N95 mask, FFP2 or equivalent standard respirator, eye protection, disposable fluid resistant gown and double gloves.8, 9 The RCOG recommend the use of a fluid resistant surgical mask, eye protection, disposal fluid resistant gown and single gloves with the respirator masks being reserved for aerosol generating procedures.7 Respirator masks such as the N95 are designed to fit tightly to the wearers face and prevent the inhalation of small-aerosolised particles.21 On the other hand, surgical masks fit loosely to the wearers face and prevent facial contact with large droplets but do not reliably prevent inhalation of small-aerosolised particles.21Respiratory viruses such as SARS-COV-2 are primarily transmitted through hand to face contact with large respiratory droplets.1Studies have not demonstrated any difference between surgical and N95 masks in the prevention of droplet transmission of other similar respiratory viruses such as influenza.21 In the absence of evidence to suggest that the second stage of labour generates aerosolised particles, the RCOG consider the surgical mask to be adequate for droplet/contact precaution and, thus, offer sufficient protection for healthcare professionals offering intra-partum care to those with COVID-19 infection.7
The use of antenatal steroids for fetal lung maturation has also been debated. The routine use of systemic steroids in the setting of viral pneumonia has previously been associated with increased maternal morbidity.22 One study has demonstrated delayed virus clearance with the administration of steroids and MERS.23 Finally and specifically with COVID-19, there is a relationship between steroid use and increased mortality (RR=2.11, 95%CI=1.13-3.94, P=0.0190).24 However, in general, these studies do not control for baseline morbidity and the course of steroids was longer than the 2-day course given for fetal lung maturity. Currently, the RCOG recommend that antenatal steroids should be given even in the context of COVID-19 when indicated such as in the event of preterm labour.7 In contrast, the ISUOG and FIGO guidelines urge caution in the use of antenatal steroids in women with COVID-19 infection and recommend close liaison with a specialist in maternal-fetal medicine.8, 9 This is because the absolute benefit of antenatal steroids reduces with advancing gestational age, is partly influenced on the presence of FGR and warrants careful evaluation of the maternal condition prior to them being given.25
All guidelines unanimously agree on the safety of regional anaesthesia for the purpose of analgesia in labour in women with COVID-19. RCOG advise that the use of epidural in labour is recommended for women with COVID-19 to minimise the need for general anaesthetic, an aerosol generating procedure, should emergency delivery be indicated.7-9 Shortening of the second stage may be required with the use of an instrumental delivery as per ISUOG, FIGO and RCOG guidelines due to the mother’s respiratory status and potential for exhaustion.7-9