Labor and Delivery

Any person could theoretically be positive for the novel coronavirus even while asymptomatic, and many hospitals have reduced the indications for NICU staff to attend deliveries, such as eliminating the necessity to attend routine Cesarean deliveries. For mothers giving birth while positive for coronavirus, it is recommended that clinicians use Airborne, Droplet, and Contact Precautions-level PPE.

Very little is known for certain about transmission of SARS-CoV-2 during pregnancy and its impact on the newborn, except that to date in utero transmission has not been verified, and peripartum transmission has been rare. There has been a single case report of COVID-19 in an infant one day old, and the youngest death thought to be due to the disease was in a 6-week old baby who was not in a NICU.

The American Academy of Pediatrics and the Centers for Disease Control made early recommendations that after birth of a baby to a mother who has COVID-19, the baby should be separated from the mother, depending on her degree of illness (AAP, 2020; CDC, 2020). However, this issue has become debatable. The World Health Organization recommends that mothers and infants should be able to remain together with rooming-in and encouraged to practice skin-to-skin contact, kangaroo mother care and breastfeeding (the SARS-CoV-2 virus has not been detected in breastmilk), whether they or their infants have suspected, probable, or confirmed COVID-19 (WHO, 2020). Separating mothers and babies may not prevent infection, especially since the baby will likely be discharged home with mother, but it could instead disrupt breastfeeding and bonding, and adversely impact maternal mental health, as well as double the work for the health care system (Stuebe, 2020). If baby does room-in, it is suggested that mother use a mask as well as meticulous breast and hand hygiene when breastfeeding. Another option for rooming in, presented by the AAP, is to place the baby in an isolette to afford some kind of protection.

This leaves us with the recommendation that a shared-decision model should be used for the COVID-19 positive mother and her clinical team to jointly determine the best care for the mother/baby dyad (NANN and NPA Position Statement #3069, 2020). These discussions should take place, if possible, before delivery.

If a baby must come to the NICU due to suspicion of infection, prematurity, or other issues, it is best if the infant can be cared for in a single-patient negative-pressure room. Airborne, Droplet, and Contact Precautions and negative room pressure should be used for the care of infants requiring CPAP or any form of mechanical ventilation. Mothers with COVID-19 (and partners, if infected) should not enter the NICU until their fever has been resolved without the use of antipyretics for at least 72 hours, their respiratory symptoms are improving, and nasopharyngeal swab testing for SARS-CoV-2 has been negative on two consecutive specimens collected more than 24 hours apart.


References

  1. CDC. 2020. “Coronavirus Disease 2019 (COVID-19).” Centers for Disease Control and Prevention. February 11, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html.
  2. “Clinical Management of Severe Acute Respiratory Infection When COVID-19 Is Suspected.” n.d. Accessed May 9, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.
  3. “National Perinatal Association – NPA + NANN Joint Statement: Mothers with COVID-29 and Their Newborn Infants, Positin Statement #3069.” n.d. National Perinatal Association. Accessed May 9, 2020. http://nationalperinatal.org/NPAandNANN.
  4. Puopolo, KM, ML Hudak, DW Kimberlin, and J Cummings. 2020. “Initial Guidance of Infants Born to Mothers with COVID-19.” American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases. https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.
  5. Stuebe, A. 2020. “Should Infants Be Separated from Mothers with COVID-19? First, Do No Harm.” Breastfeeding Medicine, April, bfm.2020.29153.ams. https://doi.org/10.1089/bfm.2020.29153.ams.