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