Minimizing risk during labor and delivery in COVID-19

Clinical Question

How can we minimize the risk to healthcare workers during labor and delivery, either in hospital, in a birth center, or at home?

Key Findings

  • Guidelines for infectious precautions in the hospital setting continue to evolve with the COVID-19 pandemic.
  • Healthcare personnel on the labor and delivery (L&D) unit are especially vulnerable to exposures given their patient-facing responsibilities.
  • Protocols for triaging and managing COVID-19 positive patients have been described by the CDC.[1]
  • However; consensus guidelines for minimizing asymptomatic transmission from asymptomatic patients to labor and delivery staff has yet to be established during birth are not well-characterized. Nevertheless, at least one article recommends suggest that all staff and physicians during the second stage of labor should wear full PPE.

Summary of Information

The purpose of this summary is to outline the current COVID-19 safety and prevention guidelines specific to labor and delivery.

Prior to L&D Admission

In accordance with CDC guidelines, patients who are Person Under Investigation (PUI) or COVID-19 positive should be identified prior to their anticipated arrival.[2] Patients should be appropriately triaged, and the necessary preparations should be considered including rooming specifications, supplies and PPE, and notifying other hospital personnel (infection control per hospital policy). An example supply checklist from UCSF is found in the references.[3]

COVID-19 Screening for L&D

There is no consensus on COVID-19 screening and testing protocols upon admission to obstetric units.[4] Palatnik and McIntosh suggest considering testing all laboring patients for COVID-19 in light of high percent of asymptomatic pregnant women testing positive.[5]

As an example of one institution’s approach, University of Washington (UW) guidelines were updated on March 29, 2020, to mandate universal screening for L&D, antepartum, and postpartum admissions.[6] This decision was made with the following considerations: half of the L&D patients are unscheduled and will have procedures completed; delaying procedures for testing results is not always possible; results of maternal testing affect infant care. Scheduled UW patients are screened 2-3 days prior admissions and others are screened on admission. COVID-19 testing is provided if the patient is symptomatic. In the outpatient setting, an algorithm for assessing and stratifying risk for pregnant patients is provided by ACOG and shown below.[7]

Figure 1
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Novel Coronavirus 2019 (COVID-19) Practice Advisory. ACOG. [7]

PPE in L&D

All healthcare personnel caring for known or suspected COVID-19 patients are recommended to use PPE.[8] Masks should also be worn by symptomatic or confirmed patients. Universal masking of all pregnant patients is not currently supported.7 Further specifications for PPE are institution dependent. For instance, UW recommendations include standard management without PPE for asymptomatic individuals except during emergency deliveries for asymptomatic patients with pending test results.[6] There are no published studies to date investigating PPE use by healthcare personnel during labor with asymptomatic patients.

However, the second stage of labor – complete dilated cervix to birth – can last up to 4 hours with labor and delivery personnel in close contact with patients who are frequently blowing out their breath, coughing, shouting, and vomiting, all of which put the health care team at risk. Recent data also suggests a significant rate of individuals infected with SARS-CoV-2 never exhibit symptoms. Therefore, Palatnik and McIntosh, suggest that all staff and physicians in a patient’s room during the second stage of labor (or cesarean delivery) should wear full PPE including gown, gloves, eye protection and N95 masks and that the number of staff be limited to essential personnel during the second stage of labor (and cesarean delivery). [5]

Visitor Access

Visitation policies are facility dependent with suggested guidelines available by the CDC.[1] In general, visitors should be screened for symptoms and limited in number. UC San Diego allows one accompanying visitor per patient in L&D and the designated person must remain in the patient’s room.[9]

Gaps in knowledge

Asymptomatic transmission is a concern given the close physical proximity of providers to patients and the potential aerosolization of infectious particles during labor. Further studies are needed to better understand the risks afforded to HCW during the birthing process. Other considerations include fecal exposures during labor as viral shedding in fecal matter has been reported.[10]

Author Information

Authors: Brenda Young MS3; UC San Diego School of Medicine
Completed on: April 7, 2020
Last updated on: not yet updated

Reviewed by: Gary Smithson MD
Reviewed on: April 27, 2020

This summary was written as part of the CoRESPOND Earth 2.0 COVID-19 Rapid Response at UC San Diego. For more information about the project, please visit http://earth2-covid.ucsd.edu

References

  1. Infection Control: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) | CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommenda.... Published February 11, 2020. Accessed April 7, 2020.
  2. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html. Published February 11, 2020. Accessed April 7, 2020.
  3. Theme: UCSF COVID-19 Resources | Obstetrics, Gynecology & Reproductive Sciences. UCSF COVID-19 Resources. https://obgyn.ucsf.edu/block/theme--ucsf-covid-19-resources. Accessed April 7, 2020.
  4. Coronavirus Disease 2019 (COVID-19): Should You Get Tested. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html. Published February 11, 2020. Accessed April 7, 2020.
  5. Palatnik A, McIntosh JJ. Protecting Labor and Delivery Personnel from COVID-19 during the Second Stage of Labor. Am J Perinatol. 2020.  [PMID:32276282]
  6. UW Medicine COVID-19. https://covid-19.uwmedicine.org/Pages/default.aspx.... Accessed April 7, 2020.
  7. COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics. ACOG. https://www.acog.org/en/Clinical Information/Physician FAQs/COVID 19 FAQs for Ob Gyns Obstetrics. Accessed April 7, 2020.
  8. Visitor Restrictions | UC San Diego Health. UC Health - UC San Diego. https://health.ucsd.edu/patients/pages/visitors.aspx. Accessed April 7, 2020
  9. Cheung KS, Hung IFN, Chan PPY, et al. Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology. 2020.  [PMID:32251668]