key: cord-1010728-p8grb7ut
authors: Lin, Chih; Chu, Shih-Ming; Hsu, Jen-Fu; Hsu, Chin-Chieh; Chang, Yao-Lung; Lien, Reyin; Cheng, Shao-Wen; Chiang, Ming-Chou
title: Delivery Management of Suspected or Confirmed COVID-19 Positive Mothers
date: 2021-06-25
journal: Pediatr Neonatol
DOI: 10.1016/j.pedneo.2021.06.004
sha: a221400244e6beda87d04696d2ba9c0387a98384
doc_id: 1010728
cord_uid: p8grb7ut

The Coronavirus Disease-2019 (COVID-19) pandemic has brought catastrophic impact on the world since the beginning of December 2019. Extra precautionary measures against COVID-19 during and after delivery are pivotal to ensure the safety of the baby and health care workers. Based on current literature, it is recommended that delivery decisions be discussed between obstetricians and neonatologists prior to delivery, and designated negative pressure delivery rooms should be arranged for COVID person under investigation (PUI). During delivery, a minimal number of experienced staff attending delivery should don personal protective equipment (PPE) and follow the neonatal resuscitation program (NRP). Positive pressure ventilation is best used in a negative pressure room if available. At-risk babies should be transported in an isolette, and tested for COVID-19 in a negative pressure room soon after bathing. Skin-to-skin contact and breast milk feed should continue under certain circumstances. Although newborns with COVID-19 infections often present with symptoms that mimic sepsis and one third of affected patients may demand some form of respiratory support, short-term prognoses are favorable and most recover within two weeks of symptoms onset. In this article, we will further elaborate on topics covering timing and mode of delivery, antenatal steroid, vertical transmission, delivery room management, airway management, transport, testing and isolation after birth, skin-to-skin contact, breast milk feeding, clinical features, outcomes, and discharge plans. In addition, we also share our experiences of encountering neonates born of suspected COVID-19 positive mothers.

pediatric infection, and obstetrics. In this article, we will discuss and address critical 87 issues of delivery management of suspected COVID-19 positive mothers and share 88 our experiences in managing babies born to suspected COVID-19 positive mothers. 89

Most importantly, Taiwan's government has implemented strict regulations in order to 90 achieve low rates of infection in the country; therefore, our policy ensures a stringent 91 antenatal steroid below 32 weeks of gestation for hospitalized PUI women and below 119 30 weeks of gestation for those admitted to the intensive care unit (ICU). 13 However, 120 the decisions are best reached by multidisciplinary team decision-making. 14 121 122

The question of whether Severe Acute Respiratory Syndrome Coronavirus 2 124 for babies delivered by PUI or confirmed mothers prior to delivery, not only to 144 prevent neonates from contracting the virus but also to protect health care personnel 145 during delivery and management. We also believe it is imperative that delivery 146 decisions must be made together between neonatologists and obstetricians. All 147 deliveries should proceed in an isolated negative pressure room with the minimum 148 respiratory masks, or air-purifying respirator, goggles, and gloves during delivery, 150 standby and transport of the newborn. 7, 9, 22 In situations where insufficient negative 151 pressure rooms are available during an outbreak or in limited resource areas, at least a 152 designated delivery room should be accessible, equipped with an infant warmer 153 situated more than 2 meters from the mother. 23 The AAP also recommends that bathing newborns at the earliest possible time 204

after birth is optimal to facilitate the removal of potential virus residues on the skin. 32 205 precautions in a designated isolation room if clinically stable; others, however, 207 suggest mother and child be isolated separately, 4 in which case, video visits may be 208 considered to help alleviate parental distress. 26 It is also advised that physicians 209 inform the parents regarding separation from their baby prenatally to reduce stress and 210 prevent conflict. The AAP and the WHO declare room-in may be practicable for 211 low-risk mothers with only mild symptoms, 20, 27 provided that the newborn be 212 separated 2 meters from the mother or there is a physical shield such as a curtain in 213 between to ensure most extensive protection. 33 However, vast differences in each 214

country's epidemic status should be taken into consideration, and management should 215 comply with the CDC's policy and regulations. 216 217

Skin-to-skin contact has been shown to have multiple beneficiary effects on 219 newborns, 34 so most guidelines reach a consensus that skin-to-skin contact should 220 

The first case was referred to our institution on March 1, 2020, a 32-year-old 253 woman (gravida 1, para 0) without remarkable systemic disease due to suspected 254 preterm premature rupture of membrane at 31+4 weeks of gestation. She developed a 255 low-grade fever with progressive exertional dyspnea and throat irritation. The 256 dyspnea worsened on March 5, and an oxygen mask of 5L/min was needed to 257 maintain an oxygen saturation of 90−95%. The obtained chest radiograph revealed 258 bilateral lower lobes pneumonia. During the time that COVID-19 infection could not 259 be ruled out, she was immediately transferred to a negative pressure room for 260 preparation of cesarean section due to maternal respiratory compromise. The second 261 case, a 31-year-old (gravida 1, para 0) HBV carrier, was pregnant at 38+5 weeks of 262 radiograph disclosed left lower lobe pneumonia. She was moved to a negative 264 pressure room for emergency C/S due to impending respiratory failure. The 265 attendance of pediatricians during delivery followed a protocol developed at the 266 beginning of January (Figure 1) . 267

A designated COVID-19 bag equipped with the all the necessities for delivery 268 attendance was prepared prior to delivery as listed in Table 1 is avoided, and early intubation using endotracheal tubes with HEPA filter is 276 performed when the patient is distressed and requires PPV. A pulse oximeter is 277 connected for monitoring heart rate and saturation, and an end-tidal carbon dioxide 278 (EtCO2) monitor confirms endotracheal intubation. Endotracheal intubation is 279 performed by the most experienced pediatrician on site, and the difficult airway 280 response team is alerted. 281 pressure room in the pediatric ICU and tested for COVID-19 using PCR analysis 283 obtained from both oropharyngeal and rectal swabs. Once the test is negative, the 284 patient is transferred to an isolation room apart from other unaffected infants for a 285 total of 14 days. Protective gowns, gloves, standard procedural masks, and goggles 286 are required when caring for these newborns. If the newborn tests positive, a repeated 287 PCR is performed at least 24 hours apart from the previous examination, and the 288 patient will remain in the negative pressure room until two consecutive negative 289 results, followed by transferal to a non-negative pressure isolation room for further 290 isolation of 14 days. While in isolation, family visits are prohibited, and breast milk 291 feeding is restricted until the mother is confirmed to be negative for COVID-19 292

Although our initial protocol may seem to contradict global recommendations for 294 management in the delivery room, and prohibits family visits and breast milk feeding, 295

the basis of our initial approach originates from our hospital's experience on the 2003 296 organizations; however, some limitations of this review exist including the lack of our 302 own country's experience as there are no reported COVID-19 confirmed newborns in 303

Taiwan and we are unable to provide the most updated recommendations as 304 world-wide guidelines are updated rapidly in accordance to the emergence of new 305 information regarding COVID-19. We recommend each facility should adhere to each 306 country's policy and regulations when encountering COVID-19 cases. 307 308

Since the beginning of the COVID-19 pandemic, debate over vertical transmission 310 has yet to reach a definitive conclusion. The general principal of separating the PUI 311 mother and the newborn by 2 meters during and after delivery is proposed until the 

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