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COVID-19: Intrapartum and postpartum issues

COVID-19: Intrapartum and postpartum issues
Authors:
Vincenzo Berghella, MD
Brenna L Hughes, MD, MSc
Section Editor:
Charles J Lockwood, MD, MHCM
Deputy Editor:
Vanessa A Barss, MD, FACOG
Literature review current through: Jun 2022. | This topic last updated: Apr 07, 2022.

INTRODUCTION — Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19). Information about COVID-19 continues to accrue, and interim guidance by multiple organizations is constantly being updated and expanded in an attempt to balance evidence-based maternity care with COVID-19-related infection control practices. The screening and infection control guidance in this topic generally applies to areas where the infection is prevalent; these measures can be relaxed in areas of low prevalence and high rates of vaccination.

This topic will discuss issues related to COVID-19 during labor, delivery, and the postpartum period. Other pregnancy issues and antepartum care of symptomatic patients are reviewed separately. (See "COVID-19: Overview of pregnancy issues" and "COVID-19: Antepartum care of pregnant patients with symptomatic infection".)

APPROACH TO INFECTION CONTROL DURING THE PANDEMIC

Vaccination — We recommend that all unvaccinated postpartum people, including those who are breastfeeding, undergo COVID-19 vaccination, and those who are vaccinated should receive booster doses, when eligible. Maternal COVID-19 antibodies induced by maternal vaccination can pass into breast milk and offer passive protection to the infant. These vaccines do not contain infectious virus and, in recently vaccinated individuals, the minimal amount of vaccine that crosses into breast milk and is then ingested by the infant is likely to be inactivated by the infant's digestive system [1,2]. (See "COVID-19: Overview of pregnancy issues", section on 'Vaccination in people planning pregnancy and pregnant or recently pregnant people'.)

Home birth versus birth at a medical facility — Although some pregnant people have considered home birth to reduce their risk of exposure to individuals with COVID-19, medical facilities have safety measures in place to protect patients, staff, and visitors from infection. Nosocomial transmission of SARS-CoV-2 is extremely rare when these measures are appropriately implemented. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)

Multiple issues besides COVID-19 risk need to be considered when choosing the birthing site. Hospitals and accredited birth centers are the safest settings for birth, including during the COVID-19 pandemic. (See "Planned home birth".)

Infection control precautions, intrapartum and postpartum — Infection control interventions have been widely implemented to reduce transmission of SARS-CoV-2 in areas of high community transmission. These include early identification and isolation of patients with suspected disease and universal source control (eg, covering the nose and mouth to contain respiratory secretions). Health care facilities have developed policies and procedures to prevent COVID-19 transmission among patients, visitors, and staff. Such policies and procedures are reviewed separately. (See "COVID-19: Occupational health issues for health care personnel", section on 'Preventing COVID-19 in health care settings'.)

Key interventions — Key interventions for the Obstetric Service include:

Prescreening before scheduled procedures – Within the 24 hours prior to arrival at the health care facility, patients with scheduled procedures (eg, induction, cesarean birth) should be prescreened for clinical manifestations of COVID-19 (table 1) and for close contact with a confirmed case or persons under investigation. Although the within 24 hour timeframe is ideal, hospital guidelines vary and some perform this screening up to 72 hours before arrival.

Screen-positive patients should undergo SARS-CoV-2 testing. Management of patients with COVID-19 is discussed separately. (See "COVID-19: Antepartum care of pregnant patients with symptomatic infection", section on 'Patients with nonsevere (or asymptomatic) COVID-19'.)

Universal screening upon unscheduled admission to or observation on the labor unit – Universal screening is advocated for patients who have not been prescreened, such as those arriving for unscheduled labor or rupture of membranes [3]. Patients are screened for clinical manifestations of COVID-19 (table 1), diagnosis of COVID-19 in the past 10 days, and close contact with a confirmed case or persons under investigation upon entry into the health care facility. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Screening prior to and upon entry into the health care facility'.)

-Screen-positive patients – All patients with symptoms should be managed as though they have COVID-19, pending additional evaluation (SARS-CoV-2 testing). Isolation precautions are indicated for patients with suspected or confirmed COVID-19 until at least 10 days have passed since the onset of symptoms or first positive test. The duration of isolation may need to be extended for immunocompromised patients and those who had severe disease. Note, this approach differs from that in the community. Specific infection control interventions are described separately. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Precautions for patients with suspected or confirmed COVID-19'.)

Asymptomatic patients who have had close contact with someone with suspected or confirmed COVID-19 are typically quarantined; the approach to quarantine depends primarily upon the patient's vaccination status (all recommended vaccines received versus not received) and history of recent COVID-19 (within the last 90 days), as well as the predominant circulating variant. Infection prevention precautions during quarantine in the hospital are similar to those used for patients with suspected or confirmed disease. Evaluation and management of asymptomatic patients who have had a close contact exposure to COVID-19 is described separately. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Asymptomatic patients'.)

-Screen-negative patients – When there is a moderate to high level of SARS-CoV-2 transmission in the community (defined as 10 to >100 cases per 100,000 people or a test positivity rate of 5 to >10 percent [4]), enhanced infection prevention precautions should be used when caring for patients, even those who are not suspected of having COVID-19 (eg, asymptomatic, received all recommended vaccines, and/or had a recent negative test for SARS-CoV-2) based on concerns that some patients with COVID-19 are asymptomatic or presymptomatic, a single polymerase chain reaction (PCR) test does not reliably rule out SARS-CoV-2 in all patients, and breakthrough infections may occur. (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Precautions for those NOT suspected of having COVID-19'.)

Universal testing prior to/on admission during periods of increased COVID-19 prevalence

In areas with a moderate to high level of SARS-CoV-2 transmission in the community (moderate to high viral transmission is defined as >10 (moderate) to >100 (severe) cases per 100,000 people or a test positivity rate of >5 (moderate) to >10 (severe) percent [4]), universal testing with a rapid SARS-CoV-2 test upon presentation to the labor and delivery unit (or the day before if a scheduled admission) it is reasonable for most patients, given the correlation between community and obstetric inpatient rates and the insensitivity of symptom- and contact-based screening alone [5,6]. This information is useful to inform infection control precautions both intrapartum and postpartum, including newborn care.

It is reasonable to phase out universal testing after a sustained period of low disease activity.

We omit testing in individuals who had a positive SARS-CoV-2 test within the previous 90 days. Patients who tested positive in the previous 11 to 90 days can be considered COVID-recovered unless symptomatic and are managed based on their symptoms.

Universal use of masks in the health care setting – Universal masking is required for all patients, support persons, visitors, and health care personnel. We prefer a N95 or KN95/KF94 mask if available; otherwise, a well-fitting surgical or medical procedure mask should be used. Use of other personal protective equipment depends on the specific patient setting. (See "COVID-19: General approach to infection prevention in the health care setting" and 'Health care workers' below.)

Outside of the health care setting, in the United States, we agree with CDC recommendations on masking, which depend on the estimated COVID-19 Community Levels (low, medium, high); reflect a combined measure of local case counts, new COVID-19 hospital admissions, and the percent of staffed inpatient beds occupied by patients with COVID-19; and can be found online [7]. In locations with low community levels, the CDC suggests that mask wearing is optional; at medium levels, it advises individuals who are immunocompromised or otherwise at risk for severe disease (such as pregnant people) to consider masking in public and advises their close contacts to wear masks; at high levels, the CDC recommends that all individuals wear masks in indoor public settings. It is reasonable for pregnant people to wear a mask in indoor public spaces even at the low community level, as there is no known harm from wearing a mask. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Wearing masks in the community'.)

Other potential interventions

Limiting time on the labor unit – Time in the labor unit should be limited, as is safely feasible, during periods of moderate to high viral transmission. For example, patients with low-risk pregnancies who are in early labor can remain at home, with telephone support by a midwife if possible. Patients with low-risk pregnancies who are going to be inducted can undergo outpatient rather than inpatient cervical ripening with a balloon catheter. For inpatient cervical ripening, using two methods (eg, mechanical and misoprostol or mechanical and oxytocin) may decrease the time from induction to birth, compared with using a single agent.

Although nosocomial transmission rates are very low, health care systems tend to be overburdened during periods of moderate to high viral transmission in the community.

Limiting support persons and visitors – Most facilities recognize that a support person is important to many laboring patients and permit at least one support person. A doula is considered a type of health care personnel by some facilities and a visitor by others. In some areas, both a family support person and a doula are allowed. (See "Continuous labor support by a doula".)

For patients with suspected or confirmed COVID-19, we limit movement of the support person. In these cases, the support person should remain with the laboring patient (ie, may not leave the room and then return) throughout labor and birth.

A support person with any signs/symptoms consistent with COVID-19 or a positive test for COVID-19 within 10 days should not be allowed to physically attend the labor and birth. When screen-positive or additional support persons are desired, they can be a part of the patient's labor and delivery via video.

Limiting time in the hospital and office visits after birth – As discussed above, although nosocomial transmission rates are very low, health care systems tend to be overburdened during periods of moderate to high viral transmission in the community. (See "COVID-19: Outpatient evaluation and management of acute illness in adults", section on 'Rationale for outpatient management and remote care'.)

After the birth, we suggest sending patients home as soon as they are stable and ready [3]. This may be as soon as one day after a cesarean birth. However, this should be considered in the context of the clinical scenario (eg, infection prevalence in the community, vaccination status) since early discharge may place additional burdens on families to access recommended newborn care and pediatric offices to provide this care [8].

Modifying or reducing in-person postpartum outpatient care in the midst of the pandemic is appropriate. For example, it may be possible to perform early postpartum assessments, including wound and blood pressure checks, with telehealth. A comprehensive postpartum visit may still be important by 12 weeks, especially in patients with comorbidities and in patients who lose insurance coverage at that time.

In-person health care provider visits require the patient to leave their home, traveling via public, private, or emergency transport and potentially exposing others to SARS-CoV-2.

INTRAPARTUM CARE OF PATIENTS NOT SUSPECTED OF INFECTION — Intrapartum care is generally routine for patients not suspected of being infected, except for the infection control precautions described above. (See 'Infection control precautions, intrapartum and postpartum' above.)

Some additional issues to consider include:

Intrapartum fever — COVID-19 should be part of the differential diagnosis of intrapartum fever, particularly when accompanied by respiratory symptoms and hypoxemia. Such patients should be tested for SARS-CoV-2 if not previously tested, along with evaluation for common causes of intrapartum fever (eg, chorioamnionitis, epidural fever) [9]. We do not routinely retest febrile patients within 72 hours of a negative polymerase chain reaction (PCR) test if a non-COVID-19-related cause of fever has been diagnosed (eg, chorioamnionitis) and the patient has no respiratory symptoms. (See "Intrapartum fever".)

Umbilical cord blood banking — Umbilical cord blood banking can be performed if planned; the risk of COVID-19 transmission by blood cells has not been documented and is unclear at present [10].

INTRAPARTUM CARE OF INFECTED PATIENTS

Health care workers — When caring for patients with confirmed or suspected COVID-19, health care workers should use contact and droplet precautions with eye protection (ie, gown; gloves; N95, surgical, or medical procedure mask; face shield or goggles). In particular, during episodes of patient deep respiratory efforts in the active phase and while pushing, health care workers should use both contact and droplet precautions with eye protection and airborne precautions (ie, N95 mask or powered air purifying respirator). (See "COVID-19: General approach to infection prevention in the health care setting", section on 'Health care personnel'.)

Of note, health care workers are at risk for developing COVID-19 through exposures in the community, as well as in the health care setting. Guidelines for work restriction and monitoring after exposure and returning to work after exposure and after confirmed or suspected COVID-19 are available separately. (See "COVID-19: Occupational health issues for health care personnel".)

Choosing the route of birth — COVID-19 is generally not an indication to alter the planned route of birth [10]. Induction generally can be performed safely, even in intubated patients [11,12].

Cesarean birth is performed for standard obstetrical indications and does not appear to reduce the already low risk for neonatal COVID-19, which generally causes only mild symptoms in newborns [13,14] (see "COVID-19: Overview of pregnancy issues", section on 'Risk of vertical transmission'). In patients with severe or critical COVID-19, cesarean birth may be indicated because of concern for acute maternal and/or fetal decompensation. In addition, in patients who are intubated and laboring in an operating room or intensive care unit, a long induction can be impractical logistically due to the specialized equipment and personnel at these sites. (See "COVID-19: Antepartum care of pregnant patients with symptomatic infection", section on 'Timing of delivery'.)

Although one study of 37 cesarean and 41 vaginal births in patients with COVID-19 reported cesarean birth was associated with an increased risk for clinical deterioration (8 out of 37 [22 percent] versus 2 out of 41 [5 percent]) that remained after adjustment for confounders (adjusted odds ratio 13, 95% CI 1.5-122.0), the issue of possible harm from cesarean birth should not preclude indicated cesarean birth [15]. The small number of events and bias in case selection for route of delivery could account for the findings.

Clinical care team — For severely/critically ill patients, a multidisciplinary care team should be present (eg, intensivists, maternal-fetal medicine, neonatology, nursing support from obstetrics, pediatrics, and medical disciplines) to care for them and their potentially heavily sedated newborn, regardless of the type or site of birth (eg, labor and delivery unit, main operating room, intensive care unit). The intensity of maternal monitoring beyond intrapartum routine care should be directed by this team.

COVID-19-specific therapy — Any COVID-19-specific therapy initiated antepartum should be continued intrapartum and postpartum to complete the typical course of the therapy. Considerations in breastfeeding mothers are discussed below. (See 'Antiviral drug safety' below.)

Prophylaxis against venous thromboembolism is discontinued while the patient is intrapartum. (See "COVID-19: Antepartum care of pregnant patients with symptomatic infection", section on 'Venous thromboembolism prophylaxis'.)

Labor analgesia and anesthesia — Neuraxial anesthetic is not contraindicated in patients with known or suspected COVID-19 and has several advantages in laboring patients: it provides excellent analgesia and thus reduces cardiopulmonary stress from pain and anxiety and, in turn, the chance of viral dissemination during repeated forceful exhalation and panting [3,16,17]. In addition, it is available in case an emergency cesarean is required, thus obviating the need for and risks of general anesthesia. (See "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)

Nitrous oxide – There is insufficient information about the cleaning, filtering, and potential aerosolization with the use of nitrous oxide labor analgesia systems in the setting of COVID-19. For this reason, the Society for Obstetric Anesthesia and Perinatology and the Society for Maternal-Fetal Medicine suggest that individual labor and delivery units discuss the relative risks and benefits and consider suspending use for patients with suspected or confirmed COVID-19 or unconfirmed COVID-19 negative status; however, it remains an option for patients with a negative SARS-CoV-2 test [18,19]. One guideline suggests use with a single patient microbiologic filter [20].

Anesthetic care for patients with suspected or confirmed COVID-19 is reviewed separately. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control".)

Use of magnesium sulfate

Patients with respiratory compromise In nonintubated patients with respiratory compromise due to COVID-19, those receiving magnesium sulfate for seizure prophylaxis and/or neonatal neuroprotection should be monitored particularly carefully (eg, check magnesium levels, frequently assess respiratory rate and oxygen saturation [pulse oximetry]) since high magnesium levels (10 to 13 mEq/L [12 to 16 mg/dL or 5.0 to 6.5 mmol/L]) can cause respiratory paralysis. In intubated, mechanically ventilated patients, signs of magnesium-related respiratory toxicity will not be observed; thus, cardiac arrhythmias or arrest can be the first sign of serious toxicity. Consultation with maternal-fetal medicine and pulmonary/critical care specialists is advised. (See "Neuroprotective effects of in utero exposure to magnesium sulfate".)

Patients with acute kidney injury – In patients who have COVID-19-related acute kidney injury receiving magnesium sulfate for seizure prophylaxis and/or neonatal neuroprotection, we suggest dose-adjustment rather than withholding the drug. Consultation with maternal-fetal medicine and/or nephrology/critical care specialists is advised.

Fetal monitoring and procedures — In laboring patients with COVID-19, maternal and fetal monitoring and procedures are performed according to standard indications, with the following considerations:

Continuous electronic fetal monitoring is recommended for all symptomatic patients since an increased frequency of nonreassuring tracings has been reported among pregnant patients with suspected or confirmed COVID-19, but these case series typically had a high proportion of patients with pneumonia. (See "Intrapartum fetal heart rate monitoring: Overview".)

SARS-CoV-2 is uncommon in vaginal secretions and amniotic fluid, so maternal infection is not a contraindication to rupture of fetal membranes, application of a fetal scalp electrode, or insertion of an intrauterine pressure catheter, but data are limited.

Pushing — Either immediate or delayed pushing is reasonable for most patients, and the choice is best made as a shared decision. Delayed pushing results in a longer second stage, but less time spent actively pushing. Although pushing can involve repeated forceful exhalation and panting and loss of feces (which commonly contains the virus [21,22]), which theoretically could increase the risk for viral transmission, we suggest not delaying pushing in attempt to mitigate this risk. (See "Labor and delivery: Management of the normal second stage", section on 'Early versus delayed'.)

Ideally, patients with COVID-19 should continue to wear a mask while pushing; however, we allow them to remove the mask if they are uncomfortable wearing the mask during this exertion.

Umbilical cord clamping — As in noninfected patients, we perform delayed umbilical cord clamping in patients with known or suspected infection since it is highly unlikely to increase the risk of vertical transmission [10,23]. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Early versus delayed cord clamping'.)

Management of the third stage — Management of the third stage of labor is not affected by COVID-19, and most patients who develop postpartum hemorrhage can be managed according to standard protocols. However, some clinicians, including some UpToDate contributors, do not use tranexamic acid in COVID-19 patients with postpartum hemorrhage because its antifibrinolytic properties may increase the risk for thrombosis in individuals with a hypercoagulable state, such as patients with severe or critical disease, and alternative strategies for control of bleeding are usually available [24]. Other UpToDate contributors use tranexamic acid as part of the management of postpartum hemorrhage in patients with COVID-19.

Ergot derivatives (eg, methergine) should be avoided in patients receiving nirmatrelvir-ritonavir because of the risk for ergot toxicity (ischemia of an extremity, coma, and even death). Some authorities suggest avoiding ergot derivatives in patients with symptomatic COVID-19 because of rare cases of respiratory failure and severe vasoconstriction in severely ill patients [25]. There is no consensus about this among the contributors of this topic and no data on which to base a recommendation. (See "Postpartum hemorrhage: Medical and minimally invasive management" and "Postpartum hemorrhage: Management approaches requiring laparotomy".)

Skin-to-skin contact — We encourage skin-to-skin contact between all mothers and newborns in the birthing room. Mothers with COVID infection can reasonably safely practice skin-to-skin contact and breastfeed in the birthing room if they wear a surgical mask and use proper hand hygiene [26]. (See 'Care of newborns of infected mothers' below.)

Placenta — There is no consensus regarding whether maternal COVID-19 alone is an indication for placental examination by a pathologist.

There are no standard criteria for diagnosis of placental SARS-CoV-2 infection and no definite COVID-19-specific placenta changes [27]. A consensus statement from the National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development SARS-CoV-2 placental infection workshop proposed five categories for documenting placental infection based on the rigor of the diagnostic technique [28]:

Definite: Evidence of active replicating virus in the placental tissues

Probable: Evidence of viral RNA or protein located in placental tissues

Possible: Evidence of viral RNA in placental homogenates or viral-like particles by electron microscopy in placental tissues

Unlikely: No evidence of any of the above

No testing: Testing not done

They also provided detailed recommendations for placental handling, processing, and examination.

SARS-CoV-2 placentitis is characterized by chronic histiocytic intervillositis, increased perivillous fibrin deposition (including massive perivillous fibrin deposition), and villous trophoblast necrosis. These changes can cause widespread and severe placental destruction, resulting in placental malperfusion and insufficiency and leading to perinatal death from fetal hypoxic-ischemic injury. In a case series of 64 stillborns (15 to 39 weeks of gestation) and four neonatal deaths with SARS-CoV-2 placentitis, all 68 placentas tested positive for SARS-CoV-2, whereas the virus was detected from a stillborn/newborn body specimen in only 16 out of 28 cases tested (59 percent) [29]. Importantly, there was no evidence that fetal SARS-CoV-2 infection had a direct role in causing the deaths. Further study is needed to determine the frequency of SARS-CoV-2 placentitis in pregnant patients with COVID-19 and the frequency of stillbirth/neonatal death in those with SARS-CoV-2 placentitis. (See "COVID-19: Overview of pregnancy issues", section on 'Risk of stillbirth'.)

POSTPARTUM CARE OF INFECTED PATIENTS

Postpartum infection control precautions — In general, patients with suspected or confirmed SARS-CoV-2 infection should be isolated from uninfected patients and cared for according to standard infection control guidelines. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Maternal monitoring — The intensity of maternal monitoring in patients with COVID-19 depends on maternal status. The goal is to identify disease progression, as well as usual postpartum problems and complications. (See "Postpartum perineal care and management of complications".)

For asymptomatic patients, routine postpartum maternal monitoring is adequate. (See "Overview of the postpartum period: Normal physiology and routine maternal care".)

For patients with mild illness (see "COVID-19: Overview of pregnancy issues", section on 'Classification of disease severity'), postpartum monitoring is routine.

For patients with moderate illness (see "COVID-19: Overview of pregnancy issues", section on 'Classification of disease severity'), we perform continuous pulse oximetry monitoring for the first 24 hours or until improvement in signs and symptoms, whichever takes longer. The type and frequency of follow-up laboratory studies and chest imaging (initial or repeat) are guided by the patient's course. Several institutional protocols are available. (See "COVID-19: Management in hospitalized adults", section on 'Institutional protocols'.)

In patients who develop acute dyspnea and hypoxemia postpartum, the differential diagnosis (table 2) includes progression to severe COVID-19, sepsis, influenza, cardiomyopathy, and pulmonary embolism. The combination of symptoms, physical examination, laboratory tests, and imaging can usually distinguish among these disorders.

For patients with severe or critical illness (see "COVID-19: Overview of pregnancy issues", section on 'Classification of disease severity'), very close maternal monitoring and care on the labor and delivery unit or intensive care unit are indicated. Several institutional protocols are available. (See "COVID-19: Management in hospitalized adults" and "COVID-19: Management of the intubated adult".)

Venous thromboembolism prophylaxis

Postpartum patients with asymptomatic COVID-19 hospitalized for reasons other than COVID-19 (ie, labor and delivery) – There is consensus that anticoagulation is not required unless the patient has other thrombotic risk factors, such as prior venous thromboembolism (VTE) or, in some cases, cesarean birth [30]. (See "Overview of the causes of venous thrombosis".)

Postpartum patients with severe COVID-19 – There is consensus for use of prophylactic-dose anticoagulation, if there are no contraindications to its use. It is generally discontinued when the patient is discharged to home [30].

Postpartum patients with symptomatic nonsevere COVID-19 hospitalized for reasons other than COVID-19 (ie, labor and delivery) – Practice patterns vary. Some practitioners administer prophylactic-dose anticoagulation to all symptomatic patients while they are in the hospital. Others make this decision on a case-by-case basis, taking into account all of the patient's risk factors for venous thrombosis. (See "Overview of the causes of venous thrombosis".)

Either low molecular weight heparin or unfractionated heparin is acceptable, and both are compatible with breastfeeding. Choice of drug, dosing, and timing after vaginal and cesarean birth are discussed in more detail separately. (See "COVID-19: Hypercoagulability", section on 'Inpatient VTE prophylaxis' and "Use of anticoagulants during pregnancy and postpartum", section on 'Postpartum and breastfeeding' and "Cesarean birth: Preoperative planning and patient preparation", section on 'Thromboembolism prophylaxis'.)

Postpartum analgesia — Pain management of patients with COVID-19 is routine. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Pain management' and "Post-cesarean delivery analgesia".).

We use nonsteroidal anti-inflammatory drugs (NSAIDs) when clinically indicated. (See "COVID-19: Management in hospitalized adults", section on 'NSAID use'.)

Postpartum fever — The differential diagnosis of postpartum fever in patients with COVID-19 includes the infection itself as well as postpartum endometritis, surgical site infection, breast inflammation or infection, influenza, pyelonephritis, other viral or bacterial respiratory infections, and, rarely, pseudomembranous colitis due to Clostridioides difficile. The combination of symptoms, physical examination, and laboratory tests can usually distinguish among these disorders. (See "Postpartum endometritis", section on 'Differential diagnosis'.)

In newly symptomatic patients who previously tested negative for SARS-CoV-2, retesting may be appropriate as part of the evaluation of fever or other potential manifestations of COVID-19 (table 1). However, we do not routinely retest febrile patients within 72 hours of a negative polymerase chain reaction (PCR) test if a non-COVID-19-related cause of fever has been diagnosed (eg, chorioamnionitis, endometritis, surgical site infection) and the patient has no respiratory symptoms.

Acetaminophen is the preferred antipyretic agent. (See "COVID-19: Management in hospitalized adults", section on 'NSAID use'.)

Permanent and reversible contraception — Permanent contraception (tubal sterilization) does not add significant additional time or risk when performed at an uncomplicated cesarean birth and, thus, should be performed if planned regardless of COVID-19 status. After a vaginal birth, the decision to schedule a procedure for permanent contraception in a patient with COVID-19 should be made on a local level, based on available resources.

If not performed or if a reversible contraceptive method is desired, an alternative form of contraception should be provided (eg, immediate postpartum long-acting reversible contraception or depot medroxyprogesterone acetate) as long as the patient desires one of these methods. This avoids additional outpatient postpartum visits. (See "Overview of female permanent contraception" and "Postpartum permanent contraception: Procedures" and "Postpartum contraception: Counseling and methods".)

Discharge from hospital and medical follow-up — The decision to discharge a patient with COVID-19 is generally the same as that for other conditions and depends on the need for hospital-level care and monitoring. We counsel all patients on the warning symptoms that should prompt reevaluation by a telehealth or in-person visit, including emergency department evaluations. These include new onset of dyspnea, worsening dyspnea, dizziness, and mental status changes, such as confusion. Patients are also counseled about persistent symptoms (table 3), when to expect recovery, and what to expect after recovery. These issues, as well as evaluation of patients after discharge and return to normal activities, are discussed in detail separately. (See "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")".)

Obstetric follow-up — Obstetric follow-up of patients with COVID-19 is routine. (See "Overview of the postpartum period: Normal physiology and routine maternal care".)

The psychological impact of COVID-19, which may include depression or moderate to severe anxiety, should also be recognized and support offered. All postpartum patients should still be screened for postpartum depression four to eight weeks after the birth. The most widely used instrument is the self-reported, 10-item Edinburgh Postnatal Depression Scale (figure 1A-B), which can be completed in less than five minutes [31], but alternatives are available. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment' and "COVID-19: Psychiatric illness", section on 'Patients with COVID-19'.)

A tool is also available for screening for anxiety. (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment and Diagnosis'.)

CARE OF NEWBORNS OF INFECTED MOTHERS

Newborn evaluation — The risk of neonatal COVID-19 in the first 24 to 96 hours of life is approximately 2 percent overall, but higher (approximately 4 percent) when maternal infection is close to the time of birth [32]. (See "COVID-19: Overview of pregnancy issues", section on 'Risk of vertical transmission'.)

The infants of mothers with suspected or confirmed COVID-19 are considered persons under investigation, and they should be tested for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) [33]. The American Academy of Pediatrics (AAP) suggests the following for diagnosis of newborn infection:

Test at approximately 24 hours of age and, if negative, again at approximately 48 hours of age since some infants have had a negative test at 24 hours only to have a positive test at a later time. If a healthy, asymptomatic newborn will be discharged prior to 48 hours of age, a single test at 24 to 48 hours of age can be performed.

Obtain either a single swab of the nasopharynx, a single swab of the throat followed by the nasopharynx, or two separate swabs from each of these sites, and submit for a single test. Some centers have transitioned to swabs of the anterior nares. The specifics of testing depend on the requirements of local testing platforms.

Two tests are ideal because a single positive RT-PCR in a newborn respiratory sample may indicate active viral replication, but it could also represent viral fragments acquired during passage through the vagina or from the immediate postnatal environment and thus not be a true neonatal infection. Likewise, cord blood may be RT-PCR positive as a result of maternal contamination. In a report of universal SARS-CoV-2 nasopharyngeal RT-PCR screening in neonates, 9 of 418 (2 percent) neonates tested positive within 24 hours of birth, and seven were negative on the second test [34]. Persistence of a positive test on subsequent specimens is critical to differentiate whether there is superficial contamination (resulting in a false-positive test) or actual neonatal infection. If performed, the presence of additional positive tests of normally sterile specimen types (eg, neonatal blood, lower respiratory tract samples, cerebrospinal fluid) also enables differentiation of contamination from neonatal infection [35].

Serologic testing is of limited utility as both false-positive and false-negative immunoglobulin M (IgM) tests occur; therefore, a positive serologic test always requires confirmatory testing of a second specimen, preferably using molecular diagnostic tests to directly detect the pathogen [35]. A true positive newborn SARS-CoV-2 IgM at less than seven days of age is assumed to represent in utero infection whereas a negative IgM at less than seven days followed by a positive test after day 7 is assumed to reflect intrapartum or early postnatal infection.

Mother-newborn contact in the hospital — We recommend not separating the mother with COVID-19 and newborn after birth. The newborn's risk for acquiring SARS-CoV-2 from its mother is low, and data suggest no difference in risk of neonatal SARS-CoV-2 infection whether the neonate is cared for in a separate room or remains in the mother's room [13,33,36-40]. However, mothers should wear a well-fitting N95, KN95/KF94, or surgical or medical procedure mask and practice hand hygiene during contact with their infants. At other times, reasonable physical distancing between the mother and neonate or placing the neonate in an incubator is desirable, when feasible. Passive transplacental transfer of maternal anti-SARS-CoV-2 antibody may not protect the newborn from maternal infection [41].

Factors to consider include the following:

Rooming-in helps establish breastfeeding, facilitates bonding and parental education, and promotes family-centered care.

Separation may be necessary for mothers who are too ill to care for their infants or who need higher levels of care.

Separation may be necessary for neonates who may be at higher risk for severe illness (eg, preterm infants, infants with underlying medical conditions, infants needing higher levels of care).

Separation to reduce the risk of mother-to-newborn transmission is not useful if the neonate tests positive for SARS-CoV-2, and probably not useful if the mother and newborn will not be able to maintain separation after discharge until they meet criteria for discontinuation of quarantine.

If separation is implemented, newborn COVID-19 suspects/confirmed cases should be isolated from other healthy newborns and cared for, in the United States, according to the Centers for Disease Control and Prevention's (CDC) newborn guidelines.

If another healthy family member is providing newborn care (eg, diapering, bathing, feeding), they should use appropriate personal protective equipment and procedures (eg, well-fitting mask [eg, N95, KN95/KF94, surgical, or medical procedure mask], hand hygiene).

Criteria for discontinuing mother-newborn infection precautions — These are the same as for nonpregnant individuals (table 4). Detailed information is available separately. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Viral shedding and period of infectiousness' and "COVID-19: Epidemiology, virology, and prevention", section on 'Risk of transmission depends on exposure type' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)

Breastfeeding and formula feeding — The risk of SARS-CoV-2 transmission from ingestion of breast milk is unclear, but appears to be very low. No publication has reported detection of replication-competent virus in breast milk [35]. Although samples of breast milk positive for SARS-CoV-2 by RT-PCR have been detected [42,43], these samples do not necessarily contain viable and transmissible virus [44].

There is general consensus that breastfeeding should be encouraged because of its many maternal and infant benefits. In the setting of maternal COVID-19 infection or maternal COVID-19 vaccination, the infant may receive passive antibody protection against the virus since breast milk is a source of maternal antibodies and other anti-infective factors. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)

Breastfeeding – The AAP supports breastfeeding in mothers with COVID-19, with appropriate infection control precautions [45]. This approach considers the clear mother-infant benefits of breastfeeding, the low likelihood of passing maternal infection to the newborn when infection precautions are taken, and the nonsevere course of newborn infection when it does occur. This policy was based, in part, on a study from New York City that tested and followed 82 infants of 116 mothers who tested positive for SARS-CoV-2: no infant was positive for SARS-CoV-2 postnatally, although most roomed-in with their mothers and were breastfed [26]. The infants were kept in a closed isolette while rooming-in, and the mothers wore surgical masks while handling their infants and followed frequent hand and breast washing protocols. Subsequent studies have reported similar findings [46].

Infection control precautions to prevent transmission to the infant during feeding include wearing a well-fitting mask (eg, surgical, medical procedure, KN95/KF94, or N95 mask), performing hand hygiene, and disinfecting shared surfaces that the symptomatic mother has contacted. However, it should be noted that the value of precautions, such as cleansing the breast prior to breastfeeding, for reducing potential transmission of SARS-CoV-2, has not been formally studied [47].

We agree with CDC guidance for management of various clinical scenarios. For example:

Mothers without suspected or confirmed COVID-19 and who have not been in close contact with someone who has COVID-19 do not need to take special precautions when feeding at the breast, expressing milk, or feeding from a bottle.

When the mother has suspected or confirmed COVID-19, they should take precautions (including wearing a well-fitting surgical, medical procedure, N95, or KN95/KF94 mask; hand hygiene) before contact with the infant. Neither masks nor plastic face shields should be placed on newborns. In the less common scenario where only the infant has suspected or confirmed COVID-19, mothers should take similar precautions and practice hand hygiene after contact with the infant.

When both the mother and the breastfed infant have suspected or confirmed COVID-19, no special precautions (eg, wearing a mask) are needed during breastfeeding, expressing milk, or feeding from a bottle, or during the period of isolation.

Feeding pumped breast milk – If mother and infant separation has been implemented, ideally, the infant is fed expressed breast milk by another healthy caregiver until the mother has recovered or has been proven uninfected, provided that the other caregiver is healthy and follows hygiene precautions. Expressing breast milk is important to support establishment of the maternal milk supply.

Before pumping, ideally with a dedicated breast pump, mothers should wear a well-fitting mask (eg, surgical, medical procedure, N95, or KN95/KF94 mask) and thoroughly clean their hands with soap and water and clean pump parts, bottles, and artificial nipples [48]. The CDC has issued guidance about cleaning breast pumps and breastfeeding. If possible, the pumping equipment should be thoroughly cleaned by a healthy person. It should be noted that the value of precautions, such as disinfecting external surfaces of milk collection devices (eg, bottles, milk bags) or cleansing the breast prior to milk expression for reducing potential transmission of SARS-CoV-2, has not been formally studied [47].

Formula feeding – Ideally, mothers with known or suspected COVID-19 who choose to formula feed should have another healthy caregiver feed the infant. If this is not possible or desired, they must also take appropriate infection control precautions, as described above, to prevent transmission through close contact when feeding.

Pasteurized donor human milk – If the mother is too ill to breastfeed or express milk, donor milk may be used. Holder pasteurization is commonly used in human milk banks and appears to eliminate replication-competent SARS-CoV-2 virus [49,50].

Antiviral drug safety — Information on transfer of maternal drugs into breast milk is available in the Lexicomp drug interactions program included with UpToDate and the Drugs and Lactation Database (LactMed) of the National Library of Medicine.

Remdesivir – Infants are not likely to absorb clinically important amounts of the drug from breast milk. No serious adverse drug reactions have been reported in newborn infants who received intravenous remdesivir therapy for Ebola. Breastfeeding is not contraindicated [51].

Nirmatrelvir-ritonavir – There are no data on the presence of nirmatrelvir in breast milk, the effects on the breastfed infant, or the effects on milk production. Limited data suggest that ritonavir is present in breast milk, but no information is available on the effects on the breastfed infant or the effects on milk production. Lactation is not a contraindication to use, but pumping and discarding milk during maternal treatment may be prudent.

Sotrovimab – The amount of sotrovimab in breast milk is likely to be very low since it is a large protein [52]. It is also likely to be partially destroyed in the infant's gastrointestinal tract; thus, absorption and infant effects are probably minimal. Lactation is not a contraindication to use, but pumping and discarding milk during maternal treatment may be prudent.

Molnupiravir – There is no information on use of molnupiravir during lactation. Pumping and discarding milk is advised during treatment and for four days after the last dose because of concerns about mutagenicity.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: COVID-19 and pregnancy (The Basics)" and "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)")

SUMMARY AND RECOMMENDATIONS

Infection control measures – Infection control interventions include vaccination/booster and prescreening before scheduled procedures, universal screening upon unscheduled admission to or observation on the labor unit, universal testing prior to/on admission in areas of moderate to high SARS-CoV-2 transmission in the community, universal use of appropriate masks, and use of other personal protective equipment when appropriate. (See 'Vaccination' above and 'Infection control precautions, intrapartum and postpartum' above and 'Health care workers' above.)

Route of birth – COVID-19 is generally not an indication to alter the planned route of birth. Induction generally can be performed safely, even in intubated patients. (See 'Choosing the route of birth' above.)

Management of labor and birth

In patients with nonsevere COVID-19, intrapartum management is generally routine, except for enhanced infection control precautions (including possible avoidance of nitrous oxide labor analgesia systems). Ergot derivatives should be avoided in patients receiving nirmatrelvir-ritonavir because of the risk for ergot toxicity. (See 'Intrapartum care of infected patients' above.)

In patients with severe or critical COVID-19, cesarean birth may be indicated because of concern for acute maternal and/or fetal decompensation or the logistic problems of a long induction in an intensive care or similar unit. (See 'Choosing the route of birth' above.)

Magnesium levels should be monitored in patients receiving magnesium sulfate for obstetric indications because of the increased risk of magnesium toxicity. (See 'Use of magnesium sulfate' above.)

A multidisciplinary care team (eg, intensivists, maternal-fetal medicine, neonatology, nursing support from obstetrics, pediatrics, and medical disciplines) is needed to care for these patients and their potentially heavily sedated newborn. The intensity of maternal monitoring beyond intrapartum routine care should be directed by this team. (See 'Clinical care team' above.)

Postpartum care Obstetric aspects of postpartum care are generally routine for patients with COVID-19. Maternal medical care is commensurate with the severity of maternal illness.

Antithrombotic prophylaxis – (See 'Venous thromboembolism prophylaxis' above.)

-Asymptomatic COVID-19 hospitalized for labor and delivery – Anticoagulation is not required unless the patient has other thrombotic risk factors, such as prior venous thromboembolism (VTE) or, in some cases, cesarean birth.

-Severe COVID-19 – Prophylactic-dose anticoagulation is required, if there are no contraindications to its use. Discontinue when the patient is discharged to home.

-Symptomatic nonsevere COVID-19 hospitalized for labor and delivery – Practice patterns vary. Some practitioners administer prophylactic-dose anticoagulation to all symptomatic patients while in the hospital. Others make this decision on a case-by-case basis, taking into account all of the patient's risk factors for venous thrombosis.

Evaluation of intrapartum and postpartum fever – COVID-19 should be part of the differential diagnosis of intrapartum and postpartum fever. Such patients should be tested for SARS-CoV-2 if not previously tested, along with evaluation for common causes of intrapartum and postpartum fever. We do not routinely retest febrile patients within 72 hours of a negative polymerase chain reaction (PCR) test if a non-COVID-19-related cause of fever has been diagnosed (eg, chorioamnionitis, endometritis, surgical site infection) and the patient has no respiratory symptoms. (See 'Intrapartum care of patients not suspected of infection' above and 'Postpartum fever' above.)

Newborn evaluation – The infants of mothers with suspected or confirmed COVID-19 are considered persons under investigation and should be tested for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR). (See 'Newborn evaluation' above.)

Rooming-in and breastfeeding – (See 'Mother-newborn contact in the hospital' above and 'Breastfeeding and formula feeding' above.)

Mothers without suspected or confirmed COVID-19 and who have not been in close contact with someone who has COVID-19 do not need to take special precautions when feeding at the breast, expressing milk, or feeding from a bottle.

Mothers with suspected or confirmed COVID-19 should take precautions (including wearing a well-fitting surgical, medical procedure, N95, or KN95/KF94 mask; hand hygiene) before contact with the infant. Neither masks nor plastic face shields should be placed on newborns. In the less common scenario where only the infant has suspected or confirmed COVID-19, mothers should take similar precautions and practice hand hygiene after contact with the infant.

When both the mother and the breastfed infant have suspected or confirmed COVID-19, no special precautions (eg, wearing a mask) are needed during breastfeeding, expressing milk, or feeding from a bottle, or during the period of isolation.

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References