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\begin{document}

\title{Safe Delivery Solutions for COVID-19 Infected Pregnancies}



\author[1]{Hongbo Qi}%
\author[2]{Xin Luo}%
\author[3]{Yangxi Zheng}%
\author[4]{Hua Zhang}%
\author[5]{Jiafu Li}%
\author[6]{Li Zou}%
\author[7]{Ling  Feng}%
\author[8]{Dunjin Chen}%
\author[1]{Yuan Shi}%
\author[2]{Chao Tong}%
\author[9]{Philip Baker}%
\affil[1]{Chongqing Medical University Affiliated Children's Hospital}%
\affil[2]{Affiliation not available}%
\affil[3]{University of Texas-Houston Medical School}%
\affil[4]{The First Affiliated Hospital of Chongqing Medical University, Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University}%
\affil[5]{Wuhan University Zhongnan Hospital}%
\affil[6]{Huazhong University of Science and Technology Tongji Medical College}%
\affil[7]{Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology}%
\affil[8]{Third Affiliated Hospital of Guangzhou Medical University}%
\affil[9]{University of Leicester}%


\vspace{-1em}



  
  \date{March 14, 2025}


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Since December 2019, a new coronavirus (COVID-19) infection has rapidly
become prevalent in central China {[}1{]}. On the basis of knowledge
obtained from a previous coronavirus outbreak {[}2{]}, pregnant women
are believed to be susceptible to this virus. Once a maternal infection
of 2019-nCoV is suspected or confirmed, childbirth becomes complicated
and challenging. Efficient obstetric treatment is required, and is key
to optimizing the prognosis for both mother and child. Care should be
taken in determination of the timing of delivery, assessment of the
indications for caesarean section, preparation of the delivery room to
prevent infection, choice of the type of anesthesia, and newborn
management.

Timing of delivery

According to the Expert Advice on Novel Coronavirus Infection in
Pregnancy and Puerperium {[}1, 3{]}, issued by Chinese Medical
Association (CMA), the current consensus is that 2019-nCoV infection is
not an absolute indication for ending pregnancy, but that expedition of
delivery should be evaluated on a case-by-case basis. Maternal disease
progression, gestational age and fetal intrauterine status are primary
concerns. If maternal safety is assured, the timing of delivery should
primarily be determined by the gestational age.

After consulting with several obstetric experts in Wuhan city, who have
each dealt with COVID-19 infected pregnancies, we suggest that the
timing of delivery for COVID-19 infection complicated pregnancies should
be based on the following four principles:

1. If the infected pregnant women demonstrate obstetric indications for
early delivery, such as placenta previa, preeclampsia, malpresentation
etc., the timing of delivery should be based on the specific obstetric
circumstances.

2. If the infection of COVID-19 is not improved by treatment, early
delivery should be considered, even in the absence of obstetric
indications.

3. If the maternal COVID-19 infection is assessed as severe or critical,
according to the diagnostic criteria in the National Health and Medical
Commission's New Coronavirus Infection Pneumonia Diagnosis and Treatment
Program (the fifth edition), early delivery needs to be considered to
ensure maternal safety, regardless of gestational age {[}4{]}.

(a) Severe: Respiratory distress (RR[?]30 beats / min), or mean oxygen
saturation [?]93\% at rest, or arterial blood oxygen partial pressure
(PaO2) / oxygen concentration (FiO2) [?]300mmHg;

(b) Critical: Respiratory failure and mechanical ventilation required,
or shock, or combined with other organ failure and requires ICU
monitoring and treatment.

4. Whether mild or common COVID-19 infection is an indication for
delivery in the third trimester remains to be determined. During severe
epidemics, delivery after 32-34 gestational weeks may be beneficial to
the subsequent treatment and safety of these patients {[}5{]}.

In summary, the current opinion of obstetric experts is that timing of
delivery should be determined by the maternal disease status. Maternal
safety is the priority; multidisciplinary consultation and the opinions
of critical care medical experts should be considered carefully.

Indications for caesarean section

\par\null

The determination of mode of delivery should be based on obstetric
indications. However, the safety of vaginal birth, cesarean section or
other methods in the context of COVID-19 infection has yet been
confirmed {[}6{]}. Nevertheless, senior obstetricians in Wuhan suggest
two recommendations:

1. During the current period of emergency {[}7{]}, the indications for
caesarean section for women with COVID-19 infection should be applied
flexibly and the threshold for Caesarean section lowered;

2. In particular, the threshold for caesarean section on the basis of
delay in the first stage of labour should be lowered;

These suggestions are aimed at reducing maternal in-patient stays,
minimizing the chance of cross-infection, reducing maternal physical
exertion during delivery and ensuring the safety of other postnatal
women, newborns and health care workers. There are currently very few
COVID-19 infected pregnant women, thus a lowered threshold for caesarean
section will not significantly increase the overall caesarean section
rate.

Delivery room and infection protection

1. Delivery should take place on a negative pressure isolation ward
{[}3{]};

2. If a negative pressure isolation ward is unavailable, then an
infection isolation ward or infection isolation surgery room should be
used for delivery. A regular delivery room should not be used;

3. Unnecessary items should be removed from the delivery room, and the
number of medical and other attending staff minimized (2-3 skilled
obstetricians and midwives/nurses are sufficient);

4. Strict infection protection for all attending staff must be adhered
to throughout the entire delivery process, including vaginal
examinations, artificial rupture of fetal membranes, etc. This entails
the use of disposable hats and protective clothing, shoe covers, N95
masks, goggles/face shields and two-layer gloves which can cover the
sleeves of protective clothing. Hands should be washed in strict
accordance with the Seven-steps Hand Washing Method and then disinfected
by the use of alcohol or hydrogen peroxide disinfection liquid {[}8{]};

6. Patients with non-general anesthesia should wear surgical masks
during delivery.

Anesthesia

Epidural anesthesia or general anesthesia can be used for delivery in
pregnant women infected with pneumonia of COVID-19 {[}3, 9{]}; for those
COVID-19 infected pregnant women who already have had intubation,
general anesthesia through endotracheal intubation can be used during
the cesarean section.

Most practitioners advocate the use of epidural anesthesia for pregnant
women infected with pneumonia of COVID-19 to reduce exacerbation of
infection during the intubation/extraction process, and to avoid the
side effects of general anesthesia on newborns (muscle tone and
breathing). Importantly, anesthesiologists must apply airborne
precautions to prevent infection during performing trachea intubation.

Neonatal management

1. Obstetricians and pediatricians should cooperate closely; the
neonatologist should be notified at least 30 minutes in advance of any
planned delivery, in order to attend and make any necessary
preparations;

2. Newborns of the suspected COVID-19 infected mother should be
transferred to the neonatal isolation ward immediately after being
evaluated as in good general condition by the attending neonatologist.
If the maternal nucleic acid test is negative for 2 consecutive tests,
the newborn may be transferred out of the isolation ward for
mother-to-child or home care {[}3{]};

3. If the maternal nucleic acid test is positive or if a maternal
infection is confirmed, newborns should be quarantined for at least 14
days {[}5{]}.

Points to note

1. Caesarean section should be performed by a senior obstetrician, in
order to minimize the likelihood of complications;

2. During the caesarean section, careful attention should be paid
achieving hemostasis, to prevent postpartum hemorrhage and risk of
challenging blood transfusion;

3. Biospecimen including vaginal secretions, umbilical blood, amniotic
fluid, placenta, neonatal throat swab should be collected during
delivery to determine the potential intrauterine vertical transmission
of COVID-19;

3. Following delivery, all surgical instruments should be labeled
''COVID-19'', and then stored, transported and sterilized in processes
separate from other instruments;

4. Medical and midwifery staff who participate in vaginal birth or
cesarean section of COVID-19 infected mothers should be followed up and
given body temperature monitoring. If any of the signs of infection
occur, including but not limited to fever, cough, fatigue, nasal
congestion, runny nose, diarrhea and other manifestations, potentially
affected staff should attend the fever clinic of a designated hospital
as soon as possible, in order that a definitive diagnosis be obtained.

\textbf{Funding}

None.

\textbf{Ethics Approval}

Not required.

\textbf{Contribution to Authorship}

H.Q, X.L, Y.Z, H.Z, J.L, L.Z, L.F, D.C, Y.S, C.T, and P. B conceived
this study, H.Q, X.L, Y.Z, C.T, and P. B wrote the draft, H.Z, J.L, L.Z,
L.F, D.C, and Y.S revised the manuscript.

\textbf{Disclosure of Interests}

None declared.

References

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respiratory infection when novel coronavirus (nCoV) infection is
suspected:Interim guidance;{[}EB/OL{]}.(2020-01-28){[}2020-01 29{]}.12
January 2020; WHO/nCoV/Clinical/2020.1
https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

{[}2{]} Jamieson DJ, Honein MA, Rasmussen S.A, et al. H1N1 2009
influenza virus infection during pregnancy in the USA. Lancet,
2009,374(9688) :429-430.

{[}3{]} Maxwell C, McGeer A, KFY T, et al. No. 225-Management guidelines
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{[}4{]} Huang C, Wang Y, Li X, et al. Clinical features of patients
infected with 2019 novel coronavirus in Wuhan, China.~~Lancet. 2020,
S0140-6736(20)30183-5.DOI: 10.1016/S0140-6736(20)30154-9

{[}5{]} Wang J, Qi H, Bao L, et al. A contingency plan for the
management of the 2019 novel coronavirus outbreak in neonatal intensive
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https://doi.org/10.1016/S2352-4642(20)30040-7

{[}6{]} Julien R, Christian AL. Pattern of early human-to-human
transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019
to January 2020. Euro Surveill. 2020;25(4):pii=2000058.
https://doi.org/10.2807/1560-7917.ES.2020.25.4.2000058

{[}7{]} Lancet T. Emerging understandings of 2019-nCoV. Lancet, 2020,
Jan 24.pii.S0140-6736 (20)30186-0. DOI: 10.1016/S0140-6736(20)30186-0.

{[}8{]} Office of the National Health Commission, Office of the National
Administration of Traditional Chinese Medicine. Guidelines for the
Diagnosis and Treatment of Novel Coronavirus (2019-nCoV) Infection
(Interim Version 5, the Revision). National Health Commission Bulletin
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{[}EB/OL{]}.{[}2020-02-08{]}.http://www.gov.cn/zhengce/zhengceku/2020-02/09/content\_5476407.htm

{[}9{]} Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS
clinical practice guidelines: noninvasive ventilation for acute
respiratory failure. Eur Respir J, 2017, 50(2). pii:1602426.
DOI:10.1183/13993003.02426-2016.

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