Pregnancy and labour management of women with COVID-19 infection

Following things can be done to provide appropriate antenatal care to pregnant health care workers, who are working with the patients infected with COVID-19 infection:

• If possible, work from home should be given to the pregnant healthcare workers. 
• Pregnant healthcare workers should be given a choice of whether they want to work in direct patient-facing roles or not.
• If the healthcare worker is pregnant for less than 28 weeks, they need to practice physical distancing and should be given proper PPE for their safety.
• If a healthcare worker is pregnant for more than 28 weeks and has an underlying medical condition, contact with COVID-19 confirmed patients should be totally eliminated. If possible, they should be asked to work from home.

If a pregnant woman is showing mild symptoms of COVID-19 infection such as fever, cough and difficulty breathing, she should contact her maternity doctor and let her know about her present condition. The doctor would assess whether the symptoms are pregnancy-related or infection-related and work accordingly. 

However, if the patient shows severe symptoms such as extreme difficulty in breathing, continuous pain in the chest, confusion (delirium) and bluish discolouration of the face and lips, then they need to contact the hospital (assigned specially for COVID-19 patients) immediately. The patient should go to the designated screening areas for suspected cases of COVID-19 infection.

The pregnant woman should take fewer people with her to minimize the risk of spreading the infection to them. 

The patient should come to the hospital in a private vehicle, if not possible, they should ask the hospital to send their COVID-19 ambulance for the pregnant woman.

Read more: Pregnant women and COVID-19

When a woman with a suspected COVID-19 infection reaches a hospital she would be examined by an infectious disease specialist, who would assess the severity of the case, and an obstetrician, who would assess any obstetric emergency.

If a woman is showing mild symptoms but does not have any obstetric emergency, then the she would be asked to stay under isolation at home for 14 days, and if the symptoms persist then a COVID-19 test would be done after 14 days.

If the pregnant woman comes to the hospital with severe symptoms along with obstetric emergency, then she would be admitted to the COVID section of the hospital. The woman would be kept in an isolation ward and nasopharyngeal swabs would be taken for immediate testing. The obstetrician would visit to check the health status of the pregnant lady as well as her baby.

If the pregnant woman is COVID-19 positive but asymptomatic

• If a pregnant woman is confirmed with COVID-19 infection but does not show any symptoms or does not have any underlying medical condition or an obstetric emergency, then the patient would be kept in home isolation and the foetus (the unborn baby) would be monitored in every two weeks to check their growth and heartbeat with the help of a doppler.
• All routine scans like foetal monitoring, glucose tolerance test and other tests are done after the isolation period is over. 
• In case of any obstetric emergency during the isolation period, the woman can contact her obstetrician.

If the pregnant woman is COVID-19 positive but symptomatic

• If the pregnant woman is symptomatic, the patient is hospitalised. 
• The temperature, blood pressure, respiratory rate and heart rate of the pregnant woman should be check 3 to 4 times a day.
• Investigation examinations like chest X-rays or CT scans should only be performed in case of emergencies and under complete precaution. An abdominal shield should be placed on the pregnant lady to prevent the fetus from the radiation.   
• Oxygen therapy can be prescribed to make sure that saturation stays above 95%.
• Hydration should be given orally rather than intravenously.
• Antipyretic medications should be given to maintain the temperature of the mother as well as protect the baby from the increased maternal temperature.
• Testing should be done for any superimposed viral or bacterial infection other than COVID-19.
• Pregnant women should be offered thromboprophylaxis with Low Molecular Weight Heparin unless there is a specific contraindication such as the risk of labour or active bleeding. Thromboprophylaxis is done to prevent the risk of venous thromboembolism, which is very common in the pregnancy as well as COVID-19.
• Foetal heart rate and foetal movement are checked on a daily basis. Antenatal corticosteroids can be given to the patients who are at a high risk of preterm delivery.

The pregnant woman is admitted to the Intensive Care Unit (ICU) based on the maternal early warning criteria which involve:

1. Systolic blood pressure (the upper limit of the blood pressure which is normally 120 mm Hg) is less than 90 mm Hg or more than 160 mm Hg.
2. Diastolic blood (the lower limit of the blood pressure which is normally 80 mm Hg) is more than 100 mm Hg.
3. Heart rate is less than 50 beats per minute or more than 120 beats per minute.
4. Respiratory rate is less than 10 breaths per minute or more than 30 breaths per minute.
5. Oxygen saturation is less than 94%.
6. Oliguria (urine output of less than 35ml per hour). 
7. Confusion, agitation, unresponsiveness.
8. A person with a history of preeclampsia complaining of a headache or shortness of breath.

A pregnant woman can also be admitted to the ICU if she shows any of the two symptoms out of the three symptoms used for Sequential Organ Failure Assessment (SOFA):

1. Systolic blood pressure is less than 100 mm Hg.
2. Respiratory rate is more than 22 breaths per minute.
3. The patient is in an altered state of consciousness.

If the pregnant woman is asymptomatic and is not showing any signs of respiratory distress, then she can give birth to her baby naturally. However, if the patient’s condition worsens or she suffers from septic shock or acute organ failure, the doctors should consider immediate caesarian delivery.

The delivery of the baby should not be affected by the mother’s infection and is not an indication for induced labour (provoke labour with the help of medications).

If the infection has occurred during the early pregnancy, there should be no alterations in the time of delivery. 

If the infection has occurred in the third trimester, the delivery should be postponed until the two consecutive tests of the mother turns out negative.

However, if the woman is critically ill, the delivery of the baby should be done immediately to reduce the metabolic and respiratory load from the mother’s body. Before delivering the baby, the doctors also have to make sure that the mother is clinically stable, the gestational period is more than 25 weeks (which is normally 40 weeks) and the fetus is otherwise healthy.

If a woman who has already been advised a planned induction or C-section due to any prior medical issues gets infected with COVID-19 infection, the delivery would then depend upon her current health situation.

If the woman has COVID-19 infection but is asymptomatic, then the delivery can be carried out in the way it was planned. 

If the woman has the infection and has symptoms, the delivery would be held until the two-week isolation period ends. But if the patients get severely ill by the second week, the doctors may either have to continue or terminate the pregnancy.