Recommendations for Postpartum Management
The authors believe that there is a need to reduce the risk of transmission to the baby after delivery. Steps to reduce this risk of transmission may include avoiding delayed cord clamping, skin-to-skin contact and breastfeeding. In addition, in our protocol, the newborn will be transferred to a separate room or to the ante-chamber for neonatal management to reduce the risk of droplet transmission. However, the evidence to support these measures is lacking and it is important to discuss them with the mother.
Direct breastfeeding has been discouraged in preference to formula-feeding. Wang et al reported an advisory panel from the Department of Neonatology, National Clinical Research Center for Child Health and Disorders and Ministry of Education Key Laboratory of Child Development and Disorders in China, advising avoiding breastfeeding from mothers with probable or laboratory-confirmed 2019-nCoV infection until the recovery of confirmed mothers or rejection of probable infection.(26) Although breastmilk tested in six cases of mothers with COVID-19 were found to be negative for the virus (6), the close proximity of breastfeeding exposes the infant to respiratory droplets which risks transmission. In contrast, other organisations such as the RCOG, ACOG, CDC are far less draconian and permit breastfeeding with precautions such as good hand hygiene and wearing a facemask (10,14,15).
Another controversial area concerns the practice of separating mother and baby to prevent the risk of neonatal transmission until the mother is fully recovered or is found to be negative for the COVID-19 virus. Again, evidence for this is limited. RCOG has cautioned against routine separation of mother and baby given the detrimental effects on feeding and bonding. (10) Efforts should be made to discuss these issues with the mother and her perinatal management individualised to her wishes.
The strengths of our paper include the meticulous and detailed nature of our protocols which encompasses the principles of detection, containment, intrapartum care and training. In addition, these protocols were developed after rigorous literature review and multidisciplinary discussion. While our centre has not yet managed a patient with suspected or diagnosed COVID-19, our multiple simulation runs have identified deficiencies in the protocols which we have addressed in this paper.