Recommendation on caesarean section
The recently published guidelines from the RCOG on the management of COVID-19 in pregnancy discussed the mode of delivery. With no evidence to favour one mode of delivery over the other, the RCOG’s view was to take into account the mother’s preferences and obstetric indications present. (10)
Given the practical challenges identified in vaginal delivery in our institution, the authors have proposed consideration for elective caesarean section instead. This is also supported by Chen et al who reported a series of nine patients infected with COVID-19 who had caesarean sections in their third trimester. None of the neonates had evidence of vertically transmitted intrauterine infection.(6) This information is used when counselling mothers on mode of delivery. Mothers who still wish to have a vaginal delivery after counselling will have their wishes respected.
The high rate of fetal compromise reported during labour (6) increases the risk of requiring a category 1 caesarean section. There are difficulties in arranging a category 1 caesarean section from our hospital’s isolation ward, being situated in a different block from the labour ward and the operating theatres. Timely delivery in the event of fetal distress during labour is difficult to achieve. Given the high rate of fetal compromise, we would monitor the fetuses with continuous electronic fetal monitoring.
Provisions have also been made in our protocols to allow perimortem caesarean section if clinically indicated. Infection containment principles will still apply in this event.
Although there have not been any reported cases of vertically transmitted intrauterine infection from the Chinese experience (6,25), the COVID-19 virus was found in a stool sample from a patient with diarrhoea. (21) The authors are concerned that viral shedding in stools may infect the neonate during vaginal birth.
However, in patients that present in imminent delivery, delivery by caesarean section may be difficult to achieve safely. In such situations, vaginal delivery should proceed with special precautions pertaining to infection containment.