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.