Discussion
Our study supports the recommendations from WHO,11CDC,12 and the Spanish Government5on the management of deliveries and neonate care during the COVID-19 pandemic. Current evidence does not conclusively support intrauterine transmission of SARS-CoV-2.6-8 However it is known that DCC, and not ECC, can reduce the risk of death before hospital discharge in preterm neonates,17 and provide benefits in those born at term. Thus, there is no evidence for not continuing to perform it. The routine separation of the neonate from the mother interferes in the mother/infant relationship.18 A woman with a probable or confirmed suspicion of COVID-19 disease can give skin-to-skin contact in the delivery room, and exclusively breastfeed her baby. Breastfeeding improves the health of both mother and infant, results in benefits for the families, and has a positive social and economic impact.18 On the whole, this current pandemic has led to combining the promotion of breastfeeding with adequate measures of infection control (wearing a mask, frequent hand washing, and social distancing). In Spain, the lack of solid evidence on the vertical transmission of the coronavirus during the initial days of the pandemic led to very conservative recommendations from the Spanish Ministry of Health for the management of deliveries in women with COVID-19.5 ECC, little skin-to-skin contact, and negativity to breastfeeding practices, were the decisions made in many cases. According to our study, ECC was more prevalent over DCC during the early period. Both ECC and DCC were equally used between 16th and 30th April. Once Healthcare Authorities proclaimed the safety of these interventions,19 the clinical practice took a new stance and progressively returned to DCC and early skin-to-skin contact. Moreover, hygienic measures (wearing a mask and frequent hand washing) were introduced to avoid mother/infant transmission during breastfeeding.
The characterization of our present study is the provision of perinatal outcomes of neonates born to COVID-19-positive mothers with DCC, practicing skin-to-skin contact and early breastfeeding under appropriate safety measures. Moreover, we included perinatal outcomes of neonates with ECC due to diverse reasons. No significant differences in COVID-19 infections were detected between the ECC and the DCC groups. Likewise, no COVID-19 symptomatology was found in neonates at day 14 of follow-up in both groups. This fact corroborates the safety of DCC and skin-to-skin contact and breastfeeding practices in women with COVID-19, in agreement with main Scientific Societies.5,11,12 It is interesting to highlight in our study the large percentage of preterm neonates with ECC. The fear of vertical transmission of COVID-19 (principle reason for choosing ECC) probably caused the decrease in the number of DCC in these neonates, who in turn are those who may benefit most from this intervention.
The possible intrapartum infection of neonates has been described.19 The suspicion could originate from a positive nasopharyngeal PRC test within 12 hours after delivery and confirmed within 24-48 hours. Horizontal transmission is suspected in the case of a positive nasopharyngeal PRC test within 24-48 hours, but a prior negative one.20 In our study, we reported 5 cases of positive nasopharyngeal PRC within 12 hours of delivery, and all were negative in the confirmation test within 24-48 hours post-delivery. This result points to the probable contamination during sample collection or a false positive. Another study from our research group also evidenced two positive PCR cases (cesarean deliveries at term), who experienced COVID-19 symptoms within 10 days of delivery.4 In that study, the initial test was negative but positive when confirmed. In both cases, neonates were in contact with parents immediately after delivery. The COVID-19 symptoms resolved within 48 hours. No information about the timing of the cord clamping was available. In our present study, we reported one positive case within 12–48 hours after delivery, possibly related to contact with a relative unaware of being infected. This neonate showed COVID-19 symptoms for some days and did not require admission into the ICU. None of the neonates from our cohort showed COVID-19 symptoms when the phone evaluation took place at day 14 after delivery, and while writing this manuscript (June 2020). Moreover, none of the neonates required admission into the ICU due to severe symptomatology of SARS-CoV-2 infection.