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.