Intrapartum care

In July 2020, NHS England produced a document on intrapartum care under COVID-19 protocols. 

• All women should be encouraged to call the maternity unit for advice in early labour. Women with mild COVID-19 symptoms can be encouraged to remain at home (self-isolation) in early (latent phase) labour, as per standard practice.
• Continuous fetal monitoring in labour is currently recommended for all women with COVID-19, due to the potential increased fetal compromise noted in the Chinese case series of 18 women. This guidance may change as more evidence becomes available.
• If the woman has signs of sepsis, investigate and treat as per RCOG guidance on sepsis in pregnancy(link is external), but also consider active COVID-19 as a cause of sepsis and investigate according to the guidance.
• Maternal observations (hourly blood pressure, pulse rate, 4-hourly temperature) should be done as per standard practice. In addition, hourly oxygen saturations must be recorded. Aim to keep oxygen saturation >94%, titrating oxygen therapy accordingly. Women with moderate chest symptoms should have strict hourly fluid balance checks, to avoid fluid overload.
• Be aware of possible myocardial injury, and that the symptoms are similar to those of respiratory complications of COVID-19.
• Following birth, women should be risk-assessed for venous thromboembolism and the first dose of LMWH administered as soon as possible after delivery, provided there is no postpartum haemorrhage and regional analgesia has not been used. Where regional analgesia has been used, LMWH can be administered four hours after the last spinal injection or removal of the epidural catheter (RCOG, 2015(link is external)). 

Mode of delivery

• Mode of birth should not be influenced by the presence of COVID-19, unless the woman’s respiratory condition demands urgent delivery.
• An individualised decision should be made regarding shortening the length of the second stage of labour, with elective instrumental birth in a symptomatic woman who is becoming exhausted or hypoxic.
• When urgent birth of the baby is required to aid supportive care of a woman with severe or critical COVID-19 and vaginal birth is not imminent, consider whether the benefits of an urgent caesarean birth may outweigh any risks to the woman.
• Given a lack of evidence to the contrary, delayed cord clamping is still recommended following birth, provided there are no other contraindications. The baby can be cleaned and dried as normal, while the cord is still intact. Following birth, women should be risk-assessed for venous thromboembolism and the first dose of LMWH administered as soon as possible after delivery provided there is no postpartum haemorrhage and regional analgesia has not been used. Where regional analgesia has been used, LMWH can be administered four hours after the last spinal injection or removal of the epidural catheter (RCOG, 2015(link is external)). 
• Delay of elective caesarean birth or induction for women with symptoms suggestive of COVID-19, as well as those with confirmed COVID-19, should be considered.
• The level of PPE required by healthcare professionals caring for a woman with COVID-19 who is undergoing a caesarean birth should be determined based on the risk of requiring a general anaesthetic (GA); where GA is planned from the outset, all staff in theatre should wear PPE, with a FFP3 mask. The scrub team should scrub and don PPE before the GA is commenced.
• Women and their families should be aware that donning PPE for emergency caesarean birth is time-consuming but essential, and that this may impact on the time to delivery and potentially result in adverse outcome. This should be taken into account during decision making.
• Waterbirth is not contraindicated for women who are asymptomatic of COVID-19 and presumed or confirmed SARS-CoV-2 negative, providing adequate PPE can be worn by those providing care.
• The International Confederation of Midwives recommends that in countries where the health systems can support homebirth, healthy women experiencing a low-risk pregnancy may benefit from giving birth at home or in midwife-led units rather than in a hospital where there may be many COVID-19 patients, if there is the ability to provide appropriate midwifery support and appropriate emergency equipment and transfer (International Confederation of Midwives, 2020). 
• For women who are symptomatic of COVID-19 with a cough, fever or feeling unwell, labour and birth in water is not recommended.
• For women who are asymptomatic of COVID-19 but test positive for SARS-CoV-2, there is inadequate evidence about the risk of transmission during waterbirth. Advice should be sought from Infection Prevention and Control authorities.

Pain relief in labour

• There is no evidence that the use of Entonox is an aerosol-prone procedure. Entonox should be used with a single-patient microbiological filter. This is standard issue throughout maternity units in the UK.
• There is no evidence that epidural or spinal analgesia or anaesthesia is contraindicated in the presence of coronaviruses. Epidural analgesia should therefore be recommended before or early in labour to women with suspected/confirmed COVID-19, to minimise the need for general anaesthesia if urgent delivery is needed.

Birth partners and visitors

On attendance at the maternity unit, all birth partners should be asked whether they have experienced any symptoms suggestive of COVID-19 in the preceding 14 days, e.g. fever, acute persistent cough, or changes in or loss of sense of smell (anosmia) or taste.

• If they have had symptoms within the past 14 days, they should be asked to leave the maternity unit immediately and self-isolate at home, unless they have had a negative test result for coronavirus.
• If they have had a fever within the past 48 hours, they should be asked to leave the maternity unit immediately and self-isolate at home, regardless of their test result.
• Guidance about testing of women and their birth partners is discussed in the RCOG document Principles for the Testing and Triage of Women Seeking Maternity Care in Hospital Settings, During the COVID-19 Pandemic.
• Asymptomatic birth partners should be permitted to stay with the woman throughout labour and birth, unless the birth occurs under general anaesthetic. Further guidance about access to maternity services for birth partners and other supportive adults has been published by the NHS, and should be followed as far as possible.