**8. Antenatal care for women with suspected/confirmed covid-19**

Care of symptomatic pregnant women suffering from Covid-19 should be a multidisciplinary team approach.

American College of Obstetricians & Gynaecologists (ACOG) has developed an algorithm for management of outpatient pregnant women with suspected or confirmed COVID-19. If a woman has no symptoms to suggest infection with SARS-CoV2, she should receive routine prenatal care. If she has symptoms, severity of symptoms should be assessed. Assessment of severity of illness should include any shortness of breath, coughing up blood, dizziness, chest pain, not being able to keep down fluids and any history of confusion. If any of these are present, pregnant woman is at elevated risk and should be asked to seek care in an emergency department in a centre that has facilities for antenatal and obstetric care. If the woman has symptoms but those are not severe, she should be screened for any co-morbidities and any obstetric complications. If any co-morbidities or obstetric complications are present, she is categorised as having moderate risk and should be evaluated in ambulatory setting as soon as possible and should be investigated for severity of illness. CT Scan with abdominal shielding should be done if clinically indicated. If the woman does not have any high risk factors, she should be sent for symptomatic care at home, including hydration and rest and evaluated repeatedly for development of any of the above symptoms [26].

Indian Council of Medical Research (ICMR) recommends that symptomatic women with fever >38°C and respiratory symptoms should be hospitalised in a tertiary care centre with facilities for maternal and fetal monitoring. Seriousness of maternal situation is assessed by quick SOFA score, parameters of severity being systolic blood pressure < 100 mmHg, respiratory rate > 22, and Glasgow consciousness scale <15. Any pregnant woman with more than one of these factors should be admitted in Intensive Care Unit (ICU) [27].

FIGO recommends anomaly scan at 18–23 weeks in women with confirmed SARS-CoV2 infection and monthly scan after that for fetal growth. ICMR (Indian Council for Medical Research) recommends a growth scan 14 days after recovery from acute illness [25].

#### **9. Management during labor**

#### **9.1 Preparation before admission**

Admission for labor and delivery represents a unique scenario in that admission, though planned, cannot be delayed. The basic principles remain the same as those for outpatient visits, i.e., to avoid unnecessary hospital visits, maintain social distancing and other measures to prevent spread of SARS-CoV2. Women should be advised to quarantine themselves or work from home at least 14 days before planned admission for delivery or caesarean. This should start in most women by 37 weeks of gestation. Woman and her birthing partner should be screened for symptoms of COVID-19 telephonically one day before admission [28].

#### **9.2 Screening on arrival**

All women arriving for admission for delivery should be screened verbally for fever, cough and respiratory symptoms. Birthing partner should be similarly screened. Those testing positive should be sent for testing and care by Obstetric care

#### *Pregnancy and COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.98710*

provider. Some women would already be diagnosed with SARS-CoV2 infection and they should directly be delegated to area dedicated for infected patients.

Case can be made for testing all women at the time of admission to labor and delivery unit because of high number of asymptomatic infections [20]. Local guidelines could also mandate testing at the time of admission.

After screening at the time of admission, women will be categorised into one of the three categories: infected, suspect and non-infected. Under ideal circumstances, all health care facilities caring for pregnant women should have well demarcated zones with separate passageways for all of these categories. These zones should include separate wards, intensive care areas and operation theatres. If not possible, all care should be taken to avoid infected and non-infected people coming in proximity of each other.

#### **9.3 General precautions during admission**

All women and their birthing partners should wear triple layer surgical masks throughout admission. All healthcare providers should wear triple layer surgical mask for each patient contact. Hands should be sanitised with alcohol based handrub after every patient contact. Droplet precautions should be used when caring for women with respiratory symptoms. This requires the use of gloves, gown, surgical mask and face shield. Gown, gloves, face shield and N95 mask should be used for any woman with suspected COVID and during any aerosol generating procedure including second stage of labour [28]. Disinfection of rooms should be done between patients.

Women should be allowed to have one birthing partner who should stay throughout admission. Other support persons should be given option to provide support through video. Visitors should not be allowed in person, although visitation may be considered in end of life situations.

Shifting of woman from one area to other should be avoided and all efforts should be made to provide services at women's bedside.

All preoperative investigations needed for caesarean should also be done on the day of admission to decrease the number of pre-admission hospital visits.

#### **9.4 Intrapartum care**

Management of first stage of labour remains essentially the same as in a woman not infected with Covid-19. Women with mild disease require management of fluidelectrolyte balance during labor, in addition to symptomatic management and close monitoring of maternal well-being. Woman should be encouraged to take oral fluids to maintain hydration. Intravenous fluids should be used with caution because of association of Covid-19 with Acute Respiratory Distress Syndrome (ARDS) [25]. Early use of oxytocin for slow and dysfunctional labour is recommended to avoid the stress and complications of a prolonged labor. Use of Nitrous Oxide during labour should be avoided because of insufficient data about cleaning, filtering and potential aerosolization of nitrous oxide systems [28].

Oxygen is used intrapartum for fetal benefit, to increase fetal oxygenation. A recent meta-analysis has shown that it does not provide fetal benefit and may even be harmful [29, 30]. ACOG recommends against the use of oxygen therapy for fetal resuscitation during labour [28].

Second stage of labour is considered an aerosol generating procedure and should be managed with appropriate precautions. Obstetric management remains the same as before the pandemic.

Blood resources have become scarce during the pandemic because of inability to conduct donation drives. Maintaining pre-delivery haemoglobin is the most efficient way to decrease the use of blood during labour and delivery admissions. Utmost importance should be given to aggressively treat anaemia detected during pregnancy. Blood transfusion should only be used when absolutely necessary and in minimum quantity.

Misoprostol and tranexamic acid should be used prophylactically in third stage of labor to decrease blood loss after delivery.

#### **10. Management of pregnant woman with COVID-19**

A pregnant woman with SARS-CoV2 infection should be counselled about the risk of serious infection and the methods to protect family members from infection. Next step is to assess systemic status of woman for severity of infection and need of hospitalisation.

Management of infection should be same as management of non-pregnant patients with COVID-19. If the patient needs hospitalisation, she should be admitted in a facility where maternal as well as fetal monitoring can be done [31]. The facility should be able to provide fetal and uterine contraction monitoring, individualised delivery planning and team based approach including obstetrician, paediatrician, anaesthetist and respiratory medicine specialist. The basic principles and medications remain the same as in non-pregnant patients. Potentially effective treatment for COVID-19 should not be withheld from pregnant women due to theoretical concerns regarding safety. Decisions regarding treatment options should be made keeping in mind safety of the medication, the severity of maternal disease and in shared decision-making with the patient [31].

A very important limitation is exclusion of pregnant women from most clinical trials involving new treatment modalities and the safety data remains scarce.

In most cases, timing of delivery should not be altered by maternal COVID-19 infection [32]. Patients who get infected in early pregnancy and subsequently recover do not require any change in the timing of delivery. For patients who contract SARS-CoV2 infection in the third trimester of pregnancy, attempt should be made to postpone delivery till negative SARS-CoV2 report or lifting of quarantine status to decrease the risk of perinatal transmission. Maternal COVID-19 infection is not an indication for caesarean section, which should be done for obstetric indication or on maternal request [32]. Because the risk of transmission from umbilical cord blood is low, delayed cord clamping should be continued as pre-pandemic. Similarly, umbilical cord blood banking can be done if the parents desire.

#### **11. Lactation and COVID-19**

Several studies have detected SARS-CoV2 nucleic acid in breast milk. However, infectious virus particles have not been detected in breast milk [33]. Also, antibodies specific to SARS-CoV2 have also been detected in breast milk, which could potentially protect the neonate. Therefore, it is recommended to continue breastfeeding in mothers with SARS-CoV2 infection, with precautions. These precautions include hand hygiene before breast feeding and wearing a face mask. Breast milk may be expressed after hand-hygiene and fed to infant by uninfected care-provider after disinfection (pasteurisation) [33].
