As I begin writing this story I sit at my desk in the hospital ready for the next page on my phone asking me to attend a C-section delivery, evaluate a newborn with low blood sugar, admit a youth with a seizure, or a myriad of other issues that might arise during my shift tonight. As a hospitalist physician trained in internal medicine and pediatrics, I cover many areas of the hospital while caring for adults and children of all ages. Tonight I am on-call for pediatrics which includes the pediatric floor, the newborn nursery, and the labor and delivery unit.
What happens if an infant is born this evening to a mother with the novel coronavirus? Perhaps you are pregnant or have a friend or loved one expecting soon and are asking yourself a similar question. Let’s take a look at how things have played out so far during the pandemic and talk about the most up-to-date recommendations on handling this complex situation.
A concerning event
A story was recently published about a woman in Montreal who was separated from her newborn for 55 days. The infant required care in the neonatal ICU because of prematurity. His mother had tested positive for Covid-19 but recovered quickly. Regional policy dictated that this mother would require two consecutive negative tests before being allowed in the hospital to visit her child. Surprisingly, she continued to test positive weeks after her symptoms had resolved. This was not an isolated occurrence as other similar events have been noted elsewhere. The regrettable outcome, in this case, and others like it, was an unnecessary separation of mother and baby during a crucial phase of the infant’s emotional and physical development.
Based on recent evidence, many experts have advised against such policies. The reason being that the PCR (polymerase chain reaction) test performed in this setting assesses for the presence of viral RNA. The test is very sensitive to pick up small fragments of the virus, SARS-CoV-2, but unfortunately, it cannot distinguish between active or dead viral particles. This can lead to persistently positive results even in a patient who has already recovered from Covid-19 and is no longer able to spread the virus to others.
“Someone that is PCR-positive, especially after they’ve recovered, especially if they’re weeks and weeks into their recovery, it’s not likely that they are still infectious,” — Maria Van Kerkhove, epidemiologist, and technical lead of the Covid-19 response for the World Health Organization.
During this health crisis, how should women in labor be cared for if they choose to deliver at a hospital? Multiple organizations including the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) have provided guidelines for managing birth in the midst of the pandemic and these guidelines generally agree with one another. What follows is a compilation and summary of their recommendations.
Are pregnant women considered high risk? Studies thus far have suggested that pregnant women with Covid-19 are not at increased risk for complications when compared to the general population. However, some data indicate that pregnant women may indeed be at a higher risk when compared to nonpregnant women of the same age group. Because more research is needed, the CDC currently includes pregnant women on their list of people who need to take extra precautions to avoid exposure to SARS-CoV-2.
On arrival at the hospital, those with symptoms of Covid-19 should undergo testing. Many hospitals also test women in labor even if they do not have symptoms of Covid-19, but this practice is not considered mandatory by the guidelines. For expectant mothers who either test positive for SARS-CoV-2 or have a pending test, the number of visitors should be limited — generally to just one family member or support person. Because there is no evidence that the virus can be transmitted across the placenta, delayed cord clamping may still be performed.
What is known about risk in newborns? In general, babies infected with Covid-19 recover without issue, but there have been reports of rare complications and even death in infants. This can be worrisome and troubling to expectant mothers which is why it is important to discuss ways to reduce the risk of exposure as much as possible.
Infants born to mothers who have confirmed or suspected Covid-19 should be tested within the first 24 hours of birth, and if negative, have an additional test within the first 48 hours of birth if the infant is still in the hospital. For infants who test negative, it is recommended that a discussion regarding the risks and benefits of separation be held between the mother and medical providers. Separation can occur by multiple methods and to varying degrees including keeping the infant in a separate room, placing the baby in an isolette, keeping the child greater than 6 feet from the mother, and having the mother wear a mask. As you might guess, if the infant and mother both test positive for SARS-CoV-2, separation is not indicated.
Guidelines also recommend a discussion about the risks and benefits of breastfeeding. While early data suggests that the virus cannot be transmitted through breastmilk, clearly, it remains challenging to avoid exposure through the air or by contact while feeding at the breast. Choosing to breastfeed remains reasonable as long as precautions are taken to reduce the likelihood of viral transmission such as hand hygiene and a cloth mask for the mother. Placing a mask on the infant is not recommended.
“Given the benefits of breast milk, when feasible, breast milk should be fed to infants regardless of maternal COVID-19 status.” Sonja A. Rasmussen, MD, and Denise J. Jamieson, MD, Caring for Women Who Are Planning a Pregnancy, Pregnant, or Postpartum During the COVID-19 Pandemic, Journal of the American Medical Association, June 5th, 2020
When can a mother with COVID-19 discontinue separation precautions from her infant? This is not the easiest to explain but here is my best attempt to break it down: The mother needs to either go 72 hours without a fever (without fever-reducing medication) and at least 10 days since her first symptom (or the first positive test in the case of an asymptomatic patient) or have two consecutive negative tests for SARS-CoV-2 at least 24 hours apart.
For mothers with planned pregnancies, except for those whose infants have arrived prematurely, none were aware at the time of conception that they would be giving birth during a global pandemic. Moreover, this crisis can heighten the already strong emotions often experienced by those whose pregnancy was unplanned. While missteps in caring for mothers and their newborns cannot be entirely avoided, healthcare providers and systems continue to adapt and improve. This shifts the focus away from the harsh reality of the pandemic and back to where it belongs — the welcoming of a beautiful new life.
- By: Bo Stapler