Welcome to this week’s research update on COVID-19 and pregnancy!

This week we share info about recent changes to the Centers for Disease Control and Prevention’s (CDC) Considerations for Inpatient Obstetric Healthcare Settings, new CDC reports on U.S. COVID-19 cases and hospitalizations, and findings from a case series of infected pregnant women in New York.

We will also answer a few of your questions in a new Q&A section at the bottom of this research update! To ask a question for consideration for future newsletters, submit your question here.

Next week our research update will take place via webinar and Facebook live rather than a written newsletter. You can register for that free, public event here.

Don’t forget to check out our COVID-19 resource & pregnancy page that includes archives of these newsletters, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.

Numbers Update from Johns Hopkins University

As of 10 AM EDT this morning, there are 1.86 million confirmed cases of COVID-19 around the world. For the third week in a row, the U.S. has the highest number of cases, with 557,590 positive test results. This number is much higher than the four countries with the next-highest number of cases: Spain (169,496), Italy (156,363), France (133,672), and Germany (127,854).

**Change in CDC Guidelines**

Importantly, on April 4, the CDC made revisions to their February 18 Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.

A revision was made to reflect that the decision of whether to keep a mother with known or suspected COVID-19 and her infant together or separated after should be “ on a case-by-case basis, using shared decision-making between the mother and the clinical team .”

The CDC’s earlier guidance (now outdated) from February stated, “ To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued .”

The language in that earlier guidance was widely interpreted as the CDC recommending separation, although rooming in was still possible in accordance with the mother’s wishes.

In their April update, the CDC has shifted toward a more neutral stance on mother-baby separation and draws attention to the need for shared decision-making.

They also added: “ The many benefits of mother/infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels, and maintaining infant body temperature and though transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern, the risk of transmission and the clinical severity of SARS-CoV-2 infection in infants are not clear.”

We updated the Evidence Based Birth® sample “Informed consent form for refusal to separate birthing parent and infant” with this new revised language from the CDC.

We’ve had many requests for this form, both from hospital professionals and parents, and it can be downloaded for free on our COVID-19 resource page. I’ve attached the form here. (We’re working on a Spanish translation!)

First CDC Report on who Required U.S. Hospital Care with COVID-19 in March

On April 8, the CDC published a Morbidity and Mortality Weekly Report (MMWR) that examined COVID-19 hospitalization data from 14 states—including statistics by race and sex (Garg et al. 2020).

The data in the report come from a surveillance network called COVID-NET that is tracking COVID-19 in 14 states. The surveillance area represents about 10% of the U.S. population.

The report includes 1,482 patients hospitalized with COVID-19 in the first month of U.S. surveillance (March).

The statistics point to racial health disparities and suggest, “ Black populations might be disproportionately affected by COVID-19 .” In the surveillance data, 18% of people in the study population were Black, but 33% of hospitalized patient s were Black. The CDC data on race w ere severely lacking ; race wasn’t reported for the majority (60%) of people included in the analysis.

Note from EBB: Our podcast episode coming out on Wednesday will focus on these racial disparities.

They also found that more men than women have been hospitalized for COVID-19. In the COVID-NET surveillance population, 49% were male and 51% we female, but men made up 54% of COVID-19 hospitalizations and women made up 46%.

The analysis also found that about 90% of people in the hospital with COVID-19 had at least one underlying health condition. Half of hospitalized patients had hypertension, half had a high body mass index, 36% had chronic metabolic disease (e.g., diabetes), and 35% had chronic lung disease (e.g., asthma). Rates of COVID-19 hospitalizations were highest among people 65 years and older.

First CDC Report on Pediatric U.S. COVID-19 cases

On April 10, the CDC published the first description of pediatric cases of U.S. COVID-19 (CDC COVID-19 Response Team, 2020).

In the U.S., 22% of the population is made up of infants, children, and people <18 years. Out of 149,082 lab-confirmed COVID-19 cases in the U.S. occurring during February 12 to April 2, only 2,572 (1.7% of cases) were among children <18 years. The majority (57%) of cases were males.

Fewer children than adults experience d fever, cough, or shortness of breath (73% of pediatric patients versus 93% of adults 18-64 years).

Relatively few children with COVID-19 we re hospitalized (5.7% of all pediatric infections); however, severe outcomes have been reported in children, including three deaths included in the analysis. There was no information provided about the three deaths, and the cases are still under review to confirm COVID-19 as the likely cause of death.

Case Series of 43 Pregnant Women in New York with COVID-19

A case series from New York of 43 women who tested positive for COVID-19 was published April 9 (Breslin et al. 2020).

Infection was often asymptomatic (14 out of 43 women, 33%), leading the authors to recommend universal testing of pregnant people being admitted to the labor unit. Of the asymptomatic women, 10.14 (71%) developed symptoms over the course of their admission or shortly after discharge.

The majority of women (60%) had a body mass index of 30 or greater. Many of the women (42%) had an additional comorbid condition (most commonly asthma).

The women showed a similar pattern of disease severity to non-pregnant adults: 86% mild, 9% severe and 5% critical, although the sample size was too small to make a direct comparison.

Newborns were tested on the first day of life and there were no confirmed cases of COVID-19. All 18 infants who were born during the case series had had Apgar scores ≥7 at 1 minute and ≥9 at 5 minutes. All 18 infants, including three who were initially admitted to the NICU for conditions unrelated to COVID-19, have since been discharged home.

New Q and A Section!

We have received SO MANY QUESTIONS from you and we are reading each and every one! We’ll try to answer a few of your questions each week and post them to our COVID-19 resource page.

Question: I was trying to conceive, but now I am so concerned about COVID-19 and pregnancy. How do I weigh the potential risks of infection during pregnancy versus the risks of delaying trying to conceive at my advanced maternal age?

Answer: This is a deeply personal choice, but we can share a few factors you might consider when deciding whether or not to delay trying to conceive because of the pandemic. First, pregnant people are not any more likely to become infected with this virus or to develop serious illness with COVID-19 disease compared to non-pregnant adults. The majority of infected pregnant people will only experience mild or moderate cold/flu symptoms. No reports of maternal deaths have been published. There is no evidence to suggest an increased risk of miscarriage with COVID-19. Researchers aren’t sure yet whether the virus can pass from parent to baby during pregnancy; several babies in published case series have tested positive soon after birth, but all recovered without complication. The virus has not been detected in cord blood, amniotic fluid, vaginal fluid, or breast milk.

Question: I am due in June. Do you have any idea what June will be like?

Answer: The Institute for Health Metrics and Evaluation has a great website with COVID-19 projections for the U.S. (nationally and by state) and for European countries. You can see projected resource use (ICU beds, ventilators), deaths per day from COVID-19, and total deaths from COVID-19.

Their projections go all the way out to August 1. The researchers state this is a model of the first wave of the epidemic, after which they state 97% of people will still be susceptible to the disease. The models assume social distancing will be in place through the end of May. The projections could change if social distancing recommendations are lifted before then. The model also assumes that appropriate measures will be taken in July and August to prevent further spread of the disease, including mass screening, contact tracing, testing of everyone who enters the country, and quarantine of positive individuals.

Question: Is there any evidence that waterbirth should not be done now in light of COVID-19?

Answer: We don’t have any published evidence yet on COVID-19 and waterbirth, but there are research efforts underway (if you are approached about participating in a study, please participate!) Guidance from the Royal College of Obstetricians and Gynaecologists (dated April 9) advises against waterbirth for anyone with suspected or confirmed COVID-19. However, this recommendation is based on theoretical risk, not evidence.

The virus has been detected in feces, so there is a concern that the pool water could become contaminated, increasing the risk of infection for the baby and birth attendants.

According to a CDC FAQs on Water and COVID-19, “There has been no confirmed fecal-oral transmission of COVID-19 to date.” The CDC goes on to say, “There is no evidence that COVID-19 can be spread to humans through the use of pools, hot tubs or spas, or water playgrounds. Proper operation, maintenance, and disinfection (e.g., with chlorine and bromine) of pools, hot tubs or spas, and water playgrounds should inactivate the virus that causes COVID-19.”

Barbara Harper, RN, CLD, CCCE, Midwife, and Founder/Director of Waterbirth International, has a video and opinion piece called “Keeping Waterbirth Safe During COVID-19.” She also has a protocol for cleaning the tub between births and a sample informed consent form. Barbara recommends that anyone with a fever should avoid waterbirth (that was standard protocol before the pandemic). She explains that ideally, everyone would be tested, because knowing whether a person is infected is the key to creating policy on the use of hydrotherapy in labor.

Question: How should labor and delivery personnel be protected from COVID-19 in the second stage of labor (the pushing stage)?

Answer: The CDC recommends using N95 respirators for aerosol-generating procedures (AGPs). However, there has been disagreement over whether the second stage of labor is an AGP. The Centers for Disease Control dose not list the second stage of labor as an AGP.

During the second stage of labor, birth attendants are at increased risk of exposure to fecal content as well as respiratory exposure, often spending three or four hours in close physical contact with the birthing person who may be coughing, shouting, breathing hard, or vomiting, and unable to keep a mask on themselves the entire time the staff are in the room. The International Society for Ultrasound in Obstetrics and Gynecology has included the second stage of labor, vaginal birth, and Cesareans as possible AGPs that should require appropriate PPE, including N95.

Similarly, Labor and Delivery Guidance for COVID-19 published in AJOG MFM states, “The second stage of labor is likely high risk for aerosolization and N-95 mask should be used.” The authors recommend that health care workers should use an N95 and droplet precautions while caring for any patient in the second stage, regardless of whether or not the patient has respiratory symptoms. We reached out to these authors regarding questions we have received about patients having difficulty wearing masks (since it’s been advised that all laboring patients wear a surgical mask, regardless of whether or not they have respiratory symptoms). They confirmed that the difficulty in keeping a mask on a patient during the second stage makes it even more important for health care workers to wear an N95 or equivalent during the second stage.

An article published in the American Journal of Perinatology on April 10 advises, “All staff and physicians in the room during the second stage of labor or cesarean delivery should be wearing full PPE including gown, gloves, eye protection, and N95 mask.” Again, this does not mean wearing PPE for patients with symptoms of COVID-19… instead, this means health care workers should be wearing full protection and N95 masks during the second stage for all laboring patients. Unfortunately, hospitals are attempting to conserve their equipment, and protocols for the second stage vary from hospital to hospital. The authors of this article state that their own hospital facility recommends that staff wear a surgical mask during the second stage with someone who is asymptomatic or suspected of having COVID-19, and to reserve N95 masks for COVID-19 positive patients.

Yes, there are shortages of PPE, but it is not acceptable to deny labor and delivery staff adequate protection. Health care workers deserve to be protected while doing their job, and we are all safer if we have health care workers who are not infected.

References

Breslin N, Baptiste C, Gyamfi-Bannerman C, et al. (2020). COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals, American Journal of Obstetrics & Gynecology MFM (2020).

CDC COVID-19 Response Team (2020). Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422–426.

Garg S, Kim L, Whitaker M, et al. (2020). Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 April 2020.

Palatnik A, McIntosh JJ. (2020). Protecting Labor and Delivery Personnel from COVID-19 during the Second Stage of Labor [published online ahead of print, 2020 Apr 10]. Am J Perinatol.