COVID‐19 vaginal delivery – A case report

Abstract

The novel coronavirus termed SARS‐CoV‐2 (COVID‐19) is a major public health challenge. Many maternity units around the country are currently considering management protocols for these patients. We report a case from a tertiary Australian hospital describing an uncomplicated vaginal birth in a COVID‐19 positive mother. To our knowledge this is also the first case described of a mother with COVID‐19 not separated from her infant. Management provided supports the current Royal College of Obstetricians and Gynaecologists and World Health Organization guidelines suggesting that it is possible to consider rooming in post‐delivery for COVID‐19 positive parents. Encouragement of breastfeeding appears possible and safe when viral precautions are observed.

Case Report

The novel coronavirus termed SARS‐CoV‐2 (COVID‐19) is a major public health challenge. There have been limited cases of coronavirus infection in pregnancy and delivery. Published data thus far have indicated that pregnant women do not seem to be at an increased risk of severe disease. ¹ There is no current evidence of vertical transmission from mother to baby of coronavirus. ²

The largest published experience of coronavirus in pregnancy and delivery has emerged from China. ² , ³ , ⁴ These women have almost exclusively undergone caesarean section births. They have also been separated from their infants for a minimum of 14 days and not breastfed or roomed in. The recent Royal College of Obstetricians and Gynaecologists (RCOG) guidelines have suggested that delayed cord clamping, breastfeeding and rooming in may be possible for these mothers and babies if strict viral precautions such as mask wearing and handwashing are observed. ¹ The World Health Organization (WHO) guidelines also strongly continue to support breastfeeding for COVID positive mothers. ⁵ There is currently no published literature on COVID positive women who have undergone a vaginal delivery without separation from their infant.

We describe a case report from Gold Coast University Hospital (GCUH). This case report was reviewed by the Human Research Ethics Committee at the Gold Coast Health Service and ethics approval was granted LNR/2020/QGC/63170.

The patient reported is a 31‐year‐old who was booked for antenatal care though GCUH. She was a gravida 1, para 0, at 40 weeks + 0 days. The patient contacted GCUH after a close family contact had been diagnosed with COVID‐19 following overseas travel. While the patient initially remained asymptomatic she was managed as a suspected case due to close family contact. Delivery planning occurred with a multidisciplinary team. The patient expressed a desire to attempt a vaginal delivery and not be separated from her infant even if a COVID‐19 infection eventuated.

At 40 weeks + 2 days gestation she presented to GCUH with upper respiratory symptoms. Observations and saturations remained normal and she was afebrile. The patient was admitted to the hospital for monitoring and COVID‐19 testing was confirmed to be positive. While hospitalised she spontaneously laboured at 40 + 3 and was transferred to a birth suite isolation room for delivery management. Artificial rupture of membranes was performed and an oxytocin infusion was commenced in efforts to hasten delivery and birth. Continuous cardiotocography (CTG) was commenced and an early epidural was inserted.

The patient developed a temperature of 38.4°C intrapartum with ongoing respiratory symptoms. Although this was thought to be secondary to COVID‐19 she was managed with the usual unit protocol of triple antibiotics (gentamicin, metronidazole and cephazolin) for possible chorioamnionitis. Respiratory saturations remained normal throughout labour.

Staff directly involved in the patient’s care wore full personal protective equipment including n95 masks.

The patient wore a surgical mask during second stage which lasted 33 min. Rotational vacuum delivery was performed for non‐reassuring fetal CTG. Second degree perineal tear was sutured and estimated blood loss was 250 mL. Neonatal Apgars were nine and nine. Cord blood gases were: arterial gas 7.2, base excess (BE) −6, lactate 6.3 and venous gas 7.24, BE 8.8, lactate 4.2. No neonatal resuscitation was required. There was no maternal‐neonatal separation and the baby remained with the parents in the birth suite room.

The family was transferred postnatally to an isolation room on the maternity ward. Both parents were eventually confirmed to be COVID‐19 positive. They observed strict viral precautions of handwashing and use of surgical masks around their baby. The neonate was breastfed throughout. Neonatal COVID‐19 testing was performed at 24 h post‐delivery which was negative. No further neonatal follow‐up testing was deemed necessary given the baby remained well and asymptomatic.

The mother's observations including saturations remained normal throughout her postnatal stay. The family was discharged home day 4 with follow‐up from the telehealth virtual public health fever clinic and home visiting midwifery team. The family was advised to isolate at home and continue viral precautions until clearance criteria were met (10 days from symptom onset and all symptoms resolved for a minimum of 72 h). They were provided with a box of simple surgical masks on discharge (not n95) to allow continued mask wearing around their newborn at home. Both mother and baby have remained well postnatally with complete resolution of maternal symptoms and discharge from the fever clinic at ten days post‐initial symptom onset.

The case describes an uncomplicated vaginal birth in a mother with COVID‐19. To our knowledge this is also the first case described of parents with COVID‐19 not separated from their infant. Management provided supports the current RCOG and WHO guidelines suggesting that it is possible to consider rooming in post‐delivery for COVID‐19 positive parents. Encouragement of breastfeeding appears possible and safe when viral precautions are observed.