Reply

We thank Drs Lagrew and Shields for their interest and inquiry. We apologize that not all the appropriate references were included in our manuscript. There are a number of different publications that have demonstrated aerosolization with cough, and many are summarized in a recent commentary by Brosseau.¹ We have listed some key references below, which identify aerosolization in cough.2, 3, 4, 5, 6, 7 In addition, it is important to consider that aerosolization in the setting of disease transmission is not equivalent across all diseases, but that does not mean it is nonexistent. For example, in tuberculosis (TB), the classic example of a disease with the risk of airborne transmission, the bacteria remain viable in the air for a long time. Increasing number of studies on animals and humans have reported on the role of close-range aerosol transmission by inhalation for influenza and coronaviruses.8, 9, 10 Although airborne aerosolization risk of influenza and coronaviruses is not similar to that of TB, the risk of airborne spread remains, especially when considering prolonged close-range contact, as in the second stage of labor.

Our study also discusses the issue of limited resources and the actions the healthcare system must take in dealing with patients in the second stage of labor. Things to consider include ability to test patients for severe acute respiratory syndrome coronavirus 2. With recent advances, there is now rapid testing available that would allow for testing of all admissions to labor and delivery. This allows healthcare workers to reserve the use of limited personal protective equipment (PPE) for the confirmed cases of coronavirus disease 2019 (COVID-19). The test also reassures other laboring patients that they are COVID-19 negative. All forms of PPE are risk reducing but not risk eliminating. We present what best practices should be and recognize that best practices may not always be possible, especially in the real world where resources are limited. However, we strive to advocate, and to provide data to support, policies that will promote not only patient safety but also a safe work environment for healthcare providers.

The second stage of labor presents a unique clinical scenario of close contact (<6 feet), involving deep and heavy breathing of a patient. Despite both healthcare workers and patients wearing masks, there can be scenarios allowing the possibility of droplet and aerosol transmission, for example, close contact with a patient who has trouble keeping the mask on.³ In the setting of a pandemic, it is important to consider that PPE and healthcare workers are limited resources. Knowing this, we continue to advocate for the consideration of the second stage of labor as a high-risk scenario for both droplet and aerosol transmission and advocate that the healthcare workers should be adequately protected.11, 12, 13, 14