Since the initial report of a novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan in December 2019, there has been widespread dissemination of disease worldwide.1 The impact on the neonatal population has been reported almost exclusively from China.2–8 Our study goal is to characterize for the first time in the United States the delivery room (DR) management and early course of infants born to mothers positive for coronavirus disease 2019 (COVID-19) during 3 weeks at the peak of the pandemic in New York, New York, and to describe the challenges and approaches developed to meet these excessive needs.
Methods
This is a prospective initiative of mothers admitted to labor and delivery, all of whom were tested, and is focused on those who tested positive for COVID-19 via SARS-CoV-2 polymerase chain reaction obtained from a nasopharyngeal swab only and their infants triaged to the well-baby nursery (WBN) or admitted to NICU at New York-Presbyterian Hospital Weill Cornell Medicine between March 22 and April 15th, 2020. A checklist developed during the process delineated DR preparedness including availability of essential personal protective equipment (PPE) (N95 respirator), resuscitations for COVID-19-positive or patient under investigation (PUI) deliveries to follow the neornatal resuscitation program algorithm, with subsequent transport and NICU admission steps as outlined in Fig 1. Infants triaged to the WBN were managed as per posted guidelines.9 The study received exempt status approval from the institutional review board.
Checklist depicting preparation for delivery in either the operating room (OR) or labor delivery room (LDR) and the steps to follow in preparation for resuscitation, transportation to the NICU, and early postresuscitation care. Suspected or confirmed COVID-19 alone in an otherwise uncomplicated pregnancy is not an indication for the resuscitation team or the neonatal fellow. DR preparation and management should include contact precautions. NC, nasal cannula; NIPPV, nasal intermittent positive pressure ventilation; RN, registered nurse.
Checklist depicting preparation for delivery in either the operating room (OR) or labor delivery room (LDR) and the steps to follow in preparation for resuscitation, transportation to the NICU, and early postresuscitation care. Suspected or confirmed COVID-19 alone in an otherwise uncomplicated pregnancy is not an indication for the resuscitation team or the neonatal fellow. DR preparation and management should include contact precautions. NC, nasal cannula; NIPPV, nasal intermittent positive pressure ventilation; RN, registered nurse.
Results
There were 326 deliveries resulting in 31 (9.5%) mothers testing positive for SARS-CoV-2; 15 (48%) were asymptomatic and 16 (52%) were symptomatic. In the DR, only the 2 premature infants (PIs) received any support, namely, continuous positive airway pressure (CPAP); none were intubated. Infants were triaged to the WBN (n = 29; 94%) and NICU (n = 2; 6%). SARS-CoV-2 testing results were negative in all WBN infants (n = 29) by 24 hours, at 24 and 48 hours, and at 7 and 14 days in both NICU cases. The WBN infants were cared for in the mother’s room; breastfeeding if desired was allowed.9 All patients from the WBN were discharged from the hospital with their mothers between 24 and 48 hours. Over 3 weeks, the turnaround for test results decreased from as long as 24 to ∼2 hours.
NICU Admission and Management
The 2 PIs were placed in a negative pressure room managed in an isolette (Table 1). After 2 negative test results, they were moved out of isolation. Concurrently, 9 infants born to mothers who were PUIs, 4 of whom required CPAP, were admitted to the NICU, initially isolated until maternal testing results were negative. Neonatal management remained as per standard NICU guidelines. Visitor restriction for mothers who were positive for COVID-19 included 14 days of no visitation from the start of symptoms. Communication was via video linking.
Perinatal Clinical Characteristics of the 2 Admitted Infants
| Patient | Maternal Issues | BW, g | GA, wk | Mode of Delivery | DR Resuscitation | Apgar 1 Minute | Apgar 5 Minute | Initial NICU Treatment |
|---|---|---|---|---|---|---|---|---|
| No. 1 | Preeclampsia, edema, fever | 1600 | 33 2/7 | Cesarean delivery | CPAP | 8 | 8 | RA |
| No. 2 | Preterm labor | 1740 | 32 3/7 | Vaginal | CPAP, DCC | 9 | 8 | CPAP |
| Patient | Maternal Issues | BW, g | GA, wk | Mode of Delivery | DR Resuscitation | Apgar 1 Minute | Apgar 5 Minute | Initial NICU Treatment |
|---|---|---|---|---|---|---|---|---|
| No. 1 | Preeclampsia, edema, fever | 1600 | 33 2/7 | Cesarean delivery | CPAP | 8 | 8 | RA |
| No. 2 | Preterm labor | 1740 | 32 3/7 | Vaginal | CPAP, DCC | 9 | 8 | CPAP |
BW, birth weight; DCC, delayed cord clamping; GA, gestational age; RA, room air.
During the concurrent time period, 9 infants within the NICU have been tested for COVID-19 for a variety of reasons; all test results were negative.
Discussion
The salient findings in this report are that 10% of mothers were positive for SARS-CoV-2, of whom 50% were asymptomatic during the peak of the pandemic. This resulted in 31 infants, with most (94%) triaged to the WBN with 2 admitted to the NICU. The DR management was uncomplicated in all 31 cases; both PIs received CPAP. All infants had negative test results and WBN neonates were discharged from the hospital within 48 hours; both PIs have exhibited an unremarkable clinical course.
A key factor driving DR preparedness is awareness of the mother’s SARS-CoV-2 status. This stresses the importance of rapid turnaround of testing; currently, it is ∼2 down from up to 24 hours. Knowledge of a mother’s positive status for SARS-CoV-2 facilitates adequate DR preparation and avoids unanticipated surprises. This is crucial to minimize the likelihood of a provider becoming infected and/or infecting the infant. Availability of appropriate PPE (N95 respirators were initially limited in supply) is essential in this regard, allowing providers resuscitating a depressed infant to follow the neonatal resuscitation program algorithm.
To date, there have been 10 reports, all from China, in which authors have characterized the outcomes of 82 neonates born to mothers positive for SARS-CoV-2.2–8 Four (4.8%) tested positive for COVID-19 within 36 hours; all 4 were delivered via cesarean delivery. This suggests horizontal rather than vertical transmission, likely due to breaks in infectious precautions. These cumulative findings, including the data in this report, suggest a low risk of vertical transmission. One potential caveat is a mother positive for COVID-19 with diarrhea, in which the risk of transmission may be increased.10
Study limitations include a small cohort and short-term follow-up.
We report these observations for several reasons. First, we wish to stress the importance of being prepared for a rapid surge in cases. This includes having appropriate, sufficient PPE (specifically N95 respirators or equivalent) to meet needs and a rapid turnaround in test results, which is essential to optimize DR resuscitations (all PUI cases are presumed positive for COVID-19), to minimize risk of providers becoming infected and to facilitate appropriate admissions. Second, with scrupulous attention to infectious precautions, horizontal viral transmission should be minimized. Finally, it is suggested in the cumulative data that the virus does not confer additional risk to the fetus during labor or during the early postnatal period in both preterm and term infants.
Acknowledgments
We acknowledge the incredible efforts of the physicians, nurses, and all the support services in labor and delivery, the NICU, and WBN. We also acknowledge the amazing support of the New York-Presbyterian Hospital administration during these times of excessive needs.
Drs Perlman and Oxford conceptualized and designed the study, analyzed the data, drafted the initial manuscript, and revised the manuscript; Drs Chang, Salvatore, and DiPace collected data and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
Since the prepublication release there have been a total of 47 mothers positive for COVID-19, resulting in 47 infants; 4 have been admitted to neonatal intensive care. In addition, 32 other infants have been tested for a variety of indications within the unit. All infants test results have been negative.
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