Best Practices for COVID-19-Exposed Mothers

Introduction:

The SARS-CoV-2 virus infection transmitted from the mother to child is rare. Studies have shown only two percent of babies born to COVID-19-positive mothers have tested positive for the virus. Such cases are high among severely COVID-positive patients. However, there is no proof of transmitting the virus during vaginal birth or breastfeeding babies from an infected mother. Once the baby is born, post-delivery care is detrimental in spreading the infection to the baby.

How Is COVID-19 Spread From Mother to Child?

There are few chances of transmitting the SARS-CoV-2 virus from the mother’s placenta to the child. However, there are several other modes of transmission. They are:

• Vertical Transmission: In this, IgM antibodies are present in the blood, and the child develops COVID-19.

• Postnatal Transmission: Most transmissions are developed postnatally, either in the form of pneumonia infected through a droplet or getting infected through a virus carrier.

How Can Newborns Be Protected From a COVID-Positive Mother and Highly Infectious Hospital Environment?

Many strategies have been implemented by hospital staff for safe and protected delivery. Some of the practiced guidelines are:

• Disinfecting the operation theater and isolating it for each individual procedure.

• A transparent plastic screen can be placed between the mother and the practitioners.

• Strict isolation of children from the caretakers in a separate isolation room is done.

• Strategies should be implemented to develop the mother and baby bonding through a visible physical barrier.

• Mother and all delivery team should wear N-95 masks, head caps, delivery gowns, face shields, and protective footwear.

• An incubator with an elevated hood should be practiced.

• The number of attendees should be one in low-risk and two in high-risk cases.

• A transport isolette should be kept ready to separate the baby.

• Delayed cord clamping can be practiced.

• No baths should be given to avoid skin-to-skin contact.

• For positive pressure ventilation, self-inflating bags can be used.

What Are Breastfeeding Practices Used in COVID-Positive Mothers?

Breast milk is the best source of nutrition for the growth and development of the child. It contains antibodies that can fight against the SARS-CoV virus. Breastfeeding can be done in two methods.

• Express Breast Milk: The breast milk can be pumped to feed the baby.

• Direct Breastfeeding: This can be done by washing the breast area and hands with soap and water. The mother can use face shields as well.

If the mother is asymptomatic or has few symptoms, the child can be directly breastfed. If the mother is symptomatic with persistent fever and cough, the child is best shifted to ICU care, and expressed breastfeeding should be done.

What can Lead to the Premature Delivery of Babies in COVID Positive Mothers?

Several factors are associated with preterm delivery in COVID positive mothers. They are:

• High-risk patients who have severe SARS-CoV virus infection.

• Symptomatic patients with high blood pressure are advised for cesarean delivery.

• The age of the mothers is very crucial in developing symptoms.

• Other comorbid conditions like asthma, diabetes, liver disease, and epilepsy are all detrimental to conducting a preterm delivery due to the associated complications.

• Obesity and anemic patients are other contributing factors to conducting a preterm delivery.

What Are the Precautions Taken to Protect the Baby Post-delivery?

Various precautionary measures are taken with regard to postnatal delivery in COVID positive mothers. Some of them are:

• Antenatal Counseling: According to WHO, various guidelines have been issued to secure safe and positive delivery. Eating healthy fruits and vegetables rich in citric content, keeping the body hydrated, and following all the precautionary measures can reduce risk. Vaccination and screening of fetuses timely can help in monitoring the condition.

• Delivery Room Practices: Strict isolated and disinfected operation rooms with personal protective equipment (PPE) should be worn.

• Breastfeeding Protocol: Direct breastfeeding should be performed depending on the symptomatic and asymptomatic condition.

• NICU Admission: The NICU (neonatal intensive care unit) should be strictly permissible for one or two healthcare workers with all guidelines followed like fumigation, cleaning the room, and walls, using of filters, and use of neonatal heavy metal ax (HMA) filter for cleaning the room from toxic substances like chloride, and heavy metals or use of high-efficiency particulate air (HEPA) filters to clean the air from pathogens.

• Visitor’s Policy: One or two healthcare workers should be allowed to nurse the baby; visitors are strictly prohibited.

• Testing Strategies: People of the affected family, locality, and others in contact should be tested. Asymptomatic patients should be further evaluated for blood investigating reports like lymphocyte count, which is normal to low, C-reactive protein (CRP) elevated, ferritin elevated, D-dimer elevated, lactate dehydrogenase (LDH) elevated, troponin elevated, alanine transaminase (ALT) and aspartate transaminase (AST) elevated and creatinine kinase also elevated and chest X-ray imaging should be conducted for evaluating organizing pneumonia, chronic eosinophilic pneumonia, vasculitis, and focal fibrosis.

How Is the Care Given to the Infants Born in a NICU to a COVID Positive Mother?

• Maximum respiratory support is given.

• Lifecare support ventilator systems are given to support the infant.

• Bacterial filtration should be placed close to the bubble chamber to kill the pathogens causing infection. Single or double filters are used against the spread of high-spreading aerosols.

• For respiratory support, surfactants can be used, or intubation can be done.

What Are Tests Performed to Evaluate COVID-Positive in the Newborn?

Diagnosis can be made using the following tests:

• Nasopharyngeal RT-PCR: A nasal swab is done to do a microbiology study. This should be done in the first 24 hours and the second test after 48 to 72 hours. This is considered the gold standard testing.

• Oral PCR: An oral swab containing saliva or sputum is collected and studied.

• ET-PCR (Electronic Polymerase Chain Reaction): A computer-generated study is done.

• Rectal Swab: This is not a standard test, but bacterial and viral load in the body can be calculated.

What Are the Discharge Protocols in COVID-Positive Delivery Babies?

• If the child is asymptomatic even after breastfeeding the mother’s milk, the child can be discharged.

• If a proper caretaker is available to take care of the baby who is negative for COVID, the baby can be discharged.

• If the symptoms have resolved from the date of diagnosis and the saturation is maintained, the patient can go ahead with discharge.

Conclusion:

The incidence of premature delivery in COVID-positive mothers is high. These delivered babies were kept in neonatal units (NNU) and were extremely premature (<27 weeks gestation). There are no documented studies on the presence of SARS-CoV-19 in amniotic fluid. However, various precautionary measures are taken to prevent infections from being transmitted from mother to child.