NOW!: protection for obstetrical providers and patients.

The number of cases of coronavirus disease 2019 (COVID-19) in the United States is on a quicker upward trajectory than any country in the world, and it will even exceed Italy. Given the alarming increase in both infections and deaths from exposure to severe acute respiratory syndrome coronavirus 2, the United States will soon become the most affected country in the world. In addition, since pregnant women are at a high risk of developing pneumonia from viruses, such as the influenza virus, the risk of pregnant women contracting COVID-19 disease is even higher. The limited early data show that pregnant women hospitalized with COVID-19–induced pneumonia may be at a higher risk of being intubated and becoming critically ill (approximately 8%); experiencing complications such as miscarriage, preterm birth (41%), preeclampsia (14%), cesarean delivery (91%), and stillbirth (2.4%); being admitted to the intensive care unit (8%); and neonatal death (2.4%). Although no maternal deaths have been reported in the world so far (March 21, 2020), the first ones are happening even today. Pregnancy should be considered a comorbidity, and pregnant women at risk of experiencing complications from COVID-19 disease.

Healthcare workers, such as obstetric physicians, midwives, nurse practitioners, physician assistants, nurses, and others, are at highest risk of contracting the disease and dying from it. In Italy alone—a country with one-fifth the population of the United States (data from March 20, 2020)—dozens of physicians are dead, and >3000 healthcare workers are seriously ill from COVID-19 disease. Despite a 2-week lockdown, there are still people working in healthcare settings, pharmacies, and food stores who are at a high risk of contracting COVID-19 disease.

These data forced us to make recommendations for pregnant women and the healthcare workers caring for them when they come in direct in-person contact in the outpatient offices or in the hospital, including the antepartum, labor and delivery (L&D), and postpartum departments (Table ). Healthcare workers need utmost protection now. The availability of personal protective equipment (PPE) for healthcare workers, such as surgical masks, N-95 masks, or equivalent masks, should be prioritized and provided by the federal government and individual states. At Thomas Jefferson University Hospital in Philadelphia, it is now mandatory that all obstetrical healthcare workers coming in direct contact with patients wear PPE, in both the outpatient and the inpatient (eg, L&D) settings. Although other specialties can drastically decrease provider-patient in-person outpatient and even inpatient (eg, elective surgeries) interactions, the obstetrics group is a specialty (with surgical oncology being another exception) that cannot avoid these direct interpersonal interactions, as childbirth requires direct contact and cannot be postponed.

Table

Suggested recommendations for pregnant women and the healthcare workers caring for them when in direct in-person contact in the outpatient or inpatient setting

Situation	Patients	Healthcare workers
Wear surgical masks	Alla	Alla
Test for COVID-19 infection	Upon admission to L&D	Once to all; repeat if significant exposure or symptomatic
Patient with positive/suspected COVID-19	Surgical mask	N-95 masksb

COVID-19, coronavirus 2019; L&D, labor and delivery.

Berghella et al. NOW!: protection for obstetrical providers and patients. AJOG MFM 2020.

Unless having to wear an N-95 or equivalent mask.

Equivalent mask.

Given the aforementioned data, we recommend the United States be in strict lockdown, implemented with self-isolation. In this situation, only essential workers such as healthcare workers and others (eg, pharmacists, those working in food stores) should be allowed to continue and commute to work. The police, and if necessary the military, should be empowered to strictly enforce the lockdown, with severe consequences meted out to those not following these rules.