COVID-19: Obstetric anesthesia care considerations.

Summary

The following is an infographic (Fig. 1 ) using several sources of information, including the Society for Obstetric Anesthesia and Perinatology (SOAP) Interim Considerations for Obstetric Care related to COVID-19, as well as existing recommendations from the World Health Organization (WHO) and The Centers for Disease Control and Prevention (CDC) based on the most recent updates. When considering Labor and Delivery, pre-hospital screening should be implemented for all pregnant patients set to undergo elective procedures such as planned cesarean deliveries, elective labor inductions or cerclage placement. Phone/video screening for symptoms consistent with COVID-19 should be completed on these patients and their support person or persons [1]. The CDC has recommended that pregnant patients with known or suspected positivity for the novel coronavirus, notify the Labor and Delivery floors to allow the staff to make the appropriate adjustments for isolation rooms and personal protective equipment (PPE) [2].

Fig. 1

COVID-19: obstetric anesthesia care considerations.

The number of staff in the delivery room or operating room should be specific to the number needed to adequately care for the patient during that given procedure. The donning and doffing of appropriate PPE, including eye/face protection, surgical mask (N95) or a Powered Air Purifying Respirator (PAPR) for aerosolizing procedures (such as intubation) should be practiced as well. COVID-19 kits should be assembled which will include all equipment, medications for labor analgesia, cesarean delivery, and general anesthesia. Rescue medications should remain in the patient room. Just as support staff is limited, visitors should be limited as well. Visitors should ideally be limited to one essential support person, while encouraging the use of video messaging with other members of the patient's support system.

A patient who is positive or presumed positive should be admitted to a negative pressure room, if possible. All healthcare workers in the room should don the appropriate PPE as described above, and the patient should wear a surgical mask at all times. Donning PPE takes time and can delay the response to an emergent cesarean section. The care team should do their best to minimize the chance of such a scenario by proper training and preparation. Understanding that it may cause stress to the patient, any newborn born to a COVID-19 positive patient should be suspected to be positive for COVID-19 and be tested and isolated from other healthy infants [3].

COVID-19 is not a contraindication to neuraxial analgesia. An experienced anesthesia provider with the appropriate PPE should perform neuraxial procedures and intubations, whenever possible. If general anesthesia is ever indicated, providers should don the appropriate PPE as described above. A High Efficiency Particulate Air (HEPA) filter should be used between the patient and the circuit. Again, if possible, the most experienced provider should perform the procedure to minimize mask ventilation. Video-laryngoscopy, for this reason, is also recommended. Mask ventilation should be avoided, if possible due to potential aerosolization and patients should be extubated to nasal cannula or oxygen masks with low flows. It should be noted that there is currently insufficient data on the aerosolization potential when utilizing nitrous oxide in labor analgesia systems, and how to properly clean systems after use. Individual labor and delivery units should discuss the risks/benefits and consider suspending use.

Declaration of competing interest

The authors declare the following conflicts of interest:

Jared A Herman: declares no conflicts of interest

Ivan Urits: declares no conflicts of interest

Richard D. Urman: declares unrelated research funding from Merck, Medtronic, Acacia and Mallinckrodt. Also consulting fees received from Heron and Takeda pharma

Alan D. Kaye: fees received from Merck for unrelated work

Omar Viswanath: declares no conflicts of interest