Labor and delivery guidance for coronavirus disease 2019.

To the Editors:

We read with interest the article by Boelig et al on “Labor and delivery guidance for coronavirus disease 2019” and appreciate the expedited release given the acute need of the ongoing crisis. The article is very well written and offers helpful guidance, which many will use to improve the care of maternity patients and safety of our providers. However, there is a portion of the recommendations that is contrary to the recommendations of other infection prevention experts, including the Centers for Disease Control and Prevention (CDC). These recommendations will likely impair our ability to conserve and appropriately use respirators (N95 masks) based on current national recommendations. This is outlined under the section on respiratory precautions and personal protective equipment. The specific recommendation is that N95 masks be used in the second stage of labor because of aerosolization of coronavirus disease 2019 (COVID-19). The author’s references do not include any supporting data on aerosolization of COVID-19. Therefore, the author’s proposed recommendations seem to be based on personal opinion and are not evidence based. Indeed, because laboring patients make up a large percentage of all hospital admissions, we would be putting a severe strain on the supply of this already limited equipment. This recommendation also has the potential to increase the level of anxiety for care providers, nurses, and physicians and limit appropriate care if the N95 mask is not used as recommended in their paper. The use of surgical mask and face shields seems very prudent for the second stage of labor and delivery based on the work by Kouri and Ernest, which indicates droplet exposure to providers, but without specific evidence of aerosolization, the use of the N95 mask would be considered unproven.

Again we thank the authors for the manuscript and most of their recommendations. We recognize that protection of our obstetrical providers is critical, but we also realize that we have to wisely share precious personal protective equipment supplies with our nonobstetrical colleagues. As the shortage of equipment change, it might be prudent to be more liberal with the use of N95 masks in all deliveries. Before that, we would like to ask the authors to qualify their recommendations or share the evidence of aerosolization to substantiate their recommendations.