Effect of delayed obstetric labor care during the COVID-19 pandemic on perinatal outcomes.

Since the beginning of the COVID‐19 quarantine in São Paulo, Brazil, our institution has noticed that some pregnant women, particularly those that were recommended elective cesarean sections for reasons such as repeated cesarean deliveries or abnormal fetal presentation, were admitted to São Paulo Hospital in the second stage of labor and then went on to have vaginal deliveries (Table 1). Therefore, we conducted a comparative cohort study between March 11 and June 11, 2019 and March 11 and June 11, 2020 in order to evaluate whether the quarantine period led to pregnant women with spontaneous labor arriving at our hospital in a more advanced phase of labor. The Institutional Review Board of UNIFESP provided ethical approval for this study (No. 33734620.7.0000.5505).

Table 1

Characteristics of pregnant women admitted at Sao Paulo Hospital (SPH) in spontaneous labor from 11 March, 2019–11 June, 2019, and from 11 March, 2020–11 June, 2020

Year, n	0‐3 h b		>3h b
	2019, 11 (26.8)	2020, 16 (40)	2019, 30 (73)	2020, 24 (60)
Maternal age
<20	0	1 (6.2)	3 (10)	0
20 ‐ 34	8 (72.7)	10 (62.5)	21 (70)	19 (79.1)
≥35	3 (27.2)	5 (31.2)	6 (20)	5 (20.8)
Mean (years)	32.45	31.75	28.37	28.63
Robson
1 and 3	7 (63.6)	9 (56.2)	24 (80)	15 (62.5)
5	3 (27.2)	3 (18.7)	3 (10)	6 (25)
6 to 10	1 (9)	4 (25)	3 (10)	3 (12.5)
Gestational age
<37	2 (18.1)	3 (18.7)	4 (13.3)	21 (87.5)
≥37	9 (81.8)	13 (81.2)	26 (86.6)	3 (12.5)
Parity
Nulliparous	1 (9)	2 (12.5)	12 (40)	11 (45.8)
1	4 (36.4)	7 (43.7)	8 (26.6)	10 (41.6)
≥2	6 (54.5)	7 (43.7)	10 (33.3)	3 (12.5)
Delivery type
Vaginal	10 (90.9)	15 (93,7)	21 (70)	18 (75)
Forceps	0	0	0	1 (4.1)
Cesarean section	1 (9)	1 (6.3)	9 (30)	5 (20.8)
Newborn’s weight (g)
< 2500	2 (18.1)	2 (12.5)	1 (3.3)	0
2500‐<4000	8 (72.7)	14 (87.5)	28 (93.3)	24 (100)
≥4000	1 (9)	0	1 (3.3)	0
Perineal laceration
No	3 (30)	7 (43)	9 (30)	3 (12.5)
1°	4 (40)	6 (37.5)	4 (13)	9 (37.5)
2°	2 (20)	2 (12.5)	7 (23)	7 (29)
3°	1 (10)	0	1 (3)	0
Prenatal care
None	2 (18.1)	1 (6.2)	5 (16.6)	0
Elsewhere	3 (27.3)	3 (18.7)	1 (3.3)	1 (4.1)
SPH	6 (54.5)	12 (75)	24 (80)	23 (95.8)
Apgar score
<7	2 (18.1)	1 (6.25)	0	1 (4.1)
≥7	9 (81.8)	15 (93.7)	30 (100)	23 (95.8)

Abbreviation: SPH, São Paulo Hospital.

Values shown as number (percentage.).

Time between the arrival at the hospital and the delivery.

In 2019 there were 143 deliveries during the period of study, 41 of which were initiated by spontaneous labor. By contrast, during the same period in 2020, there were 122 deliveries and 40 patients arrived at the hospital in labor. Delivery within 3 hours of hospital admission occurred in 26.8% (11/41) and 40% (16/40) of cases in 2019 and 2020, respectively. Gestational age was over 37 weeks in 81% of patients in both years. Paradoxically, in 2020 there were more nulliparous women (9% versus 12.5%), fewer women with two or more previous births (54.5% vs 43.7%), and a lower percentage of newborns weighing less than 2500 g (18.1% vs 12.5%). Most of the patients had received prenatal care at the institution (54.5% vs 75%). One potential explanation for the increase in deliveries within 3 hours in 2020 might be related to the reduction of public transport during the pandemic, given that most of the patients reside far from the hospital (median 14 km). Moreover, patients are reluctant to attend treatment at hospitals due to fear of exposure to SARS‐CoV‐2. This phenomenon appears to occur worldwide—it has been reported that delayed care in 12 children in Italy resulted in four deaths and delayed care among patients with ST‐segment‐elevation myocardial infarction. , , Regarding pregnancy, it has been reported that one third of pregnant women started working from home due to fear of being infected.

Based on this, our preliminary perception is that our population also feared COVID‐19 infection. As a result, these patients underwent initial labor at home until their concerns about exposure were outweighed by their concerns regarding the wellbeing of their babies. Although our results are limited due to the small sample size, the fact that pregnant women arrived at the hospital in advanced stages of labor with no adverse maternal and neonatal outcome leads us to think that patients should be encouraged to go to the hospital at the active stage of labor under a shared decision model.

AUTHOR CONTRIBUTIONS

SYS, CAFG, RM, and ESVA equally contributed to the conception and design of the study, and analysis and interpretation of data. LRM, FPD, MNA, PMCS, and ACS contributed to the collection and analysis of data. ACM and PMCS reviewed the literature. SYS, ACS, and LRM wrote the first draft of the paper. All authors reviewed and approved the final version of the manuscript.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.