NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date

SUMMARY:

Multiple societies and experts have weighed in on whether second stage of labor and delivery warrants respirators (e.g., N95 masks) vs surgical masks in the setting of a patient with confirmed or suspected COVID-19. The lack of clarity currently revolves around whether the second stage of labor should be considered an aerosol-generating event. ACOG, SMFM and multiple other ObGyn societies have sent a letter to the CDC requesting clarification (summarized under ‘Key Points’ below).

CDC

• CDC advises healthcare personnel to use
  • Gloves
  • Gowns
  • Airborne precautions
  • Eye protection (e.g., goggles or a face shield)
• Face masks are an acceptable alternative when the supply chain of N95 respirators (or similar respirators that filter inspired air and offer respiratory protection) cannot meet the demand
• NIOSH-approved filtering facepiece respirators, half facepiece or full facepiece elastomeric respirators, and powered air-purifying respirators (PAPRs) where feasible “might be considered”
  • However, they should not be used during surgery because exhaled air may contaminate the sterile field
• If respirators are in short supply, priority should be given to aerosol-generating procedures (e.g., intubation)
• CDC  addresses alternatives in the setting of face mask shortages on the page entitled Strategies for Optimizing the Supply of Facemasks (see ‘Learn More – Primary Sources’)
• CDC guidance states

Based on limited data, forceful exhalation during the second stage of labor would not be expected to generate aerosols to the same extent as procedures more commonly considered to be aerosol generating (such as bronchoscopy, intubation, and open suctioning)

Forceful exhalation during the second stage of labor is not considered an aerosol-generating procedure for respirator prioritization during shortages over procedures more likely to generate higher concentrations of infectious respiratory aerosols

When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19

ACOG

• Healthcare providers should use PPE, including respirators or face masks, goggles, gowns and gloves | N95 respirators should be used for aerosol-generating procedures
• ACOG states that “COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care”
• In addition to wearing appropriate PPE, respirators (e.g., N95 masks) should be worn by “All medical staff caring for potential or confirmed COVID-19 patients” when available
• In the setting of limited infection protections “physicians are not ethically obligated to provide care to high-risk patients without protections in place”
• PPE: ACOG restates CDC guidance
  • Respirators (e.g., N95 respirators) should be used when caring for patients with confirmed or suspected COVID-19
  • Aerosol-generating procedures should be prioritized during shortages
  • ACDC currently does not consider second stage an aerosol-generating procedure and adds the following

ACOG continues to review questions and data regarding the potential for aerosolization in the context of forceful exhalation during the second stage of labor 

SMFM/SOAP

• Respirators (N95 masks)
  • Should be used in any room where there is performance or anticipation of aerosol-generating procedure for patient with confirmed COVID-19 or PUI
  • Examples of potential aerosol-generating events include
    • Cesarean deliveries
    • PPH
    • Intubation
• Second stage of labor
  • Suggestions to limit exposure include
    • Use of surgical drapes as an added barrier during second stage and delivery | Check with local infection control regarding reuse of N95 masks
  • In addition, SMFM/SOAP believes it is “reasonable” to

…consider N95 mask use for HCWs caring for patients with suspected or confirmed COVID-19 in the second stage of labor, including specifically HCWs with significant and prolonged exposure to such patients

As with all resource considerations and potential supply and demand imbalances, the ability to adhere to this suggestion will need to be evaluated on an institutional level. It is acknowledged that this suggestion is above and beyond current CDC recommendations

SOGH

• The SOGH COVID-19 statement is based on the following
  • Obstetricians are frontline personnel
  • Asymptomatic patients on L&D can potentially infect frontline personnel, especially as there is close contact between patients and healthcare professionals during labor
  • The science behind COVID-19 transmission continues to evolve
• As a result of the above, SOGH recommends

Universal use of hospital masks on Labor and Delivery, for staff, patients and visitors

Universal testing for Covid19 of all pregnant women and their chosen support person/s on Labor and Delivery, where available

Use of full PPE, including N95 masks and face shields, for the second stage of labor for all Covid positive women and persons under investigation or for all women, when universal testing is not available

AAP

• AAP provides PPE guidance in the setting of a birth when the mother is COVID-19 positive
• Aside from gown and gloves, AAP recommends that staff should use

Either an N95 respiratory mask and eye protection goggles or with an air-purifying respirator that provides eye protection

The protection is needed due to the likelihood of maternal virus aerosols and the potential need to perform newborn resuscitation that can generate aerosols

AWHONN

• AWHONN recommends the following based on the fact that data on second stage is still limited and universal testing is not widely available

Healthcare personnel caring for women in the second stage of labor are in close contact for long periods of time to provide support for breathing and pushing

AWHONN recommends all healthcare personnel wear appropriate PPE during the second stage of labor, including use of N95 masks when caring for women who are known or suspected (PUI) COVID-19

Until universal testing is available, health care personnel should have the option to use N95 masks when caring for all women in the second stage of labor

KEY POINTS:

Letter to CDC Requesting Clarification

• Sent jointly from the following societies
  • AAGL | ACNM | ACOG | ASRM | AUGS | AWHONN | NANPWH | SMFM | SFP | SGS
• The letter requests clarification from the CDC regarding PPE use on L&D, specifically second stage of labor
• The societies raise concern that the current CDC recommendations are

…being interpreted as suggesting that obstetric care clinicians need not wear N95 masks and face shields when attending to patients with confirmed or suspected COVID-19 during the second stage of labor

We appreciate your clarification that the CDC recommends use of such PPE and look forward to working with you to amplify this message

‘Expert Review’

Boelig et al. AJOG MFM, 2020

• Some centers consider N95 masks to be appropriate
  • In addition to droplet precaution PPE for any patients with suspected or confirmed COVID-19 and
  • For any patient, regardless of respiratory symptoms, during indispensable aerosolizing procedures, including second stage of labor

Palatnik and McIntosh. Am J Perinatol, 2020

• The authors recommend that healthcare professionals during second stage be provided with N95 respirators
• The authors make the point that there are important factors to consider specifically regarding the second stage of labor and patients with suspected or confirmed COVID-19
  • Time: To avoid cesarean delivery, patients can be allowed up to 4 hours (nulliparous) and 3 hours (multiparous) in second stage
  • Distance: Healthcare personnel will likely be within 6 feet of the patient and likely closer when patient is pushing
• Furthermore, the authors state that that patients will be “exerting extreme effort during the second stage of labor and frequently blow out their breath, cough, shout, and vomit, all of which put the health care team at risk”

Learn More – Primary Sources:

CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings

CDC: Clinical Questions about COVID-19: Questions and Answers

Society for Maternal-Fetal Medicine and Society for Obstetric and Anesthesia and Perinatology – Labor and Delivery COVID-19 Considerations

ACOG COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

Labor and Delivery Guidance for COVID-19 (Boelig et al. AJOG MFM, 2020)

AAP issues guidance on infants born to mothers with suspected or confirmed COVID-19

AWHONN: COVID-19 Practice Guidance

Letter From Professional ObGyn Societies to the CDC

SOGH COVID-19 Position Statement

Protecting Labor and Delivery Personnel from COVID-19 during the Second Stage of Labor (Palatnik and McIntosh. Am J Perinatol, 2020)

The Right Mask for the Task

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