Care recommendations for parturient and postpartum women and newborns during the COVID-19 pandemic: a scoping review

Objective to map the current knowledge on recommendations for labor, childbirth, and newborn (NB) care in the context of the novel coronavirus. Method scoping review of papers identified in databases, repositories, and reference lists of papers included in the study. Two researchers independently read the papers’ full texts, extracted and analyzed data, and synthesized content. Results 19 papers were included, the content of which was synthesized and organized into two conceptual categories: 1) Recommendations concerning childbirth with three subcategories – Indications to anticipate delivery, Route of delivery, and Preparation of the staff and birth room, and 2) Recommendations concerning postpartum care with four categories – Breastfeeding, NB care, Hospital discharge, and Care provided to NB at home. Conclusion prevent the transmission of the virus in the pregnancy-postpartum cycle, assess whether there is a need to interrupt pregnancies, decrease the circulation of people, avoid skin-to-skin contact and water births, prefer epidural over general anesthesia, keep mothers who tested positive or are symptomatic isolated from NB, and encourage breastfeeding. Future studies are needed to address directed pushing, instrumental delivery, delayed umbilical cord clamping, and bathing NB immediately after birth.


Introduction
The World Health Organization (WHO) declared the human infection caused by the novel coronavirus Severe Acute Respiratory Syndrome-Coronavirus (SARS-CoV-2), named COVID-19", a Public Health Emergency of International Concern" (1) . This infection has been acknowledged as the most disturbing event since World War II and has put health systems worldwide under unprecedented stress. This context has led the entire population, health workers, and government officials to experience an atmosphere of fear and emotional stress, because of its severity and high mortality rates as well as the lack of sufficient services and equipment to meet the large demand of patients requiring hospitalization in Intensive Care Units and mechanical ventilators. On April 30th, 2020, infectious disease experts reported that this pandemic may last between 18 and 24 months and that everyone should be prepared for its resurgence after the first wave of contamination (1)(2)(3)(4)(5)(6)(7) .
To decrease infection or prevent the majority of the population from being infected at the same time, causing the health system to collapse, the WHO and Brazilian Ministry of Health have recommended social isolation, early detection, reporting, as well as investigation and appropriate case management (1,8) .
The novel coronavirus is transmitted through droplets and respiratory secretions of individuals infected by the disease or through contaminated objects; this virus can be also transmitted through contaminated feces (5) . Health workers are advised to observe contact and droplet precautions, according to the procedures performed. Hence, complete Personal Protective Equipment (PPE) has to be worn, such as disposable waterproof aprons or gown, goggles, head covers, gloves, and N95 masks or PFF2 respirators.
Care is advised when removing PPE (9) .
Symptoms of SARS-CoV-2 may range from mild symptoms such as fever, runny nose, nasal congestion, dyspnea, malaise, myalgia, and loss of taste up to severe symptoms such as Severe Acute Respiratory Syndrome (SARS). Complications are most common, and more frequently lethal, among elderly individuals and those with comorbidities (10-11) . The Brazilian Ministry of Health classified women in the pregnancypostpartum cycle and newborns (NB) to be risk groups (11)(12)(13) , considering that the clinical condition of these individuals may be aggravated by the infection due to low immunity and poor tolerance to hypoxia, which culminate in worse outcomes, compared to the population in general (14)(15) .
The number of pregnant women and NB infected is much lower than that of the general population, however, pregnant and puerperal women are more vulnerable to COVID-19 and, when they become infected, the symptoms may be more severe. Transmission may occur from mother to NB in the postpartum and, the NB's immunological system being still immature, they are believed to be more susceptible to SARS-CoV-2 infection. Hence, it is recommended to prevent infection of NB through contact with mothers, close family members, and health workers who are sick or carry the virus (2,11,15) .
One study conducted by Chinese researchers analyzed 2,143 cases of children younger than 18 years, 731 of whom were confirmed and 1,412 considered suggestive due to their clinical condition, imaging tests, and the fact they had been exposed to individuals with the virus. The study's results show that children younger than one year had their clinical condition worsened (15) .
Decisions concerning the route of childbirth also need to take into account individual characteristics. As usual, C-sections should be indicated depending on the maternal and fetal conditions (16) . Note that even amidst this pandemic, good practices concerning labor, birth and postpartum care should continue among women who are not suggestive of being infected or had a confirmed diagnosis of COVID-19, as well as women who have recovered from the infection (17) .
There is little scientific evidence for the development of a protocol addressing the best treatment against the novel coronavirus. Therefore, this study is intended to map the body of knowledge (2) identification of relevant studies; (3) selection and inclusion of studies; (4) data organization; and (5) collection, synthesis, and report of results (18)(19) . These stages are individually described, as follows.  (20) . The population includes parturient and postpartum women and newborns. The The search strategy used with the selected terms was ("postpartum women" OR "postnatal women" OR "perinatal women" OR "pregnant women") AND ("covid-19" OR "severe acute respiratory syndrome coronavirus 2" OR "severe acute respiratory syndrome coronavirus 2" OR "2019-nCoV" OR "SARS-CoV-2" OR "2019nCoV" OR "coronavirus") AND (parturition OR "labor, obstetric" OR "labor stage, third" OR "labor stage, fourth" OR childbirth OR delivery OR postpartum OR puerperium OR "period, postpartum").
The sources included met the following criteria: Due to the method's specificity, there was no need to formally assess the methodological quality of the studies included. This review followed the PRISMA checklist to ensure methodological rigor and content of the report (21) .

Results
In total, 108 papers were identified in the databases, while 17 were identified in reference lists and unpublished research repositories. Of these, 29 appeared more than once and were removed.  Regarding the methodological designs of the papers included in this review, these include six retrospective descriptive studies, five reviews, four opinion papers, three case studies, and one experience report.
To facilitate the presentation of information collected from the manuscripts, after reading and analyzing recommendations, the content was grouped into two    It is recommended to: keep the clinical condition of the mother-fetus pair stable as long as possible and consider that the ideal time for childbirth should be determined by gestational age.
High-risk pregnancies: Decisions regarding the course of the pregnancy should: 1) be individualized and based on underlying comorbidities (preeclampsia, gestational diabetes, heart diseases, among other obstetric conditions); 2) Obstetric history; 3) In addition to the factors mentioned for low-risk pregnancies. It should be considered that: given a steady progression with clinical conditions within expectations, a pregnancy may proceed under rigorous periodic assessment.

Route of childbirth
Normal childbirth: • Mild clinical conditions; • There are no contraindications, especially due to a lack of evidence on vertical transmissions; • If pregnant women infected with SARS-CoV-2* present spontaneous labor and good cervical conditions, normal childbirth is advised, provided that the health service has the apparatus necessary to promote appropriate precautions; • To shorten the duration of the second stage of labor, directed pushing is recommended and parturient women are supposed to wear a surgical mask. • Avoid delayed umbilical cord clamping and skin-toskin contact to reduce the most potential sources of contamination in the immediate postpartum; • NB † Bathing and drying should be performed immediately after birth to avoid exposure and neonatal hypothermia.

C-section:
• Clinical instability considering critical conditions and/or obstetrical factors; • Obstetrical indications for a C-section presented in the retrospective studies included: • Severe preeclampsia; premature rupture of membranes; prematurity; irregular uterine contractions; prior C-section history; changes in the volume of amniotic fluid; placenta previa; umbilical cord abnormalities; acute fetal distress; uncertainty about the risk of transmission during vaginal delivery. • Anesthesia: Epidural is preferred over general anesthesia to reduce the chance of exacerbating pulmonary complications due to intubation/extubation and to avoid the side effects of general anesthesia on NB † , both on muscle tone and respiratory rate at birth.
Recommendations regarding care provided to childbirth in the context of the SARS-CoV-2* infection

Preparation of the staff and childbirth room
One must choose a negative pressure birthing isolation room, isolated room, or a surgery room for respiratory diseases. Avoid regularly used birthing rooms or rotate among individuals with and without flu syndrome; Obstetricians, pediatricians, and nurses need to work together and be notified 30 minutes before delivery to plan the care that will be provided to the NB † ; The childbirth staff has to include a minimum number of workers (two to three health workers at most) and remain inside the room, avoiding the circulation of people; All those involved in childbirth care need to observe a strict personal protection protocol, wearing the following PPE ‡ : head covers, gowns, props, surgical masks, goggles or facial shields, and gloves. Additionally, perform rigorous hand hygiene before and after leaving the room; During C-sections, the women under the effect of general anesthesia must wear surgical masks during the entire procedure; Restrict to the presence of a single companion during labor and birth to decrease the levels of transmission to the community.  Attention to mother's fever, which may indicate ongoing SARS-CoV-2* infection, some physiological symptom that is characteristic of this period, or some pathology, such as breast engorgement, mastitis, urinary tract infection, genital infection, or even common colds.

Breastfeeding
• There is no evidence that SARS-CoV-2* is transmitted through breast milk; • Breastfeeding should be encouraged because its benefits outweigh potential risks of contamination; • There is no consensus regarding the initiation and maintenance of breastfeeding among mothers with COVID-19. This decision should be taken together with the mother and health workers involved in care delivery; • There is a risk of mothers transmitting SARS-CoV-2* to their NB † through respiratory droplets at the time of breastfeeding, even when wearing a surgical mask; • Women who opt not to breastfeed during the period of the disease should be encouraged to express breast milk to feed their NB † ; • The use of a breast pump is recommended.
• Instruct mothers to perform rigorous hand hygiene before and after feedings or when pumping breast milk and providing care to NB † , always wearing a surgical face mask; • Recommend a healthy caregiver to feed the baby in the case of mothers pumping milk.

Care provided to NB †
• NB † present signs and symptoms that are similar to those exhibited by infected adults: dyspnea, fever, tachycardia, vomiting, and thrombocytopenia. • When caring for an NB † , rigorously monitor the following signs: • respiratory frequency; • body temperature; • heart rate; • gastrointestinal signs and symptoms. • These should be the main focus of care provided after birth. Early intervention is recommended as soon as abnormal patterns are observed. Consider that: The studies conducted in China recommend isolating mothers from infants for 14 days whenever mothers present a positive RT-PCR ‡ . Isolation ceases when the mother presents a negative RT-PCR ‡ twice in a row. NB* need to remain in an isolated ward and have their clinical condition monitored rigorously.

Hospital discharge (when signs and symptoms of the disease minimize or cease over time)
• Normothermia is sustained for at least three days; • Good breathing pattern or significant improvement; • Chest radiography shows acute exudative lesions healed or obvious absorption of lung inflammation; • RT-PCR ‡ appears negative twice in a row with an interval above 24 hours between testing.

Care provided to NB † at home
• Keep the bedroom at appropriate temperature and humidity levels.
• Keep the bedroom airy, preferably with windows open; • Minimize visits and physical contact; • Sanitize hands and face frequently when establishing contact; • Clean and disinfect the floor and furniture with alcohol at 70% or dissolved chlorinated compounds; • Pacifiers and bottles made of heat resistant material should be disinfected at high temperatures. Consider that: Whenever health workers perform home visits, they should assess general aspects such as weight gain, height, reflexes, breastfeeding, and vital signs.   (40) .

SARS-CoV-2 infection affects parturient and postpartum
women, greater deterioration of the health condition of mothers has been observed in Brazil. Therefore, the Brazilian Ministry of Health included pregnant women, those who gave birth recently, and those who experienced an abortion or fetal death in the group of risk and provided specific guidelines (41)(42)(43) . One recent study (44)  Therefore, greater care is recommended with this group given the potential of positive cases for SARS-CoV-2 to become more severe.
In this context, a suggestive or confirmed diagnosis of COVID-19 has promoted changes in the context of childbirth and obstetric care that is provided to women with the infection. There was a need for a rigorous evaluation of pregnancy and fetal status due to the tendency to fetal growth restriction and greater chances of prematurity (31,41,45) .
Decisions regarding the course of pregnancy or its resolution should take into account: the mother's clinical condition, fetal wellbeing, gestational age, and the mother's autonomy. As long as the clinical condition of both mother and fetus is ensured, the ideal time for delivery should be determined by gestational age (22,26,29,31) . If, however, the safety of either mother or fetus is compromised due to SARS or there is no satisfactory response to the therapy implemented against COVID-19, or yet, in the presence of severe pneumonia or critical condition, a premature delivery should be considered to safeguard mother and infant, as an anticipated birth decreases fetal hypoxemia and the maternal condition is expected to improve (28)(29)31) .
In some cases, the interruption of pregnancy should be considered, even before fetal viability is achieved, seeking to improve the mother's clinical condition, considering that there is evidence showing rapid recovery of maternal oxygenation after the procedure (28)(29)31 ). Any decision by the health staff should consider the mother's and family's principles and desires, without disregarding ethical principles (31) . These precepts are endorsed by the International Confederation of Midwives, which reinforce the need of women and fetuses to be treated with dignity, compassion, and respect (46) .
Regarding the birth route, studies (23,28,32,47) show that there is no contraindication for vaginal deliveries if clinical and obstetrical assessments are favorable. Greater surveillance of both mother and fetus is recommended through cardiotocography or intermittent auscultation in a short period. Water births are contraindicated due to the possibility for the mother's fecal elimination and water contamination, and consequently, greater risk of contamination of NB (5) . C-sections should be indicated when there is clinical or obstetrical instability in addition to changes in fetal vitality (28,32,35,38,47) . These recommendations are corroborated by obstetricians in Wuhan, China, who state that C-sections indicated for women with the infection should be flexible, as the objective is to decrease the length of hospitalization of mothers to minimize cross-infection and avoid physical exertion, which is characteristic of normal deliveries (29) .
The staff providing childbirth care must be informed about a suspected or confirmed diagnosis of COVID-19 to prepare for and implement biosafety measures, as well as to grant priority for these deliveries to occur in labor, childbirth and postpartum rooms reserved for those with a suspected or confirmed diagnosis of the SARS-CoV-2 infection (26,(28)(29) . At the time of delivery, a minimum team of essential workers should be considered; hygiene measures and protective equipment guidelines should be rigorously observed; parturient women should wear surgical or N95 masks; and only one companion should be recommended during labor, childbirth and postpartum (23,26,29,(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)48) . This companion should be someone who lives with the mother, does not belong to a risk group, does not present any signs and symptoms of the flu; and wears a mask during his/her entire permanence in the service (45) .
Recommendations to hasten the expulsive period by promoting directed pushing or instrumental delivery demand caution because there is no consensus and Rev. Latino-Am. Enfermagem 2020;28:e3359.
this procedure may increase the risk of exposure, as it decreases the efficacy of face masks in preventing the propagation of particles (36) . Furthermore, there is a lack of evidence on whether the abbreviation of labor improves maternal and fetal outcomes. Epidural analgesia is preferred in the case of mothers wishing pharmacological analgesia during childbirth (48) . This option should also be offered in the case of C-sections, considering that general anesthesia may cause pulmonary complications related to intubation/extubation, in addition to side effects for NB (29,32,39) .
It is important to highlight one review addressing the guidelines concerning pregnant women and NB in the context of COVID-19, reporting that there is no consensus among the practices adopted in the different countries and that these recommendations may differ between countries, as each can give priority to follow local health government agencies or international organizations (48) .
The Chinese studies included in this review recommend isolating the mother-infant pair after birth, as this procedure is believed to decrease NB contamination by SARS-CoV-2. For this reason, these studies recommend delayed umbilical cord clamping and skin-to-skin contact to be avoided. Therefore, NB should be placed in a warm crib in an environment different from that of mothers (23,26,31,37) . One review (48) , a guide providing guidelines for pregnancy, labor and childbirth (5) , and a technical note from the Brazilian Ministry of Health (41) report, however, that umbilical cord clamping among asymptomatic women, and even among women with symptoms, does not need to be immediate. Because there is no evidence of vertical transmission, optimal timing for umbilical cord clamping may be chosen instead of immediate clamping.
It is important to consider that the pandemic demands that health workers and health services exercise good judgment and assess each case individually, encouraging and adopting good practices to promote a positive experience for mothers. The desire and clinical conditions of women should be taken into account, and physical structures should be adapted, observing biosafety maneuvers necessary to decrease the chances of virus transmission (45)(46)49) .
Vigilant attention should be intensified in the postpartum period to monitor the mother's signs and symptoms and detect any worsening of the mothers' health conditions early (43) . Even though hyperthermia is the symptom most frequently reported in the SARS-CoV-2 infection, a differential diagnosis should be made, considering that other pathologies may be associated, while other specific signs and symptoms of the respiratory infection caused by COVID-19 should be also investigated (28) .  (27)(28)37) . Evidence, however, shows that there is no virus in human breast milk. Therefore, breastfeeding should be encouraged, especially when we consider the benefits of immunization for the NB (2,23,26,33,38,46,52) .
Currently, the greatest concern with breastfeeding lies in the possibility of infants being contaminated by the mothers' respiratory droplets (33,38) . To decrease this risk, mothers are recommended to wear surgical masks during breastfeeding to protect against coughing or sneezing, in addition to constantly performing proper hand hygiene. If mothers opt not to breastfeed while the symptoms remain, health workers should encourage them to pump breast milk and allow another caregiver, who lives in the same home, to feed the infant (23,28,38,52) .
Bottles, dosing spoons, or glasses used to feed infants with breast milk have to be sterilized (52) . A multicenter retrospective study conducted in Italy addressing 42 women, recommend physicians and midwives, working in regions with high contamination rates by COVID-19, to encourage women to wear face masks, both during labor and childbirth and when providing care to infants and breastfeeding, aiming to decrease Mascarenhas VHA, Caroci-Becker A, Venâncio KCMP, Baraldi NG, Durkin AC, Riesco MLG transmission to NB, considering that individuals with the infection may be asymptomatic (47) .
As for the NB in general, neonatal variables immediately after birth were satisfactory in terms of weight, height, and Apgar indexes, while no asphyxia or neonatal death was reported (2,(23)(24)(25)27,30,(33)(34) . Even though infection due to the COVID-19 is less frequent in this population, attention should be paid to the risk of infection with greater severity among NB and children under three months of age (53) . Therefore, one should monitor for signs and symptoms, such as dyspnea and tachypnea, hyperthermia or hypothermia, tachycardia, emesis, gastrointestinal symptoms, and thrombocytopenia. In the case of infection, early intervention and differential diagnosis should apply (25,31,33,35,45) .
After hospital discharge, the routine and care provided at home are important to prevent the infant and other family members from becoming infected with SARS-CoV-2. Hence, mothers are recommended to be isolated until the symptoms disappear or present negative RT-PCR; keep at least two-meter distance from NB when not breastfeeding or providing childcare; keep bedrooms airy and with appropriate temperature and humidity levels; minimize or completely disallow visits and physical contact. It is also important to clean and disinfect the floor and furniture with alcohol or dissolved chlorinated compounds (28) . The Brazilian Ministry of Health reports an acceptable distance of one meter between mother and NB (42) .
The general health aspects of mother and infant should be assessed during home visits, childcare, and postpartum consultations. Also, checks should include anthropometric measures, weight gain, reflexes, breastfeeding, contraceptive methods, how the mother is adapting to the postpartum period, and vital signs (28,45) .
Additionally, reproductive planning is indicated to ensure the safety of contraceptive methods. It should even be intensified, considering that there is a lack of strong evidence concerning vertical transmission, premature labor, and restricted intrauterine growth. It is also noteworthy that parturient and postpartum women and newborns have been included in vulnerable groups. The choice of the contraceptive should consider the desires of women and their families, although the intrauterine device is an option that can be offered in the immediate postpartum period (40,42,46) . Rev. Latino-Am. Enfermagem 2020;28:e3359.
In some cases, women are advised to keep a distance from NB, though each case should be considered individually, taking into account the desires of women and their companions. Breastfeeding is recommended even among women infected with COVID-19, provided that they wear surgical masks and observe hand hygiene. When breastfeeding is impossible, mothers are recommended to express or pump breast milk. Vital signs should be rigorously assessed and symptoms of this infection identified during childcare consultations.
Also, support such as medication, oxygen, and guidance concerning sleeping, resting, hydration, feeding should be provided in case of worsened symptoms, along with multidisciplinary care.
Further studies with greater methodological rigor are needed to resolve controversies regarding directed pushing, instrumental delivery, delayed umbilical cord clamping and bathing NB immediately after birth.
Because this content is new, some recommendations may change as new knowledge and guidelines emerge in each country.