Consideration for delivery
In general, delivery should not be performed for the sole reason to
improve oxygenation(12). Instead, the delivery decision should balance
the risks of neonatal prematurity and the risks of exposing the fetus to
intractable maternal hypoxemia. Some authors have suggested a threshold
of 28-32 weeks(13, 22). At our institution, we first exhaust maximum
ventilatory settings, prone position, and potentially extracorporeal
membrane oxygenation. The mode of delivery is based on standard
obstetrical indications. Induction of labor in a preterm ventilated
patient with COVID-19 has been described(23). Whereas cesarean delivery
allows a faster and controlled delivery, it has been associated with
significant maternal mortality in ventilated patients(24).
Regardless of the planned mode of delivery, all the supplies necessary
for cesarean delivery and neonatal resuscitation should be set up inside
the biocontainment unit. A portable neonatal and surgical station in
close proximity allows for emergent delivery and neonatal resuscitation
if necessary.