There is no convincing indication that the cesarean section is protective against the transmission of

COVID-19.[12] Vaginal delivery is not contraindicated in patients with COVID-19.[13,14] Usual

obstetric indications should be employed as there is no clear benefit of cesarean delivery in women
with COVID-19 infection.[15] This means that obstetric and maternofetal indications are still valid to
use. Both regional or general anesthesia can be performed in pregnant women with pneumonia due
to COVID-19. However, regional anesthesia should be chosen whenever possible to reduce the risk
of transmission.[16] In poor maternal status, general endotracheal anesthesia should be used for
cesarean delivery

Preoperative management

Patients with COVID-19 should be prevented transmitting the virus right from the hospital entrance.
They should be transferred to a designated operating theater equipped with negative-pressure
ventilation.[7,8,17,18] There are no effective drugs or vaccines so far targeting COVID-19.[15]
Protection devices, hand hygiene, and personal isolation are keys to controlling further infection and
viral spread. It is important to prevent health workers from being exposed and provide a safe
environment. Limitations to the entrance/exit movements of the operating crews prior to and during
the procedure should be applied to minimize exposure and conserve valuable personal protective
equipment.[7]

All personnel must use an appropriate biosafety level-3 (BSL-3) protective suits during the surgery,
including protective suits, N95 masks, disposable caps, goggles, and rubber gloves.[8,18] Trainings
regarding infection control procedures and a thorough understanding of nosocomial COVID-19
infection must be held regularly in hospitals.

Intraoperative management

An emergency cesarean section requires a systematic plan and preparedness for minimizing
cross-contaminations.[19] Special attention must be given to the fasting time due to the nature of
insufficient fasting in emergency patients. Postoperative nausea and vomiting prophylaxis has to be
administrated to avoid nausea and vomiting, with regard to its potential to produce aerosol and
cause transmission. Regional anesthesia is suggested in COVID-19 patients because it is safer than
general anesthesia.[7,8,17] Both anesthesia and surgery should be performed by experts to ensure
reduced exposure time. Regional anesthesia reduces the need for aerosol-producing conditions (i.e.,
intubation and extubation) and avoids the use of mechanical ventilation.

If general anesthesia is indicated, rapid sequence induction without positive pressure mask
ventilation is recommended. [7]   During the surgery, a designated personnel must be stationed
outside the operating room just in case if any additional equipment or medications are needed.
COVID-19 may result in rapid deterioration of lung fun personnel ction. Although both neuraxial and
general anesthesia have been safely reported in pregnancy,[20] neuraxial anesthesia will reduce the
possibility of exacerbating respiratory complications due to intubation.

The use of high-flow nasal cannula should also be employed with cautions due to its
aerosol-producing nature. The use of masks for the patient and the employment of negative
pressure ventilation are intended to control the spread of airborne pathogens, which have been
proven to avoid cross-contamination during the SARS epidemic.[21-23]

Rapid sequence spinal anesthesia[24-26] is an emergency cesarean section where patients are
transferred in a left lateral position with supplemental oxygen, and a single shot subarachnoid block
is provided by the most experienced, available anesthetist. The time required is comparable to
general anesthesia and neonatal outcomes are better.[27]

General anesthesia should be chosen when a COVID-19 parturient presents with desaturation
(≤93%)[28] or when clinically indicated by maternofetal reasons. The general anesthesia should be
carried out with rapid sequence induction with a cuffed tube. The presence of systemic
complications of COVID-19 such as renal failure and disseminated intravascular coagulation might
warrant the use of invasive monitoring (intra-arterial blood pressure and central venous pressure).
[28] Extubation after general anesthesia should be performed with similar precautions as with
intubation.[29] Patients with COVID-19 tend be more agitated during emergence.[28] This may
result in a higher incidence of coughing compared to the intubation.[30]

Postoperative management

Transferring COVID-19 patients to the postanesthesia care unit after a cesarean delivery may
compromise and contaminate other postoperative patients. Suspected and confirmed patients
should be monitored in the operating room where the cesarean section was carried out and
subsequently transferred directly to isolation wards upon full recovery.[28]

Reusable medical and surgical instruments should be disinfected and sealed into a double-layer
disposable waste bags and sent to the designated disinfection department.[8] All medical staff who
were involved in the cesarean section and neonatal care are recommended to have a COVID-19 tests
at least once in the following 2 weeks or accordingly based on the local hospital guidelines.

Neonatal care

Not all neonates born from mother with COVID-19 require intensive monitoring. If the neonate is
stable and does not require neonatal intensive care unit (NICU) admission, the neonate should be
placed in the isolation nursery to avoid exposure risk to other babies.[7] The transfer of the neonate
from the operating complex to the NICU should be employed in a negative-pressured incubator.[31]

Delayed cord clamping for neonates born to pregnant women infected with COVID-19 is not
recommended.[8,15,28] Limited data on pregnancy with SARS-CoV infection showed a low
probability of vertical transmission.[32-35] Two cases of COVID-19 infection were reported in
neonates.[14,21] Therefore, newborns of mothers with suspected or diagnosed COVID-19 infection
should be isolated separately for 14 days after birth and closely monitored for clinical manifestations
of infection.[8] Current evidence shows that there is no vertical transmission during pregnancy.
[14,33,36-39]

As it is unstipulated if COVID-19 virus exists in breast milk, breastfeeding is not recommended. The
evidence regarding the safety of breastfeeding is still limited.[14,37,39] Isolated room for newborns
from COVID-19 patients should be selected in advance, and the team managing the newborn should
also be trained on the workflow and infection control.[28]