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COVID-19: Intrapartum and postpartum issues

Authors: Vincenzo Berghella, MD, Brenna L Hughes, MD, MSc
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2022. | This topic last updated: Oct 18, 2022.

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes
coronavirus disease 2019 (COVID-19). Information about COVID-19 continues to accrue, and
interim guidance by multiple organizations is constantly being updated and expanded in an
attempt to balance evidence-based maternity care with COVID-19-related infection control
practices. The screening and infection control guidance in this topic generally applies to
areas where the infection is prevalent; these measures can be relaxed in areas of low
prevalence and high rates of vaccination.

This topic will discuss issues related to COVID-19 during labor, delivery, and the postpartum
period. Other pregnancy issues and antepartum care of symptomatic patients are reviewed
separately. (See "COVID-19: Overview of pregnancy issues" and "COVID-19: Antepartum care
of pregnant patients with symptomatic infection".)

APPROACH TO INFECTION CONTROL DURING THE PANDEMIC

Vaccination — We recommend that all unvaccinated postpartum people, including those

who are breastfeeding, undergo COVID-19 vaccination, and those who are vaccinated should
receive booster doses, when eligible. Maternal COVID-19 antibodies induced by maternal
vaccination can pass into breast milk and offer passive protection to the infant. These
vaccines do not contain infectious virus and, in recently vaccinated individuals, the minimal
amount of vaccine that crosses into breast milk and is then ingested by the infant is likely to
be inactivated by the infant's digestive system [1,2]. (See "COVID-19: Overview of pregnancy
issues", section on 'Vaccination in people planning pregnancy and pregnant or recently
pregnant people'.)
Home birth versus birth at a medical facility — Although some pregnant people have
considered home birth to reduce their risk of exposure to individuals with COVID-19, medical
facilities have safety measures in place to protect patients, staff, and visitors from infection.
Nosocomial transmission of SARS-CoV-2 is extremely rare when these measures are
appropriately implemented. (See "COVID-19: Infection prevention for persons with SARS-
CoV-2 infection", section on 'Infection prevention in the health care setting'.)

Multiple issues besides COVID-19 risk need to be considered when choosing the birthing
site. Hospitals and accredited birth centers are the safest settings for birth, including during
the COVID-19 pandemic. (See "Planned home birth".)

Infection control precautions, intrapartum and postpartum — Infection control

interventions have been widely implemented to reduce transmission of SARS-CoV-2 in areas
of high community transmission. These include early identification and isolation of patients
with suspected disease and universal source control (eg, covering the nose and mouth to
contain respiratory secretions). Health care facilities have developed policies and procedures
to prevent COVID-19 transmission among patients, visitors, and staff. Such policies and
procedures are reviewed separately. (See "COVID-19: Occupational health issues for health
care personnel", section on 'Preventing COVID-19 in health care settings'.)

Key interventions — Key interventions for the Obstetric Service include:

● Prescreening before scheduled procedures – Within the 24 hours prior to arrival at

the health care facility, patients with scheduled procedures (eg, induction, cesarean
birth) should be prescreened for clinical manifestations of COVID-19 ( table 1) and for
close contact with a confirmed case or persons under investigation. Although the
within 24 hour timeframe is ideal, hospital guidelines vary and some perform this
screening up to 72 hours before arrival.

Screen-positive patients should undergo SARS-CoV-2 testing. Management of patients

with COVID-19 is discussed separately. (See "COVID-19: Antepartum care of pregnant
patients with symptomatic infection", section on 'Patients with nonsevere (or
asymptomatic) COVID-19'.)

● Universal screening upon unscheduled admission to or observation on the labor

unit – Universal screening is advocated for patients who have not been prescreened,
such as those arriving for unscheduled labor or rupture of membranes [3]. Patients are
screened for clinical manifestations of COVID-19 ( table 1), diagnosis of COVID-19 in
the past 10 days, and close contact with a confirmed case or persons under
investigation upon entry into the health care facility. (See "COVID-19: General approach
to infection prevention in the health care setting", section on 'Screening prior to and
upon entry into the health care facility'.)
 - Screen-positive patients – All patients with symptoms should be managed as
though they have COVID-19, pending additional evaluation (SARS-CoV-2
testing). Isolation precautions are indicated for the duration shown in the table
( table 2). The duration of isolation may need to be extended for
immunocompromised patients. Note, this approach differs from that in the
community ( table 2). Specific infection control interventions are described
separately. (See "COVID-19: General approach to infection prevention in the
health care setting", section on 'Precautions for patients with suspected or
confirmed COVID-19'.)

Asymptomatic patients who have had close contact with someone with
suspected or confirmed COVID-19 are typically quarantined; the approach to
quarantine depends primarily upon the patient's vaccination status (all
recommended vaccines received versus not received) and history of recent
COVID-19 (within the last 90 days), as well as the predominant circulating
variant. Infection prevention precautions during quarantine in the hospital are
similar to those used for patients with suspected or confirmed disease.
Evaluation and management of asymptomatic patients who have had a close
contact exposure to COVID-19 is described separately. (See "COVID-19: General
approach to infection prevention in the health care setting", section on
'Asymptomatic patients'.)

- Screen-negative patients – When there is a moderate to high level of SARS-

CoV-2 transmission in the community (defined as 10 to >100 cases per 100,000
people or a test positivity rate of 5 to >10 percent [4]), enhanced infection
prevention precautions should be used when caring for patients, even those
who are not suspected of having COVID-19 (eg, asymptomatic, received all
recommended vaccines, and/or had a recent negative test for SARS-CoV-2)
based on concerns that some patients with COVID-19 are asymptomatic or
presymptomatic, a single polymerase chain reaction (PCR) test does not reliably
rule out SARS-CoV-2 in all patients, and breakthrough infections may occur. (See
"COVID-19: General approach to infection prevention in the health care setting",
section on 'Precautions for those NOT suspected of having COVID-19'.)

● Universal testing prior to/on admission during periods of increased COVID-19

prevalence

• In areas with a moderate to high level of SARS-CoV-2 transmission in the community

(moderate to high viral transmission is defined as >10 (moderate) to >100 (severe)
cases per 100,000 people or a test positivity rate of >5 (moderate) to >10 (severe)
percent [4]), universal testing with a rapid SARS-CoV-2 test upon presentation to the
 labor and delivery unit (or the day before if a scheduled admission) it is reasonable
for most patients, given the correlation between community and obstetric inpatient
rates and the insensitivity of symptom- and contact-based screening alone [5,6].
This information is useful to inform infection control precautions both intrapartum
and postpartum, including newborn care.

• It is reasonable to phase out universal testing after a sustained period of low

disease activity.

• We omit testing in individuals who had a positive SARS-CoV-2 test within the
previous 90 days. Patients who tested positive in the previous 11 to 90 days can be
considered COVID-recovered unless symptomatic and are managed based on their
symptoms.

● Universal use of masks in the health care setting – Universal masking is required for
all patients, support persons, visitors, and health care personnel. We prefer a N95 or
KN95/KF94 mask if available; otherwise, a well-fitting surgical or medical procedure
mask should be used. Use of other personal protective equipment depends on the
specific patient setting. (See "COVID-19: General approach to infection prevention in
the health care setting" and 'Health care workers' below.)

Outside of the health care setting, in the United States, we agree with CDC
recommendations on masking, which depend on the estimated COVID-19 Community
Levels (low, medium, high); reflect a combined measure of local case counts, new
COVID-19 hospital admissions, and the percent of staffed inpatient beds occupied by
patients with COVID-19; and can be found online [7]. In locations with low community
levels, the CDC suggests that mask wearing is optional; at medium levels, it advises
individuals who are immunocompromised or otherwise at risk for severe disease (such
as pregnant people) to consider masking in public and advises their close contacts to
wear masks; at high levels, the CDC recommends that all individuals wear masks in
indoor public settings. It is reasonable for pregnant people to wear a mask in indoor
public spaces even at the low community level, as there is no known harm from
wearing a mask. (See "COVID-19: Epidemiology, virology, and prevention", section on
'Wearing masks in the community'.)

Other potential interventions

● Limiting time on the labor unit – Time in the labor unit should be limited, as is safely
feasible, during periods of moderate to high viral transmission. For example, patients
with low-risk pregnancies who are in early labor can remain at home, with telephone
support by a midwife if possible. Patients with low-risk pregnancies who are going to
be inducted can undergo outpatient rather than inpatient cervical ripening with a
 balloon catheter. For inpatient cervical ripening, using two methods (eg, mechanical
and misoprostol or mechanical and oxytocin) may decrease the time from induction to
birth, compared with using a single agent.

Although nosocomial transmission rates are very low, health care systems tend to be
overburdened during periods of moderate to high viral transmission in the community.

● Limiting support persons and visitors – Most facilities recognize that a support
person is important to many laboring patients and permit at least one support person.
A doula is considered a type of health care personnel by some facilities and a visitor by
others. In some areas, both a family support person and a doula are allowed. (See
"Continuous labor support by a doula".)

For patients with suspected or confirmed COVID-19, we limit movement of the support
person. In these cases, the support person should remain with the laboring patient (ie,
may not leave the room and then return) throughout labor and birth.

A support person with any signs/symptoms consistent with COVID-19 or a positive test
for COVID-19 within 10 days should not be allowed to physically attend the labor and
birth. When screen-positive or additional support persons are desired, they can be a
part of the patient's labor and delivery via video.

● Limiting time in the hospital and office visits after birth – As discussed above,
although nosocomial transmission rates are very low, health care systems tend to be
overburdened during periods of moderate to high viral transmission in the community.
(See "COVID-19: Evaluation of adults with acute illness in the outpatient setting",
section on 'General principles'.)

• After the birth, we suggest sending patients home as soon as they are stable and
ready [3]. This may be as soon as one day after a cesarean birth. However, this
should be considered in the context of the clinical scenario (eg, infection prevalence
in the community, vaccination status) since early discharge may place additional
burdens on families to access recommended newborn care and pediatric offices to
provide this care [8].

• Modifying or reducing in-person postpartum outpatient care in the midst of the

pandemic is appropriate. For example, it may be possible to perform early
postpartum assessments, including wound and blood pressure checks, with
telehealth. A comprehensive postpartum visit may still be important by 12 weeks,
especially in patients with comorbidities and in patients who lose insurance
coverage at that time.
 In-person health care provider visits require the patient to leave their home,
traveling via public, private, or emergency transport and potentially exposing others
to SARS-CoV-2.

INTRAPARTUM CARE OF PATIENTS NOT SUSPECTED OF INFECTION

Intrapartum care is generally routine for patients not suspected of being infected, except for
the infection control precautions described above. (See 'Infection control precautions,
intrapartum and postpartum' above.)

Some additional issues to consider include:

● Intrapartum fever — COVID-19 should be part of the differential diagnosis of

intrapartum fever, particularly when accompanied by respiratory symptoms and
hypoxemia. Such patients should be tested for SARS-CoV-2 if not previously tested,
along with evaluation for common causes of intrapartum fever (eg, chorioamnionitis,
epidural fever) [9]. We do not routinely retest febrile patients within 72 hours of a
negative polymerase chain reaction (PCR) test if a non-COVID-19-related cause of fever
has been diagnosed (eg, chorioamnionitis) and the patient has no respiratory
symptoms. (See "Intrapartum fever".)

● Umbilical cord blood banking — Umbilical cord blood banking can be performed if
planned; the risk of COVID-19 transmission by blood cells has not been documented
and is unclear at present [10].

INTRAPARTUM CARE OF INFECTED PATIENTS

Health care workers — When caring for patients with confirmed or suspected COVID-19,

health care workers should use contact and droplet precautions with eye protection (ie,
gown; gloves; N95, surgical, or medical procedure mask; face shield or goggles). In
particular, during episodes of patient deep respiratory efforts in the active phase and while
pushing, health care workers should use both contact and droplet precautions with eye
protection and airborne precautions (ie, N95 mask or powered air purifying respirator). (See
"COVID-19: General approach to infection prevention in the health care setting", section on
'Health care personnel'.)

Of note, health care workers are at risk for developing COVID-19 through exposures in the
community, as well as in the health care setting. Guidelines for work restriction and
monitoring after exposure and returning to work after exposure and after confirmed or
suspected COVID-19 are available separately. (See "COVID-19: Occupational health issues for
health care personnel".)
Choosing the route of birth — COVID-19 is generally not an indication to alter the planned
route of birth [10]. Induction generally can be performed safely, even in intubated patients
[11,12].

Cesarean birth is performed for standard obstetrical indications and does not appear to
reduce the already low risk for neonatal COVID-19, which generally causes only mild
symptoms in newborns [13,14] (see "COVID-19: Overview of pregnancy issues", section on
'Risk of vertical transmission'). In patients with severe or critical COVID-19, cesarean birth
may be indicated because of concern for acute maternal and/or fetal decompensation. In
addition, in patients who are intubated and laboring in an operating room or intensive care
unit, a long induction can be impractical logistically due to the specialized equipment and
personnel at these sites. (See "COVID-19: Antepartum care of pregnant patients with
symptomatic infection", section on 'Timing of delivery'.)

Although one study of 37 cesarean and 41 vaginal births in patients with COVID-19 reported
cesarean birth was associated with an increased risk for clinical deterioration (8 out of 37 [22
percent] versus 2 out of 41 [5 percent]) that remained after adjustment for confounders
(adjusted odds ratio 13, 95% CI 1.5-122.0), the issue of possible harm from cesarean birth
should not preclude indicated cesarean birth [15]. The small number of events and bias in
case selection for route of delivery could account for the findings.

Clinical care team — For severely/critically ill patients, a multidisciplinary care team should
be present (eg, intensivists, maternal-fetal medicine, neonatology, nursing support from
obstetrics, pediatrics, and medical disciplines) to care for them and their potentially heavily
sedated newborn, regardless of the type or site of birth (eg, labor and delivery unit, main
operating room, intensive care unit). The intensity of maternal monitoring beyond
intrapartum routine care should be directed by this team.

COVID-19-specific therapy — Any COVID-19-specific therapy initiated antepartum should be

continued intrapartum and postpartum to complete the typical course of the therapy.
Considerations in breastfeeding mothers are discussed below. (See 'Antiviral drug safety'
below.)

Prophylaxis against venous thromboembolism is discontinued while the patient is

intrapartum. (See "COVID-19: Antepartum care of pregnant patients with symptomatic
infection", section on 'Venous thromboembolism prophylaxis'.)

Labor analgesia and anesthesia — Neuraxial anesthetic is not contraindicated in patients

with known or suspected COVID-19 and has several advantages in laboring patients: it
provides excellent analgesia and thus reduces cardiopulmonary stress from pain and anxiety
and, in turn, the chance of viral dissemination during repeated forceful exhalation and
panting [3,16,17]. In addition, it is available in case an emergency cesarean is required, thus
obviating the need for and risks of general anesthesia. (See "Neuraxial analgesia for labor
and delivery (including instrumented delivery)".)

● Nitrous oxide – There is insufficient information about the cleaning, filtering, and
potential aerosolization with the use of nitrous oxide labor analgesia systems in the
setting of COVID-19. For this reason, the Society for Obstetric Anesthesia and
Perinatology and the Society for Maternal-Fetal Medicine suggest that individual labor
and delivery units discuss the relative risks and benefits and consider suspending use
for patients with suspected or confirmed COVID-19 or unconfirmed COVID-19 negative
status; however, it remains an option for patients with a negative SARS-CoV-2 test
[18,19]. One guideline suggests use with a single patient microbiologic filter [20].

Anesthetic care for patients with suspected or confirmed COVID-19 is reviewed separately.
(See "COVID-19: Perioperative risk assessment and anesthetic considerations, including
airway management and infection control".)

Use of magnesium sulfate

● Patients with respiratory compromise – In nonintubated patients with respiratory

compromise due to COVID-19, those receiving magnesium sulfate for seizure
prophylaxis and/or neonatal neuroprotection should be monitored particularly
carefully (eg, check magnesium levels, frequently assess respiratory rate and oxygen
saturation [pulse oximetry]) since high magnesium levels (10 to 13 mEq/L [12 to 16
mg/dL or 5.0 to 6.5 mmol/L]) can cause respiratory paralysis. In intubated, mechanically
ventilated patients, signs of magnesium-related respiratory toxicity will not be
observed; thus, cardiac arrhythmias or arrest can be the first sign of serious toxicity.
Consultation with maternal-fetal medicine and pulmonary/critical care specialists is
advised. (See "Preeclampsia: Intrapartum and postpartum management and long-term
prognosis", section on 'Seizure prophylaxis' and "Neuroprotective effects of in utero
exposure to magnesium sulfate".)

● Patients with acute kidney injury – In patients who have COVID-19-related acute
kidney injury receiving magnesium sulfate for seizure prophylaxis and/or neonatal
neuroprotection, we suggest dose-adjustment rather than withholding the drug.
Consultation with maternal-fetal medicine and/or nephrology/critical care specialists is
advised.

Fetal monitoring and procedures — In laboring patients with COVID-19, maternal and fetal
monitoring and procedures are performed according to standard indications, with the
following considerations:
 ● Continuous electronic fetal monitoring is recommended for all symptomatic patients
since an increased frequency of nonreassuring tracings has been reported among
pregnant patients with suspected or confirmed COVID-19, but these case series
typically had a high proportion of patients with pneumonia. (See "Intrapartum fetal
heart rate monitoring: Overview".)

● SARS-CoV-2 is uncommon in vaginal secretions and amniotic fluid, so maternal

infection is not a contraindication to rupture of fetal membranes, application of a fetal
scalp electrode, or insertion of an intrauterine pressure catheter, but data are limited.

Pushing — Either immediate or delayed pushing is reasonable for most patients, and the
choice is best made as a shared decision. Delayed pushing results in a longer second stage,
but less time spent actively pushing. Although pushing can involve repeated forceful
exhalation and panting and loss of feces (which commonly contains the virus [21,22]), which
theoretically could increase the risk for viral transmission, we suggest not delaying pushing
in attempt to mitigate this risk. (See "Labor and delivery: Management of the normal second
stage", section on 'Early versus delayed'.)

Ideally, patients with COVID-19 should continue to wear a mask while pushing; however, we
allow them to remove the mask if they are uncomfortable wearing the mask during this
exertion.

Umbilical cord clamping — As in noninfected patients, we perform delayed umbilical cord

clamping in patients with known or suspected infection since it is highly unlikely to increase
the risk of vertical transmission [8,10]. (See "Labor and delivery: Management of the normal
third stage after vaginal birth", section on 'Early versus delayed cord clamping'.)

Management of the third stage — Management of the third stage of labor is not affected
by COVID-19, and most patients who develop postpartum hemorrhage can be managed
according to standard protocols. However, some clinicians, including some UpToDate
contributors, do not use tranexamic acid in COVID-19 patients with postpartum hemorrhage
because its antifibrinolytic properties may increase the risk for thrombosis in individuals with
a hypercoagulable state, such as patients with severe or critical disease, and alternative
strategies for control of bleeding are usually available [23]. Other UpToDate contributors use
tranexamic acid as part of the management of postpartum hemorrhage in patients with
COVID-19.

Ergot derivatives (eg, methergine) should be avoided in patients receiving nirmatrelvir-

ritonavir because of the risk for ergot toxicity (ischemia of an extremity, coma, and even
death). Some authorities suggest avoiding ergot derivatives in patients with symptomatic
COVID-19 because of rare cases of respiratory failure and severe vasoconstriction in severely
ill patients [24]. There is no consensus about this among the contributors of this topic and
no data on which to base a recommendation. (See "Postpartum hemorrhage: Medical and
minimally invasive management" and "Postpartum hemorrhage: Management approaches
requiring laparotomy".)

Skin-to-skin contact — We encourage skin-to-skin contact between all mothers and

newborns in the birthing room. Mothers with COVID infection can reasonably safely practice
skin-to-skin contact and breastfeed in the birthing room if they wear a surgical mask and use
proper hand hygiene [8,25]. (See 'Care of newborns of infected mothers' below.)

Placenta — There is no consensus regarding whether maternal COVID-19 alone is an

indication for placental examination by a pathologist.

There are no standard criteria for diagnosis of placental SARS-CoV-2 infection and no definite
COVID-19-specific placenta changes [26]. A consensus statement from the National
Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human
Development SARS-CoV-2 placental infection workshop proposed five categories for
documenting placental infection based on the rigor of the diagnostic technique [27]:

● Definite: Evidence of active replicating virus in the placental tissues

● Probable: Evidence of viral RNA or protein located in placental tissues
● Possible: Evidence of viral RNA in placental homogenates or viral-like particles by
electron microscopy in placental tissues
● Unlikely: No evidence of any of the above
● No testing: Testing not done

They also provided detailed recommendations for placental handling, processing, and
examination.

SARS-CoV-2 placentitis is characterized by chronic histiocytic intervillositis, increased

perivillous fibrin deposition (including massive perivillous fibrin deposition), and villous
trophoblast necrosis. These changes can cause widespread and severe placental destruction,
resulting in placental malperfusion and insufficiency and leading to perinatal death from
fetal hypoxic-ischemic injury. In a case series of 64 stillborns (15 to 39 weeks of gestation)
and four neonatal deaths with SARS-CoV-2 placentitis, all 68 placentas tested positive for
SARS-CoV-2, whereas the virus was detected from a stillborn/newborn body specimen in only
16 out of 28 cases tested (59 percent) [28]. There was no evidence that fetal SARS-CoV-2
infection had a direct role in causing the deaths. Importantly, the mothers were
unvaccinated in all reported cases of SARS-CoV-2 placentitis causing stillbirth and neonatal
death [29]. Further study is needed to determine the frequency of SARS-CoV-2 placentitis in
pregnant patients with COVID-19 and the frequency of stillbirth/neonatal death in those with
SARS-CoV-2 placentitis. (See "COVID-19: Overview of pregnancy issues", section on 'Risk of
stillbirth'.)
POSTPARTUM CARE OF INFECTED PATIENTS

Postpartum infection control precautions — In general, patients with suspected or

confirmed SARS-CoV-2 infection should be isolated from uninfected patients and cared for
according to standard infection control guidelines. (See "COVID-19: Infection prevention for
persons with SARS-CoV-2 infection".)

Maternal monitoring — The intensity of maternal monitoring in patients with COVID-19

depends on maternal status. The goal is to identify disease progression, as well as usual
postpartum problems and complications. (See "Postpartum perineal care and management
of complications".)

● For asymptomatic patients, routine postpartum maternal monitoring is adequate. (See

"Overview of the postpartum period: Normal physiology and routine maternal care".)

● For patients with mild illness (see "COVID-19: Overview of pregnancy issues", section on
'Classification of disease severity'), postpartum monitoring is routine.

● For patients with moderate illness (see "COVID-19: Overview of pregnancy issues",
section on 'Classification of disease severity'), we perform continuous pulse oximetry
monitoring for the first 24 hours or until improvement in signs and symptoms,
whichever takes longer. The type and frequency of follow-up laboratory studies and
chest imaging (initial or repeat) are guided by the patient's course. Several institutional
protocols are available. (See "COVID-19: Management in hospitalized adults", section
on 'Institutional protocols'.)

In patients who develop acute dyspnea and hypoxemia postpartum, the differential
diagnosis ( table 3) includes progression to severe COVID-19, sepsis, influenza,
cardiomyopathy, and pulmonary embolism. The combination of symptoms, physical
examination, laboratory tests, and imaging can usually distinguish among these
disorders.

● For patients with severe or critical illness (see "COVID-19: Overview of pregnancy
issues", section on 'Classification of disease severity'), very close maternal monitoring
and care on the labor and delivery unit or intensive care unit are indicated. Several
institutional protocols are available. (See "COVID-19: Management in hospitalized
adults" and "COVID-19: Management of the intubated adult".)

Venous thromboembolism prophylaxis

● Postpartum patients with asymptomatic COVID-19 – There is consensus that

anticoagulation is not required unless the patient has other thrombotic risk factors,
 such as prior venous thromboembolism (VTE) or, in some cases, cesarean birth [30].
(See "Overview of the causes of venous thrombosis".)

● Postpartum patients with severe COVID-19 – There is consensus for use of

prophylactic-dose anticoagulation, if there are no contraindications to its use. It is
generally discontinued when the patient is discharged to home [30].

● Postpartum patients with symptomatic nonsevere COVID-19 hospitalized for labor

and delivery – Practice patterns vary. Some practitioners administer prophylactic-dose
anticoagulation to all symptomatic patients while they are in the hospital. Others make
this decision on a case-by-case basis, taking into account all of the patient's risk factors
for venous thrombosis. (See "Overview of the causes of venous thrombosis".)

Either low molecular weight heparin or unfractionated heparin is acceptable, and both are
compatible with breastfeeding. Choice of drug, dosing, and timing after vaginal and
cesarean birth are discussed in more detail separately. (See "COVID-19: Hypercoagulability",
section on 'Inpatient VTE prophylaxis' and "Use of anticoagulants during pregnancy and
postpartum", section on 'Postpartum and breastfeeding' and "Cesarean birth: Preoperative
planning and patient preparation", section on 'Thromboembolism prophylaxis'.)

Postpartum analgesia — Pain management of patients with COVID-19 is routine. (See

"Overview of the postpartum period: Normal physiology and routine maternal care", section
on 'Pain management' and "Post-cesarean delivery analgesia".).

We use nonsteroidal anti-inflammatory drugs (NSAIDs) when clinically indicated. (See

"COVID-19: Management in hospitalized adults", section on 'NSAID use'.)

Postpartum fever — The differential diagnosis of postpartum fever in patients with COVID-

19 includes the infection itself as well as postpartum endometritis, surgical site infection,
breast inflammation or infection, influenza, pyelonephritis, other viral or bacterial
respiratory infections, and, rarely, pseudomembranous colitis due to Clostridioides difficile.
The combination of symptoms, physical examination, and laboratory tests can usually
distinguish among these disorders. (See "Postpartum endometritis", section on 'Differential
diagnosis'.)

In newly symptomatic patients who previously tested negative for SARS-CoV-2, retesting may
be appropriate as part of the evaluation of fever or other potential manifestations of COVID-
19 ( table 1). However, we do not routinely retest febrile patients within 72 hours of a
negative polymerase chain reaction (PCR) test if a non-COVID-19-related cause of fever has
been diagnosed (eg, chorioamnionitis, endometritis, surgical site infection) and the patient
has no respiratory symptoms.
Acetaminophen is the preferred antipyretic agent. (See "COVID-19: Management in
hospitalized adults", section on 'NSAID use'.)

Permanent and reversible contraception — Permanent contraception (tubal sterilization)

does not add significant additional time or risk when performed at an uncomplicated
cesarean birth and, thus, should be performed if planned regardless of COVID-19 status.
After a vaginal birth, the decision to schedule a procedure for permanent contraception in a
patient with COVID-19 should be made on a local level, based on available resources.

If not performed or if a reversible contraceptive method is desired, an alternative form of

contraception should be provided (eg, immediate postpartum long-acting reversible
contraception or depot medroxyprogesterone acetate) as long as the patient desires one of
these methods. This avoids additional outpatient postpartum visits. (See "Overview of female
permanent contraception" and "Postpartum permanent contraception: Procedures" and
"Postpartum contraception: Counseling and methods".)

Discharge from hospital and medical follow-up — The decision to discharge a patient with
COVID-19 is generally the same as that for other conditions and depends on the need for
hospital-level care and monitoring. We counsel all patients on the warning symptoms that
should prompt reevaluation by a telehealth or in-person visit, including emergency
department evaluations. These include new onset of dyspnea, worsening dyspnea, dizziness,
and mental status changes, such as confusion. Patients are also counseled about persistent
symptoms ( table 4), when to expect recovery, and what to expect after recovery. These
issues, as well as evaluation of patients after discharge and return to normal activities, are
discussed in detail separately. (See "COVID-19: Evaluation and management of adults with
persistent symptoms following acute illness ("Long COVID")".)

Obstetric follow-up — Obstetric follow-up of patients with COVID-19 is routine. (See

"Overview of the postpartum period: Normal physiology and routine maternal care".)

The psychological impact of COVID-19, which may include depression or moderate to severe
anxiety, should also be recognized and support offered. All postpartum patients should still
be screened for postpartum depression four to eight weeks after the birth. The most widely
used instrument is the self-reported, 10-item Edinburgh Postnatal Depression Scale
( figure 1A-B), which can be completed in less than five minutes [31], but alternatives are
available. (See "Postpartum unipolar major depression: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Assessment' and "COVID-19: Psychiatric illness",
section on 'Patients with COVID-19'.)

A tool is also available for screening for anxiety. (See "Generalized anxiety disorder in adults:
Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis",
section on 'Assessment and Diagnosis'.)
CARE OF NEWBORNS OF INFECTED MOTHERS

Newborn evaluation — Approximately 2 percent of newborns of mothers with COVID-19

near the time of delivery have positive tests for SARS-CoV-2 in the first 24 to 96 hours of life.
The risk is highest in those whose mothers test positive during the birth hospitalization (5.6
percent) and those born before 37 weeks (4 percent) [8]. (See "COVID-19: Overview of
pregnancy issues", section on 'Risk of vertical transmission'.)

The newborns of mothers with suspected or confirmed COVID-19 are considered persons
under investigation, and they should be tested for SARS-CoV-2 [32]. The American Academy
of Pediatrics (AAP) suggests the following for diagnosis of newborn infection [8]:

● Healthy newborns should be tested at least once before hospital discharge and close to
the time of discharge, to provide family guidance. Obtain a single swab from the
nasopharynx and submit for a single test. The specifics of testing will depend on the
requirements of local testing platforms.

Centers can opt to perform one test at approximately 24 hours of age and a second
test at approximately 48 hours of age. Some infants with a negative test at 24 hours
have a positive test at a later time, particularly when rooming-in with a contagious
mother. In addition, a single positive RT-PCR in a newborn nasopharyngeal sample may
indicate active viral replication, but it could also represent viral fragments acquired
during passage through the vagina or from the immediate postnatal environment and
thus not be a true neonatal infection. In a report of universal SARS-CoV-2
nasopharyngeal RT-PCR screening in neonates, 9 of 418 (2 percent) neonates tested
positive within 24 hours of birth, and seven were negative on the second test [33].
Persistence of a positive test on subsequent specimens is critical to differentiate
superficial contamination (resulting in a false-positive test) from true neonatal
infection. If performed, the presence of additional positive tests of normally sterile
specimen types (eg, neonatal blood, lower respiratory tract samples, cerebrospinal
fluid) also enables differentiation of contamination from neonatal infection [34].

● Newborns in the neonatal intensive care unit with positive initial testing may have
follow-up testing at 48- to 72-hour intervals until two consecutive negative tests are
obtained. Care providers in the unit should use appropriate personal protective
equipment until two consecutive negative tests collected ≥24 hours apart have been
documented. This stringent approach was suggested because the duration of shedding
infectious virus has not been established for such infants.

Serologic testing is of limited utility as both false-positive and false-negative

immunoglobulin M (IgM) tests occur; therefore, a positive serologic test always requires
confirmatory testing of a second specimen, preferably using molecular diagnostic tests to
directly detect the pathogen [34]. A true positive newborn SARS-CoV-2 IgM at less than seven
days of age is assumed to represent in utero infection whereas a negative IgM at less than
seven days followed by a positive test after day 7 is assumed to reflect intrapartum or early
postnatal infection.

Mother-newborn contact in the hospital — We recommend not separating the mother

with COVID-19 and newborn after birth. The newborn's risk for acquiring SARS-CoV-2 from its
mother is low, and data suggest no difference in risk of neonatal SARS-CoV-2 infection
whether the neonate is cared for in a separate room or remains in the mother's room
[13,32,35-39]. However, mothers should wear a well-fitting N95, KN95/KF94, or surgical or
medical procedure mask and practice hand hygiene during contact with their infants. At
other times, reasonable physical distancing between the mother and neonate or placing the
neonate in an incubator is desirable, when feasible. Passive transplacental transfer of
maternal anti-SARS-CoV-2 antibody may not protect the newborn from maternal infection
[40].

Factors to consider include the following:

● Rooming-in helps establish breastfeeding, facilitates bonding and parental education,

and promotes family-centered care.

● Separation may be necessary for mothers who are too ill to care for their infants or
who need higher levels of care.

● Separation may be necessary for neonates who may be at higher risk for severe illness
(eg, preterm infants, infants with underlying medical conditions, infants needing higher
levels of care).

● Separation to reduce the risk of mother-to-newborn transmission is not useful if the

neonate tests positive for SARS-CoV-2, and probably not useful if the mother and
newborn will not be able to maintain separation after discharge until they meet criteria
for discontinuation of quarantine.

● If separation is implemented, newborn COVID-19 suspects/confirmed cases should be

isolated from other healthy newborns and cared for, in the United States, according to
the Centers for Disease Control and Prevention's (CDC) newborn guidelines.

● If another healthy family member is providing newborn care (eg, diapering, bathing,
feeding), they should use appropriate personal protective equipment and procedures
(eg, well-fitting mask [eg, N95, KN95/KF94, surgical, or medical procedure mask], hand
hygiene).
 Criteria for discontinuing mother-newborn infection precautions — These are the same
as for nonpregnant individuals and depends whether the patient is in the hospital
( table 2) or the community ( algorithm 1). Detailed information is available separately.
(See "COVID-19: Epidemiology, virology, and prevention", section on 'Viral shedding and
period of infectiousness' and "COVID-19: Epidemiology, virology, and prevention", section on
'Risk of transmission depends on exposure type' and "COVID-19: Infection prevention for
persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)

If the newborn tests positive for SARS-CoV-2 in the hospital and is asymptomatic when
discharged home, the AAP suggests frequent pediatric outpatient follow-up (eg, phone,
telemedicine, in-office) for the first 14 days after birth. Caregivers should use masks, gloves
(as available), and hand hygiene in the home environment to prevent spread from infant to
uninfected caregivers.

Breastfeeding and formula feeding — The risk of SARS-CoV-2 transmission from ingestion

of breast milk is unclear, but appears to be very low. No publication has reported detection
of replication-competent virus in breast milk [34]. Although samples of breast milk positive
for SARS-CoV-2 by RT-PCR have been detected [41,42], these samples do not necessarily
contain viable and transmissible virus [43].

There is general consensus that breastfeeding should be encouraged because of its many
maternal and infant benefits. In the setting of maternal COVID-19 infection or maternal
COVID-19 vaccination, the infant may receive passive antibody protection (both IgA and IgG
neutralizing antibodies) against the virus since breast milk is a source of maternal antibodies
and other anti-infective factors. (See "Infant benefits of breastfeeding" and "Maternal and
economic benefits of breastfeeding".)

● Breastfeeding – The AAP supports breastfeeding in mothers with COVID-19, with

appropriate infection control precautions [44]. This approach considers the clear
mother-infant benefits of breastfeeding, the low likelihood of passing maternal
infection to the newborn when infection precautions are taken, the favorable effects of
passive antibody protection, and the nonsevere course of newborn infection when it
does occur. This policy was based, in part, on a study from New York City that tested
and followed 82 infants of 116 mothers who tested positive for SARS-CoV-2: no infant
was positive for SARS-CoV-2 postnatally, although most roomed-in with their mothers
and were breastfed [25]. The infants were kept in a closed isolette while rooming-in,
and the mothers wore surgical masks while handling their infants and followed
frequent hand and breast washing protocols. Subsequent studies have reported similar
findings [45].

Infection control precautions to prevent transmission to the infant during feeding

include wearing a well-fitting mask (eg, surgical, medical procedure, KN95/KF94, or N95
 mask), performing hand hygiene, and disinfecting shared surfaces that the
symptomatic mother has contacted. However, it should be noted that the value of
precautions, such as cleansing the breast prior to breastfeeding, for reducing potential
transmission of SARS-CoV-2, has not been formally studied [46].

We agree with CDC guidance for management of various clinical scenarios. For
example:

• Mothers without suspected or confirmed COVID-19 and who have not been in close
contact with someone who has COVID-19 do not need to take special precautions
when feeding at the breast, expressing milk, or feeding from a bottle.

• When the mother has suspected or confirmed COVID-19, they should take
precautions (including wearing a well-fitting surgical, medical procedure, N95, or
KN95/KF94 mask; hand hygiene) before contact with the infant. Neither masks nor
plastic face shields should be placed on newborns. In the less common scenario
where only the infant has suspected or confirmed COVID-19, mothers should take
similar precautions and practice hand hygiene after contact with the infant.

• When both the mother and the breastfed infant have suspected or confirmed
COVID-19, no special precautions (eg, wearing a mask) are needed during
breastfeeding, expressing milk, or feeding from a bottle, or during the period
of isolation.

● Feeding pumped breast milk – If mother and infant separation has been
implemented, ideally, the infant is fed expressed breast milk by another healthy
caregiver until the mother has recovered or has been proven uninfected, provided that
the other caregiver is healthy and follows hygiene precautions. Expressing breast milk
is important to support establishment of the maternal milk supply.

Before pumping, ideally with a dedicated breast pump, mothers should wear a well-
fitting mask (eg, surgical, medical procedure, N95, or KN95/KF94 mask) and thoroughly
clean their hands with soap and water and clean pump parts, bottles, and artificial
nipples [44]. The CDC has issued guidance about cleaning breast pumps and
breastfeeding. If possible, the pumping equipment should be thoroughly cleaned by a
healthy person. It should be noted that the value of precautions, such as disinfecting
external surfaces of milk collection devices (eg, bottles, milk bags), for reducing
potential transmission of SARS-CoV-2 has not been formally studied [46].

● Formula feeding – Ideally, mothers with known or suspected COVID-19 who choose to
formula feed should have another healthy caregiver feed the infant. If this is not
 possible or desired, they must also take appropriate infection control precautions, as
described above, to prevent transmission through close contact when feeding.

● Pasteurized donor human milk – If the mother is too ill to breastfeed or express milk,
donor milk may be used. Holder pasteurization is commonly used in human milk banks
and appears to eliminate replication-competent SARS-CoV-2 virus [47,48].

Antiviral drug safety — Information on transfer of maternal drugs into breast milk is

available in the Lexicomp drug interactions program included with UpToDate and the Drugs
and Lactation Database (LactMed) of the National Library of Medicine.

● Remdesivir – Infants are not likely to absorb clinically important amounts of the drug
from breast milk. No serious adverse drug reactions have been reported in newborn
infants who received intravenous remdesivir therapy for Ebola. Breastfeeding is not
contraindicated [49].

● Nirmatrelvir-ritonavir – There are no data on the presence of nirmatrelvir in breast milk,

the effects on the breastfed infant, or the effects on milk production. Limited data
suggest that ritonavir is present in breast milk, but no information is available on the
effects on the breastfed infant or the effects on milk production. Lactation is not a
contraindication to use, but pumping and discarding milk during maternal treatment
may be prudent.

● Sotrovimab – The amount of sotrovimab in breast milk is likely to be very low since it is
a large protein [50]. It is also likely to be partially destroyed in the infant's
gastrointestinal tract; thus, absorption and infant effects are probably minimal.
Lactation is not a contraindication to use, but pumping and discarding milk during
maternal treatment may be prudent.

● Molnupiravir – There is no information on use of molnupiravir during lactation.

Pumping and discarding milk is advised during treatment and for four days after the
last dose because of concerns about mutagenicity.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: COVID-19 – Index of
guideline topics".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: COVID-19 and pregnancy (The Basics)" and
"Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19
vaccines (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Infection control measures – Infection control interventions include

vaccination/booster and prescreening before scheduled procedures, universal
screening upon unscheduled admission to or observation on the labor unit, universal
testing prior to/on admission in areas of moderate to high SARS-CoV-2 transmission in
the community, universal use of appropriate masks, and use of other personal
protective equipment when appropriate. (See 'Vaccination' above and 'Infection control
precautions, intrapartum and postpartum' above and 'Health care workers' above.)

● Route of birth – COVID-19 is generally not an indication to alter the planned route of
birth. Induction generally can be performed safely, even in intubated patients. (See
'Choosing the route of birth' above.)

● Management of labor and birth

• In patients with nonsevere COVID-19, intrapartum management is generally

routine, except for enhanced infection control precautions (including possible
avoidance of nitrous oxide labor analgesia systems). Ergot derivatives should be
avoided in patients receiving nirmatrelvir-ritonavir because of the risk for ergot
toxicity. (See 'Intrapartum care of infected patients' above.)

• In patients with severe or critical COVID-19, cesarean birth may be indicated

because of concern for acute maternal and/or fetal decompensation or the logistic
 problems of a long induction in an intensive care or similar unit. (See 'Choosing the
route of birth' above.)

Magnesium levels should be monitored in patients receiving magnesium sulfate for

obstetric indications because of the increased risk of magnesium toxicity. (See 'Use
of magnesium sulfate' above.)

A multidisciplinary care team (eg, intensivists, maternal-fetal medicine, neonatology,

nursing support from obstetrics, pediatrics, and medical disciplines) is needed to
care for these patients and their potentially heavily sedated newborn. The intensity
of maternal monitoring beyond intrapartum routine care should be directed by this
team. (See 'Clinical care team' above.)

● Postpartum care – Obstetric aspects of postpartum care are generally routine for
patients with COVID-19. Maternal medical care is commensurate with the severity of
maternal illness.

• Antithrombotic prophylaxis – (See 'Venous thromboembolism prophylaxis' above.)

- Asymptomatic COVID-19 hospitalized for labor and delivery –

Anticoagulation is not required unless the patient has other thrombotic risk
factors, such as prior venous thromboembolism (VTE) or, in some cases,
cesarean birth.

- Severe COVID-19 – Prophylactic-dose anticoagulation is required, if there are

no contraindications to its use. Discontinue when the patient is discharged to
home.

- Symptomatic nonsevere COVID-19 hospitalized for labor and delivery –

Practice patterns vary. Some practitioners administer prophylactic-dose
anticoagulation to all symptomatic patients while in the hospital. Others make
this decision on a case-by-case basis, taking into account all of the patient's risk
factors for venous thrombosis.

● Evaluation of intrapartum and postpartum fever – COVID-19 should be part of the

differential diagnosis of intrapartum and postpartum fever. Such patients should be
tested for SARS-CoV-2 if not previously tested, along with evaluation for common
causes of intrapartum and postpartum fever. We do not routinely retest febrile patients
within 72 hours of a negative polymerase chain reaction (PCR) test if a non-COVID-19-
related cause of fever has been diagnosed (eg, chorioamnionitis, endometritis, surgical
site infection) and the patient has no respiratory symptoms. (See 'Intrapartum care of
patients not suspected of infection' above and 'Postpartum fever' above.)
 ● Newborn evaluation – The infants of mothers with suspected or confirmed COVID-19
are considered persons under investigation and should be tested for SARS-CoV-2. (See
'Newborn evaluation' above.)

● Rooming-in and breastfeeding – (See 'Mother-newborn contact in the hospital' above

and 'Breastfeeding and formula feeding' above.)

• Mothers without suspected or confirmed COVID-19 and who have not been in close
contact with someone who has COVID-19 do not need to take special precautions
when feeding at the breast, expressing milk, or feeding from a bottle.

• Mothers with suspected or confirmed COVID-19 should take precautions (including

wearing a well-fitting surgical, medical procedure, N95, or KN95/KF94 mask; hand
hygiene) before contact with the infant. Neither masks nor plastic face shields
should be placed on newborns. In the less common scenario where only the infant
has suspected or confirmed COVID-19, mothers should take similar precautions and
practice hand hygiene after contact with the infant.

• When both the mother and the breastfed infant have suspected or confirmed
COVID-19, no special precautions (eg, wearing a mask) are needed during
breastfeeding, expressing milk, or feeding from a bottle, or during the period
of isolation.

Use of UpToDate is subject to the Terms of Use.

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 6. Hashim NAF, Mahdy ZA, Abdul Rahman R, et al. Universal Testing Policy for COVID-19 in
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https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guid
ance/faqs-management-of-infants-born-to-covid-19-mothers/ (Accessed on July 29, 202
2).
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among asymptomatic and symptomatic pregnant women: two weeks of confirmed
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2020; 2:100118.
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ynecologists, Obstetrics. Available at: https://www.acog.org/clinical-information/physici
an-faqs/covid-19-faqs-for-ob-gyns-obstetrics (Accessed on October 29, 2020).
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12. Slayton-Milam S, Sheffels S, Chan D, Alkinj B. Induction of Labor in an Intubated Patient

With Coronavirus Disease 2019 (COVID-19). Obstet Gynecol 2020; 136:962.
13. Walker KF, O'Donoghue K, Grace N, et al. Maternal transmission of SARS-COV-2 to the
neonate, and possible routes for such transmission: a systematic review and critical
analysis. BJOG 2020; 127:1324.
14. Cai J, Tang M, Gao Y, et al. Cesarean Section or Vaginal Delivery to Prevent Possible
Vertical Transmission From a Pregnant Mother Confirmed With COVID-19 to a Neonate:
A Systematic Review. Front Med (Lausanne) 2021; 8:634949.
15. Martínez-Perez O, Vouga M, Cruz Melguizo S, et al. Association Between Mode of
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Outcomes in Spain. JAMA 2020; 324:296.
16. Jamieson DJ, Steinberg JP, Martinello RA, et al. Obstetricians on the Coronavirus Disease
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17. Berghella V. NOW!: protection for obstetrical providers and patients. Am J Obstet
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ynecologists, Obstetrics. Available at: https://www.acog.org/clinical-information/physici
an-faqs/covid-19-faqs-for-ob-gyns-obstetrics (Accessed on July 13, 2021).
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om/2020/03/29/covid-19-the-smfm-soap-guidelines-for-labor-and-delivery. (Accessed on
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21. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical

Specimens. JAMA 2020; 323:1843.
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Patients. Physiol Rev 2020; 100:1595.

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Concerning COVID-19 and Pregnancy. Diagnostics (Basel) 2020; 10.
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COVID-19 pandemic: an observation cohort study. Lancet Child Adolesc Health 2020;
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pregnancy-related placental pathologies shows no specific pattern. Placenta 2022;
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27. Roberts DJ, Edlow AG, Romero RJ, et al. A standardized definition of placental infection
by SARS-CoV-2, a consensus statement from the National Institutes of Health/Eunice
Kennedy Shriver National Institute of Child Health and Human Development SARS-CoV-
2 Placental Infection Workshop. Am J Obstet Gynecol 2021; 225:593.e1.

28. Schwartz DA, Avvad-Portari E, Babál P, et al. Placental Tissue Destruction and
Insufficiency From COVID-19 Causes Stillbirth and Neonatal Death From Hypoxic-
Ischemic Injury. Arch Pathol Lab Med 2022; 146:660.

29. Schwartz DA, Mulkey SB, Roberts DJ. SARS-CoV-2 Placentitis, Stillbirth and Maternal
COVID-19 Vaccination: Clinical-Pathological Correlations. Am J Obstet Gynecol 2022.
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el. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of He
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botic-therapy/ (Accessed on February 02, 2022).

31. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the
10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.
32. CDC. Newborns. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.
html.
33. McDevitt KEM, Ganjoo N, Mlangeni D, Pathak S. Outcome of universal screening of
neonates for COVID-19 from asymptomatic mothers. J Infect 2020; 81:452.
34. WHO scientific brief. Definition and categorization of the timing of mother-to-child trans
mission of SARS-CoV-2. February 8, 2021 https://www.who.int/publications/i/item/WHO-
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35. Cojocaru L, Crimmins S, Sundararajan S, et al. An initiative to evaluate the safety of
maternal bonding in patients with SARS-CoV-2 infection. J Matern Fetal Neonatal Med
2022; 35:3540.
36. Gale C, Quigley MA, Placzek A, et al. Characteristics and outcomes of neonatal SARS-
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39. Fitzpatrick T, Wilton AS, Chung H, Guttmann A. SARS-CoV-2 Infection Among Maternal-
Infant Dyads in Ontario, Canada. JAMA Netw Open 2021; 4:e2120150.

40. Edlow AG, Li JZ, Collier AY, et al. Assessment of Maternal and Neonatal SARS-CoV-2 Viral
Load, Transplacental Antibody Transfer, and Placental Pathology in Pregnancies During
the COVID-19 Pandemic. JAMA Netw Open 2020; 3:e2030455.
41. Zhu F, Zozaya C, Zhou Q, et al. SARS-CoV-2 genome and antibodies in breastmilk: a
systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2021; 106:514.
42. WHO. Breastfeeding and COVID-19. Scientific Brief. 23 June 2020 https://www.who.int/p
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43. Chambers C, Krogstad P, Bertrand K, et al. Evaluation for SARS-CoV-2 in Breast Milk
From 18 Infected Women. JAMA 2020; 324:1347.

44. AAP. Post-Hospital Discharge Guidance for Breastfeeding Parents or Newborn Infants W
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pital-discharge/ (Accessed on August 12, 2022).

45. Shlomai NO, Kasirer Y, Strauss T, et al. Neonatal SARS-CoV-2 Infections in Breastfeeding
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 46. Care for Breastfeeding Women. Interim Guidance on Breastfeeding and Breast Milk Fee
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47. Unger S, Christie-Holmes N, Guvenc F, et al. Holder pasteurization of donated human
milk is effective in inactivating SARS-CoV-2. CMAJ 2020; 192:E871.
48. Walker GJ, Clifford V, Bansal N, et al. SARS-CoV-2 in human milk is inactivated by Holder
pasteurisation but not cold storage. J Paediatr Child Health 2020; 56:1872.

49. Drugs and Lactation Database (LactMed). Remdesivir. Available at: https://www.ncbi.nl
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m.nih.gov/books/NBK571318/ (Accessed on January 14, 2022).
Topic 129846 Version 56.0
GRAPHICS

Symptoms associated with coronavirus disease 2019 (COVID-19)[1]

Symptoms that may be seen in patients with COVID-19

Cough

Fever

Myalgias

Headache

Dyspnea (new or worsening over baseline)

Sore throat

Diarrhea

Nausea/vomiting

Anosmia or other smell abnormalities

Ageusia or other taste abnormalities

Rhinorrhea and/or nasal congestion

Chills/rigors

Fatigue

Confusion

Chest pain or pressure

Most patients with confirmed COVID-19 have fever and/or symptoms of acute respiratory illness.
However, various other symptoms have been associated with COVID-19; this list is not inclusive
of all reported symptoms. These symptoms are also not specific for COVID-19, and the predictive
value of a single symptom in the diagnosis of COVID-19 is uncertain.

COVID-19: coronavirus disease 2019.

Reference:
1. Centers for Disease Control and Prevention. Interim Clinical Guidance for Management of Patients with
Confirmed Coronavirus Disease (COVID-19). Available at: https://www.cdc.gov/coronavirus/2019-
ncov/hcp/clinical-guidance-management-patients.html.

Graphic 127890 Version 8.0

Discontinuing infection control precautions for patients with COVID-19 in
the healthcare setting

Patients without moderate or severe immunocompromise

Patients with asymptomatic SARS-CoV-2 Time-based (before discontinuing precautions,

infection all of the following conditions must be met):
At least 10 days have passed since the
date of their first positive viral diagnostic
test.
No subsequent illness developed.

Patients with mild to moderate disease* Symptom-based (before discontinuing

precautions, all of the following conditions
must be met):
At least 10 days have passed since
symptoms first appeared.
At least 1 day (24 hours) has passed since
resolution of fever without the use of
fever-reducing medications.
There is improvement in symptoms (eg,
cough, shortness of breath).

Patients with severe or critical disease* Symptom-based (before discontinuing

precautions, all of the following conditions
must be met):
At least 10 and up to 20 days have
passed since symptoms first appeared.
At least 1 day (24 hours) has passed since
resolution of fever without the use of
fever-reducing medications.
There is improvement in symptoms (eg,
cough, shortness of breath).

A test-based strategy is useful to help guide

when to discontinue precautions within this
time frame.

Moderately to severely immunocompromised patients – Conditions associated with moderate

to severe immunocompromise include various hereditary and acquired immune deficiencies (eg,
combined primary immunodeficiency disorder, receiving certain chemotherapy for cancer, being
within 1 year of receiving a hematopoietic stem cell or solid organ transplant, HIV and a CD4
count <200 cells/microL, receiving CAR-T cell therapy or B-cell-depleting therapies, receipt of
prednisone ≥20 mg/day for more than 14 days, or a tumor necrosis factor blocker).

Patients with asymptomatic SARS-CoV-2 Test-based¶Δ (before discontinuing

infection precautions, all of the following conditions
must be met):
Results are negative from at least two
consecutive respiratory specimens
 collected ≥48 hours apart (total of two
negative specimens) tested using an
antigen test or NAAT.
No subsequent illness developed.

Patients with symptomatic disease Test-basedΔ (before discontinuing precautions,

all of the following conditions must be met):
Resolution of fever without the use of
fever-reducing medications, and
Symptoms (eg, cough, shortness of
breath) have improved, and
Results are negative from at least two
consecutive respiratory specimens
collected ≥48 hours apart (total of two
negative specimens) tested using an
antigen test or NAAT.

This table describes the approach to discontinuing infection control precautions in patients with
COVID-19 in the health care setting based upon recommendations from the United States
Centers for Disease Control and Prevention (CDC). Protocols in other countries and at specific
institutions may differ. Hospitalized patients who are ready to be discharged prior to meeting
criteria for discontinuation of precautions can be sent home with instructions to self-isolate until
they meet the above criteria. If discharged to a nursing home or other long-term care facility, the
patient should go to a facility with an ability to adhere to infection prevention and control
recommendations for the care of residents with COVID-19. Once infection control precautions
are discontinued, all patients should still continue to follow hospital policies regarding masking.

When using a time-based strategy (ie, for patients who are asymptomatic), day 0 is the date the
specimen was collected for the positive test. When using a symptom-based strategy, day 0 is the
first day of symptoms.

COVID-19: coronavirus disease 2019; SARS-CoV-2: severe acute respiratory syndrome coronavirus
2; CAR-T: chimeric antigen receptor T; NAAT: nucleic acid amplification test; RT-PCR: reverse-
transcription polymerase chain reaction.

* Patients with mild to moderate COVID-19 typically have signs and symptoms of COVID-19
without hypoxia (eg, oxygen saturation ≥94% on room air); by contrast, those with severe or
critical disease usually have an oxygen saturation <94% on room air and/or need oxygenation or
ventilatory support. Refer to the UpToDate topic that discusses the clinical features of COVID-19
for a discussion of disease severity.

¶ Some experts prefer a non-test-based strategy for moderately immunocompromised patients

who are clinically improved; in this setting isolation can be discontinued after day 20.

Δ The CDC states an antigen test or NAAT (eg, RT-PCR) can be used for a test-based strategy.
However, we prefer to use a molecular test when testing is performed in the health care settings
since it is more sensitive than antigen testing. The first test should typically be performed on day
20.

Graphic 127962 Version 13.0

Differential diagnosis of acute dyspnea

HEENT Neurologic

Angioedema Stroke

Anaphylaxis Neuromuscular disease

Pharyngeal infections Toxic/metabolic

Deep neck infections Organophosphate poisoning
Foreign body Salicylate poisoning
Neck trauma CO poisoning
Chest wall Toxic ingestion

Rib fractures Diabetic ketoacidosis

Flail chest Sepsis

Pulmonary Anemia

COPD exacerbation Acute chest syndrome

Asthma exacerbation Miscellaneous

Pulmonary embolism Hyperventilation

Pneumothorax Anxiety

Pulmonary infection Pneumomediastinum

ARDS Lung tumor

Pulmonary contusion or other lung injury Pleural effusion

Hemorrhage Intra-abdominal process

Cardiac Ascites

ACS Pregnancy*

ADHF Massive obesity*

Flash pulmonary edema

High output failure

Cardiomyopathy

Arrhythmia

Valvular dysfunction

Cardiac tamponade

HEENT: head, eyes, ears, nose, and throat; COPD: chronic obstructive pulmonary disease; ARDS:
acute respiratory distress syndrome; ACS: acute coronary syndrome; ADHF: acute
decompensated heart failure; CO: carbon monoxide.
*While these conditions do not cause acute dyspnea directly, they can exacerbate symptoms or
contribute to other underlying causes.

Graphic 52926 Version 7.0

Type, proportion, and duration of persistent COVID-19 symptoms*

Proportion of patients
Approximate time to
Persistent symptom¶
affected by symptom symptom resolutionΔ

Common physical symptoms

Fatigue 15 to 87%[1,2,6,9,14,16] 3 months or longer

Dyspnea 10 to 71%[1,2,6-9,14] 2 to 3 months or longer

Chest discomfort 12 to 44%[1,2] 2 to 3 months

Cough 17 to 34%[1,2,9,12] 2 to 3 months or longer

Anosmia 10 to 13%[1,3-5,9,11] 1 month, rarely longer

Less common physical symptoms

Joint pain, headache, sicca <10%[1,2,8,9,11] Unknown (likely weeks to

syndrome, rhinitis, months)
dysgeusia, poor appetite,
dizziness, vertigo, myalgias,
insomnia, alopecia,
sweating, and diarrhea

Psychologic and neurocognitive

Post-traumatic stress 7 to 24%[6,10,14] 6 weeks to 3 months or longer

disorder

Impaired memory 18 to 21%[6,15] Weeks to months

Poor concentration 16%[6] Weeks to months

Anxiety/depression 22 to 23%[2,7,8,10,12-14] Weeks to months

Reduction in quality of life >50%[8] Unknown (likely weeks to

months)

COVID-19: coronavirus disease 2019.

* These data are derived from an earlier period in the pandemic; information on patient recovery
and persistent symptoms is evolving, and these figures may change as longer-term data emerge.

¶ More than a third of patients with COVID-19 experience more than one persistent symptom.

Δ Time course for recovery varies depending on premorbid risk factors and illness severity and
may be shorter or longer than that listed. Hospitalized patients, and in particular critically ill
patients, are more likely to have a more protracted course than those with mild disease.

References:
1. Carfì A, Bernabei R, Landi F, et al. Persistent Symptoms in Patients After Acute COVID-19. JAMA 2020; 324:603.
2. Xiong Q, Xu M, Li J, et al. Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal
study. Clin Microbiol Infect 2020.
3. Hopkins C, Surda P, Whitehead E, Kumar BN. Early recovery following new onset anosmia during the COVID-19
pandemic - an observational cohort study. J Otolaryngol Head Neck Surg 2020; 49:26.
 4. Cho RHW, To ZWH, Yeung ZWC, et al. COVID-19 Viral Load in the Severity of and Recovery From Olfactory and
Gustatory Dysfunction. Laryngoscope 2020; 130:2680.
5. Meini S, Suardi LR, Busoni M, et al. Olfactory and gustatory dysfunctions in 100 patients hospitalized for COVID-
19: sex differences and recovery time in real-life. Eur Arch Otorhinolaryngol 2020; 277:3519.
6. Halpin SJ, McIvor C, Whyatt G, et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19
infection: A cross-sectional evaluation. J Med Virol 2020.
7. Bowles KH, McDonald M, Barrón Y, et al. Surviving COVID-19 After Hospital Discharge: Symptom, Functional, and
Adverse Outcomes of Home Health Recipients. Ann Intern Med 2020.
8. Wong AW, Shah AS, Johnston JC, et al. Patient-reported outcome measures after COVID-19: a prospective cohort
study. Eur Respir J 2020; 56.
9. Nehme M, Braillard O, Alcoba G, et al. COVID-19 Symptoms: Longitudinal Evolution and Persistence in Outpatient
Settings. Ann Intern Med 2020.
10. Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric
disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. Lancet Psychiatry 2020.
11. Logue J K; Franko N M; McCulloch D J; et al. Sequelae in Adults at 6 Months After COVID-19 Infection JAMA
Network Open. 2021;4(2):e210830.
12. Mandal S, Barnett J, Brill S, et al. 'Long-COVID': a cross-sectional study of persisting symptoms, biomarker and
imaging abnormalities following hospitalisation for COVID-19. Thorax 2020; PMID 33172844.
13. Bellan M, Soddu D, Balbo PE, et al. Respiratory and Psychophysical Sequelae Among Patients With COVID-19 Four
Months After Hospital Discharge. JAMA Netw Open. 2021;4(1):e2036142.
14. Writing Committee for the COMEBAC Study Group, Morin L, Savale L, Pham T, et al. Four-Month Clinical Status of
a Cohort of Patients After Hospitalization for COVID-19. JAMA. 2021; PMID 33729425.
15. Del Brutto OH, Wu S, Mera A, Recalde et al. Cognitive decline among individuals with history of mild symptomatic
SARS-CoV-2 infection: A longitudinal prospective study nested to a population cohort. Eur J Neurol 2021; PMID
33576150.
16. Heesakkers H, van der Hoeven JG, Corsten S, et al. Clinical outcomes among patients with 1-year survival
following intensive care unit treatment for COVID-19. JAMA 2022; PMID 35072716.

Graphic 130356 Version 5.0

Appendix A: Edinburgh Postnatal Depression Scale

Reproduced from: Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression:
Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry
1987; 150:782. Copyright © 1987 British Journal of Psychiatry.

Graphic 67741 Version 3.0

Appendix A: Edinburgh Postnatal Depression Scale
(EPDS) (continued)

We suggest a cutoff score of 11, which appears to maximize

sensitivity plus specificity in screening for postpartum depression.
Women who report depressive symptoms without suicidal ideation
or major functional impairment (or score between 5 and 9 on the
EPDS) should be re-evaluated within one month.

Reproduced from: Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression:
Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry
1987; 150:782. Copyright © 1987 British Journal of Psychiatry.

Graphic 81407 Version 6.0

Isolation and precautions for immunocompetent patients with SARS-CoV-2 in
community

This algorithm describes the approach to discontinuing isolation and other precautions for immunocom
SARS-CoV-2 infection in the community. This same approach should be used for persons who develop re
after completing nirmatrelvir/ritonavir (Paxlovid). Refer to UpToDate content for additional information o
isolation/precautions, including the duration of immunocompromised persons.

* Outpatients with suspected or confirmed SARS-CoV-2 infection (including those awaiting test results) s
and try to separate themselves from other people and animals in the household. They should also avoid
the home. Patients should wear a face mask for source control if they must be in the same room (or veh

¶ If a patient was asymptomatic when they were diagnosed with SARs-CoV-2 infection, but then develop
is the first day of symptom onset.

Δ For immunocompetent patients with moderate disease, 10 days of home isolation is usually sufficient;
with severe disease, home isolation should generally be extended to 10 to 20. Refer to UpToDate conten
for persons with COVID-19 for additional information on discontinuing precautions in these populations

◊ If a patient is unable to reliably mask around others they should continue to isolate at home for 10 day
afebrile and their symptoms are improving.

§ For most patients who are clinically improved, the need for precautions, such as masking around other
discontinued after 10 full days. However a test-based strategy (two negative rapid antigen tests at least 4
be preferred for those who live or work with individuals at high risk for severe disease (particularly immu
individuals) in settings where masks are not required (eg, non-healthcare settings).

¥ Those with ongoing fevers or no improvement in symptoms after 10 days should continue home isolat
fever-free for >24 hours and their symptoms have improved. Alternatively, they can discontinue isolation
negative rapid antigen tests at least 48 hours apart. Such patients should also be evaluated for complica
alternative source of their symptoms.

Graphic 139926 Version 1.0

Contributor Disclosures
Vincenzo Berghella, MD Consultant/Advisory Boards: ProtocolNow [Clinical guidelines].
All of the
relevant financial relationships listed have been mitigated. Brenna L Hughes, MD, MSc No relevant
financial relationship(s) with ineligible companies to disclose. Charles J Lockwood, MD, MHCM No
relevant financial relationship(s) with ineligible companies to disclose. Vanessa A Barss, MD,
FACOG No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy