Management and Consideration of Natural Delivery in Pregnant Women with Suspected Coronavirus Pneumonia

As of February 2020, a new type of coronavirus infection (coronavirus disease 2019, COVID-19) has continued to occur in China, and confirmed cases of infection in pregnant women have been reported. Beijing Ditan Hospital Affiliated with Capital Medical University is the designated hospital for treatment of maternal-neonatal coronavirus pneumonia in Beijing. Optimized management, prevention, and control of coronavirus pneumonia during delivery in pregnant women is crucial to ensuring the safety of mothers and infants. According to the latest COVID-19 national management plan combined with the specialization of our hospital in infectious diseases, we propose a process for management of birth in pregnant women with COVID-19 to provide clinical guidance and instruction for midwifery institutions.

monitoring and pulse oxygen monitoring are recommended to avoid hypoxia and heart rhythm abnormalities. As the length of labor extends, the contractions will become increasingly stronger, oxygen consumption is increased, and gas exchange in the lungs becomes insufficient. Therefore, signs of intrauterine fetal distress could occur. The second stage of labor involves excessive exertion, breath-holding and abdominal pressure, and the process should be shortened as much as possible. The standard "New Coronavirus Pneumonia Diagnosis and Treatment Plan (Trial Version 6)" [11] criteria for severe cases include shortness of breath (RR≥30 breaths/min); resting status, oxygen saturation ≤93%; and arterial oxygen pressure (PaO2)/oxygen concentration (FiO2) ≤300 mmHg.
In severe cases, a switch to a cesarean section should be performed as soon as possible, and the pregnancy should be terminated. be used to avoid breastfeeding [9]. It is recommended to pump milk regularly to ensure lactation, and breastfeeding is not feasible until SARS-CoV-2 infection is ruled out or cured [12]. The medical instruments should be disinfected and wiped twice a day (it is best to use disposable disinfection wipes) to ensure that they are in a standby state.

Maternal psychological management:
The occurrence of pneumonia diagnosed as SARS-CoV-2 infection is a considerable source of stress, which causes uncertainty and insecurity. Coupled with natural delivery, patients may experience anxiety, such as a stress response, and even symptoms of depression. According to the "Guiding Principles for Emergency Psychological Crisis Intervention for Pneumonia Epidemic of Coronavirus Infection" [13], midwives need to fully inform the pregnant women of their disease information during childbirth and the special treatment that will be provided in infant wards. During the delivery process, the meaning of self-protection and isolation should be explained to the patient to create a sense of security, and the use of nondrug analgesics such as music can help reduce the pain and fear of childbirth. Obstetricians, pediatricians, and midwives should communicate with pregnant women in a timely manner, repeatedly informing them objectively of childbirth safety information. Patients should be informed that negative psychological reactions will damage the normal immune system of the human body and are not conducive to childbirth. Particular attention and continuous follow-up are needed to determine whether postpartum depression is present, which is one of the most associated emotional disorders in perinatal women, with a global incidence of 17.7[14]. During the epidemic, pregnant women should not only take good care of themselves but also pay attention to their mental health. If necessary, they can also conduct self-monitoring and screening through the Edinburgh Postpartum Depression Screening Scale. They should limit their exposure to epidemic information and educate family members and patients [15].

Further Consideration of Related Issues in Midwifery Effective communication with pregnant women during the delivery process
During childbirth, the midwife should provide overall and multifaceted support to the mother and explain information regarding childbirth, including the natural process of childbirth, exertion techniques, appropriate breathing methods, how to divert pain, distraction, and anxiety. However, pregnant women with COVID-19 need to wear N95 protective masks during labor, and midwives should have tertiary protection, which can easily cause poor communication, such as poor hearing and misunderstanding.
It is worth exploring how to effectively communicate with pregnant women during the delivery process. Body language mainly refers to the use of body movements instead of language for the purpose of communication [16]. Practitioners should confirm issues and communicate with pregnant women in advance, and specific Reducing occupational exposure during the delivery process.
Three levels of protection require two layers of gloves and two layers of gloves in the staging area (surgical hand cleaning cannot be performed). A total of four layers of gloves results in poor finger flexibility and sensitivity. In the second stage of labor, when the fetal head is exposed after the perineum tightens, the midwife should control the speed of the fetal head with one hand and hold the perineum with the other hand. If a perineal incision is required, actions such as perineal tissue anesthesia, side incision, and suturing should be performed (which require more flexibility and sensitivity of the hands). For such patients, the expert guidance is to shorten the labor process and implement lateral perineal resection [17]. Further confirmation is required to determine whether perineal incisions and sutures increase the risk of occupational exposure of midwives in the case of poor finger flexibility and sensitivity. The author suggests that most pregnant women with COVID-19 who undergo childbirth are patients with less severe disease. During the delivery process, comprehensive consideration should be given to minimize the degree of perineal injury, reduce the difficulty of suturing, and increase the suture speed instead of performing conventional lateral perineal resection [18].

Summary
During the outbreak of coronavirus-associated pneumonia, pregnant women are a special population, and protection against the epidemic is as important as maternal and child health. Using the latest diagnosis and treatment plan and effective resources, a good natural environment should be created to the greatest extent possible. Protecting the health of mothers and infants while reducing cross-infection and occupational exposure to health care workers requires medical staff members to study and explore different options together.