Am J Perinatol 2021; 38(04): 332-341
DOI: 10.1055/s-0040-1721658
Review Article

A Review on Mode of Delivery during COVID-19 between December 2019 and April 2020

1   Department of Medical Education, Drexel University College of Medicine, Philadelphia, Pennsylvania
Dana C. Farabaugh
2   Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
Carolyn Giordano
1   Department of Medical Education, Drexel University College of Medicine, Philadelphia, Pennsylvania
› Author Affiliations


Objective This study aims to review the published literature to determine mode of delivery in pregnant women with coronavirus disease 2019 (COVID-19) and the indications reported for cesarean section early in the pandemic to add information to the current narrative and raise awareness of trends discovered.

Study Design A systematic review was conducted by searching PubMed, Scopus, and ScienceDirect databases for articles published between December 2019 and April 29, 2020 using a combination of the keywords such as COVID-19, coronavirus 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), pregnancy, vaginal delivery, cesarean section, vertical transmission, management, and guidelines. Peer-reviewed case studies with confirmed SARS-CoV-2 women who delivered were included to determine mode of delivery, indications for cesarean section, and maternal and neonatal characteristics.

Results A review of 36 total articles revealed deliveries in 203 SARS-CoV-2 positive pregnant women. A comparable severity of disease in pregnant versus nonpregnant women was noted, as previously determined. Overall, 68.9% of women delivered via cesarean section, with COVID-19 status alone being a common indication. Maternal COVID-19 may also be associated with increased risk of preterm labor, although neonatal outcomes were generally favorable. Despite eight of 206 newborns testing positive for SARS-CoV-2, there remains no definitive evidence of vertical transmission.

Conclusion COVID-19 status alone became a common indication for cesarean delivery early in the pandemic, despite lack of evidence for vertical transmission. The increase in cesarean rate in this data may reflect obstetricians attempting to serve their patients in the best way possible given the current climate of constantly evolving guidelines on safest mode of delivery for the mother, infant, and provider. Upholding current recommendations from trusted organizations as new data are published, while also providing individualized support to expecting mothers on most appropriate mode of delivery, will reduce the amount of unnecessary, unplanned cesarean sections and could lessen the psychological impact of delivering during the COVID-19 pandemic.

Key Points

  • COVID-19 may result in an increased rate of cesarean delivery for SARS-CoV-2 positive pregnant women.

  • COVID-19 is a commonly reported indication for cesarean section, despite management guidelines urging against this.

  • Although eight neonates tested positive for SARS-CoV-2, all additional fluid and tissue samples tested negative.

Publication History

Received: 15 May 2020

Accepted: 04 November 2020

Article published online:
07 December 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Schwartz DA, Graham AL. Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: lessons from SARS, MERS, and other human coronavirus infections. Viruses 2020; 12 (02) 194
  • 2 Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the chinese center for disease control and prevention. JAMA 2020; 323 (13) 1239-1242
  • 3 Yan J, Guo J, Fan C. et al. Coronavirus disease 2019 in pregnant women: a report based on 116 cases. Am J Obstet Gynecol 2020; 223 (01) 111.e1-111.e14
  • 4 Liu D, Li L, Wu X. et al. Pregnancy and perinatal outcomes of women with coronavirus disease (COVID-19) pneumonia: a preliminary analysis. AJR Am J Roentgenol 2020; 215 (01) 127-132
  • 5 Al-Tawfiq JA. Middle east respiratory syndrome coronavirus (MERS-CoV) and COVID-19 infection during pregnancy. Travel Med Infect Dis 2020; 36: 101641
  • 6 Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med 2018; 23 (02) 60-63
  • 7 Li N, Han L, Peng M. et al. Maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia: a case-control study. Clin Infect Dis 2020; ciaa352
  • 8 Dong L, Tian J, He S. et al. Possible vertical transmission of SARS-CoV-2 from an infected mother to her newborn. JAMA 2020; 323 (18) 1846-1848
  • 9 Li Y, Zhao R, Zheng S. et al. Lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, China. Emerg Infect Dis 2020; 26 (06) 1335-1336
  • 10 Lu D, Sang L, Du S, Li T, Chang Y, Yang XA. Asymptomatic COVID-19 infection in late pregnancy indicated no vertical transmission. J Med Virol 2020; 1-5
  • 11 Peng Z, Wang J, Mo Y. et al. Unlikely SARS-CoV-2 vertical transmission from mother to child: a case report. J Infect Public Health 2020; 13 (05) 818-820
  • 12 Wang X, Zhou Z, Zhang J, Zhu F, Tang Y, Shen X. A case of 2019 novel coronavirus in a pregnant woman with preterm delivery. Clin Infect Dis 2020; 71 (15) 844-846
  • 13 Xia H, Zhao S, Wu Z, Luo H, Zhou C, Chen X. Emergency caesarean delivery in a patient with confirmed COVID-19 under spinal anaesthesia. Br J Anaesth 2020; 124 (05) e216-e218
  • 14 Xiong X, Wei H, Zhang Z. et al. Vaginal delivery report of a healthy neonate born to a convalescent mother with COVID--19. J Med Virol 2020
  • 15 Iqbal SN, Overcash R, Mokhtari N. et al. An uncomplicated delivery in a patient with COVID-19 in the United States. N Engl J Med 2020; 382 (16) e34
  • 16 Kelly JC, Dombrowksi M, O'neil-Callahan M, Kernberg AS, Frolova AI, Stout MJ. False-negative COVID-19 testing: considerations in obstetrical care. Am J Obstet Gynecol MFM. 2020;100130
  • 17 Schnettler WT, Al Ahwel Y, Suhag A. Severe ARDS in COVID-19-infected pregnancy: obstetric and intensive care considerations. Am J Obstet Gynecol MFM. 2020;100120
  • 18 Lowe B, Bopp B. COVID-19 vaginal delivery: a case report. Aust N Z J Obstet Gynaecol 2020; 60 (03) 465-466
  • 19 Lee DH, Lee J, Kim E, Woo K, Park HY, An J. Emergency cesarean section on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) confirmed patient. Korean J Anesthesiol 2020; DOI: 10.4097/kja.20116.
  • 20 Karami P, Naghavi M, Feyzi A. et al. WITHDRAWN: mortality of a pregnant patient diagnosed with COVID-19: a case report with clinical, radiological, and histopathological findings. Travel Med Infect Dis 2020; 1–4: 101665
  • 21 Zambrano LI, Fuentes-Barahona IC, Bejarano-Torres DA. et al. A pregnant woman with COVID-19 in Central America. Travel Med Infect Dis 2020; 36: 101639
  • 22 Gidlöf S, Savchenko J, Brune T, Josefsson H. COVID-19 in pregnancy with comorbidities: More liberal testing strategy is needed. Acta Obstet Gynecol Scand 2020; 99 (07) 948-949
  • 23 Kalafat E, Yaprak E, Cinar G. et al. Lung ultrasound and computed tomographic findings in pregnant woman with COVID-19. Ultrasound Obstet Gynecol 2020; 55 (06) 835-837
  • 24 Díaz CA, Maestro ML, Pumarega MTM, Antón BF, Alonso CP. First case of neonatal infection due to COVID-19 in Spain. An Pediatr (Engl Ed) 2020; DOI: 10.1016/j.anpede.2020.03.002.
  • 25 Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during pregnancy and possible vertical transmission. Am J Perinatol 2020; 37 (08) 861-865
  • 26 Cao D, Yin H, Chen J. et al. Clinical analysis of ten pregnant women with COVID-19 in Wuhan, China: a retrospective study. Int J Infect Dis 2020; 95: 294-300
  • 27 Chen H, Guo J, Wang C. et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020; 395 (10226): 809-815
  • 28 Chen S, Liao E, Cao D, Gao Y, Sun G, Shao Y. Clinical analysis of pregnant women with 2019 novel coronavirus pneumonia. J Med Virol 2020; 1-6
  • 29 Fan C, Lei D, Fang C. et al. Perinatal transmission of COVID-19 associated SARS-CoV-2: should we worry?. Clin Infect Dis 2020; ciaa226
  • 30 Khan S, Peng L, Siddique R. et al. Impact of COVID-19 infection on pregnancy outcomes and the risk of maternal-to-neonatal intrapartum transmission of COVID-19 during natural birth. Infect Control Hosp Epidemiol 2020; 41 (06) 748-750
  • 31 Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect 2020; S0163-4453(20)30109-2
  • 32 Qiancheng X, Jian S, Lingling P. et al; sixth batch of Anhui medical team aiding Wuhan for COVID-19. Coronavirus disease 2019 in pregnancy. Int J Infect Dis 2020; 95: 376-383
  • 33 Xu L, Yang Q, Shi H. et al. Clinical presentations and outcomes of SARS-CoV-2 infected pneumonia in pregnant women and health status of their neonates. Sci Bull (Beijeng) 2020; DOI: 10.1016/j.scib.2020.04.040.
  • 34 Yu N, Li W, Kang Q. et al. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Lancet Infect Dis 2020; 20 (05) 559-564
  • 35 Zhu H, Wang L, Fang C. et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020; 9 (01) 51-60
  • 36 Breslin N, Baptiste C, Gyamfi-Bannerman C. et al. Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM 2020; 1-7
  • 37 Juusela A, Nazir M, Gimovsky M. Two cases of coronavirus 2019-related cardiomyopathy in pregnancy. Am J Obstet Gynecol MFM 2020; DOI: 10.1016/j.ajogmf.2020.100113.
  • 38 Mulvey JJ, Magro CM, Ma LX, Nuovo GJ, Baergen RN. Analysis of complement deposition and viral RNA in placentas of COVID-19 patients. Ann Diagn Pathol 2020; 46: 151530
  • 39 Ferrazzi E, Frigerio L, Savasi V. et al. Vaginal delivery in SARS-CoV-2-infected pregnant women in Northern Italy: a retrospective analysis. BJOG 2020; 127 (09) 1116-1121
  • 40 Hantoushzadeh S, Shamshirsaz AA, Aleyasin A. et al. Maternal death due to COVID-19. Am J Obstet Gynecol 2020; 223 (01) 109.e1-109.e16
  • 41 Vlachodimitropoulou Koumoutsea E, Vivanti AJ, Shehata N. et al. COVID-19 and acute coagulopathy in pregnancy. J Thromb Haemost 2020; 18 (07) 1648-165
  • 42 Mullins E, Evans D, Viner RM, O'Brien P, Morris E. Coronavirus in pregnancy and delivery: rapid review. Ultrasound Obstet Gynecol 2020; 55 (05) 586-592
  • 43 Chawanpaiboon S, Vogel JP, Moller AB. et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Health 2019; 7 (01) e37-e46
  • 44 Zeng H, Xu C, Fan J. et al. Antibodies in infants born to mothers with COVID-19 pneumonia. JAMA 2020; 323 (18) 1848-1849
  • 45 Kimberlin DW, Stagno S. Can SARS-CoV-2 infection be acquired in utero?: more definitive evidence is needed. JAMA 2020; 323 (18) 1788-1789
  • 46 Qiu L, Liu X, Xiao M. et al. SARS-CoV-2 is not detectable in the vaginal fluid of women with severe COVID-19 infection. Clin Infect Dis 2020; DOI: 10.1093/cid/ciaa375.
  • 47 Yu N, Li W, Kang Q, Zeng W, Feng L, Wu J. No SARS-CoV-2 detected in amniotic fluid in mid-pregnancy. Lancet Infect Dis 2020; 1–2: S1473-3099(20)30320-0
  • 48 Elshafeey F, Magdi R, Hindi N. et al. A systematic scoping review of COVID-19 during pregnancy and childbirth. Int J Gynecol Obstet 2020; DOI: 10.1002/ijgo.13182.
  • 49 Martínez-Perez O, Vouga M, Cruz Melguizo S. et al. Association between mode of delivery among pregnant women with COVID-19 and maternal and neonatal outcomes in Spain. JAMA 2020; 324 (03) 296-299
  • 50 Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One 2016; 11 (02) e0148343
  • 51 American College of Obstetricians and Gynecologists. COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics. Updated March 26, 2020. Accessed April 30, 2020 at:
  • 52 Poon LC, Yang H, Lee JCS. et al. ISUOG interim guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals. Ultrasound Obstet Gynecol 2020; 55 (05) 700-708
  • 53 Royal College of Obstetricians & Gynaecologists. Coronavirus (COVID-19) Infection in Pregnancy. Accessed April 30, 2020 at: 2020
  • 54 Saccone G, Florio A, Aiello F. et al. Psychological impact of coronavirus disease 2019 in pregnant women. Am J Obstet Gynecol 2020; 223 (02) 293-295
  • 55 Wu Y, Zhang C, Liu H. et al. Perinatal depressive and anxiety symptoms of pregnant women along with COVID-19 outbreak in China. Am J Obstet Gynecol 2020; DOI: 10.1016/j.ajog.2020.05.009.
  • 56 Thapa SB, Mainali A, Schwank SE, Acharya G. Maternal mental health in the time of the COVID-19 pandemic. Acta Obstet Gynecol Scand 2020; 99 (07) 817-818