Obstetric–Neonatal Care during Birth and Postpartum in Symptomatic and Asymptomatic Women Infected with SARS-CoV-2: A Retrospective Multicenter Study

Citation: Vila-Candel, R.; González-Chordá, V.M.; Soriano-Vidal, F.J.; Castro-Sánchez, E.; Rodríguez-Blanco, N.; Gómez-Seguí, A.; Andreu-Pejó, L.; Martínez-Porcar, C.; Rodríguez Gonzálvez, C.; Torrent-Ramos, P.; et al. Obstetric–Neonatal Care during Birth and Postpartum in Symptomatic and Asymptomatic Women Infected with SARS-CoV-2: A Retrospective Multicenter Study. Int. J. Environ. Res. Public Health 2022,19, 5482. https:// doi.org/10.3390/ijerph19095482 Academic Editor: Paul B. Tchounwou Received: 9 April 2022 Accepted: 28 April 2022 Published: 30 April 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). International Journal of Environmental Research and Public Health Article Obstetric–Neonatal Care during Birth and Postpartum in Symptomatic and Asymptomatic Women Infected with SARS-CoV-2: A Retrospective Multicenter Study Rafael Vila-Candel 1,2,3 , Víctor M. González-Chordá4,* , Francisco Javier Soriano-Vidal 2,3,5 , Enrique Castro-Sánchez 6,7 , Noelia Rodríguez-Blanco 8,9, Ana Gómez-Seguí10 , Laura Andreu-Pejó4, Cristina Martínez-Porcar 11, Carmen Rodríguez Gonzálvez 12, Patricia Torrent-Ramos 13,14, Nieves Asensio-Tomás10, Yolanda Herraiz-Soler 15,16, Ramon Escuriet 17,18 and Desirée Mena-Tudela 4 1Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, 46010 Valencia, Spain; [email protected] or [email protected] 2Department of Obstetrics and Gynaecology, Hospital Universitario de la Ribera, 46600 Alcira, Spain; [email protected] 3Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), 46020 Valencia, Spain 4GIENF-281 Nursing Research Group, Nursing Department, Univesitat Jaume I, 12006 Castellóde la Plana, Spain; [email protected] (L.A.-P.); [email protected] (D.M.-T.) 5Department of Obstetrics and Gynaecology, Hospital Lluis Alcanyís, 46800 Xàtiva, Spain 6College of Nursing, Midwifery and Healthcare, University of West London, London TW8 9GB, UK; [email protected] 7Health Protection Research Unit, Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London SW7 2BX, UK 8Department of Nursing, Universidad CEU Cardenal Herrera, Plaza Reyes Católicos, 19, 03204 Elche, Spain; [email protected] 9Department of Obstetrics and Gynaecology, Hospital Marina Baixa, 03570 Villajoyosa, Spain 10 Department of Obstetrics and Gynaecology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain; [email protected] (A.G.-S.); [email protected] (N.A.-T.) 11 Department of Paediatrics, Hospital Universitario de la Ribera, 46600 Alzira, Spain; [email protected] 12 Department of Obstetrics and Gynaecology, Hospital Universitario de Vinalopó, 03293 Elche, Spain; [email protected] 13 Preventive Medicine Service, Hospital General de Castellón, 12071 Castellóde la Plana, Spain; ptorr[email protected] 14 Nursing Department, Univesitat Jaume I, 12006 Castellóde la Plana, Spain 15 Department of Obstetrics and Gynaecology, Consorcio Hospital General Universitario Valencia, 46014 Valencia, Spain; [email protected] 16 Facultat d’Infermeria i Podologia, Universitat de València, 46100 Valencia, Spain 17 Ghenders Research Group, School of Health Sciences Blanquerna, Universitat Ramon Lull, Carrer Padilla 326, 08025 Barcelona, Spain; r[email protected] 18 Catalan Health Service, Government of Barcelona, Travessera de les Corts 131, 08028 Barcelona, Spain *Correspondence: vchor[email protected] Abstract: This study analyses the obstetric–neonatal outcomes of women in labour with symptomatic and asymptomatic COVID-19. A retrospective, multicenter, observational study was carried out between 1 March 2020 and 28 February 2021 in eight public hospitals in the Valencian community (Spain). The chi-squared test compared the obstetric–neonatal outcomes and general care for symptomatic and asymptomatic women. In total, 11,883 births were assisted in participating centers, with 10.9 per 1000 maternities (n= 130) infected with SARS-CoV-2. The 20.8% were symptomatic and had more complications both upon admission (p= 0.042) and during puerperium (p= 0.042), as well as transfer to the intensive care unit (ICU). The percentage of admission to the Neonatal Intensive Care Unit (NICU) was greater among offspring of symptomatic women compared to infants born of asymptomatic women (p< 0.001). Compared with asymptomatic women, those with symptoms underwent less labour companionship (p= 0.028), less early skin-to-skin contact (p= 0.029) and greater mother–infant separation (p= 0.005). The overall maternal mortality rate was 0.8%. No vertical transmission was recorded. In conclusion, symptomatic infected women are at increased risk Int. J. Environ. Res. Public Health 2022,19, 5482. https://doi.org/10.3390/ijerph19095482 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2022,19, 5482 2 of 14 of lack of labour companionship, mother–infant separation, and admission to the ICU, as well as to have preterm births and for NICU admissions. Keywords: COVID-19; SARS-CoV-2; obstetric nursing; neonatal nursing; labour; obstetric 1. Introduction Disease due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection had caused over 4.7 million deaths worldwide by 2021 [ 1 ]. Although most countries adopted measures to contain the pandemic, including lockdowns and preventive hygiene protocols [ 2 ] as well as vaccination programs wherever vaccines where available [ 3 ], SARSCoV-2 infection remains a significant global health threat. With regard to coronavirus disease-2019 (COVID-19), pregnant women do not seem to be more susceptible to infection than the general population [ 4 ]. However, in the event of disease symptoms that appear to be more severe, particularly during the third trimester of pregnancy, there are more frequent admissions to the Intensive Care Unit (ICU) and a greater risk of poorer maternal and neonatal health outcomes (such as preterm birth, caesarean sections, and low birth weight) [5–8]. Routine evidence-based clinical practices of benefit for maternal and childbirth care (labour companionship, early skin-to-skin contact, breastfeeding, and rooming-in in maternity) have been modified or interrupted during the pandemic, which could reduce the quality of birth care models [ 9 , 10 ]. Furthermore, vertical transmission seems possible [ 11 ], although the mechanisms of such transmission remain unclear [ 12 , 13 ]. Whilst severe events for newborn infants seem rare [ 13 ], perhaps thanks to the passive transmission of antiSARS-CoV-2 antibodies via the transplacental route and in breast milk [ 14 ], there may still be concern about these potential effects [15,16]. The primary aim of this study was to analyse the obstetric–neonatal outcomes of women in labour with symptomatic and asymptomatic SARS-CoV-2 infection. The study also aimed to describe and contrast the routine care received by these groups of women and their newborns. 2. Materials and Methods 2.1. Study Population and Sampling Criteria A retrospective, multicenter, observational study was carried out based on the review of the clinical records of pregnant women assisted during labour and birth, with a positive real-time polymerase chain reaction (RT-PCR) test result for SARS-CoV-2 in nasopharyngeal exudate at the time of admission. The study was carried out in eight state-funded hospitals of the Valencian community in Spain. These hospitals (four in Valencia, one in Castellón, three in Alicante) were all reference centers for their province, and cared for at least 1000 births per year, or were located in rural areas with large catchment populations. Overall, the participating hospitals served one million people and attended ~12,000 births in the previous year. The information about the study was disseminated via the regional research network and suitable health care organizations approached by the researchers. The study period was from 1 March 2020 to 28 February 2021. The study population comprised women giving birth in any of the participating hospitals. The inclusion criteria were: (a) women with a positive RT-PCR test for SARSCoV-2 RNA in nasopharyngeal exudate performed on hospital admission for labour and birth; and (b) infants born of infected mothers, with RT-PCR testing for SARS-CoV-2 in nasopharyngeal exudate during hospital admission (<48 h, not extracted from the placenta or amniotic fluid). Pregnant women infected with SARS-CoV-2 and admitted to the hospital for medical reasons other than birth were excluded from the study. Int. J. Environ. Res. Public Health 2022,19, 5482 3 of 14 2.2. Measurements The research staff at each participating center reviewed the obstetric history, neonatal and postpartum outcomes, and general labour care records of all the positive patients assisted during the study period. The variables related to birth and postpartum were collected from the Orion Logis ® electronic health records, while the data for mothers and newborns related to follow-up during the first six weeks after birth were obtained from the Abucasis II ® health database. Any readmission via the emergency room of mothers or newborns registered at the same hospitals were identified during the 6 weeks from the Abucasis II ® database. Both electronic medical records are routinely used by all the health facilities in the Valencian Community, including all the centers participating in the study. The following variables were collected: • Demographic variables: maternal age, country of origin, and the hospital where the birth occurred. • Obstetric–neonatal variables: Gestational age at the time of birth, parity (primiparous/multiparous), previous maternal history of health problems (diabetes mellitus/hypertension/cardiac diseases/neurological diseases/thrombotic diseases/thyroid diseases/drugs misuse/COVID-not related infection diseases), gestational disease (preeclampsia/eclampsia/gestationalhypertension/gestational diabetes/hypothyroidism/ hyperthyroidism/COVID-not related infectious diseases), fetal alterations identified by health care providers (preterm birth, small for gestational age/large for gestational age/fetal growth restriction/congenital abnormality), start of labour (spontaneous/induced/elective caesarean section), type of birth (eutocic, instrumental birth/caesarean section [CS]), cause of CS, maternal complications prior labour and during puerperium (respiratory, cardiac, neurologic, thrombotic manifestations, and COVID-related coagulopathy), maternal admission to the intensive care unit (ICU) prior to birth and/or puerperium, cause of maternal admission to the ICU, and Apgar score at one and five minutes. Mother to child transmission can occur in different stages, including in utero, intrapartum, or postnatal. Our study defined vertical transmission in the early postnatal period (<48 h) as a positive test for SARS-CoV-2 maternal infection at admission, coupled with a confirmed positive test for the newborn [ 17 ], infant admission to the neonatal ICU (NICU), and cause of admission to the NICU. • Symptomatic with SARS-Cov-2: Participants with SARS-CoV-2 infection that present symptoms such as fever, cough, shortness of breath, fatigue, body aches, headache, anosmia, ageusia, nausea or vomiting, and diarrhea. • Asymptomatic with SARS-Cov-2: Participants with SARS-Cov-2 infection but who did not develop compatible clinical manifestations. • Clinical variables: Time of result of the RT-PCR SARS-CoV-2 test for the mother (ante-, intra-, or postpartum), the result of the RT-PCR SARS-CoV-2 test for the newborn infant within 48 h (positive or negative), and follow-up of complications and readmissions (mother/newborn infant, with reasons) during the first six weeks after birth. Maternal or newborn death (up to 28 days) if COVID-related. • Obstetric and neonatal general labour care: Late clamping (clamping and cutting the cord at least one minute from birth, or when the umbilical cord stopped pulsating [ 18 ]), early skin-to-skin contact [SSC] (defined as prone placing of the naked infant on the mother’s bare chest at birth, in the first minute after birth, or very soon afterwards [ 19 ]), labour companionship, mother–infant separation during hospital admission, and the reason for separation. • Breastfeeding-related variables: Type of feeding at discharge and 6 weeks postpartum (exclusive breastfeeding, formula feeding, mixed feeding). Exclusive breastfeeding (EBF) was defined as offering only breast milk and excluding all other food or fluids, including water. This case definition did, however, allow the infant to receive oral rehydration salts, drops, and syrups (vitamins, minerals, and medicines) [ 20 , 21 ]. Mixed feeding was defined as the combination of breastfeeding and formula feed. Int. J. Environ. Res. Public Health 2022,19, 5482 4 of 14 Obstetric and neonatal outcomes were compared between symptomatic and asymptomatic SARS-CoV-2 infected women. • The obstetric outcomes were: Preterm birth < 37 weeks; foetal growth restriction (birth weight percentile < 5); induced hypertension in pregnancy; gestational diabetes; CS; operative birth; ICU admission; maternal complications prior labour/during puerperium COVID-related: cardiac, neurologic, thrombotic, and respiratory manifestations; and maternal death. The neonatal outcomes were: small for gestational age (birth weight below the 10th percentile for babies of the same gestational age); large for gestational age (birth weight beyond 90th percentile for babies of the same gestational age); Apgar < 7 at 5 min; and NICU admission. The obstetric and neonatal general care were compared between symptomatic and asymptomatic SARS-CoV-2-infected women were: a labour companion; late umbilical cord clamping; early SSC; mother–infant separation; and EBF (at discharge/6 weeks). A common database was created through REDCap ® , where all the researchers responsible for each hospital were entering the data for later analysis. 2.3. Statistical Analysis Basic descriptive statistics were expressed as the mean ± standard deviation (SD) in the case of continuous variables, and as frequencies and percentages in the case of categorical variables. Normal data distribution was assessed using the Kolmogorov–Smirnov test. The incidence rate was determined using the total number of new positive SARSCoV-2 cases per 1000 maternities and divided by the number of births during the study period. The chi-squared test was used to compare the obstetric–neonatal general care rates according to the different qualitative variables, corrected by the Fisher exact test. Likewise, the chi-squared test and crude odds ratio (OR) with 95% confidence intervals (CIs) were used to compare the different study variables between asymptomatic SARS-CoV-2 positive women and women who developed COVID-19 (symptomatic cases). Statistical significance was considered for p< 0.05. Data analysis was performed using the R statistical package (version 4.0.5, R Foundation for Statistical Computing, Vienna, Austria). 2.4. Ethical Considerations Patients were not involved in the development of the research questions, the study’s design, or the recruitment of participants. Due to the retrospective study design, patient informed consent was not required. All patient data were handled anonymously. The local ethics committees approved the study protocols in the eight centers. The ethical principles of medical research contemplated by current Spanish legislation have been considered, and the study was conducted following the Declaration of Helsinki. 3. Results In total, 11,883 births were assisted during the study period in the participating hospitals. We included all women with SARS-CoV-2 infection admitted to the participating hospitals during the study period (130; 10.9 per 1000 maternities). There was no loss of any participant. The case distribution according to hospitals is shown in Table 1. Hospital H4 had an incidence of 17.8 per 1000 maternities, and hospital H8 assisted the largest number of positive cases. The majority of women were born in Spain (53.8%), with a mean age of 32 ± 5.1 years. There were statistically significant differences between symptomatic and asymptomatic women for any maternal age (Table 2). Int. J. Environ. Res. Public Health 2022,19, 5482 5 of 14 Table 1. Births and incidence of women with SARS-CoV-2 infection during the study. Hospital Total Births Births in Women Infected with SARS-CoV-2 Incidence H1 1288 18 14.0 H2 1090 7 6.4 H3 1308 7 5.4 H4 1182 21 17.8 H5 1256 14 11.1 H6 679 11 16.2 H7 920 8 8.7 H8 4160 44 10.6 TOTAL 11,883 130 10.9 Table 2. Demographic characteristics of women infected with SARS-CoV-2 in the study. Study Variables Women Infected with SARS-CoV-2 Asymptomatic (n= 103; 79.2%) Symptomatic (n= 27; 20.8%) p* Mean (SD) Mean (SD) Age 31.5 (4.9) 33.9 (5.5) 0.049 n(%) n(%) Country of origin 0.287 Spain 64 (81.0) 6 (29.0) Central and South America 14 (70.0) 15 (30.0) Rest of EU countries 12 (80.0) 3 (20.0) Africa 9 (81.8) 2 (18.2) Asia 4 (80.0) 1 (20.0) Hospital of birth H8 34 (97.1) 1 (2.9) 0.112 H1 18 (100.0) 0 (0.0) H4 15 (71.4) 6 (28.6) H5 10 (71.4) 4 (28.6) H6 8 (72.7) 3 (27.3) H3 7 (70.0) 3 (30.0) H2 6 (37.5) 10 (62.5) * Chi-squared; severe acute respiratory syndrome coronavirus-2 = SARS-CoV-2; EU = European Union; H = Hospital. Regarding the women’s characteristics, 50% were primiparous, with a mean gestational age of 39.2 ± 1.6 weeks, and most had no previous maternal, gestational, or foetal disease conditions, without significant differences between symptomatic and asymptomatic women (p< 0.05). Positivity for SARS-CoV-2 was confirmed before or during labour in 91.5% of cases, and 8.5% after birth; 56.2% had laboured spontaneously, with an overall induction rate of 39.2%. Induction of labour was higher, but without significant differences, among symptomatic women (44.4% vs. 37.9%; p= 0.09). The 4.6% of women had an elective CS, without significant differences between symptomatic and asymptomatic women (p= 0.09). There were no statistically significant differences between symptomatic and asymptomatic women in terms of maternal (p= 0.084), gestational (p= 0.089), or fetal disease conditions (p= 0.719). In terms of the clinical parameters, 20.8% of women had symptoms upon admission, fever and cough (22.2% each) and headache (18.5%) being the most frequent manifestations. Other symptoms were 11.1% anosmia, 11.1% dyspnoea, 3.7% vomiting, 3.7% ageusia, and 7.4% body aches. Prior to birth, 7.4% of symptomatic women were admitted to the Int. J. Environ. Res. Public Health 2022,19, 5482 6 of 14 ICU with COVID-related respiratory distress versus none of the asymptomatic women (p= 0.042); of these women, 3.7% required mechanical ventilation due to dyspnoea and COVID-related thrombotic stroke, while 7.4% of symptomatic women were admitted to the ICU during the postpartum period compared with 1.9% asymptomatic women (p= 0.042). Mechanical ventilation was not required for any asymptomatic women admitted to the ICU. The admissions were not COVID-related (one preeclampsia, and one postpartum haemorrhage). However, both symptomatic women required mechanical ventilation. The mortality rate was 0.8%; among all participants, death was recorded in a woman with symptoms (specific mortality rate = 3.7%) (Table 3). Table 3. Obstetric–neonatal characteristics of the study sample. Variable Women Infected with SARS-CoV-2 (n/%) Asymptomatic Symptomatic p* (103/79.2%) (27/20.8%) Mean (SD) Mean (SD) Gestational age (weeks) 39.4 (1.4) 38.8 (2.2) 0.595 Apgar 1 min 9.63 (0.8) 9.56 (1.0) 0.694 Apgar 5 min 9.93 (0.4) 9.93 (0.4) 0.825 n(%) n(%) Parity Multiparous 52 (50.5) 13 (48.2) 0.829 Primiparous 51 (49.5) 14 (51.8) Previous maternal disease No 94 (91.3) 21 (77.8) 0.084 Yes 9 (8.7) 6 (22.2) Gestational disease No 88 (85.4) 19 (70.4) 0.089 Yes 15 (14.6) 8 (29.6) Foetal disease No 94 (91.3) 24 (88.9) 0.713 Yes 9 (8.7) 3 (11.1) Start of labour Elective caesarean section 5 (4.8) 1 (3.7) 0.09 Spontaneous 59 (57.3) 14 (51.9) Induced 39 (37.9) 12 (44.4) COVID-related Maternal complications prior to labour Asymptomatic 103 (100.0) 23 (85.2) 0.002 Respiratory distress 0 (0.0) 3 (11.1) Thrombotic stroke 0 (0.0) 1 (13.7) Type of birth Elective caesarean section 5 (4.9) 1 (3.7) 0.269 Urgent caesarean section 11 (10.7) 6 (22.2) Eutocic 75 (72.8) 15 (55.6) Instrumental birth 12 (11.6) 5 (18.5) Cause of caesarean section (n= 23) Other 10 (58.8) 6 (85.7) 0.366 NRFHR 7 (41.2) 1 (14.3) Int. J. Environ. Res. Public Health 2022,19, 5482 7 of 14 Table 3. Cont. Variable Women Infected with SARS-CoV-2 (n/%) Asymptomatic Symptomatic p* (103/79.2%) (27/20.8%) Mean (SD) Mean (SD) Maternal complications COVID-related before discharge No complications 101 (98.1) 23 (85.2) 0.002 Dyspnoea 0 (0.0) 1 (3.7) Respiratory distress 0 (0.0) 2 (7.4) Others 2 (1.9) 0 (0.0) Death 0 (0.0) 1 (3.7) RT-PCR testing of newborn infant on day 1 of life Positive 0 (0.0) 0 (0.0) 1 Negative 103 (100.0) 27 (100.0) Mother required ICU admission prior to labour No 103 (100.0) 25 (92.6) 0.042 Yes 0 (0.0) 2 (7.4) Mother required ICU admission before discharge No 101 (98.1) 25 (92.6) 0.042 Yes 2 (1.9) 2 (7.4) Newborn infant required admission to NICU before discharge No 88 (85.4) 16 (59.3) 0.005 Yes 15 (14.6) 11 (40.7) Mother requiring emergency readmission after discharge in first 6 weeks No 102 (99.0) 27 (100.0) 1 Yes 1 (1.0) 0 (0.0) Newborn infant requiring emergency readmission after discharge in first 6 weeks No 100 (97.1) 26 (96.3) 1 Yes 3 (2.9) 1 (3.7) Reason for maternal readmission after discharge in first 6 weeks Puerperal fever 1 (0.9) 0 (0.0) 1 No 102 (99.1) 27 (100.0) Reason for newborn infant readmission after discharge in first 6 weeks No reason 100 (97.0) 26 (96.3) Choking 1 (1.0) 0 (0.0) 1 Non-COVID-19 respiratory infection 0 (0.0) 1 (3.7) SARS-CoV-2 + (hospital admission) 1 (1.0) 0 (0.0) SARS-CoV-2 + (emergency room care) 1 (1.0) 0 (0.0) * chi-squared; severe acute respiratory syndrome coronavirus-2 = SARS-CoV-2; NRFHR = non-reassuring foetal heart pattern; RT-PCR = real-time polymerase chain reaction; ICU = Intensive Care Unit; NICU = Neonatal Intensive Care Unit. None of the newborn infants tested positive for SARS-CoV-2 infection during hospital admission. Organizational issues caused the reasons for admission of newborns to the NICU before discharge (19.2%), and none of them concerned a disease associated with maternal COVID-19. The reasons were separation following protocol active on the date (26.9%), prematurity (23.1%), stabilization to maladaptation after birth (15.4%), hyperbilirubinemia (11.5%), social services/adoption (7.6%), 3.8% sepsis (3.8%), observation following cerebral-vascular event (3.8%), and maternal drug misuse (3.8%). The obstetric and neonatal general care is presented in Table 4. Early SSC occurred in 75.4% of births, and late clamping was performed in 55.6%. Mother–infant separation Int. J. Environ. Res. Public Health 2022,19, 5482 8 of 14 occurred in 19.2% of the cases, with no clinical indication in 5.4% and with a maternal accompaniment rate of 53.8%. On the other hand, asymptomatic women had a greater percentage of early SSC (79.6% vs. 59.3%; p= 0.029), a greater labour companion rate (64.1% vs. 40.7%; p= 0.028), and less mother–infant separation (13.6% vs. 40.7%; p< 0.001). There were no statistically significant differences in late umbilical cord clamping (asymptomatic = 57.3%; symptomatic = 40.7%; p= 0.125). Table 4. Obstetric–neonatal general care of the study participants. Variable Women Infected with SARS-CoV-2 Asymptomatic (n/%) Symptomatic (n/%) *p (103/79.2%) (27/20.8%) Labour companion 0.028 No 37 (35.9) 16 (59.3) Yes 66 (64.1) 11 (40.7) Late umbilical cord clamping 0.125 No 44 (42.7) 16 (59.3) Yes 59 (57.3) 11 (40.7) Early skin-to-skin contact 0.029 No 21 (20.4) 11 (40.7) Yes 82 (79.6) 16 (59.3) Mother-infant separation during hospital admission <0.001 No 89 (86.4) 16 (59.3) Yes 14 (13.6) 11 (40.7) Reason for mother–infant separation <0.001 No separation 89 (86.4) 16 (59.3) Monitoring and control 2 (1.9) 2 (7.4) Other 5 (4.9) 9 (33.3) Protocol to date 7 (6.8) 0 (0.0) Feeding at discharge 0.450 Formula feeding (maternal decision) 12 (11.6) 5 (18.5) Formula feeding (medical recommendation) 1 (0.9) 3 (11.1) Exclusive breastfeeding 76 (73.8) 16 (59.3) Mixed feeding (maternal decision) 6 (5.8) 2 (7.4) Mixed feeding (medical recommendation) 8 (7.9) 1 (3.7) Feeding at six weeks 0.408 Formula feeding 26 (25.2) 9 (33.3) Exclusive breastfeeding 55 (53.4) 14 (51.6) Mixed feeding 22 (21.4) 4 (14.8) * chi-squared; SARS-CoV-2 = severe acute respiratory syndrome coronavirus-2. Concerning EBF, the percentage at the time of hospital discharge was 70.8%. The EBF rate at six weeks after birth was 53.1%. We recorded no statistically significant differences in the type of feeding at hospital discharge or the type of feeding at six weeks after birth, between women with and without COVID-19 symptoms. Table 5presents the obstetric–neonatal results and care received during labour, birth, and puerperium of women infected with SARS-CoV-2. There were differences between symptomatic and asymptomatic participants. The symptomatic women were nine times more likely to have a preterm birth (95% CI: 2.2–41.2) and eight times more likely to be Int. J. Environ. Res. Public Health 2022,19, 5482 9 of 14 admitted to the ICU (95% CI: 1.5–50.9); their infants were five times more likely to be admitted to the NICU (95% CI: 1.9–13.8). Table 5. Obstetric–neonatal outcomes and general care of the participants. Women Infected with SARS-CoV-2 Asymptomatic Symptomatic (103/79.2%) (27/20.8%) n%n%apbOR 95% CI Obstetric outcomes Preterm birth <37 w 3 2.9 6 22.2 <0.001 9.52 2.2–41.2 ≥37 w 100 97.1 21 77.8 Foetal growth restriction No 102 99.3 26 96.3 0.304 3.92 0.2–64.8 Yes 1 0.7 1 3.7 Gestational diabetes No 100 97.1 26 96.3 0.832 1.28 0.1–12.8 Yes 3 2.9 1 3.7 Induced hypertension in pregnancy No 103 100.0 26 96.3 0.051 - - Yes 0 0.0 1 3.7 Caesarean section No 87 84.5 20 74.1 0.208 1.90 0.7–5.2 Yes 16 15.5 7 25.9 Operative delivery No 91 88.3 22 81.5 0.346 1.72 0.6–5.4 Yes 12 11.7 5 18.5 ICU admission No 101 98.1 25 92.6 0.005 8.78 1.5–50.9 Yes 2 1.9 2 7.4 Maternal complications prior labour/during puerperium COVID-related: cardiac. neurologic, thrombotic, respiratory manifestations No 103 100.0 26 96.3 0.057 - - Yes 0 0.0 1 3.7 Maternal death No 103 100.0 26 96.3 0.051 - - Yes 0 0.0 1 3.7 Neonatal outcomes Small for gestational age No 97 94.2 27 100.0 0.199 - - Yes 6 5.8 0 0.0 Large for gestational age No 103 100.0 26 96.3 0.052 - - Yes 0 0.0 1 3.7 Apgar < 7 at 5 min No 100 97.1 26 96.3 0.832 1.28 0.1–12.8 Yes 3 2.9 1 3.7 NICU admission No 91 88.3 16 69.6 <0.001 5.21 1.9–13.8 Yes 12 11.7 11 30.4 SARS-CoV-2 infection No 0 0.0 0 0.0 - - - Yes 0 0.0 0 0.0 General care Mother–infant separation during hospital admission No 89 86.4 16 59.3 0.005 4.03 1.5–10.4 Yes 14 13.6 11 40.7 Early skin-to-skin-contact No 21 20.4 11 40.7 0.029 2.11 1.1–4.1 Yes 82 79.6 16 59.3 Late umbilical cord clamping No 44 42.7 16 59.3 0.125 1.69 0.9–3.4 Yes 59 57.3 11 40.7 Labour companion No 37 35.9 16 59.3 0.028 2.11 1.1–4.2 Yes 66 64.1 11 40.7 EBF at discharge No 27 26.2 11 59.3 0.140 0.52 0.2–1.3 Yes 76 73.8 16 40.7 EBF at six weeks No 48 46.6 13 48.1 0.866 0.94 0.4–2.2 Yes 55 53.4 14 51.9 a Chi-squared; b OR = crude odds ratio; CI = confidence interval; SARS-CoV-2 = severe acute respiratory syndrome coronavirus-2; EBF = exclusive breastfeeding; ICU = intensive care unit; NICU = neonatal intensive care unit. Regarding general care for symptomatic women, they were more likely to be unaccompanied during labour (95% CI: 1.1–4.2), also markedly likely to experience mother–child separation (95% CI: 1.57–10.36) and twice as likely to experience non-performance of early SSC (95% CI: 1.1–4.1) compared to asymptomatic women. CS was significantly associated to preterm birth (OR = 12.2; 95% CI: 2.8–53.6), admission to the ICU (OR = 11.1; 95% CI: 1.9–64.7), and admission to the NICU (OR = 5.6; 95% CI: