Recently, a novel coronavirus severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) causing the clinical disease novel coronavirus disease 2019 (COVID-19) has been declared a worldwide pandemic, with 3 million cases and 200,000 deaths. 1, 2 The first case reported in the United States occurred in early March. 3 The United States has had 1,171,510 confirmed cases and 68,279 deaths as of May 5, 2020. 4 In late March, hospitals in New York City (NYC) were faced with a surge of cases and by May 5, New York State had 313,636 cases and 24,717 deaths with more than half of the cases (171,723) and confirmed deaths (13,684) occurring in NYC. 5, 6 In just 4 weeks, one NYC hospital saw a 40-fold increase in COVID-19 infection among their maternity patients. 7 As knowledge of the disease evolved, rapid changes in hospital practices were necessary. While the pandemic appears to be plateauing in NYC, the virus is affecting other regions of the United States, and in the coming months, there remains a risk of a second wave in cases.
Recent data from a systematic review of COVID-19 during pregnancy highlighted the outcomes of 51 cases and stresses the importance of additional studies exploring the implications of SARS-CoV-2 infection in pregnancy, as well as the rationaledriving obstetric interventions. 8 A report from NYC described 43 SARS-CoV-2 infected pregnant women, including seven diagnosed prior to adoption of universal SARS-CoV-2 polymerase chain reaction (PCR) testing. 9 In this study, 9% of the women developed severe disease, and almost 5% had critical disease. This data are consistent with reports from Wuhan where there was an 8% risk of severe disease in pregnant women. 10 Given the lack of data, the relatively immunocompromised state of pregnancy, and the potential for severe disease, further understanding of COVID-19 clinical management, as well as hospital level preparation for its control are crucial.
In the United States, both expert opinion and advice from professional societies have guided the clinical management of COVID-19. 11-13 Guidance on cesarean delivery, prevention of postpartum hemorrhage, and collection of biospecimens have come from obstetrical centers with experience in prior coronavirus outbreaks. 14 An overview of COVID-19 in pregnant women proposed a framework for the unique complexities and logistics in managing this disease in obstetrics. 15 Finally, public health agencies have provided guidance on how to modify practices during this pandemic. 16 To date, the literature is limited on how hospitals are providing obstetric care and have responded to COVID-19. As the threat of the disease remains, hospitals, practitioners, and health systems may benefit from the real-world information gained by centers that have been at the forefront of the pandemic.
Herein, we report a survey of members of the NYC Maternal-Fetal Medicine (MFM) Research Consortium across four health systems during the peak of the pandemic. The survey aims to elucidate the practices put into place to guide patient care after four weeks managing SARS-CoV-2 infections in obstetrical patients. Given the dynamic nature of this disease, practices changed quickly as new issues arose, and our goal was to report our experience to other obstetrical providers, hospitals, and leaders as they formulate their own local-practices in managing the pandemic.
This was an internet-based survey conducted with four sites participating in the NYC MFM Research Consortium during the SARS-CoV-2 pandemic. The NYC MFM Research Consortium was formed in 2017 and in March to April 2020, decided to focus solely on COVID-19-related research. We developed a survey that focused on practices and procedures around the following domains: (1) screening for COVID-19 in patients presenting to labor and delivery; (2) management of SARS-CoV-2 infected and noninfected patients undergoing labor and delivery; (3) management of SARS-CoV-2 PCR positive and negative antepartum inpatients; (4) management of neonates of SARS-CoV-2-positive and -negative patients; (5) antepartum fetal surveillance for COVID-19 inpatients; and (6) obstetrical interventions in the COVID-19 patient. Given the nature of the pandemic and our desire to conduct the survey in realtime, we did not perform pretesting for survey validation.
Surveys were administered via Redcap. 17 Participants were either MFM specialists, or obstetrical service or labor and delivery directors, and received no incentives. Because we wanted to capture practice patterns during the height of the pandemic, the survey time spanned from April 14, 2020 through April 17, 2020. A member of each Consortium site completed 118 questions over six survey pages/screens. Redcap allowed us to check for survey completeness, and respondents were able to review and correct their answers as needed.
Given the small number of centers involved, we did not weight the responses, and did not adjust for nonrepresentative samples. We did not plan to perform a statistical analysis and limited this manuscript to the survey responses. The Institutional Review Board of Mount Sinai Health System approved this survey.
Four centers agreed to participate in the survey, and all participants completed the survey in its entirety. ►Table 1 presents the characteristics of the hospitals surveyed. All the hospitals are tertiary referral centers located in different regions in NYC, representing a diverse patient population. Site 1 included only one hospital within its health system, while the other three sites included two hospitals within their system. In two of the sites, the majority of patients were non-Hispanic Whites, while in the other two, the majority were Hispanic. During the study, the prevalence of SARS-CoV-2 infected women presenting to labor and delivery ranged from 8 to 46%.
All sites reported having adequate personal protective equipment (PPE) available, and required staff to wear surgical masks at all times. In SARS-CoV-2 PCR negative or persons under investigation (PUI), most sited limited N95 (N95) respirator use to procedures with a risk of intubation and during the second stage of labor. Only one center required full PPE for care of a PUI or SARS-CoV-2 PCR negative patient. All sites screened patients for COVID-19 using clinical history and temperature on presentation to labor and delivery. Most sites performed universal nasopharyngeal PCR for SARS-CoV-2 on admission, or 24 to 48 hours prior to a scheduled admission, although, since the time of survey completion, all four sites adopted this procedure. The majority of sites also screened the patient's support person using clinical symptoms and temperature checks during admission. One center performed SARS-CoV-2 PCR testing for all support persons either on admission to labor and delivery (L&D), or 24 to 48 hours prior to a scheduled admission.
Most sites made changes to their procedures and protocols forSARS-CoV-2 negative and PUI (►Table 2). Early in the pandemic, centers prohibited a support person. This policy was changed, and by the time of the survey, all sites, allowed only one support person. All sites recommended early epidural placement to reduce chance of general anesthesia in the case of emergency cesarean. Nitrous oxide analgesia was suspended in the one site where it was available. Most sites continued to perform delayed cord clamping. No sites used oxygen for nonreassuring fetal heart rate tracing (NRFHT), and most sites continued to use carboprost for the management of postpartum hemorrhage (PPH). All centers also continued to use nonsteroidal anti-inflammatory drugs (NSAIDS). During the postpartum period, most centers cohorted patients based on SARS-CoV-2 status. All centers allowed rooming in of newborns. All sites had a nursery available for newborns of SARS-CoV-2-negative mothers. No sites tested newborns and the majority of sites continued to perform circumcisions. All sites continued to make lactation consultation available. All sites encouraged early discharge if appropriate (at 24 hours for vaginal deliveries or 48 hours for cesarean deliveries) and performed a phone follow-up shortly after discharge.
In SARS-CoV-2-positive pregnancies, most sites changed policies to attempt to limit virus exposure (►Table 3). 
There was less consensus on antepartum fetal surveillance in COVID-19 patients. For example, there was variability in the level of fetal testing for a COVID-19, non-ICU patient, with a viable fetus. One site would do no testing until 34 weeks, and another would start at 24 weeks (►Table 4). One site would not start testing until 26 weeks. When patients were admitted to the ICU, but not intubated, half of the respondents performed daily non-stress tests (NSTs) while half performed only daily fetal heart (FH) tone checks. One site had an obstetrical ICU and performed continuous monitoring for all ICU patients, regardless of their clinical status. For ICU patients who were intubated with viable fetuses, half of the sites monitored by FHs check, while the other half performed an NST. In a patient with a fetus beyond 24 weeks of gestation that was decompensating, half of the centers would perform a FH check, while one center would do an NST, and one would not monitor the fetus. For half of the sites, after 34 weeks, the risks of continued expectant management of a patient with COVID-19 seemed to outweigh the risks of prematurity, and these centers would forgo testing and recommend delivery.
In a critically ill COVID-19 patient, all centers would perform an emergent cesarean for worsening maternal status starting at 24 weeks. For worsening fetal status, the majority would perform an emergent cesarean starting at 28 weeks. There was less consensus on emergent delivery for fetal indications at less than 28 weeks, as only half of the sites would intervene, and only under certain circumstances after shared decision making with the patient. For an unstable COVID-19 in the ICU, most centers would deliver the patient, if possible, in an AIIR room in the main OR. Half of the centers would deliver a patient with COVID-19 symptoms who is otherwise stable and with reassuring fetal status between 34 to 36 weeks. Seventy five percent of the sites would deliver a stable COVID-19 patient with reassuring fetal status between 37 to 39 weeks. Finally, most sites were using novel COVID-19 treatments and recommending thromboprophylaxis (►Table 5).
Here we report on the obstetrical practices and protocols from four academic medical centers in NYC at the height of the COVID-19 pandemic. All sites made changes to their practices that were consistent with public health recommendations and practical for local circumstances. There appeared to be agreement with screening and testing for COVID-19, as well as L&D protocols for SARS-CoV-2-positive patients, particularly involving use of PPE, and medication use such as corticosteroids, magnesium sulfate, carboprost, and thromboprophylaxis, as well as procedures for newborn testing. We found less consensus with respect to inpatient antepartum fetal surveillance. While we were unable to document specific practice changes from weeks 1 to 4, there was evidence of independent changes in practice by the time of the survey and after. For example, very early in the pandemic, hospitals prohibited support persons from accompanying laboring patients. This policy changed by the time the survey was performed. Additionally, at the time of the survey, only half the centers were doing universal testing. As of this writing, all centers have adopted this policy. Knowledge of SARS-CoV-2 status may affect downstream decisions, and identifying infected patients allows for appropriate cohorting and protection of staff. If a center elects a strategy of selective 
Our study has several strengths. We surveyed leaders of obstetrical units in NYC immersed in the development and testing of new protocols in an early epicenter of the pandemic. We document the practices put into place after 4 weeks of planning and caring for pregnant COVID-19 patients. The sites surveyed also cared for a large diverse patient population. Finally, we were able to demonstrate how sites independently arrived at similar conclusions in certain areas while differing practices in others. We also acknowledge several limitations that could introduce bias. This survey included only large, urban centers with access to robust resources. One site had an obstetrical ICU, an uncommon practice model nationally. This may make some of the protocols less generalizable to smaller centers. Additionally, resources varied at different sites and so consensus on areas such as negative pressure operating rooms or delivery rooms could not be obtained.
Several expert commentaries have provided guidance on PPE, procedures during L&D, and management of common obstetrical issues during the pandemic. 20-22 A recent Cochrane review aimed at compiling international guidelines related to COVID-19 during pregnancy. 23 This group found international consensus in a few important areas, including which pregnant women should wear a mask or respirator, and how centers were managing support persons in asymptomatic women. 23 Less consensus was noted with respect to antepartum fetal surveillance in COVID-19 patients, or whether COVID-19 was a contraindication to antenatal steroids for fetal lung maturity. To our knowledge, this is the first survey to document obstetrical protocols and procedures put into place at multiple centers within an urban setting during the COVID-19 pandemic, and that specifically surveyed policies on inpatient antepartum fetal surveillance and corticosteroids for fetal lung maturity. While we are not able to say whether the protocols mentioned here represent "the best practices," they do represent practices that were developed over time to best care for patients, and at the same time to protect health care workers. Ultimately, our hope is that sharing policies such as SARS-CoV-2 universal testing on patients in labor or scheduled for delivery, cohorting patients, antepartum fetal surveil-lance, and obstetrical interventions will help simplify and direct care for a COVID-19 obstetrical patients.