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3

HIV during labour and delivery

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Contents

Objectives

When you have completed this unit you should be able to:

HIV transmission during labour

3-1 Can HIV be transmitted from mother to infant during labour and delivery?

Yes. During labour and delivery the infant is exposed to cervical and vaginal secretions as well as maternal blood, all of which may contain HIV that can infect the infant. Without ARV prophylaxis or treatment, there is a risk of HIV transmission from a mother to her fetus is during labour and vaginal delivery.

3-2 What is the risk of an infant being infected with HIV during labour and delivery without antiretroviral prophylaxis or treatment?

The risk of HIV transmission from mother to infant during pregnancy, labour and vaginal delivery together is about 20% if ARV prophylaxis or treatment is not used. The risk of HIV transmission during labour and vaginal delivery alone is about 15%. Therefore, most of this transmission takes place during labour and delivery. Therefore efforts to reduce HIV transmission during labour and delivery are very important.

Most vertical spread of HIV takes place during labour and vaginal delivery if antiretroviral prophylaxis or treatment is not used.

3-3 Can HIV infection be diagnosed for the first time during labour?

If a woman has not been screened for HIV during her pregnancy, she can still be screened during labour using a rapid test. However it is preferable to screen all women for HIV during pregnancy when there is still time for adequate counselling.

Reducing HIV transmission during labour and delivery

3-4 Is there any need to isolate HIV-positive women during labour?

No. There is no need to isolate HIV-positive women before, during or after labour. However, there is a need for privacy when counselling these women.

3-5 Can the duration of ruptured membranes influence the risk of HIV transmission if ARV treatment or prophylaxis is not given?

Yes. Ruptured membranes exposes the infant to cervical and vaginal secretions. The longer the duration of ruptured membranes, the greater the risk of HIV in cervical and vaginal secretions getting into the uterine cavity and infecting the infant. The risk of transmission from mother to infant increases if the membranes have been ruptured for more than four hours, especially if the woman is not on ARV prophylaxis or treatment.

The risk of vertical transmission of HIV to the infant is increased if the membranes have been ruptured for more than four hours, without ARV treatment or prophylaxis.

Note
Without ARV treatment or prophylaxis, the risk of HIV infection of the second twin is less than that in the first twin, as the second twin is exposed to maternal secretions for a shorter time.

3-6 Should the membranes be ruptured routinely in HIV-positive women?

No. The membranes should not be ruptured unless there is a good clinical indication. Artificial rupture of the membranes often results in the infant being exposed to vaginal and cervical secretions for more than four hours. Routine artificial rupture of the membranes must no longer be practised. This principle is also adhered to if patients are on ARV drugs.

Note
There is no need to rupture membranes if labour progresses normally. However, with intact membranes and poor progress in the active phase of labour, rupture of the membranes should be considered. These patients need to be reassessed after a further two hours. Many patients will have progressed by then and be close to delivery. Those that have not progressed should be considered for Caesarean section.

3-7 How may the duration of labour influence the risk of HIV transmission?

In long labours there is a greater risk of transmission than in short labours, without ARV treatment or prophylaxis. As with the duration of ruptured membranes, the infant is exposed to HIV in vaginal and cervical secretions for a longer time with long labours than with shorter labours. It is believed that labour increases the risk of HIV crossing the placenta. Therefore prolonged labour should be avoided.

3-8 Is preterm labour more common in HIV-infected women?

Yes. The risk of preterm labour is doubled in women who are HIV positive.

3-9 May preterm labour increase the risk of HIV transmission?

Yes. The risk of HIV transmission is higher in preterm than in term infants, possibly because preterm infants have a more immature immune system and have fewer maternal antibodies. HIV in swallowed maternal blood or vaginal secretions may pass through the walls of their immature guts more easily. Even with ARV treatment or prophylaxis preterm infants still have a higher risk HIV transmission.

Note
The presence of chorioamnionitis, which is a common cause of preterm labour, may also increase the risk of vertical transmission.

3-10 Does HIV infection in the mother cause intra-uterine growth restriction?

Intra-uterine growth is usually normal in HIV-positive women who are well nourished. However, poor fetal growth may occur if the mother is underweight and clinically ill with AIDS. Therefore, HIV infection itself does not appear to cause slow fetal growth.

Note
HIV-associated infections such as CMV may cause fetal infection and restrict intra-uterine growth.

3-11 Can Caesarean section reduce the risk of HIV transmission from mother to infant?

There is good evidence from the pre-ARV drug era that HIV transmission can be reduced by as much as 50% if a Caesarean section is performed, especially if it is done electively before the onset of labour. An elective Caesarean section prevents the fetus being exposed to cervical and vaginal secretions. As the infant does, however, still come into contact with maternal blood during the delivery, the risk of transmission is not eliminated. The risk of vertical transmission is not reduced much if a Caesarean section is done after the membranes have been ruptured. As a Caesarean section is expensive and requires the necessary staff and facilities, this is not a practical method of reducing the risk of vertical transmission in most poor communities. The benefit of an elective Caesarean section is much reduced if correct ARV prophylaxis or treatment is given to mother and infant. Therefore, Caesarean section is not used to reduce transmission in high HIV prevalence poorer resourced countries.

Routine elective Caesarean section is not recommended to reduce the risk of HIV transmission to the infant.

3-12 Is a Caesarean section dangerous in HIV-positive women?

Caesarean section has more complications in women who are HIV positive, especially if their CD4 count is low. The risks of wound sepsis and post-operative pneumonia are increased in HIV-positive women. Routine elective Caesarean section is, therefore, not recommended in HIV-positive women. Caesarean section should only be done if there are good clinical indications. Prophylactic antibiotics must be given to HIV-positive women who have a Caesarean section.

Note
If a Caesarean section is done in an HIV-positive woman, a spinal or epidural anaesthetic is preferable to a general anaesthetic as it carries a lower risk of pneumonia.

3-13 Can instrumental delivery increase the risk of HIV transmission?

Vacuum extraction, even with a silicone cup, always causes a small abrasion of the fetal scalp and should be avoided. Forceps delivery done with necessary caution will seldom result in skin injury and may be used for the correct indications.

Vacuum extraction may increase the risk of HIV transmission to the infant.

3-14 Should an episiotomy be done in HIV-positive women?

Whether a woman is HIV positive or not, an episiotomy should only be done if there is a good clinical indication. It should not be a routine procedure. HIV in maternal blood from an episiotomy may be swallowed and, thereby, may infect the infant during delivery. Healing of the episiotomy may also be delayed if the woman has depressed immunity.

3-15 Which women are most likely to transmit HIV to their infant during labour and delivery?

  1. Women who did not receive ARV drugs or started ARV drugs late in pregnancy:
  2. Women who become infected with HIV during their pregnancy as they have a high viral load
  3. Women who have advanced HIV infection (AIDS) as they have a high viral load
  4. Women with preterm labour and delivery
  5. Women with rupture of the membranes for longer than four hours
  6. Women who have prolonged labours

3-16 Are scalp clips safe in HIV-infected women?

No. Scalp clips damage the infant’s skin and may allow the entrance of HIV. Therefore attaching scalp clips should not be done if the woman is HIV positive. Scalp clips should not be used routinely. However scalp clips could be used if clinically indicated in HIV negative women.

3-17 What is the value of vaginal cleaning with chlorhexidine (Hibitane) in reducing the risk of HIV transmission?

Wiping the vagina with 0.25% chlorhexidine (Hibitane) or povidone iodine (Betadine) does not reduce the risk of HIV transmission to the infant. Vaginal cleaning may reduce the risk of puerperal sepsis and neonatal sepsis. Routine use of chlorhexidine cream for vaginal examinations is recommended.

3-18 Should all infants born to HIV-positive women be suctioned at delivery?

Unless infants are meconium stained or need resuscitation, they must not have their mouth and nose suctioned after birth as this may damage the mucous membranes and increase the risk of HIV infection. Sometimes, deep suctioning may cause apnoea in the infant. It may be helpful to wipe the infant’s mouth and face after delivery to remove maternal blood and secretions. Suctioning of the mouth should not be done routinely on any infant.

Infants should not be routinely suctioned after delivery.

3-19 Should you clean infants born to HIV-positive women after delivery?

It may reduce the risk of HIV transmission if these infants are well dried and all the maternal blood and vaginal secretions are wiped off with a towel immediately after delivery. These infants do not need to be bathed straight after delivery. Once dried they should be given to the mother if they are breathing well.

Antiretroviral prophylaxis in labour

3-20 Are antiretroviral drugs useful during labour to reduce the vertical transmission of HIV?

Women who have been on ARV prophylaxis or treatment during pregnancy do not need AZT and a prophylactic dose of NVP during labour as they have a low viral load with only a small risk of transmitting HIV during labour and delivery. They should continue their ARV drugs during labour. Most women would be on FDC and should continue taking a single tablet daily. Women taking ARV drugs will have a risk of HIV transmission during pregnancy and labour of less than 2%.

HIV-infected women who did not receive ARV drugs during the antenatal period must be given both NVP and AZT in labour.

Antiretroviral drugs given during pregnancy and labour will reduce the risk of spreading HIV to the infant to less than 2%.

3-21 How is AZT used prophylactically to reduce the risk of vertical transmission of HIV?

Oral AZT 300 mg should be given three-hourly during labour to HIV positive women who have not had ARV drugs during pregnancy.

3-22 How is nevirapine used prophylactically to reduce the risk of vertical transmission of HIV?

A single oral dose of NVP is taken by the mother as soon as possible after the onset of labour. If possible, the dose should be taken more than two hours before delivery to allow the drug time to cross the placenta to the fetus. NVP is absorbed rapidly. It is never too late to give single dose NVP during labour if women are on no ARV drugs. The dose of NVP for the mother is 200 mg (a single tablet). This is followed by NVP syrup to the infant, started as soon as possible after delivery. A single dose NVP taken during labour reduce transmission during labour by 50%.

All women not receiving ARV drugs during pregnancy must receive a single dose NVP plus 3 hourly AZT as soon as possible after the onset of labour.

A single dose of NVP to a woman in labour can result in HIV resistance to NVP and possibly EFV. Therefore a single dose of Truvada (TDF and FTC) should be given to the woman together with the single dose NVP or as soon as possible after the dose of NVP. This measure significantly reduces the risk of developing resistance against NVP.

3-23 Which risk factors are associated with an increased risk of transmission during labour even if antiretroviral drugs are used correctly for prophylaxis or treatment?

A high viral load remains a high risk factor

Preterm delivery and vaginal delivery are lesser risk factors

HIV in the puerperium

3-24 What complications may occur in the puerperium in an HIV-positive woman?

Infectious complications are more common in the puerperium in women with HIV infection. Therefore, these women must be closely observed for:

  1. Infection of the genital tract (puerperal sepsis). This may cause secondary postpartum haemorrhage.
  2. Urinary tract infection, especially acute pyelonephritis.
  3. Pneumonia, especially in women who have had a general anaesthetic.
  4. Wound infections, especially after Caesarean section, episiotomy or tubal ligation.

If any of the above occurs, appropriate antibiotics must be started immediately.

Preventing accidental HIV infection

3-25 Are nurses and doctors at risk of accidental infection when delivering HIV-positive women?

Yes. As vaginal and cervical secretions, blood and amniotic fluid may contain HIV. Healthcare workers can become infected by HIV via the following routes:

  1. By needle-stick injuries or cuts during surgery
  2. By exposing cuts or abrasions on one’s hand to body fluids infected with HIV
  3. By splashes into the mouth or eyes of body fluids infected with HIV

The risk of acquiring HIV infection by needle-stick injury or accidentally cutting one’s finger during surgery is 1 in 300 without ARV prophylaxis while the risk of HIV infection after blood splashes or getting blood on cuts or abrasions is less than 1 in 1000 if ARV prophylaxis is not given. These risks are much reduced with ARV prophylaxis.

3-26 How can staff reduce the risk of becoming infected with HIV during a delivery?

In the absence of screening, all women should be regarded as HIV positive. Therefore, the following universal precautions should be practised during the labour and delivery of all women:

  1. Gloves must always be worn during delivery.
  2. Glasses, goggles or a mask with a visor must be worn if there is a risk of blood or amniotic fluid splashing into one’s eyes.
  3. A plastic apron should be worn to prevent soiling of one’s clothes.
  4. Full precautions must be taken when handling needles or lancets. Both should be placed into a sharps container immediately after removal from the skin. Hollow and suturing needles must never be put down to be cleared away after completion of the procedure.
  5. Great care must be taken to avoid pricking or cutting one’s finger during surgery or while suturing an episiotomy.

3-27 What measures should be taken during a surgical procedure to reduce the risk of staff becoming infected with HIV?

  1. All sharp instruments must be removed from the operating field as soon as they are no longer required. Sharp instruments must never be allowed to lie around.
  2. A separate tray for sharp instruments is of value. The operator should then pick them up and put them down herself or himself.
  3. A needle should always be held with forceps and not with one’s fingers when suturing. A Bonney’s forceps is ideal for this purpose as it has the necessary strength to grasp the needle.
  4. Needles should always be safeguarded with the sharp point against the needle holder when not being used; even in between sutures while the knot is being tied.

Family planning for HIV-positive women

3-28 Why may an HIV-positive woman want family planning after delivery?

She may want to discuss family planning because:

  1. A further pregnancy may speed up the progression of her disease, especially if she already has symptomatic HIV infection.
  2. Of the risk of infecting her sexual partner during unprotected intercourse.
  3. Of the risk of infecting any further children she may have with HIV.
  4. She is worried that she may die of AIDS while her children are still young.

Family planning should be discussed with all women who have delivered. Women who are well and on ARV treatment should continue to use condoms because of the risk of becoming infected with another subtype of HIV or infecting uninfected partners.

3-29 What family planning advice should be given to an HIV-positive woman after delivery?

A permanent form of contraception may be advisable for HIV-positive women because of their reduced life expectancy that will result in their children being orphaned at a young age. The risk of transmitting HIV to each additional child also requires consideration. Postpartum tubal ligation should, therefore, be considered.

The methods of contraception usually offered to HIV-positive women are:

  1. Tubal ligation: This is a very effective method but should not be done if the woman has AIDS because of the anaesthetic risk and the risk of post-operative sepsis. Vasectomy of the male partner is also an option in selected cases.
  2. Injectables: medroxyprogesterone acetate (Depo-Provera or Petogen) and norethisterone enanthate (Nur-Isterate) provide reliable temporary contraception and are the contraceptives of choice. Both these contraceptives regimen remain effective irrespective of which ARV regimen are used.
  3. Intra-uterine contraceptive devices (IUD): These devices can be used with safety, unless women are at risk of other sexually transmitted diseases. An IUD should not be inserted if women have AIDS (Stage 4 disease). Women who had an IUD inserted prior to their health deteriorating should continue with this method of contraception.
  4. Combined oral contraceptives (COC): Effective if taken regularly. COC can be used with all ARV regimen except when ARV includes a protease inhibitor (PI). Women requiring a PI should switch to another form of contraception. LPV/r is a PI commonly used as a second-line ARV regimen. COC may also fail if taken with antibiotics.
  5. Male or female condoms: They are less reliable and must be used correctly every time intercourse takes place. Condoms also provide some protection against the risk of spreading HIV infection and other sexually transmitted diseases.
  6. Abstinence: This is the only certain method of preventing both pregnancy and the spread of HIV.

Emergency contraception with levonorgestrel 1.5 mg (2 pills) is effective but should not be used as a method of regular contraception. Lactational amenorrhoea (not ovulating during breastfeeding) is also effective if used with condoms during the first 6 months of breastfeeding if the infant is exclusively breastfed. However, not all HIV-positive women will be breastfeeding.

Whatever method of contraception is used, if there is a risk of spreading HIV, a condom must be worn.

3-30 How should you provide family planning for an HIV-positive woman?

  1. Ask the woman what method she would prefer.
  2. Decide whether there are any contraindications to this method.
  3. If there are no contraindications, then this method should be used.
  4. If there are contraindications, then more appropriate methods should be discussed.

Always give the woman information on the health benefits and the possible side effects of the method chosen. The need for proper compliance must be stressed. If both or only one of the sexual partners is HIV positive, a condom must be used during every act of intercourse.

Follow-up care of HIV-infected women

3-31 How should HIV-positive women be followed up after delivery?

If managed according to option B:

  1. HIV-positive women who are healthy (stage 1 or 2 disease) with CD4 counts of more than 350 cells/µl during pregnancy must be reassessed in the puerperium. If they remained well FDC is stopped and they should be followed up with a CD4 count every six months at their local primary-care clinic.
  2. Women who become ill with symptoms or signs of stage 3 or 4 HIV infection or have a CD4 count of 350 cells/µl or less must remain on lifelong ARV treatment and need referral for follow-up at their nearest ARV clinic.

If managed according to option B+:

  1. All these women must remain on lifelong ARV treatment and need referral for follow-up at their nearest ARV clinic
  2. If diagnosed to be HIV positive during labour or postpartum:
  3. The mother need to be started on FDC, a CD4 count and serum creatinine requested and a follow-up date given for 1 week’s time.
  4. Good adherence and exclusive breast must be encouraged and supported.
  5. Careful follow up during the puerperium for sepsis (uterus, breasts or wound) is important.
  6. The infant also needs to be carefully followed up.

3-32 How should HIV positive women with TB or hepatitis B be managed?

All women must remain on lifelong ARV treatment irrespective of the CD4 count, if diagnosed with:

Case study 1

An HIV positive G3 P2 woman, who is clinically well, with a CD4 count of 450 cells/ml, has been on FDC since 24 weeks gestation. At term she went in spontaneous labour, but progressed slowly from 4 to 5 cm cervical dilation, with membranes intact. The fetal condition was good. As the risk of HIV transmission was regarded as too high with rupturing membranes, a Caesarean section was performed.

1. Do you agree with the decision to perform a Caesarean section?

No, although there is evidence from the pre-ARV drug era that transmission can be reduced by as much as 50% if a Caesarean section is performed, especially if it is done electively before the onset of labour. She is already in established labour and the possible benefit of an elective Caesarean section has been lost.

2. How should she have been managed?

The membranes could have been ruptured and the woman reassessed following 2 hours. If there was still no progress a Caesarean section could be done. With normal progress of labour she will be close to a normal delivery.

3. Does a Caesarean section reduce the risk of transmission if a patient is taking ARV drugs?

The additional benefit of an elective Caesarean section is much less if correct ARV prophylaxis or treatment is given to mother and infant. Although the risk of intrapartum transmission is slightly reduced if an elective Caesarean section is performed, Caesarean section is not used to reduce transmission in high HIV prevalence and under resourced countries.

4. Is a Caesarean section dangerous in HIV-positive women?

Caesarean section has more complications in women who are HIV positive, especially if their CD4 count is low.

5. What complications could be expected if a Caesarean section is performed on HIV positive patients?

The risks of wound sepsis and post-operative pneumonia are increased in HIV-positive women. Caesarean section should only be done if there are good clinical indications.

Case study 2

An HIV positive G1 P0 woman is clinically well, with a CD4 count of 500 cells/ml and has been on FDC since 20 weeks gestation. At term she went in spontaneous labour and was admitted to a midwife obstetric unit for her delivery. She had already taken her FDC tablet for the day before arrival at the MOU. She had read up on the internet and is concerned about transmission of HIV to her infant during labour. The attending midwife decides to give her an additional single dose of NVP and to add 3 hourly AZT while in labour. Her membranes ruptured spontaneously at a cervical dilatation of 5 cm. She expressed her concern to the midwife that the risk of transmission had now increased.

1. What is the risk of HIV transmission during labour when women are healthy (stage 1 disease) and are on FDC?

Women who have been on ARV prophylaxis or treatment during pregnancy have a low viral load with only a small risk of transmitting HIV during labour and delivery. These women will have a risk of transmission during pregnancy and labour of less than 2%.

2. Will an additional single dose of NVP and 3 hourly AZT add any benefit to reduce HIV transmission?

Women who have been on ARVs during pregnancy do not need a prophylactic dose of NVP and AZT during labour. They already have a low viral load and no additional benefit is to be gained by adding more ARV drugs.

3. What should the midwife explain to her patient regarding her concern following rupture of membranes?

She should explain that because she is on ARVs for a considerable time her viral load will be very low or may not be detectable. The risk of transmission, therefore, is not increased because her membranes ruptured.

4. What would be a correct policy regarding artificial rupture of membranes?

Membranes should not be ruptured unless there is a good clinical indication. Routine artificial rupture of the membranes must no longer be practised. This principle is still adhered to if patients are on ARV drugs.

Case study 3

An unbooked primigravida at term was admitted to a midwife obstetric unit following spontaneous onset of labour. She appeared healthy with an uncomplicated pregnancy. Her cervix is 3 cm dilated. She had never been tested for HIV. The midwife tells her that as she is already in labour she could only have an HIV test following her delivery.

1. Do you agree with the decision to postpone her HIV test until after delivery?

No, if a woman has not been screened for HIV during her pregnancy, she can still be screened during labour using a rapid test.

2. What would be the advantages of screening for HIV during labour?

Women diagnosed to be HIV positive in labour must receive single dose NVP during labour as well as 3 hourly AZT. The single dose NVP alone will reduce the risk of intrapartum transmission by 50%. The opportunity to reduce intrapartum transmission is lost if the HIV test is postponed until after the delivery.

3. Should you be concerned about resistance to NVP because the drug was given as a single dose?

A single dose of NVP to a woman in labour can result in HIV resistance to NVP and possibly EFV.

4. What measures must be taken to reduce the risk of resistance when using single dose NVP?

A single dose of Truvada (TDF and FTC) must be given to the mother together with the single dose NVP or as soon as possible after delivery.

5. How should the patient be followed up after delivery?

The mother need to be started on FDC, a CD4 count and serum creatinine requested and a follow-up date given for 1 week’s time.