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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.
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.
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.
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.
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.
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.
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.
Yes. The risk of preterm labour is doubled in women who are HIV positive.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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%.
Oral AZT 300 mg should be given three-hourly during labour to HIV positive women who have not had ARV drugs during pregnancy.
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.
A high viral load remains a high risk factor
Preterm delivery and vaginal delivery are lesser risk factors
Infectious complications are more common in the puerperium in women with HIV infection. Therefore, these women must be closely observed for:
If any of the above occurs, appropriate antibiotics must be started immediately.
Yes. As vaginal and cervical secretions, blood and amniotic fluid may contain HIV. Healthcare workers can become infected by HIV via the following routes:
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.
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:
She may want to discuss family planning because:
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.
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:
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.
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.
If managed according to option B:
If managed according to option B+:
All women must remain on lifelong ARV treatment irrespective of the CD4 count, if diagnosed with:
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.
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.
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.
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.
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. Caesarean section should only be done if there are good clinical indications.
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.
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%.
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.
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.
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.
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.
No, if a woman has not been screened for HIV during her pregnancy, she can still be screened during labour using a rapid test.
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.
A single dose of NVP to a woman in labour can result in HIV resistance to NVP and possibly EFV.
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.
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.