HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.): SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN: Care during labour and delivery

HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.)

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EXECUTIVE SUMMARY

INTRODUCTION

SECTION A : HIV IN PREGNANCY

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Epidemiology of HIV

Susceptibility of women to HIV infection

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Biological factors

Socio-cultural factors

Effect of pregnancy on the natural history of HIV infection

Effect of HIV infection on pregnancy

Mother-to-child transmission

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Factors affecting mother-to-child transmission of HIV-1

Interventions to prevent mother-to-child transmission of HIV

Appropriate interventions to reduce mother-to-child transmission

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Antiretroviral therapy

Immune therapy

Nutritional interventions

Mode of delivery

Vaginal cleansing

Modification of infant feeding practice

Voluntary HIV counselling and testing in pregnancy

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Testing of antenatal women

Counselling before and after HIV testing in pregnancy

Counselling about pregnancy-related issues

SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN

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Antenatal care

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Obstetrical management

Examination and investigations

Medical treatment during pregnancy

Antiretroviral therapy

Care during labour and delivery

Postpartum care

Care of neonates

SECTION C : INFECTION CONTROL MEASURES

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Universal precautions

Risks of needlestick injuries

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Management of needlestick injuries and other accidental blood exposure

REFERENCES

Care during labour and delivery

Care during labour for HIV positive women should follow routine practice in most respects. Prolonged rupture of membranes should be avoided, as mother-to-child transmission is increased where membranes are ruptured for more than four hours¹¹⁹. Artificial rupture of membranes should not be undertaken if progress of labour is adequate. Given these advantages, this may be introduced as a routine part of the management of labour for all women in high prevalence areas.

There are conflicting reports of the importance of obstetric interventions in the facilitation of transmission^111,113. As a general rule, any procedure which breaks the baby's skin or increases the baby's contact with the mother's blood - such as scalp electrodes or scalp blood sampling - should be avoided unless absolutely necessary, due to the unconfirmed magnitude of the risk of these for HIV transmission. Universal precautions should be applied in managing labouring women in all cases. Episiotomy should not be performed routinely, but reserved for those cases with an obstetrical indication.

If an assisted delivery is required, forceps may be preferable to vacuum extraction, given the risk of micro-lacerations of the scalp from the vacuum cup. There is increasing evidence that elective Caesarean section may help prevent transmission of HIV to the baby²²⁵. The operation carries risks of maternal complications and is associated with higher post operative morbidity in HIV positive women¹¹⁰. The decision on Caesarean section delivery should be made on an individual basis, taking into account the available facilities, and will not be possible in most developing countries with high HIV prevalence. Prophylactic antibiotics should be given for both elective and emergency Caesarean sections.