Box 7.1: Special considerations for the care and management of pregnant women

Consolidated ARV guidelines, June 2013

General guidance

  • Pregnant women with HIV should receive at least the minimum package of recommended antenatal visits and pregnancy care, and additional interventions such as screening for sexually transmitted infections, nutritional support and infant feeding and family planning counselling should be considered.
  • There is a high risk of HIV transmission during labour and delivery. This risk can be minimized by following several key principles and practices, including reinforcing recommended antenatal clinic visits, especially high-risk management in the late third trimester; promoting facility-based delivery by trained skilled birth attendants; avoiding unnecessary instrumentation and premature rupture of membranes by using a partograph to monitor stages of labour; and non-invasive suction of nasogastric secretions and washing away blood in the newborn.

Additional measures to reduce HIV transmission include the following:

  • The early identification of mothers with HIV and providing ARV drugs to both the mother and the newborn baby are essential.
  • For mothers presenting at labour with unknown HIV status, rapid HIV testing should be done during labour or immediately postpartum.
  • For women testing positive, ARV drugs should be provided to both the mother and child in accordance with current treatment recommendations and with consideration of extended prophylaxis to the infant (see section 7.2.2: First-line ART for pregnant and breastfeeding women and ARV drugs for their infants).
  • Health care workers should follow universal precautions for all deliveries, including those involving mothers with HIV.
  • Special efforts should be made to ensure that delivery care is provided in a nonstigmatizing and supportive manner.
  • Although Caesarean section has been shown to protect against HIV transmission, especially in the absence of ARV drugs or in the case of high viral load, WHO does not recommend it in resource-limited settings specifically for HIV infection; rather it is recommended for obstetric and other medical indications.
  • Women with HIV and women of unknown HIV status who deliver outside health facilities should be encouraged to be medically assessed at a maternal and child health facility as soon as possible after delivery and to begin or continue appropriate HIV interventions.
  • Providing follow-up, linkages to care and treatment and postpartum care are especially important for women with HIV and their HIV-exposed infants. Initial care of the child is usually scheduled at the first immunization visit at four to six weeks, including reinforcement of safe feeding practices, review of ARV coverage and early infant diagnosis testing. Follow-up care for the mother should ideally be scheduled at the same time and should include a postpartum check, family planning counselling, review of ARV regimen and adherence support.

Sources of guidance: