Neobook — clinical reference

Other Care for the Mother living with HIV at delivery

Care of the HIV-exposed Infant at Delivery

Prevention of transmission of Syphilis, HBV and other infections

Testing for HIV

PICT should be provided to all women presenting in labour ward who are not known to be HIV-positive (including born-before-arrivals [BBAs]):

Offer couples counselling and partner testing. For the management of the discordant couple, go to the HIV Prevention.
Women who choose not to be tested should be offered ‘post-refusal’ counselling and offered a re-test at every subsequent visit.
If a woman tests positive at any stage, encourage testing of her other children, and linkage to HIV care and treatment as necessary.
If a woman has indeterminate or discrepant HIV test results, treat the baby as a high-risk HIV-exposed infant until mother’s HIV status can be confirmed. Communicate clearly to the mother and document the results and plan of action in the maternal record and RTHB.

Antiretrovirals

Pregnant women already on ART should continue their current ART regimen at usual dosing times during labour.

Newly diagnosed, or known HIV positive women not on ART:

Give a stat single fixed dose combination tablet of TDF, 3TC and DTG (TLD) and a stat single dose of NVP.
Lifelong ART should be initiated the following day after contra-indications to ART have been excluded (Go to ART Initiation Algorithm). TLD is the preferred regimen. A contraceptive method is recommended. Provide her with a choice of contraceptive options as desired.
Appropriate ART literacy education should be given to the women before she leave the facility. (Go to Key Adherence Messages).
Mothers must understand and anticipate the adherence challenges that may be experienced in the postpartum period.

An elevated viral load at delivery increases the risk for poor maternal outcomes and vertical transmission during labour and through breastfeeding.

VL Monitoring and Management

All women must have a VL test done at the time of delivery.
Remember to insert the laboratory barcode sticker into the postnatal discharge form and the RTHB.
The results of the delivery VL will determine the infant’s risk-profile. Until the results are known, all infants will receive dual prophylaxis with NVP and AZT.
The results of the delivery VL must be checked within 3 to 6 days, and the management of the mother-infant pair adjusted accordingly.
If the mother’s delivery HIV VL < 50 c/mL
- Affirm and encourage good adherence
- Repeat maternal VL 6 monthly during breastfeeding
- The infant should be re-classified as low-risk
If the mother’s delivery HIV VL ≥ 50 c/mL
- The mother should be managed as per “Management of a High Maternal Viral Load after Delivery”.
- The infant should be re-classified as higher-risk and managed as per “Prophylaxis for the HIV-Exposed Infant at Birth”.

Remember to put the correct VTP code in the EGK code field of the laboratory form for each HIV VL done to ensure the electronic gatekeeping rules (EGK) do not lead to sample rejection. Use the code C#Delivery for all VLs done at the time of delivery.

Screening for TB and Other OI's

Screen all women for TB at entry to the labour ward, and initiate TPT for women living with HIV before discharge, if eligible (Go to “TB Screening and TPT during Pregnancy, Labour, and the Breastfeeding Period”).
Initiate Cotrimoxazole Prophylaxis before discharge if CD4 count ≤ 200 cells/uL, or WHO clinical stage 2, 3, or 4.

Other Care for the Mother living with HIV at delivery

For all pregnant women, including those living with HIV, provide routine, safe and respectful care during labour and delivery according to the Maternity Care Guidelines of SA. This includes:

avoiding unnecessary episiotomies
avoiding unnecessary assisted deliveries
avoiding unnecessary rupture of membranes
avoiding excessive suctioning of the infant
If a C/section is required, provide prophylactic antibiotics, unless sepsis in the mother requires the use of therapeutic antibiotics

Within 1 hour of delivery

Encourage skin-to-skin contact with baby and initiate exclusive breastfeeding. Hospitals and labour wards can support mothers to breastfeed by following the WHO The Ten Steps to Successful Breastfeeding. In addition, counsel mother on Breastfeeding Plus.

At discharge

Ensure contraception has been administered after appropriate counselling (go to Contraception and Safe Conception).
Provide the mother with two-months’ supply of ART and six-weeks supply of infant prophylaxis.
Communicate follow-up appointment dates for the six-day post-natal visit at a named facility. Provide necessary referral letters. Provide an ART transfer-out letter, if she will receive her ART at a different facility. However, it is recommended that the mother-baby pair continue to receive integrated care within the maternal and child health stream until the baby is two years old or no longer breastfeeding.

Care of the HIV-exposed Infant at Delivery

All HIV-exposed Infants should receive a birth HIV-PCR to identify HIV transmission that occurred in-utero.
All HIV-exposed Infants should be initiated on dual post-exposure prophylaxis with NVP and AZT until the result of the delivery-VL can be reviewed.
- If the mother-baby pair have already been discharged, this may be at the 3-6 day postnatal visit at the clinic. Clinicians working in postnatal clinics should therefore review the results of delivery VL.
- If the baby is still admitted to hospital, ward staff should ensure that the results are reviewed.
Once the result of the delivery VL is known, prophylaxis should be adjusted accordingly.
If the mother’s delivery HIV VL < 50 c/mL regardless of feeding choice:
- Re-classify the infant as low-risk
- Stop AZT
- Continue NVP daily for six weeks
If the delivery HIV VL ≥ 50 c/mL in a breastfeeding mother
- Re-classify as higher-risk
- Continue AZT twice daily for six weeks
- Continue NVP daily for a minimum of 12 weeks. NVP should only be stopped when the breastfeeding mother has a HIV VL of less than 50 c/mL, or until four weeks after she has stopped breastfeeding.
- The mother should be managed as per the “VL Non-Suppression Algorithm”

All higher-risk infants who are exclusively formula fed should receive AZT for 6 weeks and NVP for 6 weeks. (Go to "Prophylaxis for the HIV-Exposed Infant at Birth”)

Provide oral polio vaccine, BCG and other routine neonatal care as per the Maternity Care and Neonatal Care Guidelines. Do not give BCG if baby is TB-exposed, and will be receiving TB prophylaxis (Go to “Management of the Newborn exposed to TB”).

Prevention of Transmission of Syphilis, HBV and Other Infections

Syphilis: Examine the newborn of the mother who has confirmed or suspected syphilis (see “Congenital Syphilis”). All symptomatic newborns will require admission for 10 days of treatment. If unable to admit at the current level of care, refer all babies with suspected congenital syphilis infection to the appropriate level of care for inpatient admission & work-up. The following babies should be treated:

Any symptomatic baby born to a mother with syphilis, regardless of the mother’s treatment status. Admit/refer for admission and 10 days of treatment (see “Congenital Syphilis”).
Asymptomatic babies born to mothers with inadequately treated or untreated syphilis:

a. mother did not complete three doses in full, or
b. mother received three doses but there was a delay of > 14 days between weekly IM doses, or
c. the last dose was less than 30 days before delivery, or
d. the dose that the mother received was incorrect, or
e. mother did not receive any treatment for syphilis, or
f. mother was treated for syphilis with an antibiotic that was not penicillin

Treat with single dose Benzathine Penicillin G 50 000 units/kg IM

HBV: All babies born to mothers who are Hepatitis B infected should be delivered at a facility where both hepatitis vaccine and anti-HepB immunoglobulin can be given to the baby on the day of birth. The baby can then continue with the normal hepatitis B vaccination schedule in accordance with the EPI schedule (Go to “Management of the Infant Exposed to Hepatitis B”).

Click here for the pdf.

South African National Department of Health, Guideline for Vertical Transmission Prevention of Communicable Infections, Version 2_August 2023