Choices for Delivery

• Choices for Delivery and Use of C-Section

Choices for Delivery and Use of C-Section

The way your baby is born -- whether you choose to have a vaginal birth or Caesarean section (C-section) -- is an important consideration for HIV-positive women. If you do have a Caesarean section, the operation must be carried out before the onset of labour and ruptured membranes. This is called "pre-labour" "elective" or "scheduled" C-section.

Several early studies showed that pre-labour C-section significantly reduced mother-to-child transmission compared to vaginal birth.

But these studies were before combination therapy and viral load testing were routinely used. Recent data from the UK and Ireland indicate that mothers on combination therapy with an undetectable viral load can deliver vaginally and that prelabour Caesarean delivery does not offer any additional benefit to the babies.

Should I have a pre-labour C-section?

If you do not need treatment for your own health and choose to use AZT alone, a pre-labour C-section will be necessary to reduce transmission risk to minimal levels.

If a woman's viral load is undetectable on HAART, there is such a low risk of transmission associated with either mode of delivery that no advantage in transmission risk occurs through pre-labour Caesarean.

HIV transmission to the baby is uncommon among mothers who are taking HAART, even when their viral load is greater than 50 copies/mL but in the UK pre-labour Caesarean is indicated, especially if the viral load was undetectable and has become detectable.

What strategy is recommended?

Current British guidelines say: "Mode of delivery must be discussed with the woman and her wishes taken into account."

A choice of either C-section or vaginal birth is offered when a mother's viral load is below detection on combination therapy.

If you have a high CD4 count and low viral load and choose to receive AZT, you will have the pre-labour C-section at 38 weeks. If your viral load is undetectable on treatment and you choose to have a pre-labour C-section, you will have it at 39-40 weeks.

What is the likelihood of complications?

As mentioned earlier, C-section is major surgery. Therefore some complications -- particularly the risk of infections -- are slightly more common in women having Csections than women having vaginal delivery.

C-sections appear to carry a slightly greater risk of complications among HIV-positive women compared to HIV-negative women. The difference is most notable in women with more advanced disease.

A pre-labour C-section will not offer protection to your baby if you go into labour earlier than expected.

If your waters break before your C-section is due your medical team will consider managing you as though you had presented late in pregnancy with an emergency C-section and additional anti-HIV therapy.

Will a C-section now stop me having a natural birth in the future?

This is a very important consideration. If you use a C-section now, having a natural birth in the future is more complicated and difficult. You may be offered the choice of vaginal delivery but you will be more likely to need a C-section than a woman who has previously delivered vaginally. Once a woman has given birth by C-section it is usually recommended that she uses C-section for future babies. This is important to know if you plan to have more children in a country where elective C-section is not possible, safe or easily available.

How do I make a decision?

The first thing to remember is that you have the right to choose how you deliver your baby. Your doctor and other caregivers must respect and support your decision.

Caesarean or C-section is a procedure to deliver a baby that involves making a cut through the abdominal wall to surgically remove the infant from the uterus. It is important to understand that if your HIV is well managed and your viral load is below detection on combination therapy, then the risk of transmission with either mode of delivery is practically zero. If you are receiving treatment and do choose to have a vaginal birth there is still a possibility that you may need to have an emergency C-section for obstetric reasons. This can also happen to any woman having a vaginal delivery whether she is HIV-positive or negative. Medical teams will be a bit more cautious though with an HIV-positive woman than an HIV-negative woman with vaginal delivery.

Before making a choice, though, it is important that you are informed of the risks and benefits associated with each mode of delivery. You should spend time discussing any concerns that you have with either mode of delivery with your healthcare team.

It is also important that you and your doctor make sure that your HIV is well managed and that your viral load is below 50 copies/ml. This is not only for the risk of transmission but for your own health.

What else do I need to remember for the birth?

Many books on pregnancy recommend that you pack a bag or small suitcase in advance. This is especially important if you choose a natural, unscheduled delivery. Include pyjamas or something to wear in hospital, a toothbrush, wash bag -- and of course your anti-HIV drugs.

It is very important that you remember to take all your drugs on time as usual, including the day of delivery or planned pre-labour C-section. This is a critically important time to make sure that you don't miss any doses.

Remembering to do so can be difficult with everything going on, particularly if you are waiting for a long time.

Make sure that your partner or friend and healthcare team know your medication schedule, where you keep your medication, and feel comfortable helping you to remember to take your pills on time.