Can I Have a Vaginal Delivery?
BHIVA guidelines recommend that mothers on ART with an undetectable viral load at 36 weeks of pregnancy, and no other complications, deliver vaginally.
Elite controllers can also deliver vaginally.
The guidelines recommend that decisions about the way you deliver your baby -- called mode of delivery -- are made at 36 weeks after a review of your viral load results.
Caesarean 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 ART, 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 Caesarean section for obstetric reasons. This can also happen to any woman having a vaginal delivery whether she is HIV positive or negative.
Healthcare teams will be a bit more cautious with an HIV positive woman than an HIV negative woman with vaginal delivery.
Can I Have a Vaginal Birth If I Have Had a Caesarean Before?
If your viral load is undetectable, and there are no other reasons to have one, this can be carefully managed by your healthcare team.
In HIV negative women, 70 percent of those in this situation manage a vaginal delivery.
Why Is a Caesarean Sometimes Recommended If You Are HIV Positive?
Several early studies showed that planned Caesarean section significantly reduced vertical transmission compared to vaginal birth. But these studies were before ART and viral load testing were routinely used.
For mothers on ART with an undetectable load, having a planned Caesraean section does not offer any extra benefit (unless she needs one for another reason).
If you do have a planned Caesarean section, the operation must be carried out before the onset of labour and ruptured membranes. This is also called "pre-labour" "elective" or "scheduled" Caesarean section.
When Should I Have a Planned Caesarean Section?
If your viral load is between 50 and 399 copies/mL at 36 weeks you should consider a planned Caesarean section. Your doctor will discuss your most recent and previous viral load results, how long you have been on treatment and your adherence with you. Your own preference is important in this decision.
If your viral load is above 400 copies/ mL, a planned Caesarean section is recommended.
If you do not need treatment for your own health and choose to use AZT alone, a planned Caesarean section will be necessary to reduce transmission risk to minimal levels. If the planned Caesarean section is to prevent vertical transmission (and not for another reason) you will need to have at 38 to 39 weeks of pregnancy.
What If My Waters Break Before My Planned Caesarean Section?
If your waters break before your planned Caesarean section is due and your viral load is 50 to 999 copies/mL your medical team will consider an emergency Caesarean section.
If it is above 1000 copies/mL you will be strongly recommended to have one.
Will a Caesarean Section Now Stop Me Having a Vaginal in the Future?
If you have a Caesarean section now, having a vaginal birth in the future is more complicated.
This is important to know if you plan to have more children in a country where planned Caesarean section is not possible, safe or easily available and there is less access to obstetric care.
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 antiretrovirals. Remember to bring them with you even if you are not sure that you are in labour.
It is important that you remember to take all your drugs on time as usual, including the day of delivery or planned Caesarean 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.