Choices for delivery and use of C-section

The way your baby is born and whether you choose to have a vaginal birth or Caesarean section is an important decision.

What is a C-section?
Should I have an elective C-section?
What strategy is recommended?
What is the likelihood of complications?
Will a C-section now stop me having a natural birth in the future?
How do I make this decision?
Is there anything else that I should remember for the birth?

Stork flying in with a baby The way your baby is born – whether you choose to have a vaginal birth or Caesarean section (C-section) – is controversial for HIV-positive women.

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.
Whether or not pre-labour Caesarean delivery offers any benefit to babies born to mothers using combination therapy is unknown.

If you do have a C-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.

What is a C-section?

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.

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.

As mentioned above, studies showing a reduced risk of transmission from using C-section do not account for the benefits from combination therapy.

If a woman's viral load is undetectable, there is such a low risk of transmission associated with either mode of delivery that it may never be possible to show an advantage in transmission risk either way.

Interestingly, HIV transmission to the baby is rare among mothers who are taking combination therapy, even when their viral load is greater than 50 copies/mL.

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 38-40 weeks.
If your viral load is undectable 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?

C-section is major surgery. Complications, particularly infections, are more common in women having C-sections 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.
There is also no benefit if your waters break before your C-section.

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

If you use a C-section now, having a natural birth in the future is more complicated and difficult. This is a very important consideration.

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 this decision?

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.

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.
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.

Is there anything else that I should 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. 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.