1 MODULE 4 Management of Labor and Delivery for PMTCT

2 Objectives Describe introduction of intra partum care and PMTCT during labor and delivery Describe the principles and practices of the use of Standard precaution and general cleanliness during L and D Conduct HIV counseling during L and D Describe the use of ARV drugs, prophylaxis and treatment during L and D Immediate post partum care for women and newborn

3 Section 1: Management of Labor and Delivery

4 Goals of Labor and Delivery Reduce MTCT risk by providing ARV prophylaxis or treatment Minimize exposure of fetus to maternal blood and body fluids Support safer delivery practices

5 Reducing MTCT Risk During Labor and Delivery Minimize cervical examinations Use partograph to monitor labor Avoid Routine rupture of membranes Prolonged labor Unnecessary trauma during childbirth

6 Reducing MTCT Risk During Labor and Delivery Minimize risk of postpartum hemorrhage Use safe transfusion practices (blood screened for HIV, Syphilis, malaria, hepatitis B and C when possible)

7 Elective Caesarean Section versus Vaginal Delivery Elective caesarean section - Consider elective caesarean delivery when safe and feasible -Done at the onset of labor or membrane rupture Vaginal delivery -When ARV prophylaxis or treatment has effectively reduced the viral load

8 Reducing MTCT Risk in Women with Unknown HIV Status Offer rapid HIV testing with right to refuse Discuss benefits of knowing HIV status If HIV-positive, ARVs can be given for PMTCT and refer for treatment and care

9 Reducing MTCT Risk in Women with Unknown HIV Status Describe the testing process Provide posttest counseling If HIV-positive, provide ARV prophylaxis as per national protocol

10 Section 2 Standard Precaution

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12 Standard Precautions Definition Standard Precautions (SP) means placing a physical, mechanical or chemical barriers between microorganisms and an individual in order to prevent infections.

13 Blood Borne Pathogens In addition to HIV, blood borne pathogens include Hepatitis B and C virus Syphilis Brucellosis

14 Prevention of HIV Transmission Practice standard precautions - Healthcare worker to patient - Patient to healthcare worker - Patient to patient Proper instrument processing - Patient to patient

15 Infection Prevention Measures Practicing standard precaution for all patients/clients at all time Management of safe work environment Ongoing education of health facility workers in all aspect of infection prevention

16 Standard Precautions oApplied in caring for all patients oHand washing oWearing Gloves oUsing physical barriers (Personal Protective Equipment) oUsing antiseptic agents oUsing safe work practices oSafely disposing infectious waste materials oProcess instruments, gloves and other items after use

17 Promoting a Safe Work Environment Implement, monitor and evaluate use of standard precautions Develop procedures for reporting and treating occupational exposure to HIV infection Attain and maintain appropriate staffing levels Provide protective equipment and materials

18 Education in Infection Prevention Make all staff aware of established infection prevention and control policies Provide ongoing training to build skills in safe handling of equipments and materials Supervise and evaluate practices to remedy deficiencies

19 Safety and Supportive Care in the Work Environment Handling and Decontamination of Equipment and Materials

20 Handling of Equipment and Materials Risk reduction strategies Assess condition of protective equipment Safely dispose of waste materials Make available appropriate cleaning agents and disinfectants Decontaminate instruments and equipments Monitor skin integrity

21 Instrument Processing Decontaminate Clean, then Either Sterilize or High Level Disinfect

22 Handling and Disposal of Sharps Use syringe or needle only once Avoid recapping, bending, or breaking needles Use puncture-resistant containers for disposal Clearly label containers- “SHARPS” Never overfill or reuse sharps containers Dispose of sharps

23 Handling Needles and Sharp Use a puncture proof container for storage and /or disposal Do not recap a needle before disposal but when absolutely indicated use a one- handed (scoop) technique.

24 Hand Hygiene Recommended practice Soap and water handwashing using friction under running water for at least 15 seconds Using alcohol based hand rubs or antimicrobial soap and water for hand antisepsis.

25 Personal Protective Equipment Basic personal protective equipment Gloves-correct size Aprons- as a waterproof barrier Eyewear- to avoid accidental splash Footwear- rubber boots or clean leather shoes

26 Safe Work Practices To reduce occupational risks Assess high-risk situation and areas Develop safety standards and protocols Institute measures to reduce occupational stress Orient new staff to protocols Provide ongoing staff education and supervision Develop protocols for post-exposure prophylaxis (PEP) and general first aid

27 Risk Reduction in the Obstetric Setting Minimize high risk of exposure to HIV- infected blood and body fluids in obstetric unit Cover broken skin with waterproof dressing Wear proper protective clothing Dispose of solid and liquid wastes according to National guidelines

28 Section 3 Testing and Counseling and During L and D

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30 Section 4 Use of ARVs for PMTCT

31 ARV prophylaxis for the HIV-Exposed Infants Women presenting in Labor who have NOT received any antenatal prophylaxis Facilities where ART service is functional and available Mother Intra Partum: Single dose (sd) NVP (200 mg) + AZT( 600 mg during Labour) + 3TC (150 mg during labor and every 12 hours until delivery) Postpartum : AZT ( 300 mg Bid) + 3TC (150 mg Bid) for 7 days Infant Single dose (sd) NVP ( 2 mg/kg) + AZT ( 4 mg/kg) for four weeks

32 B.2.2 Facilities with no ART service OR referral to the nearest ART clinic is not possible or difficult for the client) Mother ::Single dose (Sd) NVP (200 mg) at the onset of Labor Infant:: Single dose (Sd) NVP within the first 72 hours of life

33 Treatment, Care and Support of HIV-Exposed Infants Routine assessment for signs/symptoms of HIV (persistent diarrhea, failure to thrive) HIV testing PCP Prophylaxis (starting at 6 weeks) Prevention and treatment of malaria and TB

34 Section 5 Immediate Post partum care

35 Immediate Postpartum Care Patient education Symptoms of infection Information on where to return for care Perineal care Breast care Disposal of blood-stained pads

36 Immediate Postpartum Care of Women with HIV Infection Gynecologic care, including pap smear Monitor for OIs, provide prophylaxis Prevent or treat TB and malaria Refer to ARV treatment, care and support

37 Immediate Postpartum Care of Women with HIV Infection Newborn Feeding Mother chooses and begins feeding option Support the choice of feeding option Provide training on feeding option Observe feeding technique

38 Immediate Postpartum Care of Women with HIV Infection Signs and Symptoms of Postnatal Infection Instruct on signs and symptoms of infection Provide information on where and when to seek health care Instruct on perineal and breast care Instruct on safe disposal of lochia & blood stained materials.

39 Postpartum care of Women Family Planning Prevent unintended pregnancies Support child spacing Promote continued safer sex practices

40 Women of Unknown HIV Status: Benefits of HIV Testing After Delivery Initiate ARV prophylaxis for infant if indicated Encourage safer feeding option should she test positive Encourage exclusive breastfeeding if she tests negative or refuses to be tested

41 Specific Interventions to Prevent MTCT of HIV Immediate Newborn Care of HIV-Exposed Infants and Infants with Unknown HIV Status

42 Immediate Newborn Care of HIV-Exposed Infants Do Cut cord under cover of light gauze Determine mother’s feeding choice Administer vitamin K Use silver nitrate eye ointment (within 1 hour of birth) Administer BCG and OPV

43 Immediate Neonatal Care of Infant DO NOT Suction unless meconium-stained liquor is present Use mouth-operated suction Use mechanical suction at greater than 100 mm Hg. pressure

44 Key Points Integrating PMTCT services into the essential package of ANC services promotes improved care for all pregnant women and provides the best opportunity for a successful PMTCT program Specific interventions to reduce MTCT include ARV prophylaxis, safer delivery procedures, and counseling and support for safe infant feeding.

45 Key Points Antiretroviral drugs used for treatment and prophylaxis reduce the risk of MTCT. Longer combination regimen are more effective, but short-course prophylaxis regimens may be more feasible in some resource-constrained settings like Ethiopia PCP prophylaxis and prevention and treatment of TB and malaria are part of comprehensive care for HIV-infected mothers and their infants.

46 Key Points Safer delivery practices include avoiding unnecessary invasive obstetrical procedures and offering the option of elective caesarean section when safe and feasible Infant feeding options to minimize the risk of MTCT require support and guidance throughout ANC, labor and delivery, and postpartum.