HIV in Labor — Scheduled Cesarean Orderset

Clinical Context

• Confirmed HIV infection in pregnancy.
• High or unknown HIV RNA viral load at or near term, or cesarean recommended per national or institutional guidelines to reduce perinatal transmission.
• Scheduled cesarean delivery typically at 38 weeks (or per local guideline) when feasible.
• Consideration of additional intrapartum antiretroviral measures per current guidance.

Preoperative Orders — Day of Scheduled Cesarean

Pre-admission / Pre-op Checklist

• Verify gestational age and indication for cesarean delivery.
• Review last HIV viral load, CD4 count, and full ART regimen.
• Confirm no interval intercurrent illness that would change timing (e.g., COVID-19, acute infection).
• Ensure pediatric/neonatology and pediatric infectious disease are aware of the timing of cesarean and maternal HIV status.

Pre-op Labs

• CBC with platelets.
• Type and screen (or crossmatch if indicated).
• Basic metabolic panel if renal impairment, diabetes, or other comorbidities are present.
• Coagulation profile if indicated (e.g., thrombocytopenia, liver disease, anticoagulant use).

Pre-op Medications

• Continue maternal combination ART per routine schedule on the morning of surgery if compatible with NPO status and anesthetic plan.
• Administer preoperative antibiotics per cesarean prophylaxis protocol, considering any ART–antibiotic interaction.
• Venous thromboembolism prophylaxis per institutional risk assessment.

Intrapartum Antiretroviral Management

Maternal ART

• Continue the patient’s chronic ART regimen where possible (oral dosing with sips of water if allowed by anesthesia, or IV/liquid formulations as available).
• If NPO status precludes oral dosing and IV equivalents are not available, consult HIV or infectious disease specialist for bridging strategy.

Additional IV Antiretroviral (if indicated)

For patients with high or unknown viral load, many guidelines recommend additional intrapartum IV antiretroviral therapy (e.g., IV zidovudine) starting before cesarean and continuing until cord clamping. Exact drug, dose, and duration should follow the most current national guidance and institutional protocol.

• Confirm agent, loading dose, and maintenance infusion rate with institutional protocol and pharmacy.
• Use weight-based dosing calculators to double-check mg/kg math, and adjust for renal or hepatic impairment as recommended.
• Record start and stop times clearly, including time of cord clamp.

Weight-Based Calculators (Educational)

These calculators perform only mg/kg arithmetic. Enter the mg/kg factors required by your institutional regimen to obtain total mg and mg/hour values.

Cesarean Technique & Anesthesia Considerations

• Regional anesthesia (spinal, combined spinal–epidural) is generally preferred when not contraindicated.
• Review platelet count and anticoagulant use prior to neuraxial anesthesia.
• Minimize time from rupture of membranes to delivery when feasible.
• Use standard cesarean technique; there is no specific incision type mandated solely for HIV status.
• Use routine infection-prevention practices, including appropriate personal protective equipment and careful handling of sharps.

Postoperative & Neonatal Planning

Immediate Post-op

• Continue IV antiretroviral infusion (if used) until cord clamping, then discontinue per protocol.
• Resume maternal oral ART as soon as clinically feasible.
• Monitor fluid balance, hemoglobin, and standard postoperative parameters.

Neonatal Management

• Ensure pediatric team receives full maternal HIV history, viral load data, and intrapartum regimen details.
• Initiate neonatal antiretroviral prophylaxis per high/unknown-risk protocol (single-, dual-, or multi-drug regimen per current guidelines).
• Arrange HIV NAT testing for the infant on the schedule recommended by current guidance and local policy.
• Document feeding plan (formula, donor milk, or breastfeeding if permitted by guideline and local policy).