“Labor and Delivery Management of Women with Human Immunodeficiency Virus Infection” (2018), by the American College of Obstetricians and Gynecologists Committee on Obstetric Practice

In September 2018, the American College of Obstetricians and Gynecologists, or ACOG, published “Labor and Delivery Management of Women with Human Immunodeficiency Virus Infection,” hereafter “Labor and Delivery Management.” It appeared as ACOG Committee Opinion Number 751 in the journal Obstetrics & Gynecology. The article contains recommendations for physicians who care for pregnant people with human immunodeficiency virus, or HIV, to reduce the risk of transmission of the virus from parent to child. Those recommendations include treating pregnant people with HIV therapies, consistently testing and monitoring the levels of HIV in a pregnant person’s blood, and scheduling a cesarean section, or C-section, rather than a vaginal birth to reduce transmission risk in some cases. “Labor and Delivery Management” provides recommendations for physicians to decrease the risk of mother-to-child transmission and emphasizes that physicians and pregnant people make decisions regarding labor and delivery together.

1. Background
2. Article Contents
3. Impacts

Background

The ACOG Committee on Obstetric Practice, in collaboration with committee member Neil S. Silverman and the ACOG HIV Expert Work Group, authored ACOG Committee Opinion 751. ACOG is a professional organization made up of obstetricians and gynecologists in the United States and includes members across twelve districts in North and South America at various stages in their medical careers. Fellows of the organization are board-certified physicians whose professional activities have advanced the general practice of obstetrics and gynecology. As of 2025, ACOG has over thirty committees, each with its own criteria for membership. Some ACOG committees include Clinical Consensus Committee–Obstetrics, the Committee on Clinical Practice Guidelines–Obstetrics, and the Committee on Health Economics and Coding. Members of a given committee co-author Committee Opinion reports which reflect the ACOG’s assessment of certain issues in obstetrics and gynecology, and reports are subject to periodic revision. The journal Obstetrics and Gynecology publishes those reports, some of which serve as national practice guidelines for obstetricians and gynecologists.

At the time of the “Labor and Delivery Management” publication, Silverman served on the ACOG committee that authored the report. He holds a faculty appointment as professor of clinical obstetrics and gynecology at the David Geffen School of Medicine at the University of California, Los Angeles, in Los Angeles, California, and serves as director of the Maternal-Fetal Medicine Fellowship program. As of 2025, Silverman is also the director of the Infectious Diseases in Pregnancy Program, an initiative that addresses education, research, and clinical care for pregnancies impacted by certain diseases.

“Labor and Delivery Management” includes obstetrician-gynecologist recommendations for the care of pregnant people infected with HIV. HIV infects immune cells, particularly T lymphocyte cells, or T cells. T cells are a type of white blood cell whose purpose is to eliminate infection sources within the body. If untreated, HIV infection can lead to the development of acquired immune deficiency syndrome, or AIDS, and can be fatal. HIV passes from one person to another through blood and other bodily fluids. There is a risk of perinatal transmission, or transmission of HIV from a pregnant person to a fetus or child either during pregnancy, childbirth, or breastfeeding if a person infected with HIV becomes pregnant. Perinatal transmission is also referred to as mother-to-child or vertical transmission.

ACOG’s recommendations in “Labor and Delivery Management” focus on preventing mother-to-child transmission. Pregnancy, or gestation, refers to the period in which a fetus develops inside a person’s womb, or uterus, and typically lasts forty weeks, just over nine months. During that period, a fertilized egg grows within the uterus inside a sac filled with fluid called an amniotic sac, or the innermost membrane enclosing the developing embryo. That membrane typically ruptures naturally around thirty-seven weeks gestation either at the beginning of or during labor, which is when muscles of the uterus begin to contract. That is called a rupture of membranes and is colloquially referred to as a person’s water breaking. When a pregnant person’s water breaks, fluid within the amniotic sac surrounding the fetus might flow out of the vagina, which typically indicates that labor has started. In other cases, labor begins within twenty-four hours of water breaking. When a pregnant person’s water breaks, the amniotic sac no longer protects the fetus, and the pregnant person or the fetus can get infected. A pregnant person’s water may break before the onset of labor, called a premature or prelabor, rupture of membranes.

ACOG committee members write Committee Opinions as assessments of emerging issues in obstetric and gynecologic practice, and members of the organization regularly review reports for accuracy. “Labor and Delivery Management” replaces Committee Opinion Number 234, originally published in Obstetrics & Gynecology in 2000. “Labor and Delivery Management” provides updated guidance for clinical practitioners about the management of labor and delivery care for pregnant people with HIV, with the goal to reduce or prevent viral transmission from pregnant person to fetus or newborn. The report highlights research that addresses perinatal HIV transmission. The exact mechanisms of perinatal HIV transmission are unknown. Research in that area includes studies that address the administration of antiretroviral therapy, or ART, to reduce the concentration of virus within the blood, or viral load, of an HIV-infected pregnant person. The authors write that they revised an earlier Committee Opinion to provide updated guidance on the management of HIV-infected pregnant people during pregnancy and delivery to prevent mother-to-child transmission of HIV. They further state that prevention of HIV transmission from a pregnant person to a fetus or newborn is a major goal in the care of HIV-infected pregnant people.

Article Contents

Committee Opinion Number 751, “Labor and Delivery Management,” consists of six main sections. In “Recommendations,” the authors list the recommendations they make on behalf of the ACOG Committee on Obstetric Practice, prior to explaining further background and details about each of them in the article’s later sections. In the “Introduction” section, the authors explain that research into mother-to-child transmission of HIV suggests that a substantial number of cases occur as the result of fetal exposure to the virus during labor and delivery, though the precise mechanisms remain unknown. In the third section, “Management of Labor and Delivery of HIV-Infected Women,” the authors indicate that performing C-sections before the onset of labor and before rupture of membranes, which they refer to as scheduled cesarean delivery, in conjunction with the use of ART during pregnancy, can reduce the risk of mother-to-child transmission in HIV-infected people with high viral loads. In the fourth section, “Management of Human Immunodeficiency Virus-Infected Women With Prelabor Rupture of Membranes at Term,” the authors explain that the viral load of pregnant people during delivery more significantly impacts the risk of mother-to-child transmission rather than the duration of prelabor rupture of membranes, or PROM, before delivery. In “Other Considerations,” the authors provide commentary on seven additional topic areas surrounding the care of pregnant people with HIV. In the final section entitled “Conclusion,” the authors note that as with all complex clinical decisions the physician should consider the wants and needs of the individual person regarding labor and delivery, on a case-by-case basis. They iterate that once the physician and pregnant person discuss maternal and neonatal risks, the physician should respect the pregnant person’s decision regarding the route of delivery.

In “Recommendations,” the committee makes eight recommendations that include specific instructions for clinical providers to follow to reduce mother-to-child HIV transmission. The first recommendation states that pregnant people infected with HIV taking combined anti-retroviral therapy, or cART, can reduce their risk of mother-to-child transmission if the maternal viral load is below a threshold of 1,000 copies of virus per milliliter of blood. The second recommendation states that people should receive ART during pregnancy in accordance with drug administration guidelines for adults. The committee’s third recommendation then states that physicians should suggest a prelabor C-section at thirty-eight weeks gestation for pregnant people near or at the delivery stage infected with HIV and whose viral loads are more than 1,000 copies per milliliter of blood to reduce the risk of mother-to-child transmission. Recommendation four says that clinical providers should plan for the care and management of all newborns delivered to people infected with HIV with pediatric care providers who are experienced in HIV preventive drug therapy for neonates and infants, regardless of viral load levels.

Continuing in “Recommendations,” for the fifth recommendation, the committee states that some medications that treat HIV may have significant interactions with drugs providers often administer during labor and delivery. A class of drugs called uterotonics, or drugs that induce labor, can narrow blood vessels if combined with certain drugs. The sixth recommendation then says that clinical providers should respect the pregnant person’s autonomy in deciding the route of delivery and honor their informed decision to undergo vaginal delivery or a C-section. For recommendation seven, the committee explains that for people whose HIV status is unknown or those who did not receive an HIV test earlier in pregnancy, clinical providers should test them during labor and delivery or during the immediate period following pregnancy using the opt-out approach. Providers will administer an HIV test along with the standard group of tests commonly administered to all pregnant people. In the final recommendation, the committee states that the duration of rupture of membranes before delivery is not a consideration regarding the route of delivery for mother-to-child transmission in pregnant people who have appropriate viral loads. The committee refers to their recommendations throughout the report and organizes their discussion around each recommendation.

In “Introduction,” the authors review several factors of HIV infection that correlate with mother-to-child transmission risk, as well as the efficacy of some treatments. They state that the exact mechanisms of mother-to-child transmission are not known, but the risk of mother-to-child transmission is proportional to maternal viral load, or the concentration of virus in maternal plasma. Plasma is the liquid component of blood and contains water, salts, and various proteins. Virus molecules are in the plasma of infected people. Physicians can measure the viral load according to the total number of virus particles per milliliter of blood. The authors explain that the higher a pregnant person’s viral load, the more likely they are to transmit the virus to their fetus or newborn.

The authors explain that two studies in 1999 helped establish a threshold level for maternal viral load, or 1,000 copies of virus per milliliter of blood, which is still the threshold as of 2025. When viral load is below that threshold, researchers found that mother-to-child transmission was no more than two percent out of 141 mother-infant pairs. They further explain that a study from 2014 indicated that when an HIV-infected pregnant person received cART along with the maintenance of low or undetectable viral loads during pregnancy, observed rates of mother-to-child transmission were less than one percent. cART refers to the administration of a combination of three or more drugs to treat HIV infection and is also called highly active ART, or HAART. Regardless of delivery method or duration of ruptured membranes before delivery, there is a one to two percent lower risk of mother-to-child transmission of HIV with the use of cART and low maternal viral loads.

In the second section, “Management of Labor and Delivery of HIV-Infected Women,” the authors explain that C-section reduces transmission rates for pregnant people with high viral loads. They begin with a description of results regarding the mode of delivery and vertical transmission of HIV and explain that earlier studies were inconsistent. They briefly describe data from studies prior to the use of cART and without data regarding maternal viral load. Those studies indicated a significant relationship between mode of delivery and vertical transmission. They found that scheduled C-sections reduced the risk of HIV transmission compared to unscheduled C-sections or vaginal delivery. For HIV-infected people whom physicians treat with cART and whose viral loads they monitor, the authors express there is no evidence that elective C-section offers additional protection against mother-to-child transmission in pregnancies in people with undetectable or low maternal viral loads.

The authors state the committee’s second recommendation, that pregnant people should receive ART during pregnancy according to accepted guidelines for adults. They further recommend that clinical providers should monitor HIV levels in pregnant people at the initial prenatal visit, two to four weeks after they initiate or change cART drug regimens, monthly until virus levels are undetectable, and then at least every three months during pregnancy. Monitoring the viral load during specified times during pregnancy can inform decisions about the mode of delivery and best treatment for the newborn.

Continuing in the second section, the authors describe recommendation three, or that clinical providers should explain the potential benefit of and offer scheduled prelabor C-section a on the first day of the thirty-eighth week of pregnancy to reduce the risk of mother-to-child transmission. That recommendation is specific to pregnant people with high viral loads at or near the time of delivery, independent of prenatal ART, or whose viral load levels are unknown. The committee recommends intravenous administration of zidovudine, or ZDV, for those pregnant people. ZDV, also known as azidothymidine, is a drug that slows HIV progression and prevents vertical transmission. The authors also indicate specifications of intravenous ZDV administration in the event a pregnant person elects for vaginal delivery despite an unsuppressed viral load. Then, the team provides ZDV recommendations for pregnant people with low HIV viral loads. The authors conclude with recommendation four, or that experienced pediatric care providers should assist in the initiation of planning for care and management of HIV-infected people, including monitoring the continuation of HIV preventive therapy for at-risk neonates and infants, regardless of maternal viral load before delivery.

In “Management of Human Immunodeficiency Virus-Infected Women with Prelabor Rupture of Membranes at Term,” the authors discuss the management of care for HIV-infected people who experience PROM at term. The rupture of the amniotic sac ruptures exposes the fetus to pathogens, which increases infection risk. Studies in the early 2000s demonstrated that the longer the duration of PROM, the greater the risk of vertical transmission. However, the authors describe that more recent research had shown that a low maternal viral load at delivery affected the risk factor of mother-to-child transmission more than the time between rupture and delivery. Specifically, the authors describe results indicating vaginal delivery resulted in zero cases of mother-to-child transmission for 539 pregnant people with a viral load of less than 1,000 copies per milliliter of blood. Additionally, in the case of vaginal delivery with a rupture of membranes duration of up to twenty-five hours, researchers identified no mother-to-child transmission. The authors mention that data supports vaginal delivery, even in the setting of a longer rupture of membranes time prior to delivery, if the pregnant person has been on an effective cART regimen and has a viral load of 1,000 copies or less per milliliter of blood at or near delivery.

The authors also discuss uncertainty as to whether C-section lowers the risk of mother-to-child transmission in cases of longer PROM duration in pregnant people with a high viral load in the third section. They describe the results of one study indicating pregnant people who did not receive any antiretroviral drugs or ZDV demonstrated a two percent increase in vertical transmission risk for every additional hour of rupture of membranes. However, the authors state it is not clear how soon after the onset of labor or rupture of membranes the benefit of electing to deliver via C-section is lost. As a result, clinical providers should decide on a case-by-case basis how to manage the care of a pregnant person with HIV who experiences PROM and has planned for a C-section. The physician will need to decide quickly in those cases, so the authors state that consulting an expert in perinatal HIV might be helpful. The authors additionally provide the phone number of the National Perinatal HIV/AIDS Clinical Consultation Center for physicians to use.

The fourth section, “Other Considerations,” includes commentary on seven topic areas relevant to the care of HIV-infected pregnant people that the authors did not explicitly address in the report’s previous two sections. In the subsection, “Scheduled Delivery Versus Expectant Management,” the authors conclude that there is no correlation between delivery week and vertical transmission risk for pregnant people with low viral loads. In “Maternal Morbidity,” the authors describe that maternal morbidity, or states of illness that arise from being pregnant and giving birth, is greater with C-section than with vaginal delivery for HIV-infected pregnant people and that the same is true for those not infected with HIV. In “Fetal Scalp Electrodes,” the authors comment against the use of fetal scalp electrodes in labor. Fetal scalp electrodes are wires that physicians place on the scalp of the fetus to monitor fetal heart rate. They state that clinicians should avoid routine use for fetal monitoring in the case of maternal HIV infection due to the increased risk of fetal exposure to maternal blood.

Continuing in the fourth subsection, in the subsection “Drug Interactions,” the authors include recommendation five, which serves as a warning against the use of some medications that treat HIV that may have significant interactions with medications during labor. Specifically, the authors name uterotonics, or medications that induce uterine contractions, as well as methergine, a drug that stops uterine bleeding. The use of those drugs in combination with some antiretroviral medications can trigger a strong vasoconstrictive response, or the narrowing of blood vessels.

In the subsection, “Patient Autonomy,” the authors focus on recommendation six, or that physicians should respect patient autonomy in making the decision regarding the route of delivery. Physicians should honor a pregnant person’s informed decision to undergo vaginal delivery despite having a viral load above the accepted threshold, as well as in the case of a decision to undergo a C-section when the viral load is below the accepted threshold. In the next subsection, “Standard Universal Precautions,” the authors comment that providers should always take appropriate care to follow standard universal precautions against skin-penetrating injuries to protect physicians, which should not affect decision-making about the mode of delivery.

In the final subsection of “Other Considerations,” titled “Perinatal Testing,” the authors conclude with the seventh and penultimate recommendation, or that providers should perform a rapid HIV screening during labor and delivery or the immediate period after childbirth using the opt-out approach, particularly for people whom physicians did not test earlier in pregnancy or whose HIV status is unknown. The seventh recommendation also states that HIV screening results should be available twenty-four hours a day and within one hour of testing. The opt-out approach to HIV screening involves a clinical provider explaining to a pregnant person that they will include an HIV test in the standard group of prenatal tests and that they may decline the test. Under the opt-out approach, unless the person declines, they will receive an HIV test.

In the “Conclusion” section, the authors end with a short summary of their recommendations, as well as the eighth and final recommendation regarding the duration of rupture of membranes and vertical transmission risk. They state that vaginal delivery is appropriate for HIV-infected pregnant people who receive cART and have viral loads of 1,000 copies or less per milliliter of blood at or near the time of delivery. The authors further maintain that clinicians may manage those pregnant people similarly to those not infected with HIV. The final recommendation states that the duration of rupture of membranes before delivery is not an independent risk factor for maternal-child HIV transmission in people who have appropriately suppressed their viral load. Thus, physicians do not have to consider the rupture of membranes duration when making decisions about the route of delivery.

Impacts

ACOG Committee Opinions such as “Labor and Delivery Management” provide guidelines for the practice of obstetrics and gynecology for over 60,000 physicians across the United States, as well as public health officials, public policymakers, and legislators who access and use the reports. Although mechanisms of perinatal HIV transmission are unknown, “Labor and Delivery Management” raised awareness of what physicians can do to reduce transmission risk. The World Health Organization, or WHO, reports that an estimated 1.3 million women and girls living with HIV become pregnant each year. In the absence of medication intervention, the rate of mother-to-child transmission ranges from fifteen to forty-five percent. The updated ACOG Committee Opinion provides recommendations for the widespread use of ART and contributes to an established global agenda to reduce HIV transmission, especially among pregnant HIV-infected people and their infants.

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