- Close monitoring of HIV+ pregnant women is essential
- Current recommendations are for HIV+ mothers to not breastfeed because of transmission risk
- Ongoing assessment of the newborn up to 18 month after birth is necessary, as mother’s antibodies persist that long
- Lab tests
- Modes of transmission
- Across the placenta during pregnancy
- During childbirth
- Through breastmilk
- Asymptomatic at birth
- CBC with differential (CD4 count)
- Blood test for HIV
- AZT (zidovudine)
- Watch for signs of immunocompromise (enlarged liver or spleen)
- Immediate bath
- Lab tests
- HIV testing
- Unreliable until around 18 months because of maternal antibodies
- HIV testing
- Infection control
- Lab values
- Guidelines for breastfeeding
- Guidelines for vaccinations
- No live vaccines until it is confirmed that there is no HIV
- Importance of follow-up and testing
In this lesson I will explain the significance of a newborn of a HIV+ mom and your role in care for this patient.
So you have a patient that is pregnant and has HIV. Our care will revolve around protecting the newborn as best we can. To do this you need to understand how it is transmitted. So there are a few ways. It could cross the placenta during pregnancy, it could transmit during childbirth and through breast milk. So if it crosses through the placenta we can’t prevent that but things we can do is have the patient deliver by c-section. This will limit the exposure risk. We also want to help limit the exposure risk by encouraging bottle feeding because breastfeeding can continue to expose the newborn. I was once caring for a newborn whose mother was HIV+. I went in her room prior to delivery to let her know everything that would be done after delivery. The reason why I wanted to prep her with what to expect was because I was told that the father of the baby was unaware that she had HIV. It was crazy because the patient was also a lawyer. Right?! Just the whole legal piece to this. So the labor nurse went in and she said she had told the father everything and we were good. So I was thinking, great no more secrets. Well then I walk back to the OR for delivery and the doctor was scrubbing in and the dad was sitting with his head against the wall. I just knew something had gone down. Come to find out the doctor asked him if he had any questions about the HIV. The dad’s response was “she told me about it and that all the babies receive prophylactic medication and treatment” I think as he was saying it he realized how crazy it sounded. The doctor told him “No, she has HIV and you need to be tested immediately” and then in walks me thinking everything is good. So I would fully expect anyone to storm out upset but he stayed for the delivery, took pictures and acted as everything was fine. He left after the delivery and hopefully got tested. It was awful! We all felt so bad for him and also the mom as she explained she got HIV at birth because her mom had a drug problem and she didn’t want to tell him because he wouldn’t love her anymore. I wish I knew the ending to this one but am not sure what went on after.
So now let’s look at our assessment and management. When you have a baby born of an HIV+ mother you really won’t notice anything different. They are asymptomatic of anything at this time. They will have lab work assessment done but most of this is a sent out that won’t be known while in the hospital and will be used for follow up. They will get a CD4 count and be tested for HIV. These patients have a long follow up because they have the mother’s antibodies so if you look at that immediate lab work it does appear that they have HIV but really they just have the antibody and this can take 18 months to really be able to decipher if they truly have HIV too. Before any lab work or medications are started the baby will need a bath. We want to do this as soon as possible after delivery to clean the baby of any of maternal fluids. Antiretrovirals are necessary as prophylaxis with Zidovudine or AZT will be given. This medication will continue for 4-6 weeks so they are on this for a while.
Education is going to include the recommendations for breastfeeding. Breastfeeding should not occur because this increases the exposure risk. We want to educate on the medications that the newborn will receive in the hospitals and vaccination education. So they can not be given any live vaccines until it is confirmed that they don’t have HIV. The newborns are not given any live vaccines during these first few days but education should be given so the mother understands that her baby can not receive any live vaccines. We need to also educate on the Importance of follow-up and testing for this newborn. It will be the mother’s responsibility to ensure this baby gets to the follow up appointments. This newborn will have a lot of testing in the future to confirm a diagnosis or show that there is no HIV so really important for the child to have.
Concepts will be immunity because we are worried about the immune system of the newborn, infection control because we are trying to prevent the exposure and spread of HIV and lab values because this newborn will receive frequent lab tests and monitoring.
So the key points. If you remember these main points you will have a great understanding for the care of this patient. The baby must be delivered by c-section to limit any blood exposure with the mother and will need an immediate bath to clean maternal fluids from the baby as well as prophylactic AZT, zidovudine, and no breastfeeding.
Make sure you check out the resources attached to this lesson and the immediate care that this newborn will receive. Now, go out and be your best selves today. And, as always, happy nursing.