How is the decision made to deliver vaginally or by c-section?

The best decisions about route of delivery are made together between a woman and her doctor. Obstetric indications regarding previous pregnancies and the current pregnancy (non-HIV related) must be factored into this decision. The Department of Health and Human Services Perinatal Guidelines cover this topic. The general summary of these recommendations on route of delivery are:

Vaginal delivery is safe if viral load is less than 1000 copies/ml at 36 weeks of pregnancy and the mother reports recent good adherence with antiretroviral medications. Physicians delivering women who are HIV positive should avoid all invasive monitoring devices including fetal scalp electrodes. Every attempt should be made to delay artificial rupture of membranes. Instrumental vaginal delivery with forceps should be avoided due to the potential to introduce fetal trauma and potentially increase viral exposure.

C-Section delivery is recommended if the viral load is unknown or is greater than 1000 copies/ml at 36 weeks of pregnancy. In these instances, delivery should be scheduled for 38 weeks gestation prior to the onset of labor and spontaneous rupture of membranes in order to achieve maximum benefit.