Improving services for
prevention and treatment of STI/RTI
Chapter 7. STI/RTI assessment in pregnancy, childbirth and the
- Women should be encouraged to attend antenatal clinic early
in pregnancy to allow timely detection and prevention of any problems,
- Women should be screened for syphilis at the first antenatal
visit. Screening for syphilis should be done on-site, and
results and treatment made available to the woman before she leaves
- Screening for other STIs/RTIs, including cervical
infections, bacterial vaginosis and HIV, should be offered if
- Women should be asked at each antenatal visit about
STI symptoms in themselves and their partner. Screening and/or
treatment of partners should be offered, for at least
symptomatic STIs, syphilis and HIV.
- STI prevention should be promoted during pregnancy as a way
of protecting both mother and child, and of safeguarding future
- Access to counselling and testing for HIV, interventions to
prevent mother-to-child-transmission, and care of the mother should be
available on-site or by referral.
- Prophylaxis for ophthalmia neonatorum should be given routinely to
all newborn babies.
STI/RTI prevention and management are as important during pregnancy
as at any other time. A woman’s sexual activity may increase or
decrease, and exposure to infection may change. A number of STIs—including
syphilis, gonorrhoea, chlamydia, trichomoniasis, genital herpes and
HIV—can cause complications during pregnancy and contribute to poor
pregnancy outcomes. Among endogenous infections, bacterial vaginosis
is associated with preterm labour. Yeast infection is more common during
pregnancy and, although it is not associated with any adverse pregnancy
outcomes, the symptoms may be unpleasant and women should receive
appropriate treatment. Upper genital tract infection may be a
complication of spontaneous or induced abortion, or preterm rupture of
membranes, or may occur following delivery—and may be life-threatening.
Some of the most important STI/RTI-related problems in
pregnancy—including postabortion and postpartum infections, and
congenital syphilis—are not technically difficult or expensive to manage
or prevent altogether. Yet maternal and perinatal morbidity and
mortality due to these problems remain high. Simple improvements in
service delivery using available technology—such as same-day, on-site
syphilis screening in antenatal clinics—can lead to dramatic
improvements in pregnancy outcome. Treatment of symptomatic bacterial
vaginosis can reduce the risk of preterm labour, and prevention and
effective management of postpartum and postabortion infections can
reduce maternal morbidity and mortality.
Women of reproductive age should be educated about the importance of
early antenatal care and STI/RTI screening. Couples should be counselled
during pregnancy on symptoms of preterm labour, safer sex practices and
avoidance of other partners during the pregnancy.
Antenatal clinic visits provide opportunities for preventing and
detecting STIs/RTIs, and women should be encouraged to attend early in
pregnancy. WHO recommends four antenatal care visits for women with
uncomplicated pregnancy. Figure 7.1 illustrates the WHO antenatal care
model, which provides a checklist for basic antenatal care services as
well as tools for identifying women who need additional care.
Figure 7.1. The WHO antenatal care (ANC) model
WHO antenatal randomized trial: manual for the
implementation of the new model. Geneva, World Health Organization,
Step 1: Initial assessment visit during pregnancy
A woman may first come to the antenatal clinic any time between the
first trimester and the onset of labour. She may or may not return to
the clinic before delivery. It is therefore important to make the most
of the first visit, and some consideration of STIs/RTIs should be
included in the assessment.
The following is recommended as a minimal STI/RTI assessment at the
- Ask the woman about symptoms of STI/RTI and whether her partner
has urethral discharge or other symptoms. If the woman or her partner
has symptoms, they should be managed using the flowcharts in
- Serological syphilis testing using RPR or equivalent non-treponemal
syphilis antibody test should be carried out as early as possible in
pregnancy (Chapter 3). Testing should be done on-site where possible,
and the woman should receive her results and treatment before leaving
the clinic. Treatment of her partner should also be encouraged, and
active assistance given if requested.
- Pregnant women with a history of spontaneous abortion or preterm
delivery should be screened for bacterial vaginosis and trichomoniasis.
Those who test positive should be treated (after the first trimester
of pregnancy) with metronidazole, 500 mg three times a day for seven
days, to reduce risk of adverse pregnancy outcome.
- Counselling and testing for HIV should be available on-site or
through referral. Women who test positive should be referred to
appropriate support services and advised on how to reduce the risk of
mother-to-child transmission (MTCT) (Box 7.1).
- Prevention of STIs (including HIV) should be discussed with the
woman and her partner in the context of ensuring a healthy pregnancy
and protecting future fertility.
- Plans for delivery and the postpartum period should be discussed
early in pregnancy. Infection with a viral STI such as HIV or HSV-2
may influence the birth plan. STI/RTI prevention needs should be
discussed when considering options for postpartum family planning.
Step 2: Follow-up antenatal visit
When women return for follow-up antenatal visits, attention should be
paid to STI/RTI prevention and detection since risk of infection may
persist. As at the first visit, women should be asked about symptoms in
themselves or their partners. Any symptomatic STIs/RTIs should be
managed using the flowcharts in Chapter 8 and
- Syphilis testing should be repeated in late pregnancy, if
possible, to identify women infected during pregnancy (Chapter 3).
All women should be tested at least once during each pregnancy, and
all women with reactive serology should receive treatment (see
for information on interpreting syphilis test results in women treated
- For women who are HIV positive, management during the antenatal
period will depend on the specific protocol followed. Health care
providers should review the birth plan and discuss options for infant
feeding and postpartum contraception.
- Prevention of STIs/RTIs should be stressed. The woman and her
partner should understand that, regardless of previous treatment, an
STI acquired in late pregnancy is capable of causing pregnancy
complications and congenital infection. Condoms should be offered.
Where partner treatment is indicated, it may be more readily accepted
if offered as a precaution to ensure a safe delivery and healthy
Box 7.1. HIV and pregnancy
Mother-to-child transmission (MTCT) of HIV is the
major cause of HIV infection in children throughout the world. Over
half a million children are infected this way each year. Without
intervention, up to 40% of children born to HIV-infected women will
be infected. Infection can be transmitted from mother to child
during pregnancy, during labour and delivery, and through
breastfeeding. Prevention of MTCT should begin as early as possible
in pregnancy by offering counselling and testing of the parents for
Routine antenatal care is similar for women who are
HIV positive and for those who are uninfected. Detection and
treatment of STIs/RTIs are important, since several STIs/RTIs
increase the amount of HIV in genital secretions, which increases
the risk of transmitting infection to the child during delivery.
Careful attention should be paid to symptoms or physical examination
findings suggestive of opportunistic infections or STI/RTI. Invasive
procedures such as amniocentesis should be avoided.
Apart from antiviral treatment, there is no need for
HIV-infected women to be treated differently than other women during
labour and delivery or to be isolated. Universal precautions to
reduce the risk of transmission of HIV and other infections should
be used by staff for all patients, not only for those who are known
to be HIV-infected (see Annex 2).
HIV-positive women require special attention in the
postpartum period. They may benefit from further care, counselling
and support, and may need assistance if they choose substitute
infant feeding. They should be referred to care and support
Step 3: Labour and delivery
STI/RTI concerns during labour and delivery are few but potentially
important. The objectives are to identify infection that may not have
been detected during the antenatal period, and to intervene where
possible to prevent and manage STIs/RTIs in the newborn (Box 7.3).
- Look for signs of infection. Most STIs/RTIs are not emergencies
and treatment can be delayed until after delivery. Vesicles or ulcers
suggestive of a first episode of genital herpes (primary HSV-2
infection) near delivery may be an indication for caesarean section
since vaginal delivery carries a risk for the newborn of disseminated
herpes, and a high risk of neonatal death. Where caesarean section is
not possible or would be unsafe, transport to a referral hospital
should be considered if delivery is not imminent. Caesarean delivery
is not beneficial if more than six hours have passed since rupture of
- Genital warts, even when extensive, are not an indication
for caesarean delivery.
- Preterm rupture of membranes and rupture of membranes
before the onset of labour require careful management to reduce risk
of infection (see Chapter 9).
- Manage HIV-infected women (including administration of
antiretroviral treatment) according to local protocols.
Universal precautions should be followed for all deliveries (Box
Box 7.2. Universal precautions during childbirth
The following precautions are advised for every
childbirth regardless of the HIV or STI/RTI status of the woman.
Use gloves, carefully wash hands between
procedures, and high-level disinfect or sterilize all
instruments/equipment used in the process of delivery.
Follow standard practice for the delivery,
avoiding unnecessary vaginal examinations, minimizing trauma, and
actively managing the second stage of labour. Episiotomy should
only be done for obstetric indications and not as a routine
procedure. If assisted delivery is required, this should involve
as little trauma as possible.
Cut the umbilical cord under cover of a lightly
wrapped gauze swab to prevent blood spurting. Do not apply suction
to the newborn’s airway with a nasogastric tube unless there are
signs of meconium. Mouth-operated suction should be avoided.
Regardless of the HIV status of the mother, wear
gloves when handling any newborn baby until maternal blood and
secretions have been washed off. Immediately after birth, remove
the mother’s blood as well as meconium with soap and water. All
babies should be kept warm after delivery.
Box 7.3. Prevention and management of STIs/RTIs in the newborn
1. Neonatal eye prophylaxis
All newborn babies, regardless of maternal signs or
symptoms of infection, should receive prophylaxis against
ophthalmia neonatorum due to gonorrhoea or chlamydial
infection. The eye ointments and drops that may be used are listed
Prevention of ophthalmia neonatorum
Instil one drop of the following in each eye within
silver nitrate (1%) freshly prepared aqueous
solution in a single application
2. Congenital syphilis
Syphilis test results should be reviewed at this
time, and the newborn evaluated for signs of congenital syphilis.
Women who have not previously been tested for syphilis should be
tested. Results should be obtained as soon as possible so that early
treatment can be given to newborns of mothers who test positive.
Newborn babies should be managed as described in Table 7.1,
regardless of whether the mother received treatment for syphilis
during pregnancy. The mother and her partner should also be treated
if this has not already been done.
Table 7.1. Treatment of neonatal syphilis (first month of life)
Mother’s RPR/VDRL status
Infant with signs of congenital syphilisa
1 or 2
Start treatment 1 or 2 while awaiting results (if
If reactive, continue
If negative, investigate for
other causes and modify treatment accordingly
Infant without signs of congenital syphilisa
Aqueous crystalline benzylpenicillin
100 000–150 000 units/kg of body weight per day, administered as
50 000 units/kg of body weight, intramuscularly or intravenously,
every 12 hours during the first 7 days of life and every 8 hours
thereafter for a total of 10 days
Procaine benzylpenicillin 50 000 units/kg of
body weight, intramuscularly, in a single daily dose for 10 days
Benzathine benzylpenicillin 50 000 units/kg of
body weight, intramuscularly, in a single dose
a. Signs of congenital syphilis: vesicular eruptions on
palms or soles, hepatosplenomegaly, pseudoparalysis, oedema/ascites,
fever (in first week of life), prolonged or conjugated
hyperbilirubinaemia, petechiae, bleeding, syphilitic facies. Infants are
often asymptomatic at birth.
Step 4: Postpartum care
It is as important to be aware of signs of infection following
delivery as during pregnancy. Postpartum uterine infection is a common
and potentially life-threatening condition, and early detection and
effective treatment are important measures to prevent complications. All
women are vulnerable to infection following delivery, and retained blood
and placental tissue increase the risk. Other risk factors for infection
include prolonged labour, prolonged rupture of membranes and
manipulation during labour and delivery. Management of postpartum
infection is covered in Chapter 9.
Women should be examined within 12 hours following delivery. When
they are discharged from the health care facility, women should be
advised to return to the clinic if they notice symptoms, such as fever,
lower abdominal pain, foul-smelling discharge or abnormal bleeding. They
should be given information on care of the perineum and breasts, and
instructed on the safe disposal of lochia and blood-stained pads or
other potentially infectious materials. Health care providers should be
alert to signs of infection including fever, lower abdominal pain or
tenderness and foul-smelling discharge.
- HIV-positive women may need continued care and support, including
access to treatment and support in carrying out a substitute feeding
- If contraception was not discussed before delivery, it should be
brought up early in the postpartum period. Planning for a suitable
method should include consideration of need for STI/RTI protection
(see Chapter 6). Dual protection should also be discussed with women
who choose a long-term contraceptive method, such as an IUD, following