Protocol of a woman with Hepatitis B in labour
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Intrapartum protocol: woman with hepatitis B (HBsAg-positive) in labour
1. On admission to labour ward
- Confirm and clearly document HBsAg-positive status in the maternal and neonatal records.
- Notify the paediatric/neonatal team before delivery and ensure hepatitis B vaccine and HBIG are available.
- Review:
- HBV DNA viral load, HBeAg status, liver tests
- Whether she is taking tenofovir
- Any evidence of acute hepatitis or liver decompensation: jaundice, encephalopathy, bleeding, ascites, severe coagulopathy.
- If HBV status was unknown antenatally, draw HBsAg urgently at admission. Do not delay the baby's birth-dose vaccine while awaiting a result.
2. Labour and delivery management
- Vaginal birth is appropriate. Hepatitis B infection alone is not an indication for caesarean section. Deliver by caesarean only for usual obstetric indications.
- Manage labour normally, with standard obstetric indications for induction, augmentation, analgesia and operative delivery.
- Use standard precautions for all blood and body-fluid exposure:
- Gloves, eye/face protection where splash risk exists
- Careful sharps handling and immediate disposal
- Cover maternal bleeding wounds and clean blood spills using local infection-control policy.
- Avoid procedures that may increase fetal exposure to maternal blood unless there is a clear obstetric indication, such as:
- fetal scalp electrode
- fetal scalp blood sampling
- unnecessary artificial rupture of membranes
- unnecessary instrumental trauma.
- Do not delay delivery solely to complete antiviral treatment. If she is already receiving tenofovir for high HBV DNA or her own liver disease, continue it unless the hepatology/obstetric team advises otherwise.
3. Immediately after birth: the key prevention step
For an infant of an HBsAg-positive mother:
| Intervention | Timing |
|---|---|
| Single-antigen hepatitis B vaccine | As soon as possible, ideally immediately, and within 12 hours of birth |
| Hepatitis B immunoglobulin (HBIG) | Within 12 hours of birth where indicated/available |
| Administration | Give vaccine and HBIG at separate injection sites, usually opposite thighs, with separate syringes |
In the US CDC protocol, all infants born to HBsAg-positive mothers receive both vaccine and HBIG within 12 hours. The WHO recommends a timely birth dose within 24 hours for every infant and supports HBIG shortly after birth where available, particularly for higher-risk exposure. See the CDC perinatal HBV guidance and WHO prevention guidance.
Do not give the two injections in the same limb or syringe.
4. Complete infant vaccination and follow-up
- Complete the infant hepatitis B vaccine series according to the national immunization schedule.
- In CDC practice, test the infant for HBsAg and anti-HBs at age 9-12 months, or 1-2 months after the final vaccine dose if the schedule was delayed. Do not use anti-HBc to assess infant infection because maternal antibody can persist.
- If birth weight is <2 kg, the birth dose is given within 12 hours but is generally not counted toward the routine series, so the baby needs an additional dose schedule per local neonatal guidance.
5. Breastfeeding
- Breastfeeding is permitted once the newborn has received appropriate hepatitis B immunoprophylaxis. It should not be withheld because of maternal HBV alone.
- If nipples are cracked and actively bleeding, obtain local paediatric/infectious-disease advice about temporary expressed-milk handling.
6. Maternal postpartum care
- Arrange hepatology or infectious-disease follow-up for chronic HBV assessment and longer-term treatment decisions.
- If tenofovir was used only to prevent mother-to-child transmission, the stop date and liver-function/HBV-DNA monitoring must be planned with the treating clinician, because postpartum hepatitis flares can occur.
- Counsel on avoiding blood donation, not sharing razors/toothbrushes/needles, and testing/vaccinating household and sexual contacts.
Important high-risk context
An antenatal HBV DNA level ≥200,000 IU/mL is the usual threshold at which tenofovir prophylaxis from around 28 weeks is recommended to reduce transmission. However, in a woman who presents already in labour, the immediate priority is prompt neonatal vaccine plus HBIG, not starting intrapartum antiviral treatment. WHO summarizes this threshold in its HBV mother-to-child transmission recommendations.
If the mother has acute severe hepatitis, altered mental status, significant bleeding, or suspected liver failure, manage as an obstetric and medical emergency with senior obstetric, anaesthetic, hepatology, and neonatal input.
Create a one-page labour ward checklist for HBV-positive mothers
Reading File
Labour Ward Checklist: Mother Known HBsAg-Positive
Patient name: ____________________ Hospital No.: ____________________
Gestation: ______ weeks Date/time of admission: ____________________
HBV DNA: ____________________ IU/mL HBeAg: ☐ Positive ☐ Negative ☐ Unknown
Current antiviral therapy: ☐ None ☐ Tenofovir ☐ Other: ____________________
Gestation: ______ weeks Date/time of admission: ____________________
HBV DNA: ____________________ IU/mL HBeAg: ☐ Positive ☐ Negative ☐ Unknown
Current antiviral therapy: ☐ None ☐ Tenofovir ☐ Other: ____________________
A. On Admission
☐ Confirm maternal HBsAg-positive result and flag maternal and neonatal records.
☐ Inform labour ward lead, paediatric/neonatal team and relevant infection-control/perinatal HBV service.
☐ Check documented HBV DNA, HBeAg, liver function, platelet count/coagulation results if clinically indicated.
☐ Confirm whether mother is taking tenofovir and continue prescribed treatment unless senior obstetric/hepatology advice differs.
☐ Ensure single-antigen hepatitis B vaccine and HBIG are available in the delivery area before birth.
☐ Use standard precautions for blood and body-fluid exposure, including safe sharps practice and appropriate PPE.
☐ Inform labour ward lead, paediatric/neonatal team and relevant infection-control/perinatal HBV service.
☐ Check documented HBV DNA, HBeAg, liver function, platelet count/coagulation results if clinically indicated.
☐ Confirm whether mother is taking tenofovir and continue prescribed treatment unless senior obstetric/hepatology advice differs.
☐ Ensure single-antigen hepatitis B vaccine and HBIG are available in the delivery area before birth.
☐ Use standard precautions for blood and body-fluid exposure, including safe sharps practice and appropriate PPE.
B. In Labour
☐ Manage labour and analgesia according to usual obstetric indications.
☐ Vaginal birth is appropriate. HBV alone is not an indication for caesarean birth.
☐ Avoid invasive fetal procedures where not clinically necessary, including:
☐ Vaginal birth is appropriate. HBV alone is not an indication for caesarean birth.
☐ Avoid invasive fetal procedures where not clinically necessary, including:
- ☐ Fetal scalp electrode
- ☐ Fetal scalp blood sampling
- ☐ Other procedures likely to increase fetal blood exposure
☐ Do not delay indicated obstetric intervention or delivery because of HBV status.
☐ Escalate urgently for jaundice, encephalopathy, significant bleeding, suspected coagulopathy, or clinical liver decompensation.
☐ Escalate urgently for jaundice, encephalopathy, significant bleeding, suspected coagulopathy, or clinical liver decompensation.
C. At Birth: Neonatal Prevention Bundle
Record actual time of birth: __________
☐ Notify neonatal team that birth has occurred.
☐ Give single-antigen hepatitis B vaccine IM within 12 hours of birth.
Time given: __________ Site: __________ Batch no.: __________
☐ Give single-antigen hepatitis B vaccine IM within 12 hours of birth.
Time given: __________ Site: __________ Batch no.: __________
☐ Give HBIG IM within 12 hours of birth, according to local neonatal protocol.
Time given: __________ Site: __________ Batch no.: __________
Time given: __________ Site: __________ Batch no.: __________
☐ Administer vaccine and HBIG using separate syringes at separate injection sites.
☐ Document all administration in neonatal record, immunization record and discharge summary.
☐ If vaccine or HBIG is delayed, give immediately and document reason, actions taken and senior notification.
☐ Document all administration in neonatal record, immunization record and discharge summary.
☐ If vaccine or HBIG is delayed, give immediately and document reason, actions taken and senior notification.
D. Postnatal Plan Before Transfer/Discharge
☐ Confirm infant vaccine-series appointments and document schedule.
☐ Arrange infant post-vaccination serology: HBsAg and anti-HBs at 9-12 months, or 1-2 months after final vaccine dose if delayed, per local policy.
☐ Document special neonatal plan if birth weight <2 kg.
☐ Explain that breastfeeding is generally safe after appropriate neonatal immunoprophylaxis.
☐ Arrange maternal hepatology/infectious-disease follow-up and postpartum liver/HBV monitoring.
☐ Counsel mother on follow-up, household/contact testing and vaccination.
☐ Arrange infant post-vaccination serology: HBsAg and anti-HBs at 9-12 months, or 1-2 months after final vaccine dose if delayed, per local policy.
☐ Document special neonatal plan if birth weight <2 kg.
☐ Explain that breastfeeding is generally safe after appropriate neonatal immunoprophylaxis.
☐ Arrange maternal hepatology/infectious-disease follow-up and postpartum liver/HBV monitoring.
☐ Counsel mother on follow-up, household/contact testing and vaccination.
Completed by: ____________________ Role: ____________________
Signature: ____________________ Date/time: ____________________
Signature: ____________________ Date/time: ____________________
Use alongside local obstetric, neonatal, immunization and infection-control policies. This checklist reflects CDC advice that infants of HBsAg-positive mothers receive hepatitis B vaccine and HBIG within 12 hours of birth, at separate sites, as described in the CDC perinatal HBV guidance. WHO recommends a hepatitis B vaccine birth dose as soon as possible, preferably within 24 hours, and completion of the infant series, as summarized in WHO guidance.
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