Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

1. Maternal Care
A learning
programme for
professionals
Developed by the
Perinatal Education Programme

2. Maternal Care
A learning programme
for professionals
Developed by the
Perinatal Education Programme
www.ebwhealthcare.com

3. VERY IMPORTANT
We have taken every care to ensure that drug
dosages and related medical advice in this book
are accurate. However, drug dosages can change
and are updated often, so always double-check
dosages and procedures against a reliable,
up-to-date formulary and the given drug‘s
documentation before administering it.
Maternal Care:
A learning programme for professionals
Updated: 2 June 2010
First published by EBW Healthcare in 2010
Text © Perinatal Education Programme 2010
Illustrations by Anne Westoby
Getup © Electric Book Works 2010
ISBN (print edition): 978-1-920218-27-0
ISBN (PDF ebook edition): 978-1-920218-45-4
All text in this book excluding the tests and
answers is published under the Creative Commons
Attribution Non-Commercial No Derivatives
License. You can read up about this license at http://
creativecommons.org/licenses/by-nc-nd/3.0/.
The multiple-choice tests and answers in this
publication may not be reproduced, stored in a
retrieval system, or transmitted in any form or by
any means without the prior permission of Electric
Book Works, 87 Station Road, Observatory, Cape
Town, 7925.
Visit our websites at www.electricbookworks.com
and www.ebwhealthcare.com

4. Contents
Acknowledgements 7 Case study 4 34
Introduction 9 1A Skills workshop: General examination
About the EBW Healthcare series 9 at the first antenatal visit 39
Why decentralised learning? 9 History taking 39
Books in the EBW Healthcare series 9 Examination of the patient 41
Format of the courses 11 Testing the patient’s urine 42
Contributors 12 Doing a pregnancy test 42
Updating the course material 13
Contact information 13 1B Skills workshop: Examination of the
abdomen in pregnancy 44
1 Antenatal care 15 General examination of the abdomen 44
Goals of good antenatal care 15 Examination of the uterus and the fetus 45
Diagnosing pregnancy 16
The first antenatal visit 16 1C Skills workshop: Vaginal examination
Determining the duration of pregnancy 20 in pregnancy 51
Side-room and special screening Indications for a vaginal examination 51
investigations 21 Method of vaginal examination 52
The second antenatal visit 23 1D Skills workshop: Screening tests for
Assessing the results of the special syphilis 54
screening investigations 23 Syphilis screening 54
Grading the risk 25 Syphilis rapid test 54
Subsequent visits 26 The RPR card test 55
The visit at 28 weeks 26
The visit at 34 weeks 27 Skills workshop: Screening tests for HIV 58
The visit at 41 weeks 27 HIV screening 58
Managing pregnant women with HIV
infection 29 2 Assessment of fetal growth and
Case study 1 32 condition during pregnancy 60
Case study 2 33 Introduction 60
Case study 3 33 Fetal growth 61

5. Fetal movements 65 Case study 2 114
Antenatal fetal heart rate monitoring 67 Case study 3 115
Case study 1 71 Case study 4 115
Case study 2 71
Case study 3 72 5 Preterm labour and preterm rupture
Case study 4 73 of the membranes 117
Preterm labour and preterm rupture
2A Skills workshop: Routine use of the of the membranes 117
antenatal card 78 Diagnosis of preterm labour and
preterm rupture of the membranes 120
3 Hypertensive disorders of pregnancy 84 Management of preterm labour 122
The hypertensieve disorders of pregnancy 84 Management of preterm rupture of
The classification of hypertension the membranes 125
during pregnancy 85 Prelabour rupture of the membranes 128
Pre-eclampsia 86 Case study 1 129
Patients at increased risk of pre-eclampsia 88 Case study 2 130
The management of pre-eclampsia 89 Case study 3 130
The emergency management of severe
pre-eclampsia and imminent eclampsia 90 6 Monitoring the condition of the
The management of eclampsia 92 mother during the first stage of labour 132
The further management of severe pre- Monitoring labour 132
eclampsia and imminent eclampsia at Assessing the general condition of the
the referral hospital 92 patient 133
Gestational hypertension 94 Assessing the temperature 134
Chronic hypertension 94 Assessing the pulse rate 135
Case study 1 95 Assessing the blood pressure 136
Case study 2 96 Assessing the urine 137
Case study 3 96 Maternal exhaustion 138
Case study 4 97 Case study 1 139
Case study 2 139
3A Skills workshop: Measuring blood
pressure and proteinuria 98 7 Monitoring the condition of the
Measuring blood pressure 98 fetus during the first stage of labour 140
Measuring proteinuria 99 Monitoring the fetus 140
Fetal heart rate patterns 142
4 Antepartum haemorrhage 100 The liquor 146
Antepartum haemorrhage 100 Case study 1 147
The initial emergency management of Case study 2 148
antepartum haemorrhage 101 Case study 3 148
Diagnosing the cause of the bleeding 103
Antepartum bleeding caused by 8 The first stage of labour: Monitoring
abruptio placentae 104 and management 150
Antepartum bleeding caused by The diagnosis of labour 150
placenta praevia 107 The two phases of the first stage of
Antepartum haemorrhage of unknown labour 150
cause 111 Monitoring of the first stage of labour 151
Referral of a patient with an Management of a patient in the latent
antepartum haemorrhage 112 phase of the first stage of labour 153
A blood-stained vaginal discharge 113 Management of a patient in the active
Case study 1 114 phase of the first stage of labour 154

6. Poor progress in the active phase of Case study 2 197
the first stage of labour 156 Case study 3 197
Cephalopelvic disproportion 159 Case study 4 198
Inadequate uterine action 160
The referral of patients with poor 9a Skills workshop: Performing and
progress during the active phase of repairing an episiotomy 199
the first stage of labour 161 Performing an episiotomy 199
Prolapse of the umbilical cord 161 Repairing an episiotomy 200
Case study 1 163
10 Managing pain during labour 205
Case study 2 163
Pain relief in labour 205
Case study 3 164
Use of analgesics in labour 207
Case study 4 164
Naloxone 208
8a Skills workshop: Examination of the Sedation during labour 209
abdomen in labour 166 Inhalational analgesia 209
Abdominal palpation 166 Local anaesthesia 210
Assessing contractions 169 Epidural anaesthesia 210
Assessing the fetal heart rate 169 General anaesthesia 211
Case study 1 211
8B Skills workshop: Vaginal examination Case study 2 212
in labour 170 Case study 3 213
Preparation for a vaginal examination Case study 4 213
in labour 170
Procedure of examination 171 11 The third stage of labour 215
The vulva and vagina 171 The normal third stage of labour 215
The cervix 171 Managing the third stage of labour 216
The membranes and liquor 172 Examination of the placenta after birth 219
The presenting part 172 The abnormal third stage of labour 220
Moulding 175 Managing postpartum haemorrhage 221
Protecting the staff from HIV infection 225
8C Skills workshop: Recording Case study 1 226
observations on the partogram 178 Case study 2 226
The partogram 178 Case study 3 227
Recording the condition of the mother 178 Case study 4 227
Recording the condition of the fetus 178
Recording the progress of labour 180 12 The puerperium 229
Exercises on the correct use of the The normal puerperium 229
partogram 182 Management of the puerperium 231
Case study 1 182 The six week postnatal visit 234
Case study 2 183 Puerperal pyrexia 235
Case study 3 186 Thrombophlebitis 237
Respiratory tract infection 237
9 The second stage of labour 189 Puerperal psychiatric disorders 238
The normal second stage of labour 189 Secondary postpartum haemorrhage 239
Managing the second stage of labour 190 Self-monitoring 240
Episiotomy 193 Case study 1 240
Prolonged second stage of labour 193 Case study 2 241
Management of impacted shoulders 194 Case study 3 241
Managing the newborn infant 196 Case study 4 242
Case study 1 196 Case study 1 227

7. 13 Medical problems during pregnancy,
labour and the puerperium 243
Urinary tract infection during
pregnancy 243
Anaemia in pregnancy 246
Heart valve disease in pregnancy and
the puerperium 247
Diabetes mellitus in pregnancy 250
Case study 1 252
Case study 2 254
Case study 3 255
Case study 4 255
14 Family planning after pregnancy 257
Contraceptive counselling 257
Case study 1 263
Case study 2 264
Case study 3 264
Case study 4 265
15 Regionalised perinatal care 266
Regionalised perinatal care 266
The maternal-care clinic 269
Transferring patients safely to hospital 271
Maternal mortality 272
Case study 1 273
Case study 2 274
Case study 3 274
Appendix 276
Guidelines for the management of
patients with risk factors and medical
problems during pregnancy, labour
and the puerperium 276
Tests 289

8. Acknowledgements
Maternal Care has been edited from the participants that the content of the Perinatal
Maternal Care manual of the Perinatal Education Programme courses can be
Education Programme. This learning improved.
programme for professionals is developed by
Editor-in-Chief of the Perinatal Education
the Perinatal Education Trust and funded by
Programme: Prof D Woods
Eduhealthcare.
Editor of Maternal Care: Prof G Theron
We acknowledge all the participants of the
Perinatal Education Programme who have Contributors to Maternal Care: Prof H van C
made suggestions and offered constructive de Groot, Dr D Greenfield, Ms H Louw, Ms M
criticism over the years. It is only through Petersen, Dr N Rhoda, Prof G Theron, Prof D
constant feedback from colleagues and Woods

9. Introduction
ABOUT THE EBW WHY DECENTRALISED
HEALTHCARE SERIES LEARNING?
EBW Healthcare publishes an innovative Continuing education for healthcare workers
series of distance-learning books for traditionally consists of courses and workshops
healthcare professionals, developed by the run by formal trainers at large central hospitals.
Perinatal Education Trust, Eduhealthcare, These teaching courses are expensive to attend,
the Desmond Tutu HIV Foundation and the often far away from the healthcare workers’
Desmond Tutu TB Centre, with contributions families and places of work, and the content
from numerous experts. frequently fails to address the real healthcare
requirements of the poor, rural communities
Our aim is to provide appropriate, affordable
who face the biggest healthcare challenges.
and up-to-date learning material for
healthcare workers in under-resourced areas, To help solve these many problems, a self-
so that they can manage their own continuing help decentralised learning method has been
education courses which will enable them to developed which addresses the needs of
learn, practise and deliver skillful, efficient professional healthcare workers, especially
patient care. those in poor, rural communities.
The EBW Healthcare series is built on
the experience of the Perinatal Education
Programme (PEP), which has provided BOOKS IN THE EBW
learning opportunities to over 60 000 nurses HEALTHCARE SERIES
and doctors in South Africa since 1992. Many
of the educational methods developed by PEP
are now being adopted by the World Health Maternal Care addresses all the common
Organisation (WHO). and important problems that occur
during pregnancy, labour, delivery and the
puerperium. It covers the antenatal and
postnatal care of healthy women with normal
pregnancies, monitoring and managing

10. 10 MATERNAL CARE
the progress of labour, specific medical glucose concentration, insertion of an umbilical
problems during pregnancy, labour and the vein catheter, phototherapy, apnoea monitors
puerperium, family planning and regionalised and oxygen therapy.
perinatal care. Skills workshops teach clinical
examination in pregnancy and labour, routine Primary Newborn Care was written
screening tests, the use of an antenatal card specifically for nurses and doctors who
and partogram, measuring blood pressure, provide primary care for newborn infants in
detecting proteinuria and performing and level 1 clinics and hospitals. Primary Newborn
repairing an episiotomy. Care addresses the care of infants at birth, care
of normal infants, care of low-birth-weight
Maternal Care is aimed at healthcare workers
infants, neonatal emergencies, and common
in level 1 hospitals or clinics.
minor problems in newborn infants.
Primary Maternal Care addresses the
Mother and Baby Friendly Care describes
needs of healthcare workers who provide
gentler, kinder, evidence-based ways of caring
antenatal and postnatal care, but do not
for women during pregnancy, labour and
conduct deliveries. It is adapted from theory
delivery. It also presents improved methods
chapters and skills workshops from Maternal
of providing infant care with an emphasis
Care. This book is ideal for midwives and
on kangaroo mother care and exclusive
doctors providing primary maternal care
breastfeeding.
in level 1 district hospitals and clinics,
and complements the national protocol of
Saving Mothers and Babies was developed in
antenatal care in South Africa.
response to the high maternal and perinatal
mortality rates found in most developing
Intrapartum Care was developed for doctors
countries. Learning material used in this book
and advanced midwives who care for women
is based on the results of the annual confidential
who deliver in district hospitals. It contains
enquiries into maternal deaths and the Saving
theory chapters and skills workshops adapted
Mothers and Saving Babies reports published in
from the labour chapters of Maternal Care.
South Africa. It addresses the basic principles
Particular attention is given to the care
of mortality audit, maternal mortality,
of the mother, the management of labour
perinatal mortality, managing mortality
and monitoring the wellbeing of the fetus.
meetings and ways of reducing maternal and
Intrapartum Care was written to support
perinatal mortality rates. This book should
and complement the national protocol of
be used together with the Perinatal Problem
intrapartum care in South Africa.
Identification Programme (PPIP).
Newborn Care was written for healthcare
Birth Defects was written for healthcare
workers providing special care for newborn
workers who look after individuals with birth
infants in regional hospitals. It covers
defects, their families, and women who are at
resuscitation at birth, assessing infant size and
increased risk of giving birth to an infant with a
gestational age, routine care and feeding of both
birth defect. Special attention is given to modes
normal and high-risk infants, the prevention,
of inheritance, medical genetic counselling,
diagnosis and management of hypothermia,
and birth defects due to chromosomal
hypoglycaemia, jaundice, respiratory distress,
abnormalities, single gene defects, teratogens
infection, trauma, bleeding and congenital
and multifactorial inheritance. This book
abnormalities, as well as communication with
is being used in the Genetics Education
parents. Skills workshops address resuscitation,
Programme which trains healthcare workers in
size measurement, history, examination and
genetic counselling in South Africa.
clinical notes, nasogastric feeds, intravenous
infusions, use of incubators, measuring blood

11. INTRODUCTION 11
Perinatal HIV enables midwives, nurses and nurses with wide experience in the care
and doctors to care for pregnant women and of adults with HIV, through the auspices of
their infants in communities where HIV the Desmond Tutu HIV Foundation at the
infection is common. Special emphasis has University of Cape Town.
been placed on the prevention of mother-to-
infant transmission of HIV. It covers the basics
of HIV infection and screening, antenatal FORMAT OF THE COURSES
and intrapartum care of women with HIV
infection, care of HIV-exposed newborn
infants, and parent counselling. 1. Objectives
The learning objectives are clearly stated at the
Childhood HIV enables nurses and doctors
start of each chapter. They help the participant
to care for children with HIV infection. It
to identify and understand the important
addresses an introduction to HIV in children,
lessons to be learned.
the clinical and immunological diagnosis
of HIV infection, management of children
with and without antiretroviral treatment, 2. Pre- and post-tests
antiretroviral drugs, opportunistic infections There is a multiple-choice test of 20 questions
and end-of-life care. for each chapter at the end of the book.
Participants are encouraged to take a pre-test
Childhood TB was written to enable before starting each chapter, to benchmark
healthcare workers to learn about the primary their current knowledge, and a post-test after
care of children with tuberculosis. The book each chapter, to assess what they have learned.
covers an introduction to TB infection,
and the clinical presentation, diagnosis, Self-assessment allows participants to monitor
management and prevention of tuberculosis in their own progress through the course.
children and HIV/TB co-infection. Childhood
TB was developed by paediatricians with 3. Question-and-answer format
wide experience in the care of children with Theoretical knowledge is presented in a
tuberculosis, through the auspices of the question-and-answer format, which encourages
Desmond Tutu Tuberculosis Centre at the the learner to actively participate in the
University of Stellenbosch. learning process. In this way, the participant
is led step by step through the definitions,
Child Healthcare addresses all the common
causes, diagnosis, prevention, dangers and
and important clinical problems in children,
management of a particular problem.
including immunisation, history and
examination, growth and nutrition, acute and Participants should cover the answer for a few
chronic infections, parasites, skin conditions, minutes with a piece of paper while thinking
and difficulties in the home and society. Child about the correct reply to each question. This
Healthcare was developed for use in primary method helps learning.
care settings. Simplified flow diagrams are also used, where
necessary, to indicate the correct approach to
Adult HIV covers an introduction to HIV
diagnosing or managing a particular problem.
infection, management of HIV-infected adults
at primary-care clinics, preparing patients for
antiretroviral (ARV) treatment, ARV drugs, Each question is written in bold,
starting and maintaining patients on ARV like this, and is identified with the
treatment and an approach to opportunistic number of the chapter, followed by the
infections. Adult HIV was developed by doctors number of the question, e.g. 5-23.

12. 12 MATERNAL CARE
4. Important lessons Participants need to achieve at least 80%
in the examination in order to successfully
complete the course. Successful candidates
Important practical lessons are emphasised by will be emailed a certificate which states
placing them in a box like this. that they have successfully completed
that course. EBW Healthcare courses are
5. Notes not yet accredited for nurses, but South
African doctors can earn CPD points on the
NOTE Additional, non-essential information is successful completion of an examination.
provided for interest and given in notes like this.
These facts are not used in the case studies or Please contact info@ebwhealthcare.com or
included in the multiple-choice questions. +27 021 44 88 336 when you are ready to take
the exam.
6. Case studies
Each chapter closes with a few case CONTRIBUTORS
studies which encourage the participant
to consolidate and apply what was learned
The developers of our learning materials are a
earlier in the chapter. These studies give the
multi-disciplinary team of nurses, midwives,
participant an opportunity to see the problem
obstetricians, neonatologists, and general
as it usually presents itself in the clinic or
paediatricians. The development and review of
hospital. The participant should attempt to
all course material is overseen by the Editor-
answer each question in the case study before
in-Chief, emeritus Professor Dave Woods,
reading the correct answer.
a previous head of neonatal medicine at the
University of Cape Town who now consults to
7. Practical training UNICEF and the WHO.
Certain chapters contain skills workshops,
which need to be practised by the participants Perinatal Education Trust
(preferably in groups). The skills workshops,
Books developed by the Perinatal Education
which are often illustrated with line drawings,
Programme are provided as cheaply as possible.
list essential equipment and present step-by-
Writing and updating the programme is both
step instructions on how to perform each
funded and managed on a non-profit basis by
task. If participants aren’t familiar with a
the Perinatal Education Trust.
practical skill, they are encouraged to ask an
appropriate medical or nursing colleague to
demonstrate the clinical skill to them. In this Eduhealthcare
way, senior personnel are encouraged to share Eduhealthcare is a non-profit organisation
their skills with their colleagues. based in South Africa. It aims to improve health
and wellbeing, especially in poor communities,
8. Final examination through affordable education for healthcare
workers. To this end it provides financial
On completion of each course, participants
support for the development and publishing of
can take a 75-question multiple-choice
the EBW Healthcare series.
examination on the EBW Healthcare website,
when they are ready to.
The Desmond Tutu HIV Foundation
All the exam questions will be taken from
the multiple-choice tests from the book. The The Desmond Tutu HIV Foundation at the
content of the skills workshops will not be University of Cape Town, South Africa,
included in the examination. is a centre of excellence in HIV medicine,

13. INTRODUCTION 13
building capacity through training and CONTACT INFORMATION
enhancing knowledge through research.
The Desmond Tutu Tuberculosis Centre EBW Healthcare
The Desmond Tutu Tuberculosis Centre at Website: www.ebwhealthcare.com
Stellenbosch University, South Africa, strives
Email: info@ebwhealthcare.com
to improve the health of vulnerable groups
through the education of healthcare workers Telephone: +27 021 44 88 336
and community members, and by influencing Fax: +27 088 021 44 88 336
policy based on research into the epidemiology
of childhood tuberculosis, multi-drug- Post: 87 Station Road, Observatory, 7925,
resistant tuberculosis, HIV/TB co-infection Cape Town, South Africa
and preventing the spread of TB and HIV in
southern Africa. Editor-in-Chief: Professor Dave Woods
Website: www.pepcourse.co.za
UPDATING THE Email: pepcourse@mweb.co.za
COURSE MATERIAL Telephone: +27 021 786 5369
Fax: +27 021 671 8030
EBW Healthcare learning materials
Post: Perinatal Education Programme,
are regularly updated to keep up with
PO Box 34502, Groote Schuur, Observatory,
developments and changes in healthcare
7937, South Africa
protocols. Course participants can make
important contributions to the continual
improvement of EBW Healthcare books
by reporting factual or language errors,
by identifying sections that are difficult to
understand, and by suggesting additions or
improvements to the contents. Details of
alternative or better forms of management
would be particularly appreciated. Please send
any comments or suggestions to the Editor-in-
Chief, Professor Dave Woods.

15. 1
Antenatal care
Before you begin this unit, please take the GOALS OF GOOD
corresponding test at the end of the book to
assess your knowledge of the subject matter. You ANTENATAL CARE
should redo the test after you’ve worked through
the unit, to evaluate what you have learned.
1-1 What are the aims and principles
of good antenatal care?
Objectives The aims of good antenatal care are to ensure
that pregnancy causes no harm to the mother
and to keep the fetus healthy during the
When you have completed this unit you
antenatal period. In addition, the opportunity
should be able to: must be taken to provide health education.
• List the goals of good antenatal care. These aims can usually be achieved by the
• Diagnose pregnancy. following:
• Know what history should be taken and 1. Antenatal care must follow a definite plan.
examination done at the first visit. 2. Antenatal care must be problem oriented.
• Determine the duration of pregnancy. 3. Possible complications and risk factors that
• List and assess the results of the side- may occur at a particular gestational age
room and screening tests needed at the must be looked for at these visits.
4. The fetal condition must be repeatedly
first visit.
assessed.
• Identify low-, intermediate- and high-risk 5. Healthcare education must be provided.
pregnancies.
All information relating to the pregnancy must
• Plan and provide antenatal care that is
be entered on a patient-held antenatal card.
problem orientated. The antenatal card can also serve as a referral
• List what specific complications to look letter if a patient is referred to the next level of
for at 28, 34 and 41 weeks. care and therefore serves as a link between the
• Provide health information during different levels of care as well as the antenatal
antenatal visits. clinic and labour ward.
• Manage pregnant women with HIV
infection.