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Primary Maternal Care: Introduction

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Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from …

Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions

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  • 1. PrimaryMaternal CareA learningprogramme forprofessionalsDeveloped by thePerinatal Education Programme
  • 2. PrimaryMaternalCareA learning programmefor professionalsDeveloped by thePerinatal Education Programmewww.ebwhealthcare.com
  • 3. VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Primary Maternal Care:A learning programme for professionalsUpdated 1 December 2009First published by EBW Healthcare in 2009Text © Perinatal Education Programme 2009Illustrations by Anne WestobyGetup © Electric Book Works 2009ISBN (print edition): 978-1-920218-43ISBN (PDF ebook edition): 978-1-920218-44-7All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at http://creativecommons.org/licenses/by-nc-nd/3.0/.The multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand www.ebwhealthcare.com
  • 4. ContentsAcknowledgements 7 1A Skills workshop: General examination at the first antenatal visit 35Introduction 9 History taking 35 About the EBW Healthcare series 9 Examination of the patient 37 Why decentralised learning? 9 Testing the patient’s urine 38 Books in the EBW Healthcare series 9 Doing a pregnancy test 38 Format of the courses 11 Contributors 12 1B Skills workshop: Examination of the Updating the course material 13 abdomen in pregnancy 40 Contact information 13 General examination of the abdomen 40 Examination of the uterus and the fetus 411 Antenatal care 14 Goals of good antenatal care 14 1C Skills workshop: Vaginal examination Diagnosing pregnancy 15 in pregnancy 48 The first antenatal visit 15 Indications for a vaginal examination 48 Determining the duration of pregnancy 19 Method of vaginal examination 49 Side room and special investigations 20 The second antenatal visit 21 1D Skills workshop: Screening tests for Grading the risk 24 syphilis 52 Subsequent visits 24 Syphilis screening 52 The visit at 28 weeks 25 Syphilis rapid test 52 The visit at 34 weeks 25 The RPR card test 53 The visit at 41 weeks 26 1E Skills workshop: Screening tests for Managing women with HIV infection 27 HIV 56 Case study 1 28 HIV screening 56 Case study 2 29 Case study 3 29 2 Assessment of fetal growth and Case study 4 30 condition during pregnancy 59 Introduction 59 Fetal growth 60 Fetal movements 64
  • 5. Case study 1 65 Case study 3 102 Case study 2 66 Case study 3 66 6 The puerperium and family planning 104 The puerperium 1042A Skills workshop: Routine use of the Management of the puerperium 106 antenatal card 69 The six week postnatal visit 108 Puerperal pyrexia 1093 Hypertensive disorders of pregnancy 75 Puerperal psychiatric disorders 112 The hypertensieve disorders of pregnancy 75 Secondary postpartum haemorrhage 112 Pre-eclampsia 76 Self-monitoring 113 Patients at increased risk of pre-eclampsia 78 Family planning in the puerperium 114 The management of pre-eclampsia 79 Case study 1 119 The emergency management of severe pre- Case study 2 119 eclampsia and imminent eclampsia 79 Case study 3 120 The management of eclampsia 80 Case study 4 120 Gestational hypertension 81 Case study 5 121 Chronic hypertension 82 Case study 6 122 Case study 1 82 Case study 7 122 Case study 2 83 Case study 3 83 7 Medical problems during pregnancy Case study 4 84 and the puerperium 124 Urinary tract infection during pregnancy3A Skills workshop: Measuring blood 124 pressure and proteinuria 85 Anaemia in pregnancy 126 Measuring blood pressure 85 Heart valve disease in pregnancy and the Measuring proteinuria 86 puerperium 128 Diabetes mellitus in pregnancy 1294 Antepartum haemorrhage 87 HIV infection and AIDS in pregnancy 131 Antepartum haemorrhage 87 Case study 1 134 The initial, emergency management of Case study 2 134 antepartum haemorrhage 88 Case study 3 135 Diagnosing the cause of the bleeding 89 Case study 4 136 Antepartum bleeding caused by abruptio placentae 90 Appendix 139 Antepartum bleeding caused by placenta Guidelines for the management of praevia 90 patients with risk factors and medical A blood-stained vaginal discharge 92 problems during pregnancy, labour and Case study 1 93 the puerperium 139 Case study 2 93 Case study 3 94 Tests 152 Case study 4 945 Preterm labour and preterm rupture of the membranes 96 Preterm labour and preterm rupture of the membranes 96 Diagnosis of preterm labour and preterm rupture of the membranes 99 Case study 1 101 Case study 2 102
  • 6. AcknowledgementsPrimary Maternal Care has been edited from Editor-in-Chief of the Perinatal Educationselected units of the Maternal Care manual Programme: Prof D L Woodsof the Perinatal Education Programme. This Editors of Primary Maternal Care: Prof G Blearning programme for professionals is Theron and Prof R C Pattinsondeveloped by the Perinatal Education Trustand funded by Eduhealthcare. Contributors to Primary Maternal Care: Prof H van C de Groot, Dr D H Greenfield, Ms HWe acknowledge all the participants of the Louw, Prof G B Theron, Prof D L Woods.Perinatal Education Programme who havemade suggestions and offered constructivecriticism. It is only through constant feedbackfrom colleagues and participants that thecontent of the Perinatal Education Programmecourses can be improved.
  • 7. IntroductionABOUT THE EBW WHY DECENTRALISEDHEALTHCARE SERIES LEARNING?EBW Healthcare publishes an innovative Continuing education for healthcare workersseries of distance-learning books for traditionally consists of courses and workshopshealthcare 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 contentfrom numerous experts. frequently fails to address the real healthcare requirements of the poor, rural communitiesOur aim is to provide appropriate, affordable who face the biggest healthcare challenges.and up-to-date learning material forhealthcare 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 beeneducation courses which will enable them to developed which addresses the needs oflearn, practise and deliver skillful, efficient professional healthcare workers, especiallypatient care. those in poor, rural communities.The EBW Healthcare series is built onthe experience of the Perinatal EducationProgramme (PEP), which has provided BOOKS IN THE EBWlearning opportunities to over 60 000 nurses HEALTHCARE SERIESand doctors in South Africa since 1992. Manyof the educational methods developed by PEPare now being adopted by the World Health Maternal Care addresses all the commonOrganisation (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
  • 8. 10 PRIMAR Y MATERNAL CAREthe progress of labour, specific medical glucose concentration, insertion of an umbilicalproblems during pregnancy, labour and the vein catheter, phototherapy, apnoea monitorspuerperium, family planning and regionalised and oxygen therapy.perinatal care. Skills workshops teach clinicalexamination in pregnancy and labour, routine Primary Newborn Care was writtenscreening tests, the use of an antenatal card specifically for nurses and doctors whoand partogram, measuring blood pressure, provide primary care for newborn infants indetecting proteinuria and performing and level 1 clinics and hospitals. Primary Newbornrepairing an episiotomy. Care addresses the care of infants at birth, care of normal infants, care of low-birth-weightMaternal Care is aimed at healthcare workers infants, neonatal emergencies, and commonin level 1 hospitals or clinics. minor problems in newborn infants.Primary Maternal Care addresses the Mother and Baby Friendly Care describesneeds of healthcare workers who provide gentler, kinder, evidence-based ways of caringantenatal and postnatal care, but do not for women during pregnancy, labour andconduct deliveries. It is adapted from theory delivery. It also presents improved methodschapters and skills workshops from Maternal of providing infant care with an emphasisCare. This book is ideal for midwives and on kangaroo mother care and exclusivedoctors providing primary maternal care breastfeeding.in level 1 district hospitals and clinics,and complements the national protocol of Saving Mothers and Babies was developed inantenatal care in South Africa. response to the high maternal and perinatal mortality rates found in most developingIntrapartum Care was developed for doctors countries. Learning material used in this bookand advanced midwives who care for women is based on the results of the annual confidentialwho deliver in district hospitals. It contains enquiries into maternal deaths and the Savingtheory chapters and skills workshops adapted Mothers and Saving Babies reports published infrom the labour chapters of Maternal Care. South Africa. It addresses the basic principlesParticular attention is given to the care of mortality audit, maternal mortality,of the mother, the management of labour perinatal mortality, managing mortalityand monitoring the wellbeing of the fetus. meetings and ways of reducing maternal andIntrapartum Care was written to support perinatal mortality rates. This book shouldand complement the national protocol of be used together with the Perinatal Problemintrapartum care in South Africa. Identification Programme (PPIP).Newborn Care was written for healthcare Birth Defects was written for healthcareworkers providing special care for newborn workers who look after individuals with birthinfants in regional hospitals. It covers defects, their families, and women who are atresuscitation at birth, assessing infant size and increased risk of giving birth to an infant with agestational age, routine care and feeding of both birth defect. Special attention is given to modesnormal and high-risk infants, the prevention, of inheritance, medical genetic counselling,diagnosis and management of hypothermia, and birth defects due to chromosomalhypoglycaemia, jaundice, respiratory distress, abnormalities, single gene defects, teratogensinfection, trauma, bleeding and congenital and multifactorial inheritance. This bookabnormalities, as well as communication with is being used in the Genetics Educationparents. Skills workshops address resuscitation, Programme which trains healthcare workers insize measurement, history, examination and genetic counselling in South Africa.clinical notes, nasogastric feeds, intravenousinfusions, use of incubators, measuring blood
  • 9. INTRODUCTION 11Perinatal HIV enables midwives, nurses doctors and nurses with wide experience inand doctors to care for pregnant women and the care of adults with HIV, under the auspicestheir infants in communities where HIV of the Desmond Tutu HIV Foundation at theinfection is common. Special emphasis has University of Cape Town.been placed on the prevention of mother-to-infant transmission of HIV. It covers the basicsof HIV infection and screening, antenatal FORMAT OF THE COURSESand intrapartum care of women with HIVinfection, care of HIV-exposed newborninfants, and parent counselling. 1. Objectives The learning objectives are clearly stated at theChildhood HIV enables nurses and doctors start of each chapter. They help the participantto care for children with HIV infection. It to identify and understand the importantaddresses an introduction to HIV in children, lessons to be learned.the clinical and immunological diagnosisof HIV infection, management of childrenwith and without antiretroviral treatment, 2. Pre- and post-testsantiretroviral drugs, opportunistic infections There is a multiple-choice test of 20 questionsand end-of-life care. for each chapter at the end of the book. Participants are encouraged to take a pre-testChildhood TB was written to enable before starting each chapter, to benchmarkhealthcare workers to learn about the primary their current knowledge, and a post-test aftercare 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 monitormanagement and prevention of tuberculosis their own progress through the course.in children and HIV/TB co-infection.Childhood TB was developed by paediatricians 3. Question-and-answer formatwith wide experience in the care of children Theoretical knowledge is presented in awith tuberculosis, under the auspices of the question-and-answer format, which encouragesDesmond Tutu Tuberculosis Centre at the the learner to actively participate in theUniversity 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 andand important clinical problems in children, management of a particular problem.including immunisation, history andexamination, growth and nutrition, acute and Participants should cover the answer for a fewchronic infections, parasites, skin conditions, minutes with a piece of paper while thinkingand difficulties in the home and society. Child about the correct reply to each question. ThisHealthcare was developed for use in primary method helps learning.care settings. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toAdult HIV covers an introduction to HIV diagnosing or managing a particular problem.infection, management of HIV-infected adultsat primary-care clinics, preparing patients forantiretroviral (ARV) treatment, ARV drugs, Each question is written in bold,starting and maintaining patients on ARV like this, and is identified with thetreatment and an approach to opportunistic number of the chapter, followed by theinfections. Adult HIV was developed by number of the question, e.g. 5-23.
  • 10. 12 PRIMAR Y MATERNAL CARE4. 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 are5. Notes not yet accredited for nurses, but South African doctors can earn CPD points on the NOTE Additional, non-essential information is provided for interest and given in notes like this. successful completion of an examination. 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 studiesEach chapter closes with a few casestudies which encourage the participant CONTRIBUTORSto consolidate and apply what was learnedearlier in the chapter. These studies give the The developers of our learning materials are aparticipant an opportunity to see the problem multi-disciplinary team of nurses, midwives,as it usually presents itself in the clinic or obstetricians, neonatologists, and generalhospital. The participant should attempt to paediatricians. The development and review ofanswer each question in the case study before all course material is overseen by the Editor-reading the correct answer. in-Chief, emeritus Professor Dave Woods, a previous head of neonatal medicine at the7. Practical training University of Cape Town who now consults to 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,which are often illustrated with line drawings, Books developed by the Perinatal Educationlist essential equipment and present step-by- Programme are provided as cheaply as possible.step instructions on how to perform each Writing and updating the programme is bothtask. If participants aren’t familiar with a funded and managed on a non-profit basis bypractical skill, they are encouraged to ask an the Perinatal Education Trust.appropriate medical or nursing colleague todemonstrate the clinical skill to them. In this Eduhealthcareway, senior personnel are encouraged to sharetheir skills with their colleagues. Eduhealthcare is a non-profit organisation based in South Africa. It aims to improve health and wellbeing, especially in poor communities,8. Final examination through affordable education for healthcareOn completion of each course, participants workers. To this end it provides financialcan take a 75-question multiple-choice support for the development and publishing ofexamination on the EBW Healthcare website, the EBW Healthcare series.when they are ready to.All the exam questions will be taken from The Desmond Tutu HIV Foundationthe multiple-choice tests from the book. The The Desmond Tutu HIV Foundation at thecontent 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,
  • 11. INTRODUCTION 13building capacity through training and CONTACT INFORMATIONenhancing knowledge through research.The Desmond Tutu Tuberculosis Centre EBW HealthcareThe Desmond Tutu Tuberculosis Centre at Website: www.ebwhealthcare.comStellenbosch University, South Africa, strives Email: info@ebwhealthcare.comto improve the health of vulnerable groupsthrough the education of healthcare workers Telephone: +27 021 44 88 336and community members, and by influencing Fax: +27 088 021 44 88 336policy based on research into the epidemiologyof childhood tuberculosis, multi-drug- Post: 87 Station Road, Observatory, 7925,resistant tuberculosis, HIV/TB co-infection Cape Town, South Africaand preventing the spread of TB and HIV insouthern Africa. Editor-in-Chief: Professor Dave Woods Website: www.pepcourse.co.zaUPDATING THE Email: pepcourse@mweb.co.zaCOURSE MATERIAL Telephone: +27 021 786 5369 Fax: +27 021 671 8030EBW 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 Africaprotocols. Course participants can makeimportant contributions to the continualimprovement of EBW Healthcare booksby reporting factual or language errors,by identifying sections that are difficult tounderstand, and by suggesting additions orimprovements to the contents. Details ofalternative or better forms of managementwould be particularly appreciated. Please sendany comments or suggestions to the Editor-in-Chief, Professor Dave Woods.