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. 2
Assessment of
fetal growth and
condition during
pregnancy
Before you begin this unit, please take the INTRODUCTION
corresponding test at the end of the book to
assess your knowledge of the subject matter. You
During the antenatal period, both maternal and
should redo the test after you’ve worked through
fetal growth must be continually monitored.
the unit, to evaluate what you have learned.
Individualised care will improve the accuracy
of antenatal observations.
Objectives At every antenatal visit from 28 weeks
gestation onwards, the wellbeing of the fetus
When you have completed this unit you must be assessed.
should be able to:
• Assess normal fetal growth. 2-1 How can you assess the condition
of the fetus during pregnancy?
• List the causes of intra-uterine growth
restriction. The condition of the fetus before delivery is
• Understand the importance of assessed by:
measuring the symphysis-fundus height. 1. Documenting fetal growth.
• Understand the clinical significance of 2. Recording fetal movements.
fetal movements.
• Use a fetal-movement chart. When managing a pregnant woman, remember
• Manage a patient with decreased fetal that you are caring for two individuals.
movements.
• Understand the value of antenatal fetal
heart rate monitoring.

2. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 61
FETAL GROWTH Poor maternal weight gain is of very little
value in diagnosing intra-uterine growth
restriction.
2-2 What is normal fetal growth? 2. Fetal factors
• Multiple pregnancy.
If the assessed fetal weight is within the • Chromosomal abnormalities,
expected range for the duration of pregnancy, e.g. trisomy 21.
then the fetal growth is regarded as normal. • Severe congenital malformations.
• Chronic intra-uterine infection,
To determine fetal growth you must have an e.g. congenital syphilis.
assessment of both the duration of pregnancy 3. Placental factors
and the weight of the fetus. • Poor placental function (placental
insufficiency) is usually due to a
maternal problem such as pre-
2-3 When may fetal growth eclampsia.
appear to be abnormal? • Smoking. Poor placental function is
Fetal growth will appear to be abnormal when uncommon in a healthy woman who
the assessed fetal weight is greater or less than does not smoke.
that expected for the duration of pregnancy. If severe intra-uterine growth restriction is
Remember that incorrect menstrual dates present, it is essential to look for a maternal or
are the commonest cause of an incorrect fetal cause. Usually a cause can be found.
assessment of fetal growth.
NOTE True primary placental inadequacy is
2-4 When is intra-uterine growth an uncommon cause of intra-uterine growth
restriction suspected? restriction as placental causes are almost always
secondary to an abnormality of the spiral arteries.
Intra-uterine growth restriction is suspected
when the weight of the fetus is assessed as 2-6 How can you estimate fetal weight?
being less than the normal range for the
duration of pregnancy. The following methods can be used:
1. Measure the size of the uterus on
2-5 What maternal and fetal abdominal examination.
factors are associated with intra- 2. Palpate the fetal head and body on
uterine growth restriction? abdominal examination.
3. Measure the size of the fetus using
Intra-uterine growth restriction may be
antenatal ultrasonography (ultrasound).
associated with either maternal, fetal or
placental factors:
2-7 How should you measure
1. Maternal factors the size of the uterus?
• Low maternal weight, especially a
low body-mass index resulting from 1. This is done by determining the
undernutrition. symphysis-fundus height (s-f height),
• Tobacco smoking. which is measured in centimetres from the
• Alcohol intake. upper edge of the symphysis pubis to the
• Strenuous physical work. top of the fundus of the uterus.
• Poor socio-economic conditions. 2. The s-d height in centimetres should be
• Pre-eclampsia and chronic plotted against the gestational age on the
hypertension. s-f growth curve.

3. 62 MATERNAL CARE
3. From 36 weeks onwards, the presenting Between 18 and 36 weeks of pregnancy, the s-f
part may descend into the pelvis and height normally increases by about 1 cm a week.
measurement of the s-f height will not
accurately reflect the size of the fetus. A 2-9 When will the symphysis-fundus height
reduction in the s-f height may even be suggest intra-uterine growth restriction?
observed.
If any of the following are found:
2-8 What is the symphysis- 1. Slow increase in uterine size until one
fundus growth curve? measurement falls under the 10th centile.
2. Three successive measurements ‘plateau’
The symphysis-fundus growth curve compares
(i.e. remain the same) without necessarily
the s-f height to the duration of pregnancy.
crossing below the 10th centile.
The growth curve should preferably form
3. A measurement which is less than that
part of the antenatal card. The solid line of
recorded two visits previously without
the growth curve represents the 50th centile,
necessarily crossing below the 10th centile.
and the upper and lower dotted lines, the 90th
and 10th centiles, respectively. If intra-uterine Note that a measurement that was originally
growth is normal, the s-f height will fall normal, but on subsequent examinations
between the 10th and 90th centiles. The ability has fallen to below the 10th centile, indicates
to detect abnormalities from the growth curve intra-uterine growth restriction and not
is much increased if the same person sees the incorrect dates.
patient at every antenatal visit.
SIGNATURE:
DATE:
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
45 GESTATION EST. BY: 45
Dates
Sonar
40 40
Both
SF-measurement
35 LW. 0. = Weight 35
x = measurement
30 30
25 25
20 20
15 15
10 10
Start SF measurement Repeat examination of breasts at 34 weeks
5 Uterine size using PRESENTING PART 5
anatomical
landmarks HEAD ABOVE PELVIS (fifths)
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Figure 2-1: The symphysis-fundus growth chart

4. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 63
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
45 GESTATION EST. BY: 45
Dates
Sonar
40 40
Both
SF-measurement
35 LW. 0. = Weight 35
x = measurement
30 30
25 25
20 20
15 15
10 10
Start SF measurement Repeat examination of breasts at 34 weeks
5 Uterine size using PRESENTING PART 5
anatomical
landmarks HEAD ABOVE PELVIS (fifths)
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Figure 2-2: One measurement below the 10th centile
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
45 GESTATION EST. BY: 45
Dates
Sonar
40 40
Both
SF-measurement
35 LW. 0. = Weight 35
x = measurement
30 30
25 25
20 20
15 15
10 10
Start SF measurement Repeat examination of breasts at 34 weeks
5 Uterine size using PRESENTING PART 5
anatomical Vx
landmarks HEAD ABOVE PELVIS (fifths) 5
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Figure 2-3: Three successive measurements that remain the same

5. 64 MATERNAL CARE
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
45 GESTATION EST. BY: 45
Dates
Sonar
40 40
Both
SF-measurement
35 LW. 0. = Weight 35
x = measurement
30 30
25 25
20 20
15 15
10 10
Start SF measurement Repeat examination of breasts at 34 weeks
5 Uterine size using PRESENTING PART 5
anatomical VxVxVx
landmarks HEAD ABOVE PELVIS (fifths) 5 5 5
GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
BLOOD- S st.
PRESSURE Diast.
P P
Urine
S S
OEDE A
RRT 2 01
Fetal mo ements Antenatal
Haemoglobim (g dl) card B
ENG
Figure 2-4: A measurement less than that recorded two visits before
2-10 How can you identify severe diet. It may be necessary to arrange sick
intra-uterine growth restriction? leave and social support for the patient.
2. A poor diet which is low in energy
With severe intra-uterine growth restriction,
(kilojoules) may cause intra-uterine growth
the difference between the actual duration of
restriction, especially in a patient with a
pregnancy and that suggested by plotting s-f
low body-mass index. Therefore, ensure
height is four weeks or more.
that patients with suspected intra-uterine
growth restriction receive a high-energy
2-11 Does descent of the presenting diet. If possible, patients must be given
part of the fetus affect your food supplements (food parcels).
interpretation of the growth curve? 3. Exclude pre-eclampsia as a cause.
Yes. Descent of the presenting part may occur 4. If the gestational age is 28 weeks or more,
in the last 4 weeks of pregnancy. Therefore, careful attention must be paid to counting
after 36 weeks the above criteria are no the fetal movements.
longer valid, if at subsequent antenatal visits 5. The patient should be followed up weekly
progressively less of the fetal head is palpable at a level 1 hospital.
above the pelvic inlet.
2-13 Which special investigation
2-12 What action would you take if the is of great value in the further
symphysis-fundus height measurement management of this patient?
suggests intra-uterine growth restriction? The patient must be referred to a fetal
1. The patient should stop smoking and rest evaluation clinic or a level 2 hospital for a
more, while attention must be given to her

6. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 65
Doppler measurement of blood flow in the 2. An ultrasound examination should be
umbilical arteries: done, if available, to exclude serious
congenital abnormalities.
1. Good flow (low resistance) indicates good
3. If the fetus has reached viability (28 weeks
placental function. As a result the woman
or more, or 1000 g or above), antenatal
can receive further routine management
fetal heart rate monitoring should be done
as a low-risk patient. Spontaneous onset of
regularly. If this suggests fetal distress,
labour can be allowed. Induction of labour
the fetus must be delivered by Caesarean
at 38 weeks is not needed.
section.
2. Poor flow (high resistance) indicates poor
4. In severe intra-uterine growth restriction,
placental function. Antenatal electronic
the immediate danger is of intra-uterine
fetal heart rate monitoring must be done.
death, so the delivery of the fetus should be
The further management will depend on
considered at 36 weeks.
the result of the monitoring.
If a Doppler measurement is not available, the
patient must be managed as given in 2-14. FETAL MOVEMENTS
2-14 What possibilities must be
considered if, after taking the above 2-16 When are fetal movements first felt?
steps, there is still no improvement 1. At about 20 weeks in a primigravida.
in the symphysis-fundus growth? 2. At about 16 weeks in a multigravida.
1. Intra-uterine death must be excluded
by the presence of a fetal heartbeat on 2-17 Can fetal movements be
auscultation. used to determine the duration
2. With moderate intra-uterine growth of pregnancy accurately?
restriction and good fetal movements, the
No, because the gestational age when fetal
patient must be followed up weekly and
movements are first felt differs a lot from
delivery at 38 weeks should be considered.
patient to patient. Therefore, it is only useful
3. If the above patient also has poor social
as an approximate guide to the duration of
circumstances, an admission to hospital
pregnancy.
will need to be considered. This should
ensure that the patient gets adequate rest, a
good diet, and stops smoking. 2-18 What is the value of
4. If there are decreased or few fetal move- assessing fetal movements?
ments, the patient should be managed as Fetal movements indicate that the fetus is well.
described in sections 2-25 and 2-26. By counting the movements, a patient can
5. When there is severe intra-uterine growth monitor the condition of her fetus.
restriction, the patient must be referred
to a level 2 or 3 hospital for further 2-19 From what stage of pregnancy
management. will you advise a patient to become
aware of fetal movements in order
2-15 What is the management of severe to monitor the fetal condition?
intra-uterine growth restriction?
From 28 weeks, because the fetus can now
1. All patients with severe intra-uterine be regarded as potentially viable (i.e. there is
growth restriction must be managed in a a good chance that the infant will survive if
level 2 or 3 hospital. delivered). All patients should be encouraged
to become aware of the importance of an
adequate number of fetal movements.

7. 66 MATERNAL CARE
adequate number of fetal movements has been
Asking the patient if the fetus is moving normally
recorded for the day.
on the day of the visit is an important way of
monitoring the fetal wellbeing.
A uterus which increases in size normally, and
2-20 What is a fetal-movement chart?
an actively moving fetus, indicate that the fetus
is well.
A fetal-movement chart records the frequency
of fetal movements and thereby assesses the
condition of the fetus. The name ‘kick chart’ 2-24 What is the least number
is not correct, as all movements must be of movements per hour which
counted, i.e. rolling and turning movements, indicates a good fetal condition?
as well as kicking. 1. The number of movements during an
observation period is less important than
2-21 Which patients should use a decrease in movements when compared
a fetal-movement chart? to previous observation periods. If the
number of movements is reduced by half,
A fetal-movement chart need not be used
it suggests that the fetus may be at an
routinely by all antenatal patients, but only
increased risk of fetal distress.
when:
2. If a fetus normally does not move much,
1. There is concern about the fetal condition. and the count falls to three or fewer per
2. A patient reports decreased fetal hour, the fetus may be in danger.
movements.
2-25 What would you advise if the
2-22 How should you advise a patient fetal movements suggest that the fetal
to use the fetal-movement chart? condition is not good?
Fetal movements should be counted and 1. The mother should lie down on her side for
recorded on the chart over a period of an hour another hour and repeat the count.
per day after breakfast. The patient should 2. If the number of fetal movements
preferably rest on her side for this period. improves, there is no cause for concern.
3. If the number of fetal movements does
2-23 How accurate is a fetal not improve, she should report this to her
movement count? clinic or hospital as soon as possible.
A good fetal movement count always indicates NOTE A patient who lives far away from her
a fetus in good condition. A distressed fetus nearest hospital or clinic should continue
will never have a good fetal movement count. with bed rest, but if the movements are
However, a low count or a decrease in fetal three or fewer over a six-hour period, then
movements may also be the result of periods arrangements must be made for her to
of rest or sleep in a healthy fetus. The rest and be moved to the nearest hospital.
sleep periods can last several hours.
2-26 What should you do if a patient
Tests with electronic equipment have shown with reduced fetal movements arrives
that mothers can detect fetal movements at the clinic or hospital without a
accurately. With sufficient motivation, the cardiotocograph (CTG machine)?
fetal-movement chart can be an accurate
record of fetal movements. It is, therefore, 1. Listen to the fetal heart with a fetal
not necessary to listen to the fetal heart at stethoscope or a doptone to exclude intra-
antenatal clinics if the patient reports an uterine death.
adequate number of fetal movements, or an

8. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 67
2. The patient should be allowed to rest and • If the cervix is favourable and the
count fetal movements over a six-hour pregnancy is of more than 36 weeks
period. With four or more movements duration, the membranes should be
during the next six hours, repeat the ruptured. The fetal heart rate must be
fetal movement count the next day, after carefully monitored with a stethoscope
breakfast. If there are three or fewer during labour.
movements over the next six hours, the • If the cervix is unfavourable, and the
patient should see the responsible doctor. patient is more than 42 weeks pregnant,
a Caesarean section must be done.
The patient should be given a drink containing
• If the patient does not fall into either
sugar (e.g. tea) to exclude hypoglycaemia as
of the above-mentioned categories, she
the cause of the decreased fetal movements.
must be observed for a further six hours
The management of a patient with confirmed in hospital. If there is no improvement
decreased fetal movements in a hospital is in the number of fetal movements, the
demonstrated in Flow diagram 2-2. patient must be referred to a hospital
which has facilities for electronic fetal
2-27 What should the doctor do, in heart rate monitoring.
a hospital without fetal heart rate Sections 2-28 to 2-38 need only be studied
monitoring equipment, if there are by nurses and doctors who work in a level 2
decreased fetal movements? or 3 hospital where electronic fetal heart rate
First make sure that the fetus is potentially monitoring is available. All students must study
viable (at least 28 weeks or 1000 g). Further sections 2-39 and 2-40.
management will then depend on whether
or not there are signs of intra-uterine growth
restriction: ANTENATAL FETAL HEART
1. If there are clinical signs of intra-uterine RATE MONITORING
growth restriction:
• If the cervix is favourable, the mem-
branes must be ruptured. The fetal 2-28 What is antenatal fetal
heart rate must be very carefully moni- heart rate monitoring?
tored with a stethoscope during labour.
Antenatal (electronic) fetal heart rate
• If the cervix is unfavourable, a
monitoring assesses the condition of the fetus
Caesarean section must be done.
by documenting the pattern of heart rate
• If the estimated weight of the fetus
changes. It is done with a cardiotocograph (the
is 1500 g or more, the delivery may
machine) which produces a cardiotocogram
be managed in a level 1 or 2 hospital.
(the paper strip showing the uterine
However, if the estimated weight of
contractions and the fetal heart rate pattern).
the fetus is less than 1500 g, then the
delivery must take place in a level 2 Antenatal fetal heart rate monitoring is
hospital with a neonatal intensive care currently regarded as one of the best ways
unit, or a level 3 hospital. to assess the fetal condition. Fetal heart rate
monitoring has the advantage that it can be
done reasonably quickly, and that the results
Intra-uterine growth restriction plus decreased are immediately available.
fetal movements is an indication for delivery.
Hospitals which deal with mainly low-risk
2. If there are no clinical signs of intra-uterine patients can manage perfectly well without
growth restriction: a cardiotocograph. There is also no evidence
that antenatal fetal heart monitoring of low-

9. 68 MATERNAL CARE
Reactive pattern Non-reactive pattern dependent diabetes, preterm rupture of the
membranes or severe pre-eclampsia which
200 is being managed conservatively.
180
2-30 How do you interpret an
160 antenatal fetal heart rate pattern?
140 1. The fetal condition is good when:
• There is a reactive (normal) fetal heart
120
rate pattern.
100
Beats/minute
• There is a normal stress test.
2. No comment can be made about the fetal
80
condition when there is a non-reactive fetal
Rate: 1 cm/minute 60 heart rate pattern. In this case there are no
contractions and, therefore, one cannot
Figure 2-5: Reactive and non-reactive fetal heart determine whether there is a normal or
rate patterns abnormal stress test. The variability of the
heart rate will indicate whether there is
risk patients does anything to improve the fetal wellbeing or possible fetal distress.
outcome of the pregnancy. The interpretation 3. Fetal distress is present when:
of fetal heart rate patterns needs considerable • There is an abnormal stress test.
experience, and should only be done where • There are repeated U-shaped
the necessary expertise is available. decelerations at regular intervals, even
though no contractions are observed.
2-29 When is antenatal fetal heart • There is fetal bradycardia, with a fetal
rate monitoring indicated? heart rate constantly below 100 beats
per minute.
1. If a patient with a viable fetus reports a • There is a non-reactive fetal heart rate
decrease in fetal movements or a poor fetal pattern with poor variability (i.e. less
movement count which does not improve than five beats).
when the count is repeated.
2. If a high-risk patient has a condition for
which the value of fetal movement counts
has not yet been proven, e.g. insulin-
Good variability Poor variability
200 200
180 180
160 160
140 140
120 120
100 100
80 80
60 60
Figure 2-6: Non-reactive fetal heart rate pattern with good and poor variability.

10. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 69
2-31 What are reactive and non- • The variability in the heart rate will be
reactive heart rate patterns? less than five beats, in other words, will
remain within one block (Figure 2-6).
1. The fetal heart rate pattern is said to
• The fetal heart monitoring must be
be reactive when it has at least two
repeated after 45 minutes.
accelerations per ten minutes, each with
• If the poor variability persists, there is
an amplitude (increase in the number of
fetal distress.
beats) of 15 or more beats per minute and a
duration of at least 15 seconds (Figure 2-5).
2. In a non-reactive fetal heart rate pattern 2-33 Why must you repeat the
there are no accelerations. cardiotocogram after 45 minutes in a
patient with a non-reactive fetal heart
rate pattern and poor variability?
2-32 How is the variability in the fetal
heart rate used to determine whether a 1. Because a sleeping fetus may have a non-
fetal heart rate pattern is non-reactive? reactive fetal heart rate pattern with poor
variability.
1. With good variability:
2. A fetus does not sleep for longer than 45
• The variability in the heart rate will
minutes. In a sleeping fetus the fetal heart
be five beats or more, in other words,
rate pattern should, therefore, after 45
will involve one or more blocks in the
minutes have returned to a reactive pattern
cardiogram. Each block indicates five
or a non-reactive pattern with good
beats (Figure 2-6).
variability.
• Good variability indicates fetal
3. A persistent non-reactive fetal heart rate
wellbeing.
pattern with poor variability is abnormal
2. With poor variability:
and indicates fetal distress.
Normal Abnormal
200 200
180 180
160 160
140 140
120 120
100 100
80 80
60 60
2 0 0484 69
100 100
80 80
60 60
40 40
2 2
20 20
0 0
Figure 2-7: Normal and abnormal stress tests

11. 70 MATERNAL CARE
0
0
Figure 2-8: A late deceleration
2-34 What is a stress test? 2. However, false-positive abnormal
stress tests can be caused by postural
If contractions are present during fetal heart
hypotension or spontaneous
rate monitoring in the antenatal period, then
overstimulation of the uterus. Therefore, a
the monitoring is called a stress test. The fetal
stress test must always be performed with
heart rate pattern can now be assessed during
the patient on her side in the 15 degrees
the stress of a uterine contraction.
lateral position.
3. Whenever a fetal heart rate pattern
2-35 How is a stress test interpreted? indicates fetal distress, the cardiogram
1. A normal stress test has no fetal heart rate must be repeated immediately. If it is again
decelerations during or following at least abnormal, action should be taken as shown
two contractions which last at least 30 in Flow diagram 2-4.
seconds (Figure 2-7). 4. A persistent fetal bradycardia is usually
2. An abnormal stress test has late a preterminal event and, therefore, an
decelerations associated with uterine indication for an immediate Caesarean
contractions (Figure 2-7). This indicates section if the fetus is viable.
that the fetus is distressed. The use of antenatal fetal heart rate monitoring
is demonstrated in Flow diagram 2-3.
2-36 What are the characteristics
of a late deceleration? 2-38 Why should you not immediately
On the cardiotocogram the trough of the do a Caesarean section if the fetal
deceleration occurs 30 seconds or later after heart rate pattern indicates fetal
the peak of the contraction (Figure 2-8). distress and the fetus is viable?
Studies have shown that a false-positive
2-37 What should you do in the case abnormal stress test can occur in up to 80% of
of an abnormal stress test, fetal cases (i.e. an abnormal stress test in a healthy
bradycardia, repeated decelerations, or fetus). Therefore, whenever a fetal heart
a non-reactive fetal heart rate pattern pattern indicates fetal distress, the cardiogram
with persistent poor variability? must always be repeated immediately.
1. The patient is managed as an acute
emergency as these fetal heart rate patterns
indicate fetal distress.

12. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 71
2-39 What is the emergency management CASE STUDY 1
of proven fetal distress with a viable fetus?
Immediately proceed with fetal resuscitation, A patient is seen at the antenatal clinic at 37
as follows: weeks gestation. She is clinically well and
reports normal fetal movements. The s-f
1. Turn the patient onto her side.
height was 35 cm the previous week and is
2. Give 40% oxygen through a face mask.
now 34 cm. The previous week the fetal head
3. Start an intravenous infusion of Ringer’s
was ballotable above the brim of the pelvis and
lactate and give 250 μg (0.5 ml) salbutamol
it is now 3/5 above the brim. The fetal heart
slowly intravenously if there are no
rate is 144 beats per minute. The patient is
contraindications. The 0.5 ml salbutamol
reassured that she and her fetus are healthy,
must first be diluted in 9.5 ml sterile
and she is asked to attend the antenatal clinic
water. Monitor the maternal heart rate for
again in a week’s time.
tachycardia.
4. Deliver the infant by the quickest possible
route. If the patient’s cervix is 9 cm or 1. Are you worried about the decrease in
more dilated and the head is on the pelvic the s-f height since the last antenatal visit?
floor, proceed with an assisted delivery. No, as the fetal head is descending into the
Otherwise, perform a Caesarean section. pelvis. The head was 5/5 above the brim of the
5. If the patient cannot be delivered pelvis and is now 3/5 above the brim.
immediately (e.g. she must be transferred
to hospital) then a side-infusion of 200 ml 2. What is your assessment
saline with 30 mg salbutamol (ventolin) of the fetal condition?
can be run at a speed needed to keep the
maternal pulse rate at about 120 beats per The fetus is healthy as the s-f height is normal
minute. for 37 weeks and the fetus is moving normally.
It is important that you know how to give fetal
3. What is the value of a normal fetal
resuscitation, as it is a life-saving procedure
heart rate during the antenatal period?
when fetal distress is present, both during the
antepartum period and in labour. The fetal heart rate is not a useful measure of
the fetal condition before the onset of labour.
NOTE Uterine contractions can also be suppressed If the fetus moves well during the antenatal
if 30 mg nifedipine (Adalat) is given my mouth period, there is no need to listen to the fetal
(one capsule = 10 mg). The three capsules must heart.
be swallowed and not used sublingually.
4. What is the value of fetal movements
2-40 What are the aims of
during the antenatal period?
fetal resuscitation?
Active fetal movements, noted that day,
1. Suppressing uterine contractions and
indicate that the fetus is healthy. The patient
reducing uterine tone, which increases
can therefore monitor the condition of her
maternal blood flow to the placenta and,
fetus by taking note of fetal movements.
thereby, the oxygen supply to the fetus.
2. Giving the mother extra oxygen which will
also help the fetus.
CASE STUDY 2
It is, therefore, possible to improve the fetal
condition temporarily while preparations are You examine a 28-year-old gravida 4 para 3
being made for the patient to be delivered, or patient who is 34 weeks pregnant. She has no
to be transferred to the hospital. particular problems and mentions that her

13. 72 MATERNAL CARE
fetus has moved a lot, as usual, that day. The CASE STUDY 3
s-f height has not increased over the past three
antenatal visits but only the last s-f height
A patient, who is 36 weeks pregnant with
measurement has fallen to the 10th centile. The
suspected intra-uterine growth restriction, is
patient is a farm labourer and she smokes.
asked to record her fetal movements on a fetal-
movement chart. She reports to the clinic that
1. What do the s-f height her fetus, which usually moves 20 times per
measurements indicate? hour, only moved five times during an hour
They indicate that the fetus may have intra- that morning.
uterine growth restriction, as the last three
measurements have remained the same even 1. What should the patient have done?
though the s-f height measurement has not
Rather than come to the clinic, she should
fallen below the 10th centile.
have counted the number of fetal movements
for a further hour.
2. What are the probable causes
of the poor fundal growth?
2. What is the correct management
Hard physical labour and smoking. Both of this patient?
these factors can cause intra-uterine growth
She must not go home unless you are sure that
restriction.
her fetus is healthy. She should lie on her side
and count the number of fetal movements
3. What is the possibility of fetal distress during one hour. If she has not had breakfast,
or death in the next few days? give her a cold drink or a cup of sweetened tea
Both these possibilities are most unlikely as the to make sure that she is not hypoglycaemic.
patient has reported normal fetal movements.
3. What should you do if the fetus moves
4. What can be done to more than ten times during the hour?
improve fetal growth? If the number of fetal movements returns to
Arrangements should be made, if possible, for more than half the previous count (i.e. more
the patient to stop working. She must also stop than ten times per hour), she can go home and
smoking, get enough rest and have a good diet. return to the clinic in a week. In addition, she
must count the fetal movements daily.
5. How should this patient be managed?
4. What should you do if the fetus moves
She must be given a fetal-movement chart and fewer than ten times during the hour?
you must explain clearly to her how to use
the chart. She must be placed in the high-risk If the fetal movement count remains less than
category and therefore seen at the clinic every half the previous count, the patient should
week. If the fundal growth does not improve, be transferred to a hospital where antenatal
the patient must be hospitalised and labour electronic fetal heart monitoring can be done.
should be induced at 38 weeks. Further management will depend on the result
of the monitoring.
If a Doppler blood flow measurement of the
umbilical arteries indicates normal placental
function, routine management of a low-risk
patient can be given. Induction at 38 weeks is
therefore not needed.

14. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 73
5. What is the correct management 2. Does the fetal heart rate pattern
if electronic fetal heart indicate fetal distress?
monitoring is not available?
The condition of the fetus cannot be
Fetal movements should be counted for a full determined if there is a non-reactive antenatal
six hours. If the fetus moves fewer than four fetal heart rate pattern. The variability must
times, there is a high chance that the fetus is now be examined. If there is good variability
distressed. A doctor must now examine the (five beats or more), this indicates fetal
patient and decide whether the fetus should wellbeing.
be delivered and what would be the safest
method of delivery. 3. What must you do if there is poor
variability (fewer than five beats)?
Case study 4 need only be attempted by those
who have studied the section on antenatal fetal The test should be repeated after 45 minutes.
heart rate monitoring.
4. Why must you repeat the test after
45 minutes if there is a non-reactive
CASE STUDY 4 pattern with poor variability?
A sleeping fetus may have a fetal heart rate
Antenatal fetal heart rate monitoring is done pattern with poor variability. However, a fetus
on a patient who is 36 weeks pregnant and does not sleep for longer than 45 minutes.
who reports a decrease in the number of fetal The fetal heart rate pattern in that case will
movements. She lies flat on her back during therefore have reverted to normal when the
the test. A non-reactive fetal heart rate pattern test is repeated 45 minutes later.
is found.
5. What must you do if the test,
1. What is wrong with the method performed 45 minutes later, continues
used to monitor the fetal heart rate? to show poor variability?
The patient should not have been on her back The test now indicates fetal distress. If the
during the test as this can cause postural fetus is viable, arrangements must be made to
hypotension resulting in a falsely abnormal deliver it (see Flow diagram 2-4).
fetal heart rate pattern. The patient should lie
on her side with a 15 degree lateral tilt while
the fetal heart rate is monitored.

15. 74 MATERNAL CARE
Gestation 28
Gestation 28
weeks or more
weeks or more
with normal
with normal
fetal growth
oncern about
oncern about
fetal wellbeing
fetal wellbeing
1. Inform patient about Good fetal Use fetal mo ements
importance of fetal mo ements or 4 or chart for 1 hour each
mo ements more mo ements morning
2. Routine low-risk care per hour
Decrease of 50 or
more or 3 or fewer
mo ements
per hour
Repeat
mo ements count Good fetal Repeat count for a
the next da mo ements further hour
Send patient to
nearest clinic or Fetal mo ements
hospital still poor
Flow diagram 2-1: The management of a patient with decreased fetal movements

16. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 75
Confirmed
Gestation 28
decreased fetal
movements
Intra-uterine Fetal oncern about
heart present?
death
fetal wellbeing
See flow diagram 2-3 Fetal heart rate
monitoring available?
Repeat fetal Repeat fetal
movement count Four or more fetal movement count
the next day movements over next six hours
Fewer than four
See section 2-26
fetal movements?
Flow diagram 2-2: The management of a patient with confirmed decreased fetal movements in a hospital

17. 76 MATERNAL CARE
Decreased fetal mo ements
or three or fewer mo ements
per hour
No impro ement in mo ements
after another hour
Reacti e Non-reacti e
ontinue counting Antenatal fetal heart Spontaneous
fetal mo ements rate monitoring contractions
Negati e Yes No
Stress test
Variablit
Negati e Positi e
Repeat stress test aesarean section See Flow diagram
immediatel Positi e 2-4
Flow diagram 2-3: The use of antenatal fetal heart rate monitoring

18. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 77
Fetal heart rate ariation
Good Poor
Fi e beats or more Fewer than fi e beats
ontinue with fetal Repeat after
mo ement count 45 minutes
Good ariabilit
fi e or more beats
Poor ariabilit
Fewer than fi e beats
aesarean section
Flow diagram 2-4: The interpretation of variability when the fetal heart rate pattern is non-reactive with NO
spontaneous uterine contractions.