Maternal Care: Introduction

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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

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Maternal Care: Introduction

  1. 1. Maternal CareA learningprogramme forprofessionalsDeveloped by thePerinatal Education Programme
  2. 2. Maternal CareA learning programmefor professionalsDeveloped by thePerinatal Education Programmewww.ebwhealthcare.com
  3. 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.Maternal Care:A learning programme for professionalsUpdated: 2 June 2010First published by EBW Healthcare in 2010Text © Perinatal Education Programme 2010Illustrations by Anne WestobyGetup © Electric Book Works 2010ISBN (print edition): 978-1-920218-27-0ISBN (PDF ebook edition): 978-1-920218-45-4All 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. 4. ContentsAcknowledgements 7 Case study 4 34Introduction 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 441 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. 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 rupture2A Skills workshop: Routine use of the of the membranes 117antenatal card 78 Diagnosis of preterm labour and preterm rupture of the membranes 1203 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 1393A Skills workshop: Measuring bloodpressure 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 1424 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. 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 2088a Skills workshop: Examination of the Sedation during labour 209abdomen 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 2118B Skills workshop: Vaginal examination Case study 2 212in 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 2258C Skills workshop: Recording Case study 1 226observations 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 2379 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. 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 25514 Family planning after pregnancy 257 Contraceptive counselling 257 Case study 1 263 Case study 2 264 Case study 3 264 Case study 4 26515 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 274Appendix 276 Guidelines for the management of patients with risk factors and medical problems during pregnancy, labour and the puerperium 276Tests 289
  8. 8. AcknowledgementsMaternal Care has been edited from the participants that the content of the PerinatalMaternal Care manual of the Perinatal Education Programme courses can beEducation Programme. This learning improved.programme for professionals is developed by Editor-in-Chief of the Perinatal Educationthe Perinatal Education Trust and funded by Programme: Prof D WoodsEduhealthcare. Editor of Maternal Care: Prof G TheronWe acknowledge all the participants of thePerinatal Education Programme who have Contributors to Maternal Care: Prof H van Cmade suggestions and offered constructive de Groot, Dr D Greenfield, Ms H Louw, Ms Mcriticism over the years. It is only through Petersen, Dr N Rhoda, Prof G Theron, Prof Dconstant feedback from colleagues and Woods
  9. 9. 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
  10. 10. 10 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
  11. 11. INTRODUCTION 11Perinatal HIV enables midwives, nurses and nurses with wide experience in the careand doctors to care for pregnant women and of adults with HIV, through the auspices oftheir infants in communities where HIV 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 in their own progress through the course.children and HIV/TB co-infection. ChildhoodTB was developed by paediatricians with 3. Question-and-answer formatwide experience in the care of children with Theoretical knowledge is presented in atuberculosis, through 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 doctors number of the question, e.g. 5-23.
  12. 12. 12 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 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 studiesEach chapter closes with a few case CONTRIBUTORSstudies which encourage the participantto consolidate and apply what was learned The developers of our learning materials are aearlier in the chapter. These studies give the multi-disciplinary team of nurses, midwives,participant an opportunity to see the problem obstetricians, neonatologists, and generalas it usually presents itself in the clinic or paediatricians. The development and review ofhospital. 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 to7. 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 Educationwhich 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 bothstep instructions on how to perform each funded and managed on a non-profit basis bytask. If participants aren’t familiar with a the Perinatal Education Trust.practical skill, they are encouraged to ask anappropriate medical or nursing colleague todemonstrate the clinical skill to them. In this Eduhealthcareway, senior personnel are encouraged to share Eduhealthcare is a non-profit organisationtheir 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 financialOn completion of each course, participants support for the development and publishing ofcan 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 FoundationAll the exam questions will be taken fromthe 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,
  13. 13. 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.
  14. 14. 1 Antenatal careBefore you begin this unit, please take the GOALS OF GOODcorresponding test at the end of the book toassess your knowledge of the subject matter. You ANTENATAL CAREshould redo the test after you’ve worked throughthe 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.

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