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

1. 1A
Skills workshop:
General exam-
ination at the first
antenatal visit
to some special event, e.g. Christmas or school
Objectives holidays. For example “How many periods have
you had since your birthday?, or “How many
periods had you missed before New Year?
When you have completed this skills
The expected date of delivery (EDD) must
workshop you should be able to:
now be estimated as accurately as possible. A
• Take an adequate history. quick estimate can be made by taking the date
• Perform a good general examination. of the LMP and adding 9 months and 1 week.
• Test the patient’s urine. Therefore, if the LMP was on 2-2-09, the EDD
• Perform and interpret a pregnancy test. will be on 9-11-09. If the LMP is 27-10-08, the
EDD will be 3-8-09.
HISTORY TAKING B Past obstetric history
It is important to know how many pregnancies
The purpose of taking a history is to assess the patient has lost. Patients often forget about
the past and present obstetrical, medical miscarriages and ectopic pregnancies, and
and surgical problems in order to detect risk may also not mention previous pregnancies
factors for the patient and her fetus. from another husband or boyfriend. Questions
which need to be asked are therefore:
A The last normal menstrual period (LMP)
1. How many times have you been pregnant?
Does she have a normal and regular menstrual Ask specifically about miscarriages and
cycle? ectopic pregnancies.
2. How many children do you have? This can
When did she last have a normal menstrual
bring to light the fact that she has had twins.
period?
3. How many children do you have who are
It may be difficult to establish the LMP when alive? If a child has died, one needs to
she has an irregular cycle. know approximately at what age the
child died, and the cause of death, e.g.
If the patient is uncertain of her dates, it is
“died at 15 months from diarrhoea”. If
often helpful to relate the onset of pregnancy

2. 36 PRIMAR Y MATERNAL CARE
the death occurred before delivery or 7. A retained placenta or postpartum
during the neonatal period (first 28 days), haemorrhage in previous pregnancies
information about the cause of death is should be asked for specifically.
of particular importance. Approximate
All these findings should be recorded briefly
birth weights of previous children, and
on the antenatal clinic record.
the approximate period of gestation, if the
infant was small or preterm, are useful.
Low birth weight suggests either growth C Medical history
restriction or preterm delivery, and heavy Patients must be specifically asked about
infants should alert one to the possibility diabetes, epilepsy, hypertension, renal disease,
of maternal diabetes. heart valve disease and tuberculosis. Also ask
4. Were you well during your previous about any other illnesses which she may have
pregnancies? In addition, asking about any had. Asking about allergies and medication
episodes of hospitalisation can be helpful. often brings to light a problem which the
5. How long were you in labour? It is patient may have forgotten, or thought not to
important to know if she has had a long be of significance. Always ask whether she has
labour, as this may indicate cephalopelvic ever had an operation or has been admitted to
disproportion. hospital and, if so, where and why.
6. The type of delivery is important. Any form
of assisted delivery, including a caesarean Any abnormal findings in the medical history
section, suggests that there may have been should be recorded, with a brief comment, on
cephalopelvic disproportion. The patient the antenatal record.
should always be asked if she knows the
reason for having had a caesarean section. D Family planning
Information about the type of incision The patient’s family planning needs and wishes
made in the uterus must be obtained from should be discussed at the first antenatal visit.
the hospital where the patient had her She (and her consort) should be encouraged to
caesarean section. A history of impacted plan the number and spacing of their children.
shoulders is important as it suggests that The contraceptive methods used should also
the infant was very large. be in keeping with these plans. The patient’s
wishes should be respected. The outcome of
L = Live
HISTORY * IUD
END
=
=
intra-uterine death
early neonatal death
Obstetric history LND = late neonatal death
ID = infant death
Gestation
Year (weeks) Delivery Weight Sex Complications
92 40 N 3 200 F L Gastroenteritis
98 36 C/S 2 000 M IUD Cong. Abnor.
03 38 N 2 900 F L
Description of complications
Figure 1-1 A: Recording past obstetric history

3. SK ILLS WORKSHOP 37
these discussions should be recorded on the G Examination of the breasts
antenatal record.
The patient must be undressed in order for the
breasts to be examined properly. The breasts
should be examined with the patient both
EXAMINATION sitting and lying on her back, with her hands
OF THE PATIENT above her head.
1. Look: There may be obvious gross
abnormalities. Particularly look for any
E General examination
distortion of the breasts or nipples. The
The following should be assessed: nipples should be specifically examined
with regard to their position and deformity
1. Height – measured in cm. This does not
(if any), discharge, and whether or not they
require special equipment. A tape measure
are inverted. Note any eczema of the areola.
stuck to the wall, or a wall marked at
2. Feel: Feel for lumps, using the flat hand
1 cm intervals is adequate. The patient
rather than the fingers.
should not wear shoes when her height is
measured.
2. Weight – measured in kilograms. The H Examination of the lymph nodes
patient should only wear light clothing When the thyroid is examined, the neck
while her weight (mass) is being measured. should also be thoroughly examined for
The scale should be periodically checked enlarged lymph nodes. The areas above the
for accuracy, and if necessary re-calibrated. clavicles and behind the ears must be palpated.
Latest research indicates that poor weight The axillae and inguinal areas should also be
gain, no weight gain or excessive weight examined for enlarged lymph nodes.
gain during pregnancy is not important.
Worldwide there is a swing away from Patients with AIDS usually have enlarged
weighing patients except at the first lymph nodes in all these areas.
antenatal visit.
3. General appearance: I Examination of the chest
• Is the patient thin or overweight? The patient must be undressed. Look for any
• Is there evidence of recent weight loss? of the following signs:
• The presence of pallor, oedema,
jaundice and enlarged lymph nodes 1. Any deformities or scars.
should be specifically looked for. 2. Any abnormality of the spine.
3. Any difficulty breathing (dyspnoea).
F Examination of the thyroid gland
J Examination of the cardiovascular system
This can be difficult when the patient has a
short, thick neck, or when she is obese. Look 1. Pulse: The rate is important. A rapid heart
for an obviously enlarged thyroid gland (a rate is almost always an indication that the
goitre). The patient should be referred for patient is anxious or ill.
further investigation when there is obvious 2. Blood pressure.
enlargement of the thyroid, the thyroid
feels nodular or a single nodule can be felt.
A normal thyroid gland is usually slightly
enlarged during pregnancy.

4. 38 PRIMAR Y MATERNAL CARE
TESTING THE individual tests are on the chart.
Combi-9: All the tests are read after
PATIENT’S URINE 60 seconds.
6. After 2 minutes the colours on the reagent
Urine is most conveniently tested using reagent strips no longer give a reliable result.
strips. Some strips will measure pH, glucose, The patient’s urine should be tested at every
ketones, protein and blood (e.g. Lenstrip-5) antenatal visit, and the results recorded on
while others will also measure bilirubin, specific the antenatal chart. Proteinuria of 1+ or
gravity, urobilinogen, nitrite and leucocytes more is abnormal while glycosuria must be
(e.g. Multistix and Combi-9 Test). However, investigated further.
measuring glucose and protein are most
important and, therefore, only glucose and
protein (e.g. Uristix) need to be measured in DOING A
routine antenatal screening. This is the cheapest
method. The cost can be reduced further by PREGNANCY TEST
cutting the strips in two, longitudinally.
The strips should be kept in their containers, L Indications for a pregnancy test
away from direct sunlight, and at a
temperature of less than 30 °C. A cool dry This test is usually done when a patient
cupboard is satisfactory. The strips should has missed one or more menstrual periods
only be removed from their containers one and when, on clinical examination, one is
at a time immediately before use, and the uncertain whether or not she is pregnant.
container closed immediately. The test is based on the detection of human
chorionic gonadotrophin in the patient’s urine.
K Procedure for testing urine The earliest that the test can be expected to be
1. The patient should pass a fresh specimen of positive is 10 days after conception. The test
urine. If the specimen is more than 1 hour will be positive by the time a pregnant woman
old the test results may be unreliable. first misses her period. If the test is negative
2. The specimen should be collected in a and the woman has not missed her period yet,
clean, dry container. the test should be repeated after 48 hours.
3. Dip the reagent strip in the urine so that
all the reagent areas are covered, and then M Storage of test ‘kit’
remove it immediately. If the strip is left in
The test which is described in this unit is
the urine, the reagents dissolve out of the
the U-TEST β-hCG STRIP FOIL. If another
strip, giving a false reading.
pregnancy test is used, the method of doing
4. Draw the edge of the reagent strip across
the test and reading the results must be
the edge of the urine container to remove
carefully studied in the instruction booklet. All
excess urine, and hold the strip horizontally.
these kits can be stored at room temperature.
5. Hold the strip close to the colour chart
However, do not expose to direct sunlight,
on the container label (but not touching
moisture or heat.
it). It is important to compare the colours
of the test strip with those on the chart at
the correct times. Most of the test results N Method of performing a pregnancy test
are read between 30 and 60 seconds after The patient should bring a fresh urine
dipping the strip in urine: specimen.
Lenstip-5: All the tests are read after
30–60 seconds.
Multistix: The times for reading the

5. SK ILLS WORKSHOP 39
1. Open the foil rapper and remove the test O Reading the result of the pregnancy test
strip.
1. Negative if only the control band nearest
2. Hold the blue end of the test strip so that
the upper blue part of the test strip
the blue arrow points downwards. Dip the
becomes pink.
test strip into the urine, as far as the point
2. Positive if two pink bands are visible.
of the arrow, for 5 seconds.
Between the control band and the blue part
3. Place the test strip on a flat surface and
of the test strip another pink band is seen.
read after 30 seconds. The result is not
3. Uncertain if no pink bands are seen. Either
reliable if the test strip is read more than 10
the test was not performed correctly or the
minutes after it was dipped into the urine.
test strip is damaged. Repeat the test with
another test strip.