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. 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
1. During the antenatal period, both maternal
should redo the test after you’ve worked through
and fetal growth must be continually
the unit, to evaluate what you have learned.
monitored.
2. Individualised care will improve the
Objectives accuracy of antenatal observations.
3. At every antenatal visit from 28 weeks
When you have completed this unit you gestation onwards, the wellbeing of the
should be able to: fetus must be assessed.
• Assess normal fetal growth.
• List the causes of intra-uterine growth 2-1 How can you assess the condition
of the fetus during pregnancy?
restriction.
• Understand the importance of The condition of the fetus before delivery is
measuring the symphysis-fundus height. assessed by:
• Understand the clinical significance of 1. Documenting fetal growth.
fetal movements. 2. Recording 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. 60 PRIMAR Y MATERNAL CARE
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
2-3 When may fetal growth maternal problem such as pre-
appear to be abnormal? eclampsia.
• Smoking.
Fetal growth will appear to be abnormal when Poor placental function is uncommon in a
the assessed fetal weight is greater or less than healthy woman who does not smoke.
that expected for the duration of pregnancy.
Remember that incorrect menstrual dates If severe intra-uterine growth restriction is
are the commonest cause of an incorrect present, it is essential to look for a maternal or
assessment of fetal growth. fetal cause. Usually a cause can be found.
2-4 When is intra-uterine growth 2-6 How can you estimate fetal weight?
restriction suspected? The following methods can be used:
When the weight of the fetus is assessed as 1. Measure the size of the uterus on
being less than the normal range for the abdominal examination.
duration of pregnancy, then intra-uterine 2. Palpate the fetal head and body on
growth restriction (fetal growth restriction) is abdominal examination.
suspected. 3. Measure the size of the fetus using
antenatal ultrasonography (ultrasound).
2-5 What maternal and fetal
factors are associated with intra- 2-7 How should you measure
uterine growth restriction? the size of the uterus?
Intra-uterine growth restriction may be 1. This is done by determining the
associated with either maternal, fetal and symphysis-fundus height (S-F height),
placental factors: which is measured in centimetres from the
1. Maternal factors: upper edge of the symphysis pubis to the
• Low maternal weight, especially a top of the fundus of the uterus.
low body mass index resulting from 2. The S-F height in centimetres should be
undernutrition. plotted against the gestational age on the
• Tobacco smoking. S-F growth curve.
• Alcohol intake. 3. From 36 weeks onwards, the presenting
• Strenuous physical work. part may descend into the pelvis and
• Poor socio-economic conditions. measurement of the S-F height will not
• Pre-eclampsia and chronic accurately reflect the size of the fetus. A
hypertension. reduction in the S-F height may even be
observed.

3. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 61
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 2 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.
Between 18 and 36 weeks of pregnancy, the 2-10 How can you identify severe
S-F height normally increases by about 1 cm intra-uterine growth restriction?
a week. With severe intra-uterine growth restriction,
the difference between the actual duration of
2-9 When will the symphysis-fundus height pregnancy and that suggested by plotting S-F
suggest intra-uterine growth restriction? height is 4 weeks or more.
If any of the following are found:
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. 62 PRIMAR Y 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
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. 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 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- Syst.
PRESSURE Diast.
P P
Urine
S S
OEDEMA
RRT 2/01
Fetal movements Antenatal
Haemoglobim (g/dl) card B
ENG
Figure 2-4: A measurement less than that recorded 2 visits before
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.
4. If the gestational age is 28 weeks or more,
Yes. Descent of the presenting part may occur
careful attention must be paid to counting
in the last 4 weeks of pregnancy. Therefore,
the fetal movements.
after 36 weeks the above criteria are no
5. The patient should be followed up weekly
longer valid, if at subsequent antenatal visits
at a level 1 hospital.
progressively less of the fetal head is palpable
above the pelvic inlet.
2-13 Which special investigation
is of great value in the further
2-12 What action would you take if the
management of this patient?
symphysis-fundus height measurement
suggests intra-uterine growth restriction? The patient must be referred to a fetal
evaluation clinic or level 2 hospital for a
1. The patient should stop smoking and rest
Doppler measurement of blood flow in the
more, while attention must be given to her
umbilical arteries:
diet. It may be necessary to arrange sick
leave and social support for the patient. 1. Good flow (low resistance) indicates good
2. A poor diet which is low in energy placental function. As a result the woman
(kilojoules) may cause intra-uterine growth can receive further routine management
restriction, especially in a patient with a as a low-risk patient. Spontaneous onset of
low body mass index. Therefore, ensure
that patients with suspected intra-uterine
growth restriction receive a high-energy

6. 64 PRIMAR Y MATERNAL CARE
labour can be allowed. Induction of labour patient to patient. Therefore, it is only useful
at 38 weeks is not needed. as an approximate guide to the duration of
2. Poor flow (high resistance) indicates poor pregnancy.
placental function. Antenatal electronic
fetal heart rate monitoring must be done. 2-17 What is the value of
The further management will depend on assessing fetal movements?
the result of the monitoring.
Fetal movements indicate that the fetus is well.
If Doppler measurement is not available, the By counting the movements, a patient can,
patient must be managed as given in 2-14. therefore, monitor the condition of her fetus.
2-14 What possibilities must be 2-18 From what stage of pregnancy
considered if, after taking the above will you advise a patient to become
steps, there is still no improvement aware of fetal movements in order
in the symphysis-fundus growth? to monitor the fetal condition?
1. Intra-uterine death must be excluded From 28 weeks, because the fetus can now
by the presence of a fetal heart beat on be regarded as potentially viable (i.e. there is
auscultation. a good chance that the infant will survive if
2. With moderate intra-uterine growth delivered). All patients should be encouraged
restriction and good fetal movements, the to become aware of the importance of an
patient must be followed up weekly and adequate number of fetal movements.
delivery at 38 weeks should be considered.
3. If the above patient also has poor social Asking the patient if the fetus is moving normally
circumstances, an admission to hospital on the day of the visit is an important way of
will need to be considered. This should monitoring the fetal wellbeing.
ensure that the patient gets adequate rest, a
good diet and stops smoking.
4. If there are decreased or few fetal move- 2-19 What is a fetal movement chart?
ments, the patient should be managed as A fetal movement chart records the frequency
described in sections 2-25 and 2-26. of fetal movements and, thereby, assesses the
5. When there is severe intra-uterine growth condition of the fetus. The name “kick chart”
restriction, the patient must be referred is not correct, as all movements must be
to a level 2 or 3 hospital for further counted, e.g. rolling and turning movements,
management. as well as kicking.
2-20 Which patients should use
FETAL MOVEMENTS a fetal movement chart?
A fetal movement chart need not be used
2-15 When are fetal movements first felt? routinely by all antenatal patients, but only
when:
1. At about 20 weeks in a primigravida.
2. At about 16 weeks in a multigravida. 1. There is concern about the fetal condition.
2. A patient reports decreased fetal
2-16 Can fetal movements be movements.
used to determine the duration
of pregnancy accurately?
No, because the gestational age when fetal
movements are first felt differs a lot from

7. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 65
2-21 How should you advise a patient 2-24 What would you advise if the
to use the fetal movement chart? fetal movements suggest that the fetal
condition is not good?
Fetal movements should be counted and
recorded on the chart over a period of an hour 1. The mother should lie down on her side for
per day after breakfast. The patient should another hour and repeat the count.
preferably rest on her side for this period. 2. If the number of fetal movements
improves, there is no cause for concern.
2-22 How accurate is a fetal 3. If the number of fetal movements does
movement count? not improve, she should report this to her
clinic or hospital as soon as possible.
A good fetal movement count always indicates
a fetus in good condition. A distressed fetus A patient who lives far away from her nearest
will never have a good fetal movement count. hospital or clinic should continue with bed rest,
However, a low count or a decrease in fetal but if the movements are 3 or fewer over a 6
movements may also be the result of periods hour period, then arrangements must be made
of rest or sleep in a healthy fetus. The rest and for her to be moved to the nearest hospital.
sleep periods can last several hours.
2-25 What should you do if a patient
Tests with electronic equipment have shown
arrives at the clinic or hospital without
that mothers can detect fetal movements
a cardiotocograph (CTG machine)
accurately. With sufficient motivation, the fetal
with reduced fetal movements?
movement chart can be an accurate record of
fetal movements. It is, therefore, not necessary 1. Listen to the fetal heart with a fetal
to listen to the fetal heart at antenatal clinics stethoscope or a doptone to exclude intra-
if the patient reports an adequate number of uterine death.
fetal movements, or an adequate number of 2. The patient should be allowed to rest and
fetal movements has been recorded for the day. count fetal movements over a 6 hour period.
With 4 or more movements during the next
A uterus which increases in size normally, and 6 hours, repeat the fetal movement count
an actively moving fetus, indicate that the fetus the next day, after breakfast. If there are 3 or
is well. fewer movements over the next 6 hours, the
patient should see the responsible doctor.
2-23 What is the least number The patient should be given a drink
of movements per hour which containing sugar (e.g. tea) to drink to exclude
indicates a good fetal condition? hypoglycaemia as the cause of the decreased
fetal movements.
1. The number of movements during an
observation period is less important than
a decrease in movements when compared
to previous observation periods. If the
CASE STUDY 1
number of movements is reduced by half, it
suggests that the fetus may be at increased A patient is seen at the antenatal clinic at 37
risk of fetal distress. weeks gestation. She is clinically well and
2. If a fetus normally does not move much, reports normal fetal movements. The S-F
and the count falls to 3 or fewer per hour, height was 35 cm the previous week and is
the fetus may be in danger. now 34 cm. The previous week the fetal head
was ballotable above the brim of the pelvis and
it is now 3/5 above the brim. The fetal heart
rate is 144 beats per minute. The patient is
reassured that she and her fetus are healthy,

8. 66 PRIMAR Y MATERNAL CARE
and she is asked to attend the antenatal clinic measurements have remained the same even
again in a week’s time. though the S-F height measurement has not
fallen below the 10th centile.
1. Are you worried about the decrease in
the S-F height since the last antenatal visit? 2. What are the probable causes
of the poor fundal growth?
No, as the fetal head is descending into the
pelvis. The head was 5/5 above the brim of the Hard physical labour and smoking. Both
pelvis and is now 3/5 above the brim. these factors can cause intra-uterine growth
restriction.
2. What is your assessment
of the fetal condition? 3. What is the possibility of fetal distress
or death in the next few days?
The fetus is healthy as the S-F height is normal
for 37 weeks and the fetus is moving normally. Both these possibilities are most unlikely as the
patient has reported normal fetal movements.
3. What is the value of a normal fetal
heart rate during the antenatal period? 4. What can be done to
improve fetal growth?
The fetal heart rate is not a useful measure of
the fetal condition before the onset of labour. Arrangements should be made, if possible, for
If the fetus moves well during the antenatal the patient to stop working. She must also stop
period, there is no need to listen to the fetal smoking, get enough rest and have a good diet.
heart.
5. How should this patient be managed?
4. What is the value of fetal movements
She must be given a fetal movement chart and
during the antenatal period?
you must explain clearly to her how to use
Active fetal movements, noted that day, the chart. She must be placed in the high-risk
indicate that the fetus is healthy. The patient category and, therefore, seen at the clinic every
can, therefore, monitor the condition of her week. If the fundal growth does not improve,
fetus by taking note of fetal movements. the patient must be hospitalised and labour
should be induced at 38 weeks.
If a Doppler blood flow measurement of the
CASE STUDY 2 umbilical arteries indicates normal placental
function, routine management of a low-risk
You examine a 28 year old gravida 4 para 3 patient can be given. Induction at 38 weeks is
patient who is 34 weeks pregnant. She has no not needed.
particular problems and mentions that her
fetus has moved a lot, as usual, that day. The S-
F height has not increased over the past three CASE STUDY 3
antenatal visits but only the last S-F height
measurement has fallen to the 10th centile. The
A patient, who is 36 weeks pregnant with
patient is a farm labourer and she smokes.
suspected intra-uterine growth restriction,
is asked to record her fetal movements on
1. What do the S-F height a fetal movement chart. She reports to the
measurements indicate? clinic that her fetus, which usually moves 20
They indicate that the fetus may have intra- times per hour, only moved 5 times during an
uterine growth restriction, as the last three hour that morning.

9. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 67
1. What should the patient have done? 4. What should you do if the fetus moves
fewer than 10 times during the hour?
Rather than come to the clinic, she should
have counted the number of fetal movements If the fetal movement count remains less than
for a further hour. half the previous count, the patient should
be transferred to a hospital where antenatal
2. What is the correct management electronic fetal heart monitoring can be done.
of this patient? Further management will depend on the result
of the monitoring.
She must not go home unless you are sure that
her fetus is healthy. She should lie on her side
5. What is the correct management
and count the number of fetal movements
if electronic fetal heart
during one hour. If she has not had breakfast,
monitoring is not available?
give her a cold drink or a cup of sweetened tea
to make sure that she is not hypoglycaemic. Fetal movements should be counted for a
full 6 hours. If the fetus moves fewer than 4
3. What should you do if the fetus moves times, there is a high chance that the fetus is
more than 10 times during the hour? distressed. A doctor must now examine the
patient and decide whether the fetus should
If the number of fetal movements returns to be delivered and what would be the safest
more than half the previous count (i.e. more method of delivery.
than 10 times per hour), she can go home and
return to the clinic in a week. In addition, she
must count the fetal movements daily.

10. 68 PRIMAR Y MATERNAL CARE
Gestation 28
Gestation 28
weeks or more
weeks or more
with normal
with normal
fetal growth
fetal growth
No Yes
Concern about
Concern about
fetal wellbeing
fetal wellbeing
1. Inform patient about Good fetal Use fetal movements
importance of fetal movements, or 4 or chart for 1 hour each
movements more movements morning
2. Routine low-risk care per hour
Decrease of 50% or
more, or 3 or fewer
movements
per hour
Repeat
movements count Good fetal Repeat count for a
the next day movements further hour
Send patient to
nearest clinic or Fetal movements
hospital still poor
Flow diagram 2-I: The management of a patient with decreased fetal movements