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. 15
Regionalised
perinatal care
Before you begin this unit, please take the care in that region must fall under a single
corresponding test at the end of the book to health authority as this standardises care and
assess your knowledge of the subject matter. You prevents wasteful duplication of services. The
should redo the test after you’ve worked through borders of each healthcare region will have to
the unit, to evaluate what you have learned. be negotiated with the communities and local
health authorities concerned. Similarly, other
healthcare services should also be organised
Objectives on a regional basis.
When you have completed this unit you All perinatal care provided in a region should be
should be able to: the responsibility of a single health authority.
• List the advantages of regionalised
perinatal care. 15-2 Do all women require the
• Describe the functioning of a maternal- same care during their pregnancy,
care clinic. labour and puerperium?
• Communicate better with patients and All patients should receive good care.
colleagues. However, all patients do not need the same
• Safely transfer a patient to hospital. care as they do not all run the same risk of
developing perinatal problems. Patients can be
• Determine the maternal mortality rate.
classified into three separate groups:
1. Most patients have only a small chance of
REGIONALISED developing problems during and after their
pregnancy. These women are classified as
PERINATAL CARE low risk. About 50% of women fall into the
low-risk category.
2. About 30% of patients have an increased
15-1 What is regionalised perinatal care? chance of complications during certain
Regionalised perinatal care is the care of all periods of their pregnancy, labour and
pregnant women and their newborn infants puerperium only. These patients are said
in a single health system within a clearly to be at intermediate risk. For example, a
defined region. The responsibility for perinatal patient who has had a previous Caesarean

2. REGIONALISED PERINATAL CARE 267
section for cephalopelvic disproportion immediately available should complications
is at low risk during her pregnancy and develop. The important feature of tertiary care
may, therefore, be cared for at a clinic. is the immediate availability of specialist staff
However, she is at increased risk during and facilities should they be needed.
labour and, therefore, must be delivered
in a hospital with facilities to perform a 15-5 What should be the relationship
Caesarean section. between the various hospitals
3. About 20% of women have an increased in a healthcare region?
chance of medical or obstetric problems
during their pregnancy and puerperium. Each healthcare region will have a regional
They are classified as high-risk patients. hospital (level 2) which provides secondary
care. Usually two or three regions are
supported by a tertiary hospital (level 3). Some
15-3 Should all pregnant women
tertiary hospitals are attached to a medical
be delivered in a hospital?
school while most have a nursing college.
No. Low-risk patients need primary Each region will also have a number of base or
perinatal care only. This consists of good, district hospitals (level 1) which will provide
basic perinatal care which can be provided level 1 care. The regional hospital is responsible
at a district hospital or primary-care clinic. for the district hospitals in that region.
Low-risk patients should be delivered at a
The staff at the regional hospital should
clinic or district hospital. Patients at high or
communicate closely with the staff at the
intermediate risk need more than primary
district hospitals. Patients at the district
care. They require care at a district hospital
hospitals needing tertiary care should be
with facilities to perform a Caesarean section,
transferred directly to the tertiary hospital.
secondary level care or tertiary level care.
In turn, the regional hospital staff should
Secondary perinatal care requires additional
provide educational programmes for, and give
equipment as well as doctors and nurses
management advice to, the district hospital
with special training. Tertiary perinatal care
staff. Each district hospital usually has a
usually consists of very expensive intensive
number of primary healthcare centres.
care which requires highly specialised staff and
sophisticated equipment. All medical and nursing staff in a health region
should regard themselves as members of a
team whose goal is to provide good quality
About half of all patients are at low risk of care to all the patients in that region. All
developing clinical problems during pregnancy, staff members should, therefore, co-operate
labour and the puerperium and, therefore, need and help one another. The responsibility for
primary perinatal care only. all mothers and infants in the region is then
shared between all the staff working in that
15-4 Should all patients be region. It is particularly important that the
delivered by a doctor? clinic and hospital staff work as a team and do
not regard themselves as separate services.
No. Patients at low risk who only need
primary perinatal care can be safely delivered The fragmentation of health services, with
by a midwife. Patients needing care at a various hospitals and clinics falling under
district hospital with facilities to perform a different authorities, is a major cause of poor
Caesarean section or secondary perinatal care perinatal care in many communities.
may be delivered by a doctor or a midwife.
Patients needing tertiary perinatal care are
usually delivered by a doctor who has had
specialist training, or a midwife with a doctor

3. 268 MATERNAL CARE
15-6 How should the district hospital insist that you speak to a senior staff
assist the perinatal clinics in that district? member if you are not satisfied with the
advice you receive.
Each primary-care clinic should be linked to
a district hospital (level 1) within the same
region. The district hospital is responsible 15-8 How can a referral hospital improve
for the perinatal care given at the clinics in communication with the clinic?
that district. The clinic staff should contact 1. A telephone line for incoming calls only (a
this hospital for help or advice, and problem ‘hotline’) should be available in the labour
patients should be referred to that hospital ward of the hospital so that the clinic staff
when needed. The staff of the district hospital can contact the hospital staff without delay.
should be able to rotate with the staff at the 2. The most senior and experienced nurse or
clinics. This ensures that the standard of care doctor should receive the call. Each day
in the clinics is maintained at a high level, and night someone should be allocated to
and also helps the hospital and clinics staff answer the clinic calls.
understand each other’s difficulties. 3. Listen carefully, be patient, and try to
obtain a clear idea of the problem.
15-7 How should clinic staff communicate 4. Ask for important information which has
with the referral hospital? not been provided.
5. It is better to admit the patient if there is
1. A telephone or two-way radio is essential
any doubt about her condition.
so that the clinic staff and the hospital staff
6. Arrange the transfer. Usually this is done
can speak directly to each other.
by the referring clinic or hospital. However,
2. Clear guidelines are needed to indicate
in an urban region the receiving hospital
which patients should be referred to
may prefer to arrange the transport.
hospital. If the clinic staff are uncertain
7. Indicate any emergency treatment which
whether a patient needs referral, they must
must be given before or during transport.
discuss the problem with the staff of the
8. If possible, inform the clinic after the
referral hospital.
patient has arrived at the hospital. A
3. The staff at each clinic must know which
reply letter should be used to indicate the
hospital to contact if they need help. The
patient’s condition on arrival, the diagnosis
hospital’s telephone number must be
made by the hospital staff and the patient’s
displayed next to the clinic’s telephone.
response to treatment. Feedback to the
4. The clinic staff must collect all the relevant
referring clinic is essential.
information on the patient before phoning
9. Ideally, all patients transferred from a
to discuss the patient. Good notes must
clinic should be reviewed every month.
always accompany the patient as they
This should ideally be done during an
are one of the most effective methods
outreach visit from the referral hospital.
of communication. Either the complete
In this way problems with referrals can be
patient record or at least the antenatal card
identified and corrected.
must be sent with the patient. If the patient
10. A checklist available at the emergency
is in labour, the partogram must also be
telephone in the referral hospital helps to
sent. It is essential that the clinic staff
ensure that a complete history is obtained
identify the patient’s clinical problems.
and that no important information is
5. When speaking to the hospital staff,
forgotten. If the person receiving the call
stress the important information and
does not know what advice to give, this
summarise the problem. State clearly
information is then used when discussing
where advice is needed.
the patient with a more senior colleague.
6. Always give your name and rank and ask
The name and telephone number of the
who you are speaking to. If necessary,

4. REGIONALISED PERINATAL CARE 269
person making the call must always be 15-10 What are the functions of a
recorded. midwife in a maternal-care clinic
where deliveries are done?
Excellent communication and co-operation The midwife is responsible for all the antenatal
between the staff of hospitals and clinics in a care, the care during labour and delivery,
region are needed to provide good perinatal care. and the postnatal care given at the clinic. The
midwife should function as an independent
nurse-practitioner and meet all the primary
perinatal care needs of low-risk patients.
THE MATERNAL-
CARE CLINIC 15-11 What are the functions of a
doctor in a maternal-care clinic?
15-9 What is a maternal-care clinic? The doctor does not fulfil the usual functions
of a medical practitioner and should not see
A maternal-care clinic (perinatal-care clinic) every patient who attends the clinic. The
is a special clinic where midwives provide functions of the doctor are:
primary antenatal and postnatal care. Some
maternal-care clinics also have facilities to 1. To consult, i.e. to examine and advise on
deliver low-risk patients. A maternal-care the management of patients referred by the
clinic with a delivery facility is often called a midwives with various problems.
midwife obstetric unit (MOU). These clinics 2. To teach. It is essential that the doctor
function day and night, and should be situated teaches the midwives the essential
in or near to the community which it serves. knowledge and clinical skills which
Primary maternal and newborn care (primary they need to function competently in a
perinatal care) is part of primary healthcare maternal-care clinic.
and, therefore, the facilities of a primary- 3. To administer. Together with the senior
healthcare centre are often used to provide midwife, the doctor should plan,
perinatal care. In practice, the staff providing implement and evaluate all care given at
perinatal care usually provide other forms of the maternal-care clinic.
primary healthcare as well. A maternal-care 4. To audit the number and reasons for
clinic may also be run in a level 1 hospital. In referral.
large urban or periurban communities, there
may be maternal-care clinics separate from 15-12 What is the role of the community
primary-healthcare centres. Some clinics only in a maternal-care clinic?
offer antenatal care with the mother having The maternal-care clinic should be acceptable
to deliver at another clinic further away from to the community as a facility which provides
her home. These antenatal-care clinics must excellent primary perinatal care for patients
function as an extension of the maternal-care from that community. Every effort should be
clinic with a delivery facility as very close co- made to involve the community in establishing
operation is essential. and running the clinic. It is desirable to form
a lay organisation (such as ‘Friends of the
At a maternal care clinic midwives provide Maternal-Care Clinic’) to help meet this role.
primary perinatal care to low-risk patients. Representatives from the community, together
with medical and nursing staff, should sit
on the management board of the clinic. The
community can help raise funds for the clinic
and can also help provide some of the care,
e.g. help run breastfeeding clinics and to be

5. 270 MATERNAL CARE
trained as doulas to assist women delivering in If patients are delivered at a clinic and then
clinics or hospitals. discharged home after an average of six hours,
many of the benefits of being close to the family
The clinic staff should co-operate and
and home surroundings can still be enjoyed.
communicate with community members,
such as village health workers, traditional NOTE In an affluent community it may be
birth attendants (TBAs), traditional healers, possible to safely deliver carefully selected
breastfeeding advisors, social workers and low-risk patients at home provided a
schoolteachers, who can all assist in improving telephone and immediate transport are
perinatal services in that community. available in case complications develop.
15-13 What are the advantages of a 15-15 Which patients should not be
maternal-care clinic with delivery facilities? delivered at a maternal-care clinic
but must be referred to a hospital?
1. The patient remains close to her home and
community. Every perinatal region must draw up its own
2. More personal care can be given as labour detailed and easily understood list of criteria
and delivery take place in a relaxed for referring patients from a maternal-care
atmosphere. clinic (or level 1 hospital) to either a level 2 or a
3. A saving in transfer and hospital costs. level 3 hospital. The responsibility for drawing
4. The staff often can work close to their up the list of referral criteria rests with the
homes which saves both time and money. senior members of the obstetric, neonatal and
Staff also get great work satisfaction through nursing staff at the regional (level 3) hospital,
being able to accept greater responsibility in consultation with the medical and nursing
than in a hospital, provided that they staff at the level 1 and 2 hospitals and maternal-
receive support from the hospital staff. care clinics. Referral criteria will differ between
regions as the criteria will depend on the
The many advantages of delivering low-risk
distance the patient has to be transferred,
patients in a clinic only apply if the clinic
the facilities and staff available at the clinics,
is supported by a level 1 or 2 hospital. The
and the quality of the available transport. (A
community will not accept care given at a
complete set of guidelines for the referral of
maternal-care clinic if rapid and safe transfer
antenatal patients is listed in Appendix 1.
is not available when patients develop
complications. NOTE These referral criteria should be
frequently reviewed in the light of the
15-14 Why is delivery in a maternal-care number and nature of the clinical problems
clinic safer than a home delivery? requiring referral of patients to hospital.
Many low-risk patients can be safely delivered There must be referral criteria for the mother
at home. However, many homes do not have as well as for the newborn infant.
good lighting, a telephone, clean water and
adequate space for a safe delivery. In addition,
Each maternal-care clinic must have its own list
many homes are far from the hospital or clinic
of referral criteria.
should problems occur with the mother or
infant. In these circumstances it is far safer
for the patient to deliver at a maternal-care 15-16 How can communication
clinic with a delivery facility where staff and between the clinic staff and their
equipment are available to deal with most of the patients be improved?
perinatal complications. In densely populated
1. Make time to speak to the patients.
areas midwives working in maternal-care clinics
provide a better service to the community.

6. REGIONALISED PERINATAL CARE 271
2. If possible, find a place where the patient The clinical problem and the required
can speak to you in private. management must be discussed between the
3. Be honest when you tell patients about maternal-care clinic staff and the hospital
their clinical problems. staff. Most patients who are transferred during
4. Listen to what they say and ask. the antenatal period do not need to get to
5. Use simple language. hospital urgently and, therefore, do not need
6. Allow patients to ask questions. to be transported by ambulance. However, all
7. Look at the patient when you speak to her. patients transferred to hospital during labour
8. Address the patient by name. will require ambulance transport. Usually
9. Watch, listen and learn when more the referring clinic or hospital will make the
experienced colleagues speak to patients. arrangements for transferring the patient. If
10. Try to understand what the patient is the clinic arranges transport, the hospital must
feeling. be notified of these arrangements.
11. Be kind and helpful.
12. At the completion of an antenatal visit the
patient must be clearly informed if the
Always contact the referral hospital before
findings were normal. transferring a patient.
15-17 What can be done to simplify 15-19 What can be done to make the
note-keeping in a maternal-care clinic? transfer of a patient as safe as possible?
The patient should carry a hand-held antenatal Before an ill patient may be transferred from
card or patient record which contains all her a primary maternal-care clinic to a hospital,
antenatal information. This is a simple, cheap both she and her fetus or newborn infant
and highly effective method of recording must first be stabilised. They will then be in
patient information when caring for low- the best possible condition to be moved and
risk patients. Most patients look after their will have the best chance of arriving safely at
cards and take them along to the clinic. It is the hospital. To achieve these objectives, the
uncommon for patients to lose their cards. following must be done before the patient
This system avoids the frustrating situation leaves the maternal-care clinic:
where the patient presents at a clinic or 1. The patient and/or the fetus or newborn
hospital, but her folder is being kept elsewhere. infant must be fully resuscitated.
Using an antenatal card instead of a folder also 2. An intravenous infusion (drip) must be in
shortens the time the patient has to wait at the place.
clinic and reduces the workload of the staff. If 3. All the necessary drugs must be readily
a hand-held antenatal card or patient record available while the patient is being
system is used, there is no need to issue patient transferred to hospital.
folders before labour. 4. Oxygen and resuscitation equipment in
good working order must be available. The
latter includes equipment for face-mask
TRANSFERRING PATIENTS ventilation and endotracheal intubation.
SAFELY TO HOSPITAL 5. A person competent in adult and neonatal
resuscitation must accompany the patient.
15-18 How should the transfer of a patient 15-20 Who should care for the patient while
from a clinic to a hospital be arranged? she is being transported to the hospital?
It is essential that the base hospital be There are a number of referral criteria where it
contacted before the patient is transferred. is quite safe for the patient to travel to hospital

7. 272 MATERNAL CARE
with only a lay person accompanying her, e.g. a the puerperium, and is expressed per 100 000
patient in early labour who has had a previous deliveries. Therefore, if 25 women die during
Caesarean section can use her own or public pregnancy, labour, or the puerperium in a
transport. These conditions must be detailed healthcare region where 50 000 deliveries are
in the list of referral criteria. In all other done a year, the maternal mortality ratio for
circumstances, patients with complications that region in that year will be 50 per 100 000
must be accompanied by a qualified person (i.e. 25/50 000 x 100 000).
competent in adult and neonatal resuscitation.
The maternal mortality ratio in developing
This may be a midwife, doctor or trained
countries or poor communities in developed
ambulance personnel (ambumedics). To send
countries is usually 50 or more per 100 000
an ill patient or newborn infant to hospital
deliveries. This contrasts with the maternal
without being accompanied by such a qualified
mortality ratio of less than 10 per 100 000
person is dangerous and is likely to result in
in most industrialised countries with good
serious complications or even the death of the
health services.
patient and/or her infant.
It is important to note that women who die as
15-21 What documentation should a result of complications in early pregnancy,
be sent with the patient? e.g. septic miscarriage or ectopic pregnancy,
are included under maternal deaths.
All the clinical notes of the patient (and her
newborn infant) must be sent with her to the
hospital. Good record-keeping is an essential The maternal mortality rate in developing
part of perinatal care. Before transferring a countries is high.
patient you must, therefore, make sure that
the patient record gives an accurate account 15-24 What is the value of knowing the
of what has happened to the patient up to maternal mortality ratio in your region?
the time of transfer. It is very important to
include details of the complications and the It is very important to determine the maternal
management. Clearly state why the patient mortality ratio in each region of the country
requires transfer to hospital. as this ratio reflects the quality of the care
provided to women during pregnancy, and
15-22 What are the main dangers during and after delivery. Even in a poor
to the patient while she is being community, the maternal mortality ratio can
transported to the hospital? be reduced by the provision of good perinatal
care. Knowing the maternal mortality ratio of
1. Antepartum haemorrhage. a region also allows comparisons to be made
2. Convulsions, i.e. eclampsia. with other regions or comparisons between
3. Intracranial haemorrhage due to severe patients delivered in different years in a region.
uncontrolled hypertension. As the quality of perinatal care improves, the
4. Respiratory arrest. maternal mortality ratio should decrease.
5. Cord prolapse.
6. Delivery before arrival at the hospital. By determining the causes of maternal death,
preventable causes, such as postpartum
haemorrhage, may be identified. Measures
MATERNAL MORTALITY to prevent these complications can then be
introduced throughout the region.
Information on maternal deaths should be
15-23 What is the maternal mortality ratio?
collected by the health authorities in each
The maternal mortality ratio is the number of region and be interpreted by specialists at
women who die during pregnancy, labour, or the tertiary hospital. A maternal mortality

8. REGIONALISED PERINATAL CARE 273
notification form must be used for the data 4. Infection, often complicating prolonged
collection. obstructed labour.
NOTE Since October 1997 it has been
In many developing countries, haemorrhage
compulsory to notify all maternal deaths in and infection are responsible for more deaths
South Africa to the provincial Maternal, Child than the hypertensive disorders of pregnancy.
and Women’s Health (MCWH) Directorate. As perinatal services improve, deaths due to
Maternal death notification forms, as well as an haemorrhage and infection will decrease.
explanatory document on the way the forms
have to be completed, must be available at all In contrast, the commonest causes of maternal
institutions dealing with pregnant women. mortality in a developed country, such as the
United Kingdom, are thromboembolism,
A photostat copy of the patient’s entire the hypertensive disorders of pregnancy,
folder must accompany the maternal death and deaths resulting from complications of
notification forms, as well as photocopies of anaesthesia.
the patient’s folders from any other hospitals
or clinics where the patient had been managed
15-27 Should each maternal death
before. All information in these folders will be
be discussed at a special meeting?
kept strictly confidential.
Yes. It is very important that each maternal
15-25 What is the difference death is discussed to discover the cause. The
between primary and final causes aim is not to punish anyone who made an
of maternal mortalty? error, but rather to learn from the case report
in order to prevent the same mistake being
1. The primary cause of death is the initiating made again. Once the common causes of
complication or condition that triggered a maternal death in a region are identified, steps
sequence of events ultimately resulting in a must be taken to prevent the problems which
maternal death. lead to those deaths.
2. The final cause of death is the complication
that ultimately resulted in a maternal death.
A woman develops severe pre-eclampsia during CASE STUDY 1
pregnancy, her blood pressure is not controlled,
and a fatal intracranial haemorrhage occurs. A patient is diagnosed as having poor progress
The primary and final causes of the maternal of labour at a community healthcare clinic.
death will be pre-eclampsia and an intracranial The clinic functions independently and is not
haemorrhage respectfully. formally attached to a hospital. When the
clinic staff attempt to contact the hospital they
15-26 What are the important are unable to get any reply from the hospital’s
primary causes of maternal mortality telephone exchange. They, therefore, hire
in a developing country? a taxi and send the patient to the hospital
with a letter asking for help with the further
The commonest primary causes of maternal
management of the patient.
mortality in South Africa are:
1. The complications of HIV/AIDS. 1. What is wrong with the
2. The hypertensive disorders of pregnancy, administration of this clinic?
especially uncontrolled hypertension
causing intracranial haemorrhage. Every clinic which provides perinatal care
3. Haemorrhage, especially postpartum should be attached to a hospital within the
haemorrhage. same healthcare region. This will greatly

9. 274 MATERNAL CARE
improve the communication between a clinic 1. Was the patient correctly managed?
and its referral hospital.
No. The most senior and experienced person
available at the clinic should have been
2. How could the communication consulted first. The patient’s problems would
by telephone between the clinic most probably have been solved at the clinic,
and the hospital be improved? making the referral unnecessary.
A direct telephone line from the clinic to
the labour ward is needed. This will avoid 2. What else could have been done
problems with the telephone exchange and if none of the clinic staff knew
provide immediate contact between the clinic how to manage the problem?
and hospital staff.
The referral hospital for that clinic should
have been contacted by telephone so that the
3. Why should the clinic staff patient’s problem could have been discussed
always speak to the hospital staff with the doctor on duty.
before transferring a patient?
Sometimes the patient can be safely managed 3. If the patient did require referral
at the clinic after the clinical problem has to hospital, which hospital would
been discussed with the hospital staff. This have been the most appropriate
will prevent having to transfer the patient. The to care for the patient?
management before and during transfer can
The district hospital (level 1) in the same
be decided upon during discussion with the
healthcare region as the clinic.
doctor at the hospital. If the patient has to be
transferred, the hospital must be informed
so that they can make arrangements for her 4. Why is it always important to
management at the hospital, e.g. prepare for a carefully consider the referral before
Caesarean section. transferring a patient to hospital?
Because unnecessary referral causes great
4. What is the danger of inconvenience to the patient and her family.
transferring a patient in a taxi? Transport and hospital fees also add to the
patient’s health expenses. Furthermore,
If a patient is moved to a hospital in a taxi,
unnecessary referrals place an extra workload
equipment and a person trained in resuscitation
on the already overburdened level 2 and 3
usually are not available to handle an
hospitals. These should reserve their resources
emergency, such as haemorrhage, which may
for patients with serious complications
occur while the patient is being transferred.
requiring specialist care. Therefore, patients
with minor problems should always be cared
for at a maternal care clinic or level 1 hospital
CASE STUDY 2 as this is more convenient for the patient and
reduces the cost of healthcare.
A patient presents with a minor complaint at a
maternal-care clinic. A junior member of the
clinic staff sees the patient but does not know CASE STUDY 3
how to manage her. The patient is, therefore,
referred to a regional hospital (level 2) for
All deliveries and maternal deaths are
further care.
recorded in a healthcare region. During a
certain year there were 30 000 deliveries and

10. REGIONALISED PERINATAL CARE 275
20 maternal deaths. The commonest cause of 5. Are you surprised that the
maternal death was postpartum haemorrhage. commonest cause of maternal death
was postpartum haemorrhage?
1. What is the definition of a maternal death? No. Haemorrhage is one of the commonest
The death of a woman during pregnancy, causes of maternal death in many developing
labour, or the puerperium. communities. Most of these haemorrhages
can be prevented by the correct management
2. How is the maternal mortality of the third stage of labour at a maternal-care
ratio expressed? clinic with delivery facilities.
Per 100 000 deliveries. 6. How can the common primary causes
of maternal death be identified in a
3. What is the maternal mortality ratio in perinatal care region so that steps can
the above health care region for that year? be taken to reduce their occurrence?
20/30 000 x 100 000 = 67 per 100 000 By arranging regular meetings with
deliveries. representatives of all the staff in the region
where each maternal death can be discussed.
4. Is this maternal mortality ratio typical of The primary and final causes of the death
a developing or a developed community? should be identified and the management of
the patient must be examined. In this way the
A developing community where the ratio is
staff can learn which clinical errors may result
usually 50 or more per 100 000 deliveries.
in serious complications. Steps can then be
In contrast, the maternal mortality ratio in
taken to avoid these errors in future.
a developed community is usually less than
10/100000 deliveries.