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, assessing fetal growth and well being, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical condition.

1. 84 PRIMAR Y MATERNAL CARE
weeks pregnant. On further questioning and hypertension and is managed with a diuretic.
examination she has no symptoms or signs of By dates and examination she is 14 weeks
imminent eclampsia. pregnant.
1. What is the danger to 1. Should the management of
this patient’s health? the patient’s hypertension be
changed during the pregnancy?
The patient has severe pre-eclampsia.
Therefore, the immediate danger to her Yes. The diuretic should be stopped, as
life is the development of eclampsia or an these drugs are not completely safe during
intracerebral haemorrhage. pregnancy. Instead, the patient should be
treated with alpha methyldopa (Aldomet).
2. How should this patient be managed?
2. What factors indicate a good
Her clinical condition must first be stabilised.
prognosis for a patient with chronic
An intravenous infusion should be started and
hypertension during pregnancy?
a loading dose of 14 g magnesium sulphate
must be given. This should prevent the Normal renal function, no superimposed
development of eclampsia. pre-eclampsia and good control of the blood
pressure during pregnancy.
3. Is a loading dose of magnesium
sulphate also adequate to control 3. How can superimposed pre-eclampsia
the high blood pressure? be diagnosed during pregnancy?
No. Sometimes, the diastolic blood pressure The patient will develop proteinuria and/or a
will drop to below 110 mm Hg after a loading rise in blood pressure during the second half
dose of magnesium sulphate has been given. of pregnancy.
In that case, no further management is
needed for the hypertension. However, if 4. Why is it important to detect
the patient’s blood pressure does not drop superimposed pre-eclampsia in a
after administering the magnesium sulphate, patient with chronic hypertension?
intramuscular dihydralazine (Nepresol)
6.25 mg or 10 mg (one capsule) oral nifedipine Because the risk of complications increases. As
(Adalat) should be given. a result a preterm delivery may be necessary.
The patient should, therefore, be transferred
to a level 2 or 3 hospital if superimposed pre-
4. Should you continue to manage
eclampsia develops.
this patient at a level 1 hospital?
No. The patient should be transferred to a 5. What should be seriously recommended
level 2 or 3 hospital, for further management. during the puerperium in this patient?
Both severe pre-eclampsia and the gestational
age (32 weeks) at which the complications A postpartum sterilisation. Postpartum
developed are reasons for management at least sterilisation should be discussed with the
in a level 2 hospital. patient during the pregnancy. Postpartum
sterilisation is particularly important as
the patient is a 37 year old multipara with
CASE STUDY 4 chronic hypertension.
A 37 year old, gravida 4, para 3 patient
books for antenatal care. She has chronic

2. 3A
Skills workshop:
Measuring
blood pressure
and proteinuria
6. The systolic blood pressure is taken at
Objectives Korotkoff phase 1.
7. The diastolic blood pressure is taken at
Korotkoff phase 5.
When you have completed this skills
workshop you should be able to: The patient should lie on her right side or sit
• Measure the blood pressure. when her blood prerssure is measured.
• Measure the amount of protein in the
urine. B Use the right arm
The examination couches in most clinics
stand with their left side against a wall as it is
MEASURING BLOOD most convenient for a right-handed person to
PRESSURE examine the right side of the patient. The lower
arm (i.e. the right arm if she is lying on her
right side) should be used, as the upper arm will
A The standardised method of give false low readings as it is above the level of
measuring blood pressure the heart. The arm must be fully undressed so
The following are important if you want to that the cuff can be correctly applied.
measure the blood pressure accurately:
C The patient must not lie on her back
1. The right upper arm is used.
2. The arm must be taken out of the sleeve. The patient should lie down on her side or sit.
3. The patient should lie on her right side Lying on her back may cause hypotension,
with a 30 degree lateral tilt or sit in a chair. giving a falsely low reading. She should also
4. Take the blood pressure after a 5 minute lie slightly turned onto her side. Lying on her
period of rest. back may cause the uterus to press on the
5. The cuff must be applied correctly. If inferior vena cava resulting in a decreased
the patient is sitting in a chair, the blood return of blood to the heart and a drop in
pressure apparatus must be at the same blood pressure. A false low blood pressure
level as her upper arm. may, therefore, be recorded.

3. 86 PRIMAR Y MATERNAL CARE
D Allow the patient to rest for 5 minutes I Grading the amount of proteinuria
before measuring the blood pressure
Using a reagent strip the amount of
Anxiety and the effort of climbing onto the proteinuria is graded as follows:
couch often increases the blood pressure. This
1+ = 0.3 g/l
will usually return to a resting value if the
patient can lie down and relax for 5 minutes. 2+ = 1.0 g/l
3+ = 3.0 g/l
E How to apply the cuff
4+ = 10 g/l
A standard size cuff (width of 14.5 cm) is
usually used. If the arm is very fat, then use a Remember that a trace (0.1g/l) of protein is
wide cuff (17.5 cm) to get a correct reading. not regarded as significant proteinuria and
The cuff must be applied firmly around the may occur normally.
arm, not allowing more than 1 finger between
the cuff and the patient’s arm. J The use of a reagent strip to measure
the amount of proteinuria
F Listening to the pulse 1. Collect a fresh specimen of urine.
The cuff should be pumped up with a finger 2. Remove a reagent strip from the bottle and
feeling the brachial or radial pulse. Only when replace the cap.
the pulse can no longer be felt, should the 3. Dip the strip into the urine so that all the
stethoscope be put over the brachial pulse and test areas are completely covered, then
the pressure released slowly. immediately remove the strip.
4. Wait 60 seconds.
5. Hold the strip horizontally and compare
G Recognising the Korotkoff phases 1 and 5
with the colour blocks on the side of the
The Korotkoff phases are times when the bottle. Hold the strip close to the bottle
sound of the pulse changes during the to match the colours but do not rest it on
measurement of the blood pressure: the bottle as the urine will damage the
Phase 1 is the first sound which you hear after colour chart. The darker the colour of the
the cuff pressure is released. This indicates the reagent strip, the greater is the amount of
systolic pressure. proteinuria.
Phase 5 is the time when the sound of the K Reagent strips can give a false reading
pulse disappears. Usually the sound gets
softer before it disappears but sometimes it Reagent strips may incorrectly assess the degree
disappears without first becoming softer at the of proteinuria if the urine is very concentrated
same time. However, in all cases the diastolic or very dilute. Do not use the first urine passed
blood pressure must be read when the sound in the morning as it may be concentrated and,
of the pulse disappears. therefore, give a falsely high reading.
MEASURING PROTEINURIA
H Measuring the amount of proteinuria
The amount of protein in a sample of urine
is simply and easily measured with a plastic,
reagent strip.