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 conditions

1. 2A
Skills workshop:
Routine use of
the antenatal
card
5. Fetal movements from 28 weeks onwards.
Objectives 6. Presenting part from 34 weeks onwards.
7. Haemoglobin concentration at 28 and 36
weeks.
When you have completed this skills 8. The symphysis-fundus height from 18
workshop you should be able to: weeks.
• Plot the symphysis-fundus height. 9. Any additional notes.
• Use the symphysis-fundus height graph 10. Signature of the responsible midwife or
doctor.
to assess whether the fetus is growing
adequately. The symphysis-fundus (SF) height and the
patient’s weight are recorded on the antenatal
A Recording information on graph while the other information is recorded
the antenatal card in the spaces provided.
The front of the antenatal card is used B The significance of the lines on the graph
to record details of the patient’s history,
examination, special investigations, duration There are 3 oblique lines on the antenatal graph:
of pregnancy, planned management and The 3 lines represent the normal increase in
future family planning at the first and second the symphysis-fundus height or SF height (i.e.
antenatal visits. The back of the antenatal card a centile growth chart of fundal height). The
is used to record the observations made at solid line in the centre is the 50th centile or
each antenatal visit throughout pregnancy. average growth line. The dotted lines above
The following items should be recorded on and below this represent the 90th and 10th
the back of the antenatal card every time the centiles respectively (i.e. the upper and lower
patient attends the antenatal clinic: limits of normal fundal growth).
1. Date.
2. Blood pressure.
3. Proteinuria or glycosuria.
4. Oedema.

2. 70 PRIMAR Y MATERNAL CARE
Date PROBLEM LIST
SIGNATURE: 1
2
DATE: 3
4
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 5
45 GESTATION EST. BY: 45 Date NOTES (essential facts only)
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
BLOOD- Syst.
PRESSURE Diast.
P P
Urine
S S
OEDEMA
RRT 2/01
Fetal movements Antenatal
Haemoglobim (g/dl) card B
ENG
Figure 2-A: The back of the antenatal card
C Plotting the symphysis-fundus height 5. The method whereby the gestational age
for the first time when the patient is sure was determined must now be ticked in
of the date of her last menstrual period the appropriate block at the top left-hand
corner of the chart. In this case ‘Dates’
1. Calculate the period of gestation in weeks.
should be ticked.
The gestational age is given along the top
6. Between 18 and 36 weeks the SF height
and bottom of the graph (the horizontal
in centimetre should be plotted on the SF
axis).
curve to determine the gestational age in
2. Measure the SF height. The SF height in
weeks. If the fundal height is at the level of
centimetre is given both sides of the graph
the umbilicus or higher, and the SF height
(the vertical axis). The patient’s SF height
differs from the gestational age by 4 weeks
measures 21 cm.
or more, the SF height should be plotted as
3. Knowing the gestational age and the SF
described in 2-G.
height, the SF height for the gestational age
can be plotted on the graph and should be
recorded by making a dot. A small circle is D Plotting the SF height for the first
drawn around the dot to make sure that it time when the patient does not know
is clearly seen. the date of her last menstrual period
4. The date of the antenatal visit should be 1. The patient’s SF height measures 27 cm.
written at the top of the card in the square Plot the measurement on the 50th centile
opposite the gestational age of the patient. opposite the 27 cm on the vertical axis.
The person recording the observations on 2. By plotting the SF height measurement
the antenatal card must also write her or on the 50th centile you are assuming that
his name next to the date. the fetus is growing normally and that
the measurement on the horisontal axis

3. SK ILLS WORKSHOP : ROUTINE USE OF THE ANTENATAL CARD 71
el
SIGNATURE:
N
F.
/7
DATE:
27
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
BLOOD- Syst.
PRESSURE Diast.
P P
Urine
S S
OEDEMA
RRT 2/01
Fetal movements Antenatal
Haemoglobim (g/dl) card B
ENG
Figure 2-B: A SF height measurement of 21 cm at a gestational age of 24 weeks is plotted on July 27th
represents the approximate gestational E The first recording of the SF height
age. In this case the approximate when the duration of pregnancy, as
gestational age is 29 weeks. determined by her last normal menstrual
3. The method whereby the gestational age period, differs from that determined
was determined must now be ticked in by the SF height by 4 or more weeks.
the appropriate block at the top left-hand
1. According to the patient’s last menstrual
corner of the chart. In this case ‘SF-
period, she is 31 weeks pregnant. The
measurement’ should be ticked.
SF height measurement is 25 cm which
4. The fundal growth must be carefully
indicates a gestational age of 26 weeks if
recorded at the following visits. If little or
plotted on the 50th centile of the SF curve.
no growth occurs in the next 4 weeks, the
2. In this case the fundal height is above
diagnosis of intra-uterine growth restriction
the umbilicus, and the gestational age
must be made. If excessive growth occurs,
estimated from the mother’s last menstrual
multiple pregnancy must be excluded.
period and the SF height differ by 5 weeks.
Normal growth with the SF-height between
The SF height probably indicates the true
the 90th and 10th centiles confirms a
gestational age. Make a mark on the 50th
normal growing singleton pregnancy.
centile opposite 25 cm. This indicates an
estimated gestational age of 26 weeks.
3. The method by which the gestational age
is estimated must be recorded in the box
at the top left-hand corner of the growth
chart. In this case a tick should be made
opposite ‘SF measurement’.

4. 72 PRIMAR Y MATERNAL CARE
el
SIGNATURE:
N
F.
10
DATE:
4/
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
BLOOD- Syst.
PRESSURE Diast.
P P
Urine
S S
OEDEMA
RRT 2/01
Fetal movements Antenatal
Haemoglobim (g/dl) card B
ENG
Figure 2-C: Recording the SF height of 27 cm on the 50th centile when a patient could not remember the date
of her last menstrual period. The patient attended the antenatal clinic on 4th October.
4. The fundal growth must be carefully attended the antenatal clinic, the S-F height
recorded at the following visits. If little measurement must be plotted 4 weeks later
or no growth occurs in the next 4 weeks, on the graph.
the diagnosis of intra-uterine growth
restriction must be made. If excessive G Recording the presenting part and
growth occurs, multiple pregnancy must the amount of fetal head palpable
be excluded. Normal growth with the SF- above the brim of the pelvis
height between the 90th and 10th centiles
confirms a normal growing singleton From 34 weeks gestation onwards the lie and
pregnancy. This information also confirms the presenting part must be determined at
that using the SF-height to determine every visit (as described in Skills Workshop
gestational age was correct. 1-2). The presenting part may be a vertex or
breech. If the presenting part is a fetal head,
then the amount of head above the pelvic brim
F Plotting the symphysis-fundus height
must be determined.
at subsequent antenatal visits
The symphysis-fundus height must be plotted H Writing notes on the antenatal record card
on the graph at every subsequent antenatal
clinic visit. As before, the symphysis-fundus A space is provided on the antenatal card
height measurement and the gestational age for brief notes. A block is also provided for a
are used to determine where the dot should problem list. Few notes are needed and usually
be made on the graph. For example, if the there are no notes in patients who are assessed
patient’s present visit is 4 weeks after she last as being low risk with normal pregnancies.

5. SK ILLS WORKSHOP : ROUTINE USE OF THE ANTENATAL CARD 73
el
SIGNATURE:
N
F.
/5
DATE:
20
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
BLOOD- Syst.
PRESSURE Diast.
P P
Urine
S S
OEDEMA
RRT 2/01
Fetal movements Antenatal
Haemoglobim (g/dl) card B
ENG
Figure 2-D: A patient’s gestational age, according to her last menstrual period, is 31 weeka and the S-F height
measurement is 25 cm

6. 74 PRIMAR Y MATERNAL CARE
el
el
el
SIGNATURE:
N
N
N
F.
F.
F.
/5
/6
/7
DATE:
20
17
15
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) 4
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-E: A patient’s SF height measurement is 30 cm, 4 weeks after her last visit. Four weeks later the SF
height is 32 cm
Date PROBLEM LIST
1 20/5 Grande multipara
2 20/5 Gestational diabetes
3 23/6 Pre-eclamsia
4
5
Date NOTES (essential facts only)
20/5 Diabetes to be managed with diet
23/6 Good diabetic control
Admit to ward for PET assessment
and management
Requests tubal ligation
Figure 2-F: A problem list with short notes