Guidelines for maternity care in South Africa

1 A manual for clinics, community health centres and district hospitals Guidelines FOR maternity CARE IN South Africa National Department of Health, Republic of South Africa Fourth Edition A manual for clinics, community health centres and district hospitals 2 ACKNOWLEDGEMENTS The National maternity Guidelines Committee at the Department of Health, Pretoria, has prepared this document. This fourth edition of the Guidelines is extensively updated, but follows the general format of the successful previous editions. The contents are the result of broad and intensive discussions, feedback and debate.

2 MEMBERS OF THE NATIONAL maternity Guidelines COMMITTEE Prof E Buchmann Gauteng Ms R Van der Walt Gauteng Dr J Geldenhuys Limpopo Ms E Moshabela Limpopo Ms D Mafura Free State Dr M Schoon Free State Dr D Mngomezulu Free State MS V Mubaiwa KwaZulu-Natal Dr Z Farina KwaZulu-Natal Prof J Moodley KwaZulu-Natal Dr N Moran KwaZulu-Natal Ms P Phungula KwaZulu-Natal Ms M Lekhoathi Kimberly Dr J Van Soest Kimberly Ms E Arends Western Cape Dr G Gebhardt Western Cape Dr S Ngcobo SANBS Dr M Mdaka Eastern Cape Ms N Gaba Eastern Cape Ms C Modise North West Dr M Mphatsoe North West Mr A Mafunisa National Department of Health Dr N Khaole National Department of Health Ms P Robinson National Department of Health Ms G Wilkins Reducing Maternal Mortality through Strangthening Primary Health Care in South Africa programme (RMCH) - editing and design 3 Guidelines FOR maternity CARE IN South Africa 4 TABLE OF CONTENTS ACRONYMS AND ABBREVIATIONS USED IN THE TEXT.

3 8 CHAPTER 1: maternity CARE IN South Africa .. 12 MATERNAL MORTALITY .. 13 SUMMARY OF KEY RECOMMENDATIONS FROM THE SAVING MOTHERS REPORT 2011-2013 .. 14 SAFE MOTHERHOOD IN South Africa .. 15 A NATIONAL STRATEGY FOR maternity CARE .. 15 OBJECTIVE OF THE NATIONAL Guidelines .. 16 USING THESE Guidelines .. 16 CHAPTER 2: LEVELS OF CARE .. 19 DEFINING LEVELS OF CARE .. 19 CLINIC .. 19 COMMUNITY HEALTH CENTRE .. 20 DISTRICT HOSPITAL .. 20 REGIONAL HOSPITAL .. 21 TERTIARY HOSPITAL .. 22 EMERGENCY TRANSPORT .. 22 CENTRAL HOSPITAL .. 22 CHAPTER 3: CLINICAL IN-PATIENT RECORD KEEPING: OBSTETRICS.

4 24 PURPOSE OF RECORD KEEPING STANDARDS .. 24 STANDARDS FOR INPATIENT RECORD KEEPING .. 24 ORGANISATION OF THE STANDARDS .. 25 NOTES MADE AT THE ANTENATAL CLINIC .. 25 ACUTE EVALUATION (NOT FOR ADMISSION) .. 25 ADMISSION NOTES (ACUTE ADMISSION) .. 26 FOLLOW- UP NOTES .. 27 HANDOVER NOTES: TRANSFER OF ACCOUNTABILITY .. 27 INTRAPARTUM AND LABOUR WARD NOTES .. 27 REFERRAL NOTES USING THE SBAR (SITUATION-BACKGROUND-ASSESSMENT-RECOMME NDATIONS) FORM .. 27 DELIVERY NOTES .. 28 SURGERY AND INVASIVE PROCEDURES NOTES .. 28 DISCHARGE NOTES .. 28 ABBREVIATIONS IN NOTES.

5 28 CHAPTER 4: ANTENATAL CARE .. 33 PRINCIPLES OF ANTENATAL CARE .. 33 OBJECTIVES .. 33 PRECONCEPTION CARE .. 33 RISK FOR GENETIC DISEASE .. 34 THE maternity CASE RECORD .. 34 RELATIONSHIP WITH PRIVATE CAREGIVERS .. 34 THE FIRST ANTENATAL VISIT .. 34 MID-UPPER ARM CIRCUMFERENCE .. 35 ESTIMATION OF GESTATIONAL AGE .. 36 ESSENTIAL SCREENING INVESTIGATIONS .. 37 FINAL ASSESSMENT .. 37 INFORMATION FOR PREGNANT WOMEN .. 38 SUBSEQUENT ANTENATAL VISITS .. 38 5 CHAPTER 5: NORMAL LABOUR AND DELIVERY .. 46 SKILLED ATTENDANCE AT BIRTH AND MOTHERS WAITING AREAS.

6 46 DIAGNOSIS OF LABOUR .. 46 ADMISSION OF A WOMAN IN LABOUR .. 46 GENERAL CARE OF WOMEN IN LABOUR .. 47 ROUTINE MONITORING IN THE FIRST STAGE OF LABOUR .. 48 MANAGEMENT OF THE SECOND STAGE OF 49 MANAGEMENT OF THE THIRD STAGE OF LABOUR .. 50 MANAGEMENT OF THE FOURTH STAGE OF 50 ABNORMALITIES OF THE FIRST STAGE OF LABOUR .. 50 ABNORMALITIES OF THE SECOND STAGE OF 53 VACUUM EXTRACTION/VENTOUSE DELIVERY .. 54 FORCEPS DELIVERY .. 54 CAESAREAN SECTION .. 54 EMERGENCIES DURING LABOUR .. 57 ABNORMALITIES IN THE THIRD AND FOURTH STAGES .. 58 CHAPTER 6: BLEEDING IN EARLY PREGNANCY.

7 69 MISCARRIAGE .. 70 UNSAFE MISCARRIAGES .. 72 POST-MISCARRIAGE/ABORTION FOLLOW-UP .. 73 MANUAL VACUUM ASPIRATION TECHNIQUE .. 73 ECTOPIC PREGNANCY .. 75 CHAPTER 7: BLOOD TRANSFUSION .. 79 REQUEST FOR BLOOD AND BLOOD PRODUCTS .. 79 ORDERING PRIORITIES .. 79 Guidelines ON THE MANAGEMENT OF ACUTE MODERATE/SEVERE TRANSFUSION RELATED ADVERSE EVENTS .. 80 CHAPTER 8: HYPERTENSIVE DISORDERS IN PREGNANCY .. 83 DEFINITIONS .. 83 CLASSIFICATION .. 83 HOW TO TAKE BLOOD PRESSURE IN PREGNANCY .. 84 WOMEN AT RISK FOR THE DEVELOPMENT OF PRE-ECLAMPSIA .. 85 THE ROLE OF DISTRICT HOSPITALS IN MANAGING HYPERTENSIVE DISORDERS IN PREGNANCY.

8 85 ACTIONS TO TAKE IF THERE IS A RISE IN BLOOD PRESSURE FROM A PREVIOUS VISIT .. 86 MEASURES TO PREVENT PRE-ECLAMPSIA .. 86 HOW TO MANAGE HYPERTENSION IN PREGNANCY .. 86 MANAGEMENT OF SEVERE PRE-ECLAMPSIA/IMMINENT ECLAMPSIA IN A DISTRICT HOSPITAL .. 87 STEP-WISE MANAGEMENT OF ECLAMPSIA .. 88 POSTPARTUM AND POSTNATAL CARE .. 89 CHOICE OF DRUGS FOR POST-PARTUM HYPERTENSION .. 90 CHAPTER 9: PROBLEMS IN PREGNANCY .. 93 INTRAUTERINE GROWTH RESTRICTION .. 93 ANTEPARTUM HAEMORRHAGE .. 94 MULTIPLE PREGNANCY .. 99 BREECH PRESENTATION AND TRANSVERSE LIE.

9 100 PRETERM LABOUR .. 101 PRELABOUR RUPTURE OF THE MEMBRANES .. 103 CHORIOAMNIONITIS .. 105 PROLONGED PREGNANCY .. 105 6 VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION (VBAC) .. 107 RHESUS INCOMPATIBILITY .. 109 POOR OBSTETRIC HISTORY .. 109 CHAPTER 10: MANAGEMENT OF INTRA-UTERINE DEATHS, STILLBORN BABIES AND NEONATAL DEATHS .. 111 LEGAL DEFINITIONS .. 111 INTRAUTERINE DEATH (IUD) .. 111 POSTNATAL INVESTIGATION OF STILLBIRTHS AND NEONATAL DEATHS .. 112 MANAGEMENT OF A PATIENT WITH A PREVIOUS STILLBIRTH AFTER 24 WEEKS .. 113 MANAGEMENT OF A STILLBORN BODY (28 WEEKS GESTATIONAL AGE AND MORE).

10 113 MANAGEMENT OF A STILL BORN BODY BELOW 28 WEEKS GESTATIONAL AGE .. 114 MANAGEMENT OF A NEONATAL DEATH .. 114 CHAPTER 11: MEDICAL DISORDERS IN PREGNANCY .. 116 ANAEMIA .. 116 DIABETES MELLITUS .. 117 CARDIAC DISEASE .. 119 ASTHMA .. 121 THROMBOEMBOLISM (VTE) .. 121 EPILEPSY .. 122 CHAPTER 12: INFECTIONS IN PREGNANCY .. 124 SEXUALLY TRANSMITTED INFECTIONS .. 124 GENITAL 125 URINARY TRACT INFECTION .. 125 ACUTE PYELONEPHRITIS .. 126 MALARIA .. 126 CHAPTER 13: PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) AND MANAGEMENT OF HIV POSITIVE PREGNANT WOMEN.