Clinical overview
Maternity care in South Africa is delivered within a national, public-sector framework that you, as a registrar, are expected to know not as a list of facts but as a working system — who is seen where, by whom, with what package of care, and when a woman must be moved up the chain. The single most important document is the National Integrated Maternal and Perinatal Care Guidelines for South Africa (NDoH, 2024) (the "Maternity Guideline"), released on the NDoH Knowledge Hub on 23 October 2024, which supersedes all earlier editions of the Guidelines for Maternity Care. The FCOG(SA) examiners use this as the SA source of truth: when their answer and an international guideline diverge, the SA guideline wins for SA practice.
This objective is weighted HOTS — you are not being asked to recite the guideline but to demonstrate knowledge: to apply the right pathway to a clinical scenario, justify a referral, recognise where SA practice deliberately diverges from NICE or RCOG, and explain why the system is shaped the way it is. That shape is driven by epidemiology. South Africa's maternal mortality is dominated by a small number of causes catalogued in the triennial Saving Mothers (NCCEMD) reports — non-pregnancy-related infections (chiefly HIV/AIDS and TB), obstetric haemorrhage, and hypertensive disorders of pregnancy — many of them avoidable. The guideline is, in large part, an engineering response to those audited deaths. Read this chapter as the scaffolding onto which every other obstetric chapter hangs: antenatal-booking, hiv-in-pregnancy, hypertension-in-pregnancy, postpartum-haemorrhage and normal-labour all live inside this system.
Core knowledge
The structure of the system: levels of care
South African maternity care is tiered. Knowing which level does what is the backbone of safe referral.
- Community / primary level — clinics and community health centres (CHCs), midwife-led, providing antenatal care for low-risk women and basic antenatal care, and Midwife Obstetric Units (MOUs) for low-risk delivery. No on-site doctor or theatre.
- District hospital — generalist doctors, basic emergency obstetric and neonatal care (BEmONC), caesarean section capability, basic resuscitation. The workhorse for most deliveries.
- Regional hospital — specialist obstetricians and paediatricians, comprehensive emergency obstetric and neonatal care (CEmONC), higher-care/HDU, blood bank.
- Tertiary hospital — subspecialist services, maternal-fetal medicine, neonatal ICU, the destination for the sickest mothers and fetuses.
The guideline ties this to a risk-stratified antenatal pathway: low-risk women are managed at primary level on a basic antenatal care schedule; risk factors detected at booking or during pregnancy trigger referral up a level. Detail of who is high-risk sits in high-risk-pregnancy-risks; detail of the booking visit in antenatal-booking.
Figure I1.1 — SA maternity-care levels and referral triggers: low-risk care starts at primary/MOU level, with escalation to district, regional or tertiary care when risk or capability needs change.
Antenatal care: the SA schedule and package
The SA guideline follows a Basic Antenatal Care Plus (BANC Plus) approach, structured around an increased number of contacts compared with the older goal-oriented BANC model, broadly aligning with the WHO 2016 recommendation of a minimum of eight antenatal contacts. (Standard SA teaching — confirm the exact contact schedule against the 2024 NDoH guideline; flagged in notes.)
Booking should be as early as possible, ideally in the first trimester. The booking package, classically, includes:
- History and risk assessment, calculation of gestational age (see gestational-age-assessment).
- Routine bloods: blood group and Rh (see rh-isoimmunisation), haemoglobin/full blood count, syphilis serology (RPR), and HIV testing.
- HIV — universal opt-out HIV testing at booking, with repeat testing through pregnancy and the breastfeeding period; HIV-positive women started on lifelong ART, first-line TLD (tenofovir + lamivudine + dolutegravir) per the National Consolidated Guidelines (NDoH, published January 2026). This is the cornerstone of the Prevention of Vertical Transmission (PVT) programme (formerly "PMTCT") and is expanded in hiv-in-pregnancy.
- Screening for proteinuria and blood pressure at every visit (hypertension surveillance), and gestational diabetes screening per the guideline's risk-based approach.
Routine prophylaxis classically includes calcium supplementation (the guideline recommends calcium in low-intake populations to reduce pre-eclampsia risk, per WHO), iron and folate, and low-dose aspirin from 12 weeks for women at risk of pre-eclampsia (aligned with NICE NG133). (Doses are standard teaching — verify the exact SA-recommended calcium and aspirin doses against the 2024 NDoH guideline before quoting numbers; flagged in notes.)
Intrapartum care and the labour record
Care in labour for low-risk women is midwife-led, but the guideline structures monitoring tightly because intrapartum events drive avoidable perinatal death. Labour is monitored on a partogram (see partogram-use) — South Africa has long used a partogram-based labour record, and the WHO Labour Care Guide (2020) is the modern instrument the WHO recommends in place of the classic partograph in many settings; know that the SA guideline retains structured partographic monitoring with defined action lines. Fetal monitoring in labour for low-risk women is by intermittent auscultation, with escalation to continuous CTG when risk factors appear (the principle, mirrored in NICE NG229, that monitoring intensity follows risk). CTG interpretation is covered in ctg-interpretation and the methods in fetal-monitoring-methods; the conduct of normal labour in normal-labour.
Postnatal and neonatal care
The puerperium is a high-risk window — most maternal deaths occur during or shortly after delivery — so the guideline mandates structured postnatal observation, early recognition of sepsis and haemorrhage, and defined postnatal review contacts for mother and baby (see normal-puerperium). Active management of the third stage of labour with a uterotonic — oxytocin first-line in SA — is universal PPH prophylaxis. The guideline supports exclusive breastfeeding as the default infant-feeding strategy, including for women living with HIV who are virally suppressed on ART (see infant-feeding). Postpartum contraception is offered before discharge (see postpartum-contraception).
Assessment
To demonstrate knowledge of the guidelines in an exam, you assess a scenario against the system, not against an isolated fact. Work through four questions:
- What level of care is this woman currently at, and is it the right one? A woman with severe pre-eclampsia at a primary clinic is in the wrong place; the guideline's purpose is to get her to a hospital with magnesium sulphate, antihypertensives and theatre before she fits or bleeds.
- What risk category does she fall into? Booking risk assessment sorts women into low-risk (primary-level pathway) versus those needing doctor or specialist review. Identifying the risk factor (previous caesarean, hypertension, HIV with detectable viral load, prior stillbirth, multiple pregnancy) is the trigger.
- What is the package of care she is owed at this contact? BP and urine at every visit; HIV re-testing on schedule; the right bloods at booking; aspirin and calcium where indicated.
- Does this need escalation now? The guideline embeds danger-sign recognition for both the woman (antepartum haemorrhage, severe headache, reduced fetal movements, fever) and the system (when to phone, when to transfer, who to transfer to).
Figure I1.2 — HOTS scenario lens for SA maternity-guideline questions: define level, risk, package of care and urgency before choosing a disposition.
The clinical assessment skills themselves — history, examination, danger signs — are taught in minor-complaints-pregnancy and decreased-fetal-movements; the screening battery in antenatal-screening. What this objective adds is the systemic lens: every assessment ends in a disposition decision (manage here, review by doctor, refer up).
Management
Applying the guideline: the referral pathway
Management under the SA system is, above all, correct referral and timing. The guideline operationalises this through criteria for referral from clinic to district hospital, and from district to regional/tertiary. You should be able to state, for any complication, the level at which it should be managed and how it gets there:
- Antenatal referral — risk factors at booking or in pregnancy (e.g. previous caesarean → plan level of birth; pre-eclampsia → regional; growth restriction → maternal-fetal medicine).
- Intrapartum referral — partogram action-line crossing, fetal heart-rate abnormality, malpresentation, prolonged labour → transfer to a unit with caesarean capability before the situation becomes an emergency.
- Emergency transfer — accompanied, resuscitated, with a clear hand-over and the receiving unit forewarned.
Use of essential medicines is governed by the Standard Treatment Guidelines and Essential Medicines List (EML) — hospital and primary-care levels. For obstetrics this fixes, among others, oxytocin as first-line uterotonic, magnesium sulphate for eclampsia prophylaxis and treatment, and the ART regimen. Always reason from the EML for what is actually available at a given level.
Emergency drills the guideline embeds
The guideline is built around the audited killers, and you must be able to run the drill cold.
Eclamptic seizure — immediate drill. Call for help. Protect the airway, left lateral, oxygen. Magnesium sulphate is the anticonvulsant of choice (loading then maintenance dose) — give the regimen exactly as per the SA guideline / EML; do not improvise doses. Control severe hypertension. Catheterise, monitor. Deliver once the mother is stable — stabilise then deliver, never deliver an unstable, fitting mother. Full detail in pre-eclampsia-and-hellp and hypertension-in-pregnancy.
Postpartum haemorrhage — immediate drill. Call for help and start the bundle. E-MOTIVE (NEJM 2023): Early detection (calibrated drape) → uterine Massage, Oxytocic, Tranexamic acid, IV fluids, Examine the genital tract and escalate. Give tranexamic acid 1 g IV early — within 3 hours of onset (WOMAN trial, Lancet 2017). Identify the cause (the four Ts: Tone, Trauma, Tissue, Thrombin). Move up the uterotonic ladder, prepare blood, and escalate to theatre / regional level if bleeding continues. Detail in postpartum-haemorrhage.
Maternal collapse. Modified resuscitation in pregnancy: manual left-uterine displacement, high-quality CPR, and — from around 20 weeks — perimortem caesarean within ~5 minutes if there is no return of spontaneous circulation, to aid maternal resuscitation. See resuscitation-in-pregnancy and shock-management.
Figure I1.3 — Emergency-drill board for eclampsia, postpartum haemorrhage and maternal collapse: call early, stabilise first, use SA guideline/EML regimens and escalate.
Where SA practice deliberately diverges
Demonstrating knowledge means knowing why and where the SA guideline differs from NICE/RCOG:
- HIV is woven through the entire pathway (universal testing, lifelong ART, PMTCT, viral-load-guided feeding advice) in a way that reflects SA's epidemiology — non-pregnancy-related infection is a leading Saving Mothers cause. This is a far more central thread than in UK guidance.
- Calcium supplementation is recommended routinely because dietary calcium intake is low in much of the population — a WHO-supported, population-tailored intervention.
- Resource-stratified delivery — care is organised around what each level of the system can actually provide, so referral timing is the central safety lever rather than, say, sophisticated outpatient surveillance.
- The EML constrains choice — you prescribe from the list available at the relevant level, which is why knowing the level of care matters as much as knowing the drug.
This is also where the Saving Mothers / NCCEMD loop closes the system: deaths are audited, avoidable factors identified, and the guideline revised — the (NDoH, 2024) is the latest turn of that wheel.
Red flags / pitfalls
- Citing a superseded guideline. The current document is the 2024 NDoH National Integrated Maternal and Perinatal Care Guidelines, which replaced the 2016 Guidelines for Maternity Care (the last numbered — 4th — edition). Cite it as the 2024 NDoH guideline; it carries no edition number, so don't invent one.
- Quoting exact doses or schedules you are unsure of. The guideline specifies precise regimens (magnesium sulphate, ART, aspirin, calcium, antenatal contact numbers). If you cannot recall the exact figure, state the principle and the drug, and say "per the SA Maternity Guideline / EML" rather than inventing a number — a fabricated dose is dangerous and loses marks.
- Managing at the wrong level. The single commonest systemic error: keeping a high-risk woman at a level without the capability to rescue her. Severe pre-eclampsia, antepartum haemorrhage with a viable fetus, and prolonged obstructed labour all need a unit with theatre and blood. Refer early, transfer stabilised.
- Forgetting the puerperium. Maternal death clusters around and after delivery; do not let surveillance lapse once the baby is out. Sepsis and secondary PPH are quiet killers.
- Treating HIV as a side issue. In SA it is central — missed testing, missed re-testing, or a detectable viral load near term materially changes the delivery and feeding plan.
- Improvising in an emergency. Eclampsia, PPH and collapse have defined drills. Run the drill; call for help early; do not deviate from magnesium sulphate for eclampsia or early tranexamic acid for PPH.
- Ignoring danger signs the woman reports. Severe headache, visual disturbance, epigastric pain, reduced fetal movements, fever, and any antepartum bleeding are guideline-defined triggers for urgent assessment, not "review at next visit".
Evidence anchors
- National Integrated Maternal and Perinatal Care Guidelines for South Africa (NDoH, 2024), NDoH — the SA obstetric source of truth (supersedes earlier Guidelines for Maternity Care editions).
- South African Maternal, Perinatal and Neonatal Health (MPNH) Policy (2021), NDoH.
- Saving Mothers Report (NCCEMD) — triennial confidential enquiry into maternal deaths; the audit loop driving guideline revision (obstetric haemorrhage, hypertension, non-pregnancy-related infection/HIV as leading causes).
- South African EML and Standard Treatment Guidelines — hospital and primary-care levels (oxytocin, magnesium sulphate, ART availability by level).
- South African National HIV/ART Consolidated Guidelines (2023) — first-line TLD (TDF + 3TC + DTG); PMTCT.
- WHO Labour Care Guide (2020) — modern instrument supplementing/replacing the partograph for intrapartum monitoring.
- NICE NG201 — Antenatal care (2021) and NICE NG235 — Intrapartum care (2023) — international cross-reference where SA practice aligns or diverges.
- NICE NG133 — Hypertension in pregnancy (2019) — low-dose aspirin from 12 weeks for at-risk women; magnesium sulphate for severe pre-eclampsia/eclampsia.
- WOMAN trial (Lancet 2017) — tranexamic acid 1 g IV within 3 h cuts bleeding-death; E-MOTIVE bundle (NEJM 2023) — early-detection PPH care bundle.
- RCOG GTG 52 (PPH), GTG 56 (Maternal collapse) — drill detail.