Id 3912

PRE-ECLAMPSIA, ECLAMPSIA AND SEVERE
HYPERTENSION
Subject: Pre- eclampsia,eclampsia and hypertension

Ratified By: Maternity Clinical Guideline and Audit
Group
Date Ratified: May 2014
Version: 4
Policy Executive Owner: F.Eben. WCF Divisional Director
Designation of Author: C.Biswas, Consultant Obstetrician
Name of Assurance Committee: Maternity Clinical Guideline and Audit
Group
Date Issued: June 2014
Review Date: June 2017
Target Audience: Obstetricians, Midwives and
Anaesthetists
Key Words: Hypertension, pre-eclampsia, eclampsia
and pregnancy.
Pre eclampsia, Eclampsia and Severe Hypertension. C.Biswas. Cons Obstetrician. May
2014. V4 Page 1
Version Control Sheet
Version Date Author Status Comment

2 September C.Biswas Consultant Review and update
2010 Obstetrician
3 June 2014 C.Biswas Consultant Review and update
Obstetrician
4 March 2015 (Amendment).RCOG guidance – use
of syntocinon in third stage of labour.
Withdrawal of syntometrine.
Pre eclampsia, Eclampsia and Severe Hypertension. C.Biswas. Cons Obstetrician. May
2014. V4 Page 2
¾ Criteria for use
For the diagnosis and management of pregnant women with severe hypertension,
pre-eclampsia and eclampsia.
¾ Background/ introduction
Hypertensive disorders of pregnancy remain a leading cause of direct maternal

deaths. In the last confidential enquiry1, there were 18 deaths, at a rate of 0.85
deaths per 100,000 maternities. The most common aetiology of hypertensive deaths
was intracranial haemorrhage secondary to uncontrolled systolic hypertension; the
failure of effective anti-hypertensive therapy was the most common source of sub-
standard care. However, over the last 20 years there were also deaths from
pulmonary oedema secondary to fluid overload; this has been decreasing due to
greater emphasis on fluid balance.
Specific learning points from the CEMACH report are as follows:
1. Systolic hypertension of 160 mmHg must be treated.

2. Syntocinon should be given for the management of the third stage if the
mother is hypertensive or if her blood pressure (BP) has not been checked
prior to its administration.
3. The anaesthetist should be given as much time as possible to try and prevent
the pressor effects of intubation in the pre-eclamptic woman, even if there are
pressing fetal reasons for urgent caesarean section under general
anaesthesia.
4. Severe life-threatening pre-eclampsia can occur at any gestation: preterm,
term, post-term or postpartum.
Pre eclampsia, Eclampsia and Severe Hypertension. C.Biswas.Cons Obstetrician. May 2014.V4
Page 3
¾ Inclusion/ exclusion criteria
Diagnosis of pre-eclampsia:
• Persistently elevated BP of 140/90 in a patient without pre-existing

hypertension
• New proteinuria of 1+ or more on dipstick; or urine protein: creatinine ratio
(uPCR) greater than 30mg/nmol; or 0.3g protein/24 hours in a 24 hour urine
collection.
Severe pre-eclampsia
In addition severe pre-eclampsia may present with one or more of the following:
• Symptoms and signs:

o Severe hypertension with a systolic BP > 160 on two occasions or
diastolic BP > 110 on two occasions
o Severe persistent headache
o Visual disturbance
o Nausea and Vomiting
o Epigastric or right upper quadrant pain and tenderness
o Hyperreflexia with more than 2 beats of clonus
o Papilloedema
• Abnormal Laboratory investigations:

o Significant proteinuria (at least 1g/24 hours or uPCR of greater than
100 mg/nmol)
o Falling platelet count < 100 x 109/L
o Raised urate level
o Raised AST or ALT
o Abnormal renal function
o DIC (unlikely if platelets >100 x 109/L1)
Page 4
• Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome
o A severe presentation of pre-eclampsia
o Diagnosed by confirming haemolysis by raised lactate dehydrogenase
(LDH) or a blood film to look for fragmented red cells; an AST above 75
iu/L; and a platelet count below 100 x 109/L1.
Eclampsia
Eclampsia is defined as the occurrence of one or more convulsions

superimposed on pre-eclampsia1
Inclusion criteria for severe pre-eclampsia/ eclampsia protocol
1. Blood pressure greater than or equal to 160/110

2. Eclampsia
3. Deteriorating condition i.e. the presence of symptoms, rapidly deteriorating
kidney or liver function or platelets
If these criteria are met, the patient should be managed according to the protocol
below.
¾ Clinical management
The aims of management are:
• Prompt control of blood pressure

• Meticulous fluid balance to avoid fluid overload
• Prophylaxis or treatment of eclamptic seizures
• Prompt delivery of fetus by vaginal or abdominal route
• Regular review of all parameters
• Monitoring for serious complications of severe pre-eclampsia
See: Algorithm 1: Overall management plan
Algorithm 2: Fluid management
Algorithm 3: Blood pressure management

Page 5
Algorithm 4: Eclampsia management
Algorithm 5: Magnesium Sulphate management
General measures (see Algorithm 1):
1. Once the decision has been made to commence the woman on the severe
pre-eclampsia protocol: print out checklist (appendix C), file into notes and
start it.
2. Inform Consultant Obstetrician; Labour Ward (LW) anaesthetist who should
inform the on-call consultant anaesthetist; labour ward co-ordinator; and
neonatal team if patient is antenatal.
3. The consultant haematologist on-call and intensive care unit (ICU) team may
also need to be informed depending on the situation.
4. Admit to Labour Ward (LW).
5. IV access with at least one large bore cannula.
6. Give ranitidine 150 mg (orally) and repeat 12 hourly.
7. Monitor the fetus with continuous CTG until delivery.
8. Monitor all mother’s observations on Modified Early Obstetric Warning
(MEOWs) chart.
Planning for delivery
1. Corticosteroid for fetal lung maturation: Give betamethasone or

dexamethasone 12mg IM 2 doses 12 hours apart4 if delivery is likely in a
woman between 24 and 34 weeks gestation, and consider between 34 and 36
weeks gestation.
2. Decision for delivery and mode of delivery: This should be made in

conjunction with the consultant obstetrician, and consultant neonatologist if
appropriate.
3. If allowed to labour, the fetus should be assessed with continuous electronic

fetal heart rate pattern monitoring.
Page 6
4. 2nd stage: Operative birth should be advised for those women in second stage
of labour whose severe hypertension has not been controlled by initial
treatment. This is not necessary for those with blood pressure treated to the
target range4.
5. 3rd stage: manage this with Syntocinon® 10 iu IM or slow IV administration.
6. The prophylaxis or treatment of postpartum haemorrhage with 40 units

oxytocin (Syntocinon®)3 should be administered in the following way6:
Oxytocin (Syntocinon®) 40IU in 100 mls normal saline at 26mls/ hour; via
IV infusion pump.
Fluid Management (see algorithm 2):
Special care should be taken in the fluid

management of the woman with severe pre-
eclampsia who has also undergone obstetric
haemorrhage.
1. A urinary catheter should be inserted and urine output measured hourly.
2. Total intravenous fluid input should be limited to 1ml/kg/hr- approximately

80mls/hour. This is inclusive of oxytocin (Syntocinon®) and magnesium
sulphate (MgS04) infusions; and oral intake if eating/drinking whilst on the
severe pre-eclampsia / eclampsia protocol.
3. Fluid loading in pre-eclampsia should never be done prophylactically or

routinely, as there is no evidence of the benefit of fluid expansion 2,3. Consider
a fluid load of 500 mls crystalloid prior to administration of the first dose of
hydralazine, but not of other anti-hypertensive drugs4.
Page 7
4. Postpartum oxytocin (Syntocinon®) –10 units /hr should be given to women
with fluid restriction on the severe PET protocol in the formula given above.
5. Urine Output:
a. Intrapartum: Oliguria should not precipitate any intervention except to

ensure progress to delivery3.
b. Postpartum: Continue to restrict fluids until a natural diuresis, which

may occur at 36-48 hours postpartum
c. See algorithm 2.
Magnesium Sulphate for the treatment and prevention of eclampsia

(Algorithms 4 and 5)
Inclusion criteria a) OR b)
a) Eclamptic fit
b) Consider giving intravenous magnesium sulphate to women with severe pre-

eclampsia if they have BP >140/90 AND proteinuria > 2+ AND at least one of
the following:
a. Persistent severe headache
b. Epigastric pain, vomiting or liver tenderness
c. Visual disturbance
d. Hyperreflexia with> 2 beats clonus
e. Platelet count < 100 x 109
f. ALT> 70 iu/L
g. HELLP syndrome
Always inform the Obstetric and Anaesthetic consultants on call if a patient is

commenced on MgSO4.
Page 8
¾ Anaesthetic considerations
Please see Whittington Health Guideline:
‘Obstetric Anaesthesia’
Serious complications secondary to severe pre-eclampsia
The following rare but serious complications should be considered if the woman
presents with the relevant symptoms and signs1:
Neurological: Intracranial haemorrhage
Subarachnoid Haemorrhage
Ischaemic Stroke
Cortical Blindness
Cavernous sinus thrombosis
Cerebral oedema
Pulmonary: Pulmonary oedema
Adult Respiratory Distress Syndrome (ARDS)
Hepatic Liver rupture
Liver failure/necrosis
Renal Renal failure

Page 9
¾ Postpartum Management
Note: 44% of eclamptic fits occur during the postnatal period5
1. The patient should remain on the Labour Ward for at least 24 hours after
delivery. The blood pressure and fluid balance should be recorded on the
Labour Ward MEOWS chart.
2. When the woman is transferred to the postnatal ward, the blood pressure
should be measured four-hourly on the postnatal MEOWS chart until she is
discharged. She should be asked about severe headache and epigastric pain
whenever the blood pressure is measured4. A fluid balance chart should be
kept for at least 72 hours or until the serum creatinine levels are in the normal
range.
3. Blood parameters (platelets, serum transaminases and serum creatinine)

should be measured 48-72 hours after delivery, and if normal, they should not
be repeated again. However they should continue to be repeated as clinically
indicated if they are improving but still within the abnormal range.
4. The blood pressure should be kept below 150/100. If the woman was treated
prior to delivery she should continue with her antenatal medication, except
methyldopa which should be changed to another medication within 2 days of
delivery. If the woman was not treated prior to delivery, anti-hypertensive
treatment should be started for the first time if the blood pressure exceeds
150/100.
The following antihypertensive medications are suitable for the breast-feeding

postnatal woman 4: Healthcare professionals may prescribe these medicines
during breastfeeding if they consider that this treatment is essential for the
lactating mother. Careful follow-up of the infant for possible signs of
hypotension is recommended.8
Page 10
Labetolol
Nifedipine
Enalapril
Atenolol
Captopril
5. The woman should be kept in until day 3-4 postnatal for the control of her
blood pressure. After discharge her blood pressure should be measured every
1-2 days for two weeks until she is off medication and no longer hypertensive.
A copy of the discharge letter should be faxed AND sent to the GP, as well as
giving a copy to the woman and a copy being placed in the clinical records
(See appendix A)
6. The blood pressure medication should be reduced when the BP is 130-

140/80-90
7. The woman should be seen at 6-8 weeks postnatal. She may be seen in the
Obstetric Medicine Clinic. Her blood pressure and urine dipstick should be
checked. If she is still on medication or has more than 2+ protein on urine
dipstick, her renal function should be further assessed and referral to
specialist services should be considered.
Page 11
Overall management plan (Algorithm 1)
Decision made to deliver fetus? Discuss with

Criteria for protocol satisfied? NO Consultant
YES
Transfer to LW and allocate

dedicated midwife
Give oral Ranitidine150mgs
TED Stockings
Start checklist (appendix E)
ECLAMPSIA Fitting? Assess vital signs RECORD DATA ON

PROTOCOL (ABCDEF) and MEOWS CHART
commence monitoring
Anticonvulsant BP every 15 mins Insert urinary Insert a Send blood for: FBC,
prophylaxis? initially catheter 16G Venflon coag, G&S, U+E, LFT,
urate
Mg BP FLUID Commence Hartmann’s

PROTOCOL PROTOCOL PROTOCOL 1ml/Kg/hr
Repeat FBC, coagulation studies, U /Es 12 hourly
SUBSEQUENT Stay on LW for minimum of 24 hrs post delivery
MANAGEMENT MEOWS chart to be maintained until pt leaves LW
Use standard fluid balance charts for first 4 days postnatal
Page 12
Algorithm 2: Postpartum Fluid management
Hartmann’s
1ml/kg/hr (approx 80 mls/hr)
Urine output < 100 mls/4 hrs
Check:
1. Correct estimation of
blood loss at delivery
2. Fluid input/output
3. Signs of fluid overload
4. Renal Function
5. If complete anuria
check catheter
Creatinine >100
Consultant Obstetric Input >output by more than Output > input by

and Anaesthetic 750mls more than 750
input: mls
Consider input from
ITU team
D/w senior
obstetrician/anaesthetist and Fluid challenge
consider IV furosemide with 250 mls
colloid or
crystalloid
Continued Oliguria <100mls/ 4

hours
Page 13
Algorithm 3: Blood Pressure Management**Aim for target BP 150/80-100**
Manual BP monitor: BP > 160/110 or Mean Arterial Pressure (MAP) > 125 on 3 consecutive
readings 5 mins apart at least one using a manual cuff
Oral Nifedipine-SR 10- 20 mg

or labetolol 200mg stat
1 hour later
If BP controlled to < 160/110: start

BP still > 160/110 or MAP > 125 Nifedipine- SR 10-20mg bd or
Labetolol 200mg tds as a regular
prescription
Labetolol 50mg IV given over 1 min 3, 6

(NB: contraindicated in Asthma: use hydralazine:
see below)
Repeat after 10 min if necessary, increasing dose

by 40mg-80mg to a maximum total dose of 200mg
(10 mls of 5mg/ml)
Hydralazine Regime7
-Preload with Hartmann’s 500ml IV over 30

minutes (only if antenatal)
-Give hydralazine 5mg IV in 10 mls N
Saline; as slow bolus over 1-2 minutes
-Repeat every 20 mins to max 20mg (4
doses)
Labetalol maintenance infusion6
-20 mg/hr doubling every 30 mins to max 160

mg/hr
-STOP infusion if:

-Diastolic BP < 90 mmHg
-pulse < 60 bpm
Open 2 ampoules (200mg in 40 mls) into a syringe
driver and start at 4 mls (20 mg)/hr, doubling to a
maximum of 32 mls (160 mg)/hr
Hydralazine maintenance infusion3
-2 mg/hr; increase by 0.5mg/hr to a max of

20mg/hour
- STOP infusion if:
-diastolic<90 mmHg
-pulse>120 bpm;
-maternal side-effect flushing/
headache
Page 14
Eclampsia management (Algorithm 4)
Call for midwifery help and Adult

resuscitation trolley & Fit Kit
Dial 2222
Say Obstetric
Emergency
Ward_____
Room ____
Place woman in full

left lateral position
Assess (ABCDE)
and clear airway
Give O2 (15L/min)
via AMBU bag
Airway under control and

patient well oxygenated?
yes no
When fit stops Intubate using rapid

move to LW. sequence induction
If fit prolonged
give
magnesium MAGNESIUM
sulphate 4G PROTOCOL
bolus
Recurrent seizures: Give further bolus of 2-4G Magnesium Sulphate (depending on weight; see
algorithm 5).
Consider anaesthesia and intubation/ventilation.
A CT scan of the head must be performed in women with recurrent seizures to exclude
other CNS pathology.
Page 15
Algorithm 5: Magnesium Sulphate Management
Loading dose Preparation

MgSO4 4g IV over 10 -15 20mls (1 ampoule) of 20%
mins MgSO4 into 50ml syringe for
Via syringe driver driver running at 99.9 mls/hr
Maintenance Infusion Preparation

1g MgSO4/hour 60ml (3 ampoules) 20%
For 24 hours after last MgSO4 into 50ml syringe at
seizure 5ml/hr (1g/hr)
Monitor Toxicity- hourly Recurrent Fit:

observations on MEOWS:
• RR <16/min • MgSO4 2g IV bolus if <
• O2 sats< 95% 70 kg and 4g >70kg
• Depressed patellar/biceps over 5 mins
reflexes • Take MgSO4 levels
• Drowsiness
• Paralysis
• Cardiorespiratory arrest
Monitor Mg levels if:
• Oliguria < 100 mls/4 hours

• Serum Creatinine >90
umol/l
• Signs toxicity
• Recurrent fits
Therapeutic range 2-4mmol/L

Significant toxicity at
5mmol/L
If signs of toxicity
• Stop MgSO4 infusion

• Give O2
• Call anaesthetist
• Consider Calcium
Gluconate 1g IV (10 mls
10%) over 10 mins
Page 16
¾ Contacts (inside and outside the Trust including out-of-hours contacts)
Emergency Call: 2222 ‘Obstetric Emergency Room ________ on ________ward;

room_________
On call Consultant Obstetrician Call via switchboard

On Call Consultant Anaesthetist Call via switchboard
Obstetric Registrar on call Bleep 2838

Obstetric SHO on call Bleep 3066
LW Anaesthetic Registrar on call Bleep 3067
ITU Registrar on call Bleep 2613

Critical Care Outreach team Bleep 2837
¾ References (evidence upon which the guideline is based)
1. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer

2003-2005. The Seventh Report of the Confidential Enquiries into Maternal
Deaths in the United Kingdom RCOG 2007 (ISBN: 978-0-9533536-8-2)
2. The management of severe Pre-Eclampsia/ Eclampsia RCOG Green Top

Guideline No 10(A) March 2006
3. Managing Obstetric Emergencies and Trauma: The MOET course Manual 2nd
edition RCOG 2007 (ISBN 978-1-904752-21-9)
4. NICE guideline: Hypertension in pregnancy: the management of hypertensive

disorders during pregnancy NCC-WCH 2010 April 2010
5. Eclampsia in the United Kingdom. BMJ 309 1395-1400 Douglas KA and

Redman CWG (1994).
6. British National Formulary BNF 58 BMJ Group September 2009 (ISBN 978 0
85369 848 7)
7. Consensus view see UCLH guidelines. MHRA Drug Safety Update 2 (12) July
2009
Page 17
Appendix A: Letter to GP informing them of discharge of hypertensive postnatal patient from the
Whittington Hospital (please fax as well as post, and make copies for the patient and notes)
Date:………………………………….. Re: Your Patient:
To: Dr……………………………………….. Name …………………………………..
……………………………………….…. DOB ……………………………………
…………………………………….……. Hosp No …………………..……………….
…………………………………….……. Address ……………………………………
Fax No …………………………………….……. ……………………………………
………………….…………………
Your patient was delivered at the Whittington Hospital on…………………………………………………….
***Her antenatal/postnatal course has been complicated by hypertension***
She was discharged from Whittington on (date)……………………………………………………………...…
Her Blood Pressure at booking was………………………………………………………………………...…….
Her Blood pressure on discharge was……………………………………………………..…………………..…
Her Blood pressure medication on discharge was………………………………….…………………………...
***Please send her urgently to Labour Ward (0207 288 5502) if she has any NEW symptoms suggestive of
poorly controlled hypertension, pre-eclampsia or impending eclampsia***
Her 6/52 postnatal appointment is on………………………….…in the ANC with……………..……………...
Please see her (tick as applicable):
In…………days time to check her blood pressure and then alternate days for up to 2 weeks.
With a view to tailing off /stopping her medication if her BP is consistently less than 130-140/ 80-90
Please refer her if you have any concerns about control of her hypertension.
Any other comments……………………………………………………………………………………..……...
……………………………………………………………………………………………………….……………..
…………………………………………………………………………………………………….………………..
Yours Sincerely,
Name:
Bleep
Consultant team:
Page 18
Appendix B: Audit Tool
Women’s Health Maternity

Audit Tool for Guideline
Severe hypertension, preeclampsia and eclampsia
Objectives of the audit:
The objective of this audit is to demonstrate compliance of the guideline in all cases
of severe hypertension and severe pre-eclampsia against the following standards:
1. Severe hypertension was correctly assessed and diagnosed according to the
inclusion criteria in 100% cases.
2. There were clear lines of communication between the consultant obstetrician,
consultant anaesthetist, Labour Ward co-ordinator and (neonatologist if the patient
was antenatal) in 100% cases.
3. There was appropriate control of blood pressure in 100% cases.
4. There was appropriate fluid management in 100% cases.
5. Magnesium Sulphate was used for the prevention of seizures if appropriate in 100%
cases.
6. There was appropriate control of eclamptic seizures in 100% cases.
7. The fetus was assessed and delivery planned appropriately in 100% cases.
8. Postnatal follow- up was appropriately planned in 100% cases
Data sources
The data will be collected from case notes
Re-audit
The guideline will be audited as required.
Page 19
Audit tool Hospital No: Date delivered:
Standard Severe pre-eclampsia was Assessment Time

1 correctly assessed and frame
diagnosed according to the
inclusion criteria
By case note audit Annual
Severe pre-eclampsia was
correctly assessed and yes no
diagnosed according to the
inclusion criteria
Standard 2 Clear lines of communication Assessment Time

between the disciplines frame

1. On call Obstetric yes no
consultant called N/D
2. On call anaesthetist yes no

called N/D
Standard 3 Blood pressure was Assessment Time

appropriately controlled frame

1.Blood pressure measured
every 15 mins yes no
2.Oral nifedipine/labetolol yes no
3.Intravenous labetolol yes no
4.Intravenous hydralazine yes no
5.Preloaded with gelofusine yes no
prior to hydralazine
6. BP maintained at yes no
<160/100
Page 20
Standard 4 Fluid management was Assessment Time
appropriate By case note audit frame
Annual
1. Urinary catheter was yes no
inserted
2. Fluid restriction 1ml/kg/hr yes no
3. Oliguria managed yes no
according to algorithm N/A
Assessment of U+E yes no

Assessment of pulmonary yes no
oedema
Fluid challenge if fluid
depleted yes no
N/A
IV diuretic if fluid overloaded yes no

N/A
Standard 5 Magnesium Sulphate was Assessment Time

used for the prevention of By case note audit frame
seizures if appropriate
Annual
1. MgSO4 protocol yes no
commenced appropriately N/A
BP >140/90 yes no
Proteinuria >2+ yes no
Symptoms and signs yes no
Pts<100 or ALT > 70
or HELLP yes no
2. Consultant obstetrician yes no
informed
3 Consultant anaesthetist yes no
informed
4. Signs of toxicity (RR/sats yes no
/reflexes) monitored
5. Appropriate checking of
yes no
Mg levels
N/A
Page 21
Standard 6 There was appropriate Assessment Time
control of eclamptic seizures. By case note audit frame
1.2222 called yes no Annual

2. ABCDE and O2 yes no
3. MgSO4 protocol yes no
commenced
4. Second dose of MgSO4
yes no
given if appropriate N/A
5. Intubation for recurrent fits yes no
if appropriate
N/A
6. Signs of toxicity (RR/sats yes no
/reflexes) monitored
7. Calcium Gluconate if signs yes no
toxicity
N/A
8. Appropriate checking Mg
levels yes no
N/A
Standard 7 The fetus was assessed and Assessment Time

delivery planned By case note audit frame
appropriately
1. Mode of delivery Annual

discussed with consultant yes no
obstetrician and N/A
neonatologist if appropriate
yes no
2. 2 doses betamethasone N/A
given if <34/40
yes no
3. labour induced N/A
yes no
4. continuous CTG N/A
5. Delivery by CS yes no
N/A
yes no
6.Delivery by assisted
N/A
vaginal delivery
yes no
7. SVD
N/A
Page 22
Standard 8 Postnatal (PN) follow- up Assessment Time
By case note audit frame
Annual
1. Repeat bloods within 12
hours yes no
2. MEOWS chart on Labour yes no
Ward
3.Minimum stay on LW for
24 hrs yes no
4. MgSO4 for 24 hours post
delivery yes no
5. 4-hourly BP measurement
on PN ward
yes no
6.Fluid balance chart for 72
hours yes no
7. PN HT letter sent to GP yes no
8. PN follow-up at 6-8/52
postnatal yes no
Other data collection
Baby
Gestation
Livebirth/stillbirth liveborn stillborn
Birthweight …………g Centile …………
Apgar Score at 5mins
Cord gases Arterial ………….. venous

……………..
Admission to NICU yes no
Maternal morbidity
Eclampsia yes no
Intracranial haemorrhage yes no
Hellp yes no
Page 23
Renal failure yes no
Liver failure yes no
Placental abruption in labour yes no
Pulmonary oedema yes no
Itu admission yes no
Death yes no
Page 24
Appendix C
Severe Pre-eclampsia , Eclampsia and Severe Hypertension Checklist
(Use after decision made to commence woman on protocol)
Communication
1. On call Obstetric consultant called yes

Name………..………………….
2. On call anaesthetist called
3. LW co-ordinator called yes
Name………..………………….
4. On call neonatologist informed
5. Mode of delivery discussed with consultant yes
obstetrician Name………..………………….
6. Mode of delivery discussed with NN team yes N/A
and steroids discussed Name………..………………….
yes
yes N/A
Blood Pressure Control
1. Blood pressure measured every 15 yes

mins
?? yes
2. BP maintained at <160/100
3. Observations recorded on MEOWS yes
chart
Fluid Management
1. Urinary catheter inserted yes

2. Fluid restriction 1ml/kg/hr yes
3. Oliguria managed according to algorithm
yes N/A
Page 25
Magnesium Sulphate
1. MgSO4 protocol commenced yes N/A

appropriately
yes
2. Consultant obstetrician informed Name………………………….
3 Consultant anaesthetist informed
yes
4. Signs of toxicity (RR/sats /reflexes) Name………………………….
monitored
yes
Eclamptic Fit
yes no
1.2222 called Time………………….……
yes no
2. ABCDE and O2 Time………………….………
yes no
3. MgSO4 protocol commenced Time………………….………
4. Second dose of MgSO4 given if
appropriate yes no N/A
Time…………………
5. Intubation for recurrent fits if
appropriate yes no N/A
Time…………………
6. Calcium Gluconate if signs toxicity yes no N/A

7. Appropriate checking Mg levels yes no N/A
Page 26
¾ Compliance with this guideline (how and when the guideline will be monitored e.g.
audit and which committee the results will be reported to) Please use the tool provided
at the end of this template
To be completed and attached to any procedural document when submitted to the

appropriate committee for consideration and approval
Yes/No Comments
1. Does the procedural document affect one
group less or more favourably than another
on the basis of:
• Race No
• Ethnic origins (including gypsies and No

travellers)
• Nationality No
• Gender No
• Culture No
• Religion or belief No
• Sexual orientation including lesbian, gay No

and bisexual people
• Age No
• Disability - learning disabilities, physical No

disability, sensory impairment and mental
health problems
2. Is there any evidence that some groups are No
affected differently?
3. If you have identified potential No
discrimination, are any exceptions valid,
legal and/or justifiable?
4. Is the impact of the procedural document No
likely to be negative?
5. If so can the impact be avoided? N/A
6. What alternatives are there to achieving the N/A
procedural document without the impact?
7. Can we reduce the impact by taking N/A
different action?
If you have identified a potential discriminatory impact of this procedural document, please
refer it to the Director of Human Resources, together with any suggestions as to the action
required to avoid/reduce this impact.
Page 27
For advice in respect of answering the above questions, please contact the Director of
Human Resources.
Checklist for the Review and Approval of Procedural Document

To be completed and attached to any procedural document when submitted to the relevant
committee for consideration and approval.
Yes/No
Title of document being reviewed: Comments
1. Title
Is the title clear and unambiguous? Yes
Is it clear whether the document is a guideline, Yes

policy, protocol or standard?
2. Rationale
Are reasons for development of the document Yes
stated?
3. Development Process
Is it clear that the relevant people/groups have Yes

been involved in the development of the
document?
Are people involved in the development? Yes
Is there evidence of consultation with Yes

stakeholders and users?
4. Content
Is the objective of the document clear? Yes
Is the target population clear and Yes

unambiguous?
Are the intended outcomes described? Yes
5. Evidence Base
Are key references cited in full? N/A
Are supporting documents referenced? N/A
6. Approval
Does the document identify which committee/ Yes

group will approve it?
7. Dissemination and Implementation

Is there an outline/plan to identify how this will Yes
be done?
8. Document Control
Does the document identify where it will be Yes
Page 28
Yes/No
Title of document being reviewed: Comments
held?
9. Process to Monitor Compliance and

Effectiveness
Are there measurable standards or KPIs to Yes
support the monitoring of compliance with and
effectiveness of the document?
Is there a plan to review or audit compliance Yes

with the document?
10. Review Date

Is the review date identified? Yes
Is the frequency of review identified? If so is it Yes

acceptable?
11. Overall Responsibility for the Document

Is it clear who will be responsible for co- Yes
ordinating the dissemination, implementation
and review of the document?
Executive Sponsor Approval

If you approve the document, please sign and date it and forward to the author. Procedural
documents will not be forwarded for ratification without Executive Sponsor Approval
Name Date
Signature
Relevant Committee Approval

The Director of Nursing and Patient Experience’s signature below confirms that this procedural
document was ratified by the appropriate Governance Committee.
Name Date
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Responsible Committee Approval – only applies to reviewed procedural documents with

minor changes
The Committee Chair’s signature below confirms that this procedural document was ratified by the
responsible Committee
Name Date
Name of Name &
Committee role of
Committee
Chair
Signature
Page 29
Tool to Develop Monitoring Arrangements for Policies and guidelines
What key element(s) need(s) Who will lead on this aspect What tool will be used to How often is the need to What committee will the
monitoring as per local of monitoring? monitor/check/observe/Asses monitor each element? completed report go to?
approved policy or guidance? s/inspect/ authenticate that
Name the lead and what is the everything is working How often is the need
role of the multidisciplinary according to this key element complete a report ?
team or others if any. from the approved policy?
How often is the need to
share the report?
Element to be monitored Lead Tool Frequency Reporting arrangements
Ensure that the blood The audit tool Proforma As required, however, if an Ms Biswas will read the
pressure is controlled and (appendix B) will be used increase in trend analysis of report, findings will be
fluid balance maintained Ms Chandrima Biswas, Lead patient safety incidents is reviewed at the Maternity
Obstetrician for Labour Ward identified, then this Clinical Guidelines and Audit
monitoring process may Group which meets monthly
Case notes occur more frequently as and then at the next Labour
Prevention of seizures required Ward Forum which meets
quarterly
Evidence to support this may

Fetal assessment and be found in the form of
delivery planning minutes from these meetings.
Recommendations and action

planning for any or all
deficiencies are the
responsibility of Maternity
Clinical Guidelines and Audit
Group. These will be
identified one month hence of
the report being published
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PRE-ECLAMPSIA, ECLAMPSIA AND SEVERE

Subject: Pre- eclampsia,eclampsia and hypertension

Version Date Author Status Comment

Hypertensive disorders of pregnancy remain a leading cause of direct maternal

Specific learning points from the CEMACH report are as follows:

1. Systolic hypertension of 160 mmHg must be treated.

• Persistently elevated BP of 140/90 in a patient without pre-existing

• Symptoms and signs:

• Abnormal Laboratory investigations:

Eclampsia is defined as the occurrence of one or more convulsions

Inclusion criteria for severe pre-eclampsia/ eclampsia protocol

1. Blood pressure greater than or equal to 160/110

The aims of management are:

• Prompt control of blood pressure

See: Algorithm 1: Overall management plan

Algorithm 2: Fluid management

Algorithm 3: Blood pressure management

Algorithm 5: Magnesium Sulphate management

General measures (see Algorithm 1):

Planning for delivery

1. Corticosteroid for fetal lung maturation: Give betamethasone or

2. Decision for delivery and mode of delivery: This should be made in

3. If allowed to labour, the fetus should be assessed with continuous electronic

5. 3rd stage: manage this with Syntocinon® 10 iu IM or slow IV administration.

6. The prophylaxis or treatment of postpartum haemorrhage with 40 units

Fluid Management (see algorithm 2):

Special care should be taken in the fluid

1. A urinary catheter should be inserted and urine output measured hourly.

2. Total intravenous fluid input should be limited to 1ml/kg/hr- approximately

3. Fluid loading in pre-eclampsia should never be done prophylactically or

a. Intrapartum: Oliguria should not precipitate any intervention except to

b. Postpartum: Continue to restrict fluids until a natural diuresis, which

Magnesium Sulphate for the treatment and prevention of eclampsia

b) Consider giving intravenous magnesium sulphate to women with severe pre-

Always inform the Obstetric and Anaesthetic consultants on call if a patient is

Please see Whittington Health Guideline:

Serious complications secondary to severe pre-eclampsia

Neurological: Intracranial haemorrhage

Cavernous sinus thrombosis

Pulmonary: Pulmonary oedema

Adult Respiratory Distress Syndrome (ARDS)

Hepatic Liver rupture

Renal Renal failure

Note: 44% of eclamptic fits occur during the postnatal period5

3. Blood parameters (platelets, serum transaminases and serum creatinine)

The following antihypertensive medications are suitable for the breast-feeding

6. The blood pressure medication should be reduced when the BP is 130-

Decision made to deliver fetus? Discuss with

Transfer to LW and allocate

ECLAMPSIA Fitting? Assess vital signs RECORD DATA ON

Mg BP FLUID Commence Hartmann’s

Urine output < 100 mls/4 hrs

Consultant Obstetric Input >output by more than Output > input by

Continued Oliguria <100mls/ 4

Oral Nifedipine-SR 10- 20 mg

If BP controlled to < 160/110: start

Labetolol 50mg IV given over 1 min 3, 6

Repeat after 10 min if necessary, increasing dose

-Preload with Hartmann’s 500ml IV over 30

Emergency Call: 2222 ‘Obstetric Emergency Room on ward;

Her antenatal/postnatal course has been complicated by hypertension

2. On call anaesthetist yes no

Assessment of U+E yes no

IV diuretic if fluid overloaded yes no

1.2222 called yes no Annual

Livebirth/stillbirth liveborn stillborn

Intracranial haemorrhage yes no

Liver failure yes no

Placental abruption in labour yes no

Pulmonary oedema yes no

Itu admission yes no

1. On call Obstetric consultant called yes

1. Blood pressure measured every 15 yes

1. Urinary catheter inserted yes

1. MgSO4 protocol commenced yes N/A

6. Calcium Gluconate if signs toxicity yes no N/A