Triage and Referral in a Rural Antenatal Clinic
A community health worker runs a monthly antenatal clinic in a village 90 minutes by road from the nearest hospital; the road becomes impassable in heavy rain. Three women arrive at the same visit.
- Amina, 24 weeks pregnant, gravida 2, reports a severe headache for 2 days, blurred vision, and swelling of her hands and face. Blood pressure is 158/104 mmHg on two readings; urine dipstick shows 2+ protein.
- Beatrice, 36 weeks, reports reduced fetal movement since yesterday. She has no bleeding, no contractions, and blood pressure 118/74 mmHg.
- Chidi, 18 weeks, has mild nausea and asks for vitamins. She had one previous miscarriage at 10 weeks.
The health worker has one vehicle, no ultrasound, and no ability to admit patients.
1. Rank the three women by urgency and justify each ranking using the findings, not the diagnoses alone.
Read the worked answer
1. Amina - most urgent, transfer now. Severe headache, visual disturbance, and facial and hand swelling with a blood pressure of 158/104 mmHg and 2+ protein at 24 weeks fit severe preeclampsia. The risk is progression to eclampsia, stroke, placental abruption, or HELLP syndrome, any of which can kill mother and fetus within hours. The 90-minute road and the rain risk mean she must leave before conditions worsen; waiting for the next visit is not acceptable.
2. Beatrice - urgent, same-day referral. Reduced fetal movement at 36 weeks is a warning sign for fetal compromise even with normal blood pressure and no bleeding. She needs fetal heart monitoring and assessment that this clinic cannot provide. She is less likely than Amina to deteriorate in the next hour, but she should not wait days.
3. Chidi - routine. Mild nausea at 18 weeks with no bleeding, no fever, and no severe pain is common. Her prior miscarriage warrants sensitive counseling and a plan for her next visit, but she does not need emergency transfer. She can be seen after the other two are dispatched.
Ranking by findings matters: two women are "pregnant," but only one has a hypertensive emergency. Triage on the combination of symptoms, vital signs, and distance to care.
2. Describe the actions and handover for Amina before and during transport, including what the receiving hospital must know.
Read the worked answer
Before transport:
- Repeat blood pressure and check for clonus, epigastric pain, and urine output if possible.
- Give a loading dose of magnesium sulfate per national protocol if trained and authorized, watching respiratory rate, reflexes, and urine output; have calcium gluconate available if the protocol includes it.
- Do not give antihypertensives outside protocol; if the protocol allows, treat severe hypertension to prevent stroke.
- Position her on her left side, keep her calm, and avoid bright lights and unnecessary stimulation.
- Arrange the vehicle, a companion, and a referral note; call ahead so the hospital prepares.
Handover (SBAR-style):
- Situation: 24 weeks pregnant, severe headache and visual changes, blood pressure 158/104, 2+ protein.
- Background: gravida 2, no known chronic hypertension, no prior preeclampsia reported.
- Assessment: suspected severe preeclampsia; risk of seizure and deterioration.
- Recommendation: needs obstetric review, laboratory tests, monitoring, and possible delivery planning; transport is underway and expected arrival time is stated.
Record the time of any magnesium dose and the maternal and fetal condition at departure. Tell the family the reason for transfer in plain language so they do not delay or refuse out of fear.