Hypertension at 34 Weeks in a Woman Planning Home Birth
A 28-year-old woman, G3P2 (one previous caesarean for fetal distress, one vaginal birth), attends a community antenatal clinic at 34 weeks and 2 days. She has had two readings of 148/96 mmHg and 152/98 mmHg four hours apart, and a dipstick urinalysis showing 1+ protein. She reports frontal headache and epigastric discomfort since yesterday. Her fundal height is 33 cm, fetal heart rate 146 beats/min, and she has mild ankle oedema. She lives 90 minutes by road from the district hospital, owns no vehicle, and has brought her mother to support a planned home birth. The clinic has no ultrasound, no blood cross-match service, and one nurse-midwife on duty. The woman says she feels well and does not want to be referred because her previous hospital birth was 'handled roughly'. She has no history of chronic hypertension or renal disease.
1. Classify the woman's hypertensive disorder using the findings, and explain the immediate risks that make this an emergency rather than a routine referral.
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This is pre-eclampsia with severe features, not gestational hypertension. The two readings at or above 140/90 mmHg with 1+ proteinuria establish pre-eclampsia; the new frontal headache and epigastric pain are warning symptoms. The blood pressure is not yet in the severe range (160/110 mmHg), so the classification is driven by symptoms and the clinical picture, not by the number alone.
Immediate risks to the mother are eclampsia, HELLP syndrome, placental abruption, acute kidney injury, pulmonary oedema and intracerebral haemorrhage. Risks to the fetus are placental insufficiency, growth restriction, oligohydramnios and stillbirth. The fundal height of 33 cm at 34 weeks is not reassuring and cannot be properly assessed without ultrasound.
The remote location, lack of cross-match and single midwife make this an emergency: if she convulses at home, neither she nor the baby can be resuscitated safely. Home birth is no longer an appropriate plan.
2. Set out a safe referral and transfer plan for the next two hours, naming what must be done before, during and after transfer.
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Before transfer: check airway, breathing and circulation; record blood pressure, pulse, respiration, temperature, urine output and fetal heart rate every 15 minutes. Obtain IV access with a large cannula and take blood for full blood count, platelets, liver enzymes, creatinine and group and cross-match if the clinic can do so. If severe features are confirmed and the protocol, drugs and trained staff are available, start a magnesium sulphate loading regimen (for example 4 g IV over 20 minutes plus 10 g IM) and monitor respiratory rate, reflexes and urine output; keep calcium gluconate available. Give antihypertensives only if blood pressure reaches 160/110 mmHg, using the local protocol. Explain the diagnosis and the reason for referral to the woman and her mother.
During transfer: arrange an ambulance with a skilled escort, carry a referral letter with all observations, and position her on the left side. Continue monitoring blood pressure, fetal heart rate, contractions, bleeding and level of consciousness.
After transfer: give a structured handover to the receiving obstetric team and document the time of referral, advice received and transfer. Do not plan a home birth or attempt induction at this clinic.
3. The woman refuses referral. Explain how you will counsel her and what you will document, including the limits of her choice.
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Acknowledge her fear and her previous experience before presenting the clinical facts. Say plainly that she has a condition that can cause seizures, placental separation and death, and that the clinic cannot manage an eclamptic fit or a premature baby. Use teach-back to confirm she understands, involve her mother if she agrees, and offer to have a known midwife accompany her in the ambulance. Address the 'rough handling' concern by explaining what will happen at the hospital and who will receive her.
Her choice must be respected, but it is not a choice for unsafe home birth. If she still refuses, assess her capacity, explain the risks in her own language, offer immediate obstetric telephone review and safe transport, and continue emergency monitoring. Document the diagnosis, the advice given, her reasons for refusal, the alternatives offered and her signature or witnessed refusal. Inform the obstetrician and your supervisor. Do not abandon her: arrange review, safety-netting and follow-up. If she lacks capacity or the fetus is in immediate danger, escalate under the relevant law and facility policy.