Reduced fetal movements and new hypertension at 34 weeks in a rural setting
A 29-year-old primigravida at 34+3 weeks phones her lead maternity carer (LMC) from a rural town 2.5 hours by road from the nearest tertiary obstetric unit. She reports reduced fetal movements for the past 24 hours and a frontal headache that has not settled with paracetamol. She has no vaginal bleeding or fluid loss. At the local clinic her blood pressure is 148/98 mmHg, repeated after rest as 146/96 mmHg; urine dipstick shows trace protein. She has no visual disturbance or epigastric pain. The local facility has no obstetric unit, no on-site ultrasound after hours, and CTG is available. Her partner is away for work and she cares for her mother, who needs daily support. She is unsure whether she can travel. She asks whether she can wait until the morning.
1. What is your immediate assessment and referral plan, and which findings would make this an emergency transfer rather than a clinic review?
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Priority: exclude severe pre-eclampsia and fetal compromise, not simply reassure.
I would ask about headache severity, visual changes, epigastric or right upper quadrant pain, nausea or vomiting, bleeding, fluid loss, and the pattern of fetal movements. I would arrange same-day review at the clinic, not wait until morning. On arrival I would repeat blood pressure after 5 minutes rest, check pulse, respirations, temperature, urine dipstick, and perform a CTG. At 34+3 weeks, reduced movements plus new hypertension needs a growth scan and umbilical artery Doppler if available, and bloods including full blood count, platelets, urea and electrolytes, liver function tests, uric acid, and group and hold.
Severe features would include blood pressure ≥160/110 mmHg, platelets <100 × 10^9/L, abnormal liver enzymes, rising creatinine, pulmonary oedema, or cerebral or visual symptoms. I would discuss with the tertiary obstetric team and transfer urgently if there is any severe feature, an abnormal CTG, inability to complete investigations promptly, or if preterm birth is likely. Even without severe features, her distance from definitive care lowers my threshold for transfer because deterioration can be rapid. If transfer is arranged, I would secure IV access, monitor maternal and fetal status, give antenatal corticosteroids if preterm birth is anticipated according to local guidance, and consider magnesium sulfate for eclampsia prophylaxis if severe pre-eclampsia is confirmed. I would not send her alone; I would arrange ambulance transport with a midwifery escort.
2. How would you support informed choice and culturally safe care when she says she cannot travel tonight, and what would you document?
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Start from her reality, not the clock. I would ask what travel means for her: who will care for her mother, transport costs, whānau support, and whether she feels safe travelling at night. I would explain the findings in plain language: her blood pressure is higher than normal, reduced movements need checking, and at 34 weeks the main concerns are pre-eclampsia and placental function. I would be honest that phone reassurance is not a safe option.
I would offer realistic choices: immediate clinic review with CTG and bloods, transfer tonight for tertiary assessment, or a time-limited plan only if assessment is completed and no severe features are found. I would involve the whānau she nominates, offer an interpreter if needed, and ask whether she wants a Māori health navigator or kaiāwhina involved. Te Tiriti-based equity means actively removing access barriers such as transport, dependent care and cost, rather than labelling her as non-compliant.
I would document the findings, the risks explained, the options offered, her questions, her decision and capacity, the safety-net advice, who was contacted, and the plan if symptoms worsen. If she declines transfer, I would document informed refusal, escalate to the obstetrician, arrange close monitoring, and ensure a clear ambulance plan is in place.