Headache and visual disturbance at a midwife-led unit 40 minutes from the obstetric hospital
Amara is 34, G2P1, 36+2 weeks, booked for midwife-led care. She attends the alongside birth centre, which is 40 minutes by road from the obstetric unit, for a routine 36-week appointment. She describes a frontal headache since yesterday that paracetamol has not touched, and 'flashing lights' in the last hour. After ten minutes' rest her blood pressure is 152/98 (first reading 146/94). Urine dipstick shows protein 2+. Reflexes are brisk with two beats of clonus. Fundal height is 34 cm, presentation cephalic and 4/5 palpable, fetal heart 142 regular. She has a 3-year-old at home, no partner present, no transport and no one to collect her daughter before 17:00. She asks to go home and come back in the morning when her partner can drive.
1. State your working assessment and set out, in priority order, what must happen in the next 30 minutes. Justify each action.
Read the worked answer
Assessment. This is not 'probably pre-eclampsia, refer routinely'. Headache unresponsive to analgesia plus visual disturbance plus proteinuria plus clonus means she has features of severe pre-eclampsia until proven otherwise. The clinical question is not diagnostic but temporal: is this time-critical? Yes - the risks being managed are eclampsia and intracranial haemorrhage, and both can occur within hours.
Next 30 minutes
- Do not let her leave. Stay with her, sit her down, and say plainly that you are not able to let her drive herself home today and explain why. Framing it as safety, not as a rule being imposed, preserves her agency.
- Confirm the reading with correct cuff size, arm supported, repeat after 5–10 minutes, and record both readings. Check her notes for baseline BP and any previous proteinuria.
- Auscultate the fetal heart (or apply CTG if available) - her fetus is also at risk from uteroplacental insufficiency.
- Escalate now, in parallel: telephone the obstetric unit (senior obstetrician and anaesthetist aware), arrange ambulance transfer with a midwife escort, and inform the on-call midwifery manager. Bloods (FBC, U&Es, LFTs, urate) are useful but must not delay transfer - do not wait for results before moving her.
- Antihypertensives only within your local protocol and competence; if labetalol loading is midwife-initiated in your trust, give it; if not, get it prescribed by telephone while the ambulance is en route.
- Document contemporaneously and start a clear SBAR handover.
Reasoning: the presence of symptoms and clonus, not the number alone, converts this from a same-week referral into a same-hour transfer.
2. She has no transport and no childcare until 17:00, and says she will come back tomorrow. How do you manage both the clinical risk and the practical constraint?
Read the worked answer
The practical problem is real but it does not change the clinical urgency, so the task is to solve the logistics around the transfer rather than trade one against the other.
- Name the constraint out loud and take it seriously. 'I can see the problem is your daughter - let's sort that out, because you can't drive yourself and you can't wait until tomorrow.'
- Generate options with her, not for her: ring her partner or another named adult; ring the school/nursery to ask if she can be collected by an authorised person; ask the birth centre's on-call manager whether a member of staff can sit with the child; in some areas the child can travel with her in the ambulance and be collected at the hospital. Record who she has consented to you contacting.
- Escalate the logistics too. The midwifery manager or site coordinator can authorise staff time and a taxi; this is an organisational decision, not hers to solve alone.
- If she still declines: she is an adult with presumed capacity and may refuse. Then (a) make the risk explicit and specific - collapse, seizure, stillbirth; (b) offer the safest alternative you can actually deliver, e.g. ambulance to the obstetric unit now versus admission to the birth centre with continuous observation and transfer at the earliest possible moment; (c) never leave her alone or unsupported; (d) document the discussion, her words, the advice given and her decision; (e) inform the obstetric team and your manager; (f) set a firm review time and safety-net instructions.
Reasoning: refusal of transfer is a documented risk decision, not a discharge. The record must show that she was given the information a reasonable person would need.
3. Which findings would move you towards a different plan, and what would you still need to know before she left the building in any scenario?
Read the worked answer
Findings that would allow a less urgent pathway
- Blood pressure settling below 140/90 on repeated, correctly measured readings, with no headache, no visual symptoms, no clonus and normal reflexes.
- Normal platelets, LFTs and urate, and proteinuria quantified (PCR or 24-hour collection) rather than a single dipstick.
- A clear alternative explanation for the headache (migraine history, viral illness) that a senior clinician accepts. Even then, she is 36+2 with new proteinuria and hypertension: she warrants same-day obstetric review and a plan for delivery timing, not a routine 37-week appointment.
Findings that would make it more urgent still
- BP ≥160/110, platelets falling, rising ALT, epigastric pain, reduced urine output, or reduced fetal movements / abnormal fetal heart - any of these means immediate transfer and consideration of magnesium sulphate.
- Clonus of 3+ beats or a seizure would trigger the eclampsia pathway on the spot.
Before anyone leaves the building
- Two documented BP readings with time and cuff size.
- A documented fetal heart.
- A documented conversation: what she was told, what she chose, who was informed and when.
- A named senior clinician who has accepted the referral, with a time.
- Written safety-net advice (call 999 for severe headache, visual loss, epigastric pain, bleeding, reduced movements), given to her and, where possible, to a second person.
Reasoning: the evaluation step is about demonstrating that the decision was reviewed against the data, not made once and left.