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Clinical Guideline for Pre-Eclampsia/ Eclampsia/ postnatal care V5 October 2016

A Division-Specific Clinical Guideline for Guideline Pre-eclampsia / Eclampsia/ postnatal

guidance

Status (Ratified): Ratified

Date ratified: 15th December 2016

Version: 5

Ratifying Board: WaCH Divisional Quality and Risk Group

Approved Sponsor Group: Guideline & guideline group

Type of Procedural Document Clinical Guideline

Owner: Shamila Sivarajan

Owner’s job title Consultant Obstetrician

Author: Shamila Sivarajan / Sebastian Adamson

Author’s job title: Obstetric consultant / Regitrar

Equality Analysis completion date: 15/12/2016

Date issued: December 2016

Review date: December 2019

Replaces: 4.4

Unique Document Number: 0631


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Equality statement This document demonstrates commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 to promote positive practice and value the diversity of all individuals and communities. This document is available in different languages and formats upon request to the Trust Procedural Documents Coordinator and the Equality and Diversity Lead.


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Contents Page

number

1 Assessment & Diagnosis of Severe Pre-eclampsia 3 1.1 Multi disciplinary Communications (for pre-eclampsia) 4 1.2 Management of women with severe PET / Eclampsia 5 1.3 Antihypertensive Treatment Flow chart B/P control 6 1.4 Fluid Management 8 1.5 Maintenance Fluid Flow chart 9 1.6 Prevention of Eclamptic Seizures / Control of Eclamptic

seizures

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1.7 Monitoring of Women receiving MgSO4 11 1.8 Management of Magnesium toxicity: 12 1.9 Management of Blood Clotting 12 1.10 Delivery planning 12/13 1.11 Post delivery Management 13 1.12 Post natal Antihypertensive Treatment 13 1.13 Diagnosis of Eclampsia made in the postnatal period 14 2 Rationale 14 3 Scope 16 4 Responsibilities 16 5 Compliance monitoring arrangements 17-20 6 Training to ensure compliance with this document 21 7 References and associated documents 21 8 Glossary / explanation of terms used in this document 22 9 Document Control 22

Appendices Appendix 1 Equality Analysis (EqA)


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1 Assessment & Diagnosis of Severe Pre-eclampsia The following criteria singly or in combination are compatible with a diagnosis of

severe pre-eclampsia and must be used to determine which women warrant

management according to this guideline:

The woman must have a full assessment, to include; B/P, urinalysis, tendon reflexes,

pre-eclamptic blood picture and a full medical examination to identify the entry criteria prior to being treated with any antihypertensive agents.. Presentation of pre-eclampsia can vary; consideration must be given to combinations

outside the above criteria e.g. epigastric pain, a low platelet count without any of the

classical features, could be the beginning of HELLP syndrome

Severe hypertension - Either systolic BP ≥ 160 mmHg or diastolic BP ≥110 with

proteinuria (≥2+ or ≥ 0.3g/day, PCR ≥ 30mg/mmol) OR

A moderate hypertension of = 140/100 mm/Hg on two occasions and significant

proteinuria, and at least 2 of the following signs/symptoms

The blood pressure cuff should be an appropriate size and a baseline measurement of

the blood pressure should be taken with a non-automated machine if pre-eclampsia is

suspected.

Symptoms:

• Severe headache

• Visual disturbance

• Epigastric pain / vomiting

Signs:

• Clonus (>3 beats)

• Papilloedema

• Liver tenderness

• Evidence of Haemolysis Elevated Liver enzymes, Low Platelets (HELLP) syndrome

(Platelets<100 ALT /AST >70 iu)

• Evidence of renal deterioration:(creatinine >100, creatinine clearance<80)

The following guidelines apply to a woman with severe pre-eclampsia in whom the decision to deliver the fetus has been made. In exceptional circumstances such as extreme prematurity, the guideline may be invoked without a commitment to delivery.


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Clinical judgement and the importance of involving a senior obstetrician and a senior

anaesthetist at an early stage cannot be over-emphasised.

1.1. Multi disciplinary Communications (for pre-eclampsia) Following an assessment of severe pre-eclampsi a referral for an immediate senior

obstetric review.

When a diagnosis of severe pre-eclampsia is made, the obstetric registrar must ensure

that the consultant obstetrician, the consultant anaesthetist, neonatologist and the

labour ward co-ordinator are informed and ongoing communications are maintained

between the key professionals involved.

The multidisciplinary team, including obstetrics, neonatology, midwifery and anaesthetists will be involved in assessing and planning care. Other disciplines, including medical specialities and intensive care may be required and liaison will occur as required depending on the woman’s clinical condition.

Extra support is provided when a woman is admitted and the diagnosis of severe pre-

eclampsia or if further support is required at other stages in managing her condition.

1.2 Management of women with severe PET / Eclampsia Women who are assessed and the decision made to implement this guideline should

have the following monitoring:

• Stablise the woman & then transfer / admit to the Critical care Unit ( on delivery

sute),

• 1 to 1 midwifery care

• Blood pressure every 15 minutes. Temperature 4 hourly.

• Continuous pulse Oximetry.

• Continuous CTG monitoring from 26 weeks gestation .

• Full medical examination every 6 hours.

• Fluid maintenance intake of 80 mls/ hour.

• Urine output measured hourly, recorded on the MEWS chart

• Conscious level hourly (using Glasgow score).Use UVPU score on MEWS chart

• Urinalysis PCR

• PET bloods 12 hourly (FBC, U&Es, Urates, LFTs and Clotting screen).Increased frequency of bloods depending upon results & condition to 6 hourly

• Blood for group and save in case of operative delivery.

• (Admit into Critical care register).


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N.B. • Arm circumference of 35 cm or greater requires a large blood pressure cuff.

• If BP is high- check after 15 minutes before starting treatment.

• Automated monitors may under read in pre-eclamptic women.

• In all women, an initial manual reading must be compared to an automated reading

to ensure they are equivalent.

• Treatment threshold and target blood pressure may need appropriate adjustment.

Criteria for using MgSO4:

Eclampsia

If BP uncontrolled and is above 160/110 mmHg.

Severe pre-eclampsia - symptoms of severe headache, epigastric pain or Visual

disturbance.

HELLP syndrome

Evidence of renal deteriortation ( creatinine ≥100, creatinine clearance ≤ 80)

Management of Eclamptic fit

• ABC

(b) Oxygen (4L) via face mask

(c) Dial 2222: Obstetric Emergency; state location

• Establish IV access with 16G cannula and 1L Plasmalyte solution (80mls/ hourly).

• PET bloods: FBC, G&S, Clotting Studies, U&Es, Creatinine, LFT’s, and Uric Acid.

All investigations should be repeated at least 6-12 hourly or more frequently if

clinical condition dictates.

• Repeat blood investigations 6 hourly in the presence of HELLP (Haemolysis,

Elevated liver enzymes, Low Platelets), abruption, DIC or persistent oliguria.

• Control fits. Initiate Magnesium Sulphate (MgSO4) as per guideline under

Obstetric supervision:

(a) Inform Consultant to attend.

(b) Allocate a scribe use proforma appendix 1

• Once the woman is stable transfer to the Critical Care Unit.

• The senior obstetrician documents a plan

• Catheterise and maintain strict intake and output monitoring using the Critical care

MEWS chart. • The midwife and Obstetrician must keep partner/supporter informed.

Blood pressure control and fluid balance in the management of eclampsia follows the

severe PET guidance


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No response

1.3 Antihypertensive Treatment Flow chart B/P control

ANTI HYPERTENSIVE TREATMENT

BP ≥ 160/110 Aim to keep B/P <150/90-100

Consider

1st

line

Nifedipine modified release 10mg orally –

NOT SUBLINGUAL Recheck BP 20-30 minutes later &

repeat Nipedipine 10mg.

NO RESPONSE RESPONSE

LABETOLOL REGIME

(Caution in Asthmatic)

• BP 160/110 -1st

Bolus of 20mgs IV, repeat

at 10 minute intervals to a maximum of

100mg

• If there is no response in BP IV infusion of

Labetolol 200 mgs made up to 200ml with

NaCl. Start infusion at 20mls/hrs

(20mgs/hr) -via an IVAC pump. Aim to

maintain BP ≤ 150/90

• Double every 30mins to a maximum of

160mls/hr (160mgs/hr) to maintain BP

<150/90

If Nifedipine controls the BP: • Treat with further doses

• Nifidepine may be repeated every 20

minutes up to a maximum of 4 doses (as indicated) up to a maximum of

90 mg per day (or ) start regular 6-8 hourly Nifedipine

• Aim to maintain BP ≤ 150/90-100

• BP must not drop too quickly as this may cause cerebral hypoxia / placental

insufficiency.

• Withhold the infusion if BP drops too quickly.

• Preload circulation with 500ml crystalloid with first dose of hydralazine.

• Consider using more than one agent if BP is not controlled on single agent.

• Labetalol is contraindicated in women with severe asthma or heart block

Give Hydralazine: Initial dose is 5mg IV slowly, then 5 mg IV every 20 minutes to a maximum of 20mgs. If there is response start: Infusion of 2 mg/hr for maintenance, increasing by increments of 0.5 mg/hr to a max of 20mg/hr (Suitable for asthmatics)

If no response with Nifedepine, Labetalol, Hydralazine, consider: Isosorbide Mononitrate, other negative ionotropes This will require discussion with the anaesthetist

2nd line drugs

3rd line drugs


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Labetalol Intravenous treatment ( caution in Asthma)

Instructions re: labetalol Bolus

• Give 1st I.V.bolus: 20 mgs of labetalol over a 5minute period. Recheck B/P every 5minutes for 20minutes if B/P not responding after 20 mins give 40 mg, no response give a further 40mg, no response give 80mg at 10 minute intervals upto a maximum dose of 180mg . If No response follow infusion pathway below

Labetalol Infusion

• IV infusion of Labetolol 200 mgs mix with 160ml of 0.9% Sodium Chloride to a final volume

of 200ml). (40ml Labetalol =20mg in 4ml)

Start infusion at 20mls/hrs (4ml/hr) -via an IVAC pump. Aim to maintain BP ≤ 150/90

• Double the dose of Labetalol every 30 minutes to a maximum dose of 160mgs

Hydralazine regime

This acts as a vaso-dilator, expanding intravascular volume. In an undelivered patient, volume expansion of upto 500ml of Pasma-Lyte should be considered prior to administration of hydralazine Hydralazine Bolus (reconstitute 20mgs hydralazine in 20mls of N/Saline, bolus dose is 10mgs = 10mls,

Initial dose of i . v . Hydralazine 5mg over a 10 minute interval. Check B/P every 5 minutes for 20 mins if B/P not responding Repeat doses of 5mg in 5 ml at 20 minute intervals can be given up to a maximum of 4 doses ( 20mg) . If No response follow infusion pathway below Hydralazine infusion

• Reconstitute 20mgs Hydralazine in 40 mls of N/Saline infuse via syringe driver at

4mls / hour = 2mgs/ hour. Increase by 1ml/hour = 0.5mgs/hour to a maximum of

20mgs/hour = 40mls/hour.

If BP remains at 160/110 an infusion of 2mg/hr is required for maintenance,

increasing by increments of 0.5mg/hour to a maximum of 20mg/hour.

1.4 Fluid Management:

Fluid restriction is advisable to reduce the risk of fluid overload in the intrapartum and postpartum period. In women with severe pre eclampsia, limit maintenance fluids to 80 ml/hr ( Plasmalyte / crystalloid) or 1 ml/kg/hour, in an attempt to maintain the urine output at >0.5 ml/Kg/ hour, (equates to 30ml /hour for a 60Kg woman) ( approx 50ml /hr for a 100Kg woman) unless there are other on-going fluid losses.

Input and output must be documented on the HDU chart.


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1.5 Maintenance Fluid intake should be 80mls/hr including all other IV infusions (Mgso4, Syntocinon)

PLASMALYTE at 80 ML/HR

URINE OUTPUT > 100mls in 4

hours

Continue maintenance of

80ml/hr

< 100mls in 4 hour

Or

< 30ml in 1 hour

FLUID CHALLENGE of 250mls Plasmalyte bolus.. Monitor Resps /SATs and Chest

Ausciltation.

IMMEDIATELY CEASE IF SATs <94% or RESPS > 24

URINE OUTPUT

< 30mls/hr.

Repeat Fluid Challenge

250mls Plasmalyte bolus

URINE OUTPUT < 30mls/hr:

Discuss with CONS OBS/ANAES

to consider CVP / further fluid Rx

Urine output

improves

> 100mls in 4 hours

Continue maintenance of

80ml/hr

Oliguria persists:

Treat as renal problem.

Repeat urea, creatinine &

electrolytes.

Liaise with Nephrologist

Consider transfer to ICU.

Frusemide 20 mgs

Inform consultant obstetrician

and anesthetist

Consider transfer to ICU


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1.6 Prevention of Eclamptic Seizures / Control of Eclamptic seizures

Magnesium Sulphate is the anticonvulsant of choice for severe pre-eclampsia /

eclampsia

Magnesium Sulphate Regime:

Magnesium Sulfate (MgSO4 50%, contains 1gm (4mmol) in 2ml. • Loading dose = 8ml of MgSO4 50% solution, +12ml 0.9% Sodium Chloride (=4g over 10 minutes) via syringe driver at 120mls per hour.

• Maintenance dose : MgSO4 1g per hour

20mls (10g) MgSO4 mixed with 30mls 0.9% Sodium Chloride ( final volume 50ml) Give I.V (v ia syringe drive) at r a t e o f 5 ml/hr

• Recurrent seizures ( whilst on MgSO4)

Further bolus of 2g ( =4ml of MgSO4 diluted with 6mls of 0.9% Sodium

Chloride (= to 2gm in 10ml) given over 5 minutes (via syringe driver) .

Senior obstetrician & anaesthetist to attend.

Take venous sample; assess through blood gas analyser for MgSO4 level &

serum lactate level.

• Further Seizures occurs

If seizures continue Consultant Obstetrician & Anaesthetist to make the

decision to give a bolus of Diazemuls 10 mgs IV.

Consider other causes of fits; including Intracanial haemorrhage

Follow on treatment For pre-eclampsia continue Magnesium sulphate for at

least 24 hours post delivery.

• For eclampsia continue MgSO4 for at least 48 hours post delivery or from

the last fit.

• The requirement i s for consultant obstetrician to attend in person in the

event of eclampsia.

N.B. Magnesium can cause extravasation and the injection site should be monitored.

1.7 Monitoring of Women receiving MgSO4

• Use Critical care chart and the MEWS score.

• Continuous Pulse oximetry: Oxygen saturation <95% in air should raise

concerns regarding magnesium toxicity or pulmonary oedema

Oxygen (4L) via facemask 15L via non-rebreathable mask


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B/P & Pulse & respiratory rate every 15 mins.Ensure correct size cuff is used.

• Insert Foleys catheter / hourly urine output.

RR should be >12/min

• Deep tendon reflexes: hourly.

• Continuous CTG.

• Conscious level hourly using AVPU.

• Check Magnesium blood levels if repeat fitting occurs and / or signs and

symptoms of toxicity occurs. See below under Signs and Symptoms of

Toxicity.

• PET bloods should be repeated 4-6 hourly more frequently depending upon

the severity of PET.

• Obstetric and Anaesthetic Consultant / Registrar must review the patient at

each shift change and an individualised written plan of care must be

documented in the patient’s notes.

• Chest auscultation 4 hourly.

• Consider continuous ECG.

Consideration should be given to contraindications:

• Cardiac Disease

• Renal Disease

• Neuromuscular disease

• In these situations an individualised should be made by the multidisciplinary team.

Therapeutic Range:

The plasma magnesium levels should be in the range

2-4 mmol/L. Magnesium toxicity occurs when the serum levels

exceeds 5mmol/L. Management of Renal Impairment whilst on MgSO4

if urine output is 10- 20ml/hr and creatinine is < 100mmol/l - continue MgSO4 as per the guideline.

• If serum creatinine 100-150 mmol/l - reduce infusion rate to 0.5g/hr. Check

serum magnesium levels 2 hourly.

• If serum creatinine >150mmol/l - stop the magnesium sulphate infusion.

• If urine output <10ml/hr - stop magnesium sulphate infusion. Check

magnesium levels and renal function.

1.8 Magnesium Toxicity

Anaesthetic & Senior Obstetric must be informed and attend.

Signs and Symptoms of Toxicity:

• Nausea & Vomiting Depressed respirations


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• Thirst, headache Weakness, hypothermia

• Double vision Slurred speech Hypotension

• Loss of reflexes Dizziness Drowsiness, confusion

If unrecognised, Magnesium Toxicity can lead to:

• Muscle paralysis

• Respiratory arrest

• Cardiac arrest

1.8 Management of Magnesium toxicity:

Stop Magnesium Infusion

Toxicity may be recognised by significant respiratory depression, loss of patella reflexes (deep tendon reflexes) or low oxygen saturation of < 95%.

• Calcium Gluconate should be administered at a dose of 10 ml of 10% Calcium Gluconate (1gm) by slow I.V. injection, (use syringe driver and run infusion at 60mls/hour ) & repeated if necessary at a 10 minute interval to a total dose of 2 gm (20 ml).

• Intubate early and ventilate until respirations resume

• review by senior obstetrician

Increasing Cerebral Depression (COMA) or Focal Neurological signs

• Transfer to ICU for ventilation

• CT scan or MRI Scan to exclude cerebral haemorrhage

• Use of Nimodipine

• Discuss with Neurosurgeons

1.9 Management of Blood Clotting If the platelet count is in question or less than 50x109 /l a platelet transfusion should be considered. The consultant haematologist must be consulted if a caesarean section is being considered. Consult the haematologist early where there is a clinical or haematological evidence of coagulopathy. If the woman is bleeding, check fibrinogen, low fibrinogen is an important indicater of DIC

1.10 Delivery planning

The decision to deliver should be made by the senior obstetrician, the aim should be that the woman is stable, blood pressure control is achieved and appropriate senior personnel are present.

The neonatal team should be present for the delivery.

If the fetus is ≤ 35 weeks gestation and delivery can be delayed until orticosteroids are administered.


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Conservative management at very early gestation may improve perinatal outcome but must be balanced with maternal wellbeing

Mode of delivery should be determined after considering fetal & maternal condition, together with the likihood of success of IOL .

The 3rd stage of labour should be managed with syntocinon

Thromboprophylaxis Regimen

Prescribe knee length TEDS

Prescribed Clexane dependant on their VTE risk factors (refer to VTE guideline) & current platelet levels, Any doubts should be discussed with the Haematologist.

1.11 Post delivery Management

• Titrate the magnesium syringe driver off over 1 hour.

• Monitor blood pressure every 15 minutes for the first 2 hours and then

hourly thereafter if blood pressure is within stable limits.

• Consider adjusting oral antihypertensive dosing regime to control B/P

• 12 hourly PET bloods for 24 hours.

• Keep on CCU until BP stable for 12 hours.

• Observe as inpatient for a minimum of 72 hours.

1.12 Post natal Antihypertensive Treatment

• The decision to transfer the woman to the postnatal ward must be made by the

senior obstetrian

Monitor BP four hourly.

Avoid NSAIDs

• Oral antihypertensive medication given. The dose and interval of

administration increased as necessary when the magnesium stopped.

Β blocker Labetalol 100-200mg 2-4 times a day

Or

Atenolol 25-100mg daily

Calcium channel blocker

Nifedipine SR 10-20mg daily

ACE inhibiter Enalapril 5-20mg twice a day

Or

Captopril 12.5-25mg twice a day

NICE 2010 1

B/P must have been <140/90 for at least 24 hrs prior to discharge unless decision for discharge is made by a senior obstetrician.


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A woman on discharge from hospital in whom serum biochemistry is

deranged should be given a form & instructions to have a blood test

repeated within 7 days.

Prior to discharge from the hospital a discharge plan is made which includes the community midwife monitoring blood pressure depending on the B/P reading for upto 10 days, the midwife transfers the care of the woman to her G.P. for a follow up appointment.

A woman who has had severe pre-eclampsia / eclamspsia must have a follow up 6 weeks appointment with the obstetric consultant to debrief clinical events and discuss implications for future pregnancies.

Women who deliver before 34 weeks gestation with pre-eclampsia should be investigated for antiphospholipid syndrome ( Bramham et al 2013)

N.B. A Separate more indepth guideline for management of postpartum

hypertension is available 1.13 Diagnosis of Eclampsia made in the postnatal period Call 2222 via switchboard Obstetric emergency. The above requirement to attend the emergency enables clear lines of

communication between the obstetric consultant, the anaesthetic consultant, the

Neonatologist and the delivery suite coordinator.

• .

2 Rationale The aim of this guideline is to standardise the approach to the management of severe pre-eclampsia/eclampsia in the immediate pre and post delivery interval in order to improve the outcome for the mother and fetus / baby.

Pre-eclampsia is new hypertension presenting after 20weeks gestation with significant propeinuria Severe Pre-eclampsia is pre-eclampsia with with severe hypertension and/ or with symptoms, and/ or biochemical and/ or haematological impairment. Eclampsia is a convulsive condition associated with pre-eclampsia Pre-eclampsia and eclampsia are the fifth most common cause of direct maternal death, 2.5 per million maternities. Six women died directly as a result of Pre-eclampsia & Eclampsia in the triennium 2011 – 2013 (MBRACE 2015).

The following points have been highlighted in recent CMACE and MBRACE reports:

• Inadequate treatment of hypertension.


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• Insufficient attention paid to a rise in systolic blood pressure.

• Failure to verify automated blood pressure readings by using a

manual sphygmomanometer (automated cuffs tend to under read).

• Failure to treat a woman with a moderate rise in blood pressure but with

other evidence of severe pre-eclampsia.

• Inappropriate delay in delivery to allow marginal improvements in fetal outcome.

• The use of routine syntometrine administration in the third stage

should be abandoned.

• Delay in appropriate referral to specialist Obstetric services in the

antenatal, intrapartum and postnatal period.

• Lack of communication and interdisciplinary team work

• Failure to recognise increased risk of venous thromboembolism

Key Issues

• Blood Pressure control and Fluid Management

• Prevention of seizures

• Emergency Management

• Planning delivery 3 Scope

• To Involve obstetric and anaesthetic consultants early in the clinical

decision making progress.

• To Involve the multidisciplinary team including the senior midwife,

obstetricians, anaesthetists and Neonatologists in the management plan.

• To recognise that a raised blood pressure is significant in women without

a pre- existing diagnosis of hypertension at or beyond 20 weeks gestation.

4 Responsibilities The Consultant Obstetrician is the Lead responsible for a written plan for immediate care & delivery. The on-call consultant must be available for consultation and review for obstetric / maternity staff. The Obstetric consultant must be informed and attend an emergency of a woman admitted with severe pre-eclampsia/ eclampsia.

The on-call Anaesthetist lead for obstetrics is responsible for working within the multidisciplinary team to give optimum care to a woman with severe pre-eclampsia/ eclampsia. The Obstetric Registrar is responsible for the management of the woman identified as “at risk” of severe eclampsia / eclampsia emergency. The registrar


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is responsible for his/her practice in an emergency situation, informing the on-call consultant and attending “skill drills”.

The Obstetric SHO is responsible for supporting the registrar in an obstetric emergency.

The Midwife Co-ordinator is responsible for supporting midwifery & obstetric

staff involved in an emergency situation.

The midwife is responsible for the care of a woman in t h e c r i t i c a l c a r e

u n i t / labour who is “at risk” of an eclampsic seizure and for initiating an

emergency call. All plans of care must be documented in the clinical notes


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5 Compliance Monitoring arrangements

Criterion: Standard 3 - Criterion 1: Severe Pre-Eclampsia

Criterion lead: Sharmila Sivarajan

The maternity service has approved documentation for the management of

severe pre-eclampsia, which as a minimum must include:

A. assessment and diagnosis of severe pre-eclampsia

B. clear lines of communication between the consultant obstetrician,

consultant anaesthetist, paediatrician and labour ward coordinator

C. blood pressure control and fluid balance

D. prevention of eclamptic seizures E. fetal assessment and delivery planning

F


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Minimum requirement to be monitored Process for

monitoring e.g. audit

Responsible

individual/

group/

committee

Frequency of

monitoring

Responsible individual / group /

committee (plus timescales) for:

Review of results

Development of action plan Monitoring of action plan and implementation

A. Assessment and diagnosis of severe pre-

eclampsia

Annual Audit to

include A-F and a sample size of at least 8 set of records of

women in whom a

diagnosis of severe

pre eclampsia was

made

Matron for

inpatient services (for all points A-F)

Annually (for

all points A-F)

Results of the audit will be

presented to the multidisciplinary divisional quality and risk meeting. The person responsible for the audit will formulate a resultant action plan and the action plan will be monitored by the divisional quality and risk team meeting to ensure implementation in practice. Evaluation of change will be in the form of re audit (for all points A-D).

B. Clear lines of communication between the

consultant obstetrician, consultant

anaesthetist, paediatrician and labour ward

coordinator

C. Blood pressure control and fluid balance

D. Prevention of eclamptic seizures

E. Fetal assessment and delivery planning

F. Postnatal follow up


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Criterion: Standard 3 - Criterion 2: Eclampsia Criterion lead: Sharmila Sivarajan The maternity service has approved documentation for the management of eclampsia, which as a minimum must include: A. assessment and diagnosis eclampsia B. clear lines of communication between the consultant obstetrician, consultant anaesthetist, paediatrician and labour ward coordinator C. blood pressure control and fluid balance D. control of eclamptic seizures E. fetal assessment and delivery planning F. postnatal follow up


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Minimum requirement to be monitored Process for

monitoring e.g. audit

Responsible

individual/

group/

committee

Frequency of

monitoring

Responsible individual / group /

committee (plus timescales) for:

Review of results

Development of action plan

Monitoring of action plan and

implementation

A. Assessment and diagnosis of eclampsia Annual Audit to

include a-f and all health records of women delivered with a diagnosis of eclampsia.

Matron for

inpatient

services (for all

points A-F)

Annually (for

all points A-F)

Results of the audit will be

presented to the multidisciplinary

divisional quality and risk meeting.

The person responsible for the audit

will formulate a resultant action

plan and the action plan will be

monitored by the divisional quality

and risk team meeting. Evaluation

of any changes made will be in the

form of re audit (for all points A-D).

B. Clear lines of communication between the

consultant obstetrician, consultant

anaesthetist, paediatrician and labour ward

coordinator

C. Blood pressure control and fluid balance

D. Control of eclamptic seizures

E. Fetal assessment and delivery planning

F. Postnatal follow up


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Monitoring approval, amendments and document control

The process and frequency for monitoring is in line with the clinical audit strategy for Women & Children’s health division. This can be further monitored through the divisional audit programme.

The results will be reviewed and discussed in the recognised clinical governance reporting mechanisms and appropriate clinical forums.

Improvements (in compliance) will be ensured using the clinical audit action plan report.

HDU is now called the Critical care unit .

Medication doses increased if patient not responding & polypharmacy

Band 7 team leaders are informed by E-mail of new/ updated policies and they in

turn inform their team of new and updated policies.

Hospital obstetricians informed by E-mail via the obstetric consultants’ secretary;

new and updated policies & guidelines

The guideline/ guideline is held on the Maternity database, and archived in line with the arrangements in the Organisation wide Guideline for the Management and Development of Procedural Documents. Working copies will be available on request by E-mail from the Guideline Editor Eileen Lanzon / maternity I.T. ( Anne Durell / Arkadiusz Kozlowski). Authorization needs to be sought from Adaline Smith, the Lead Matron.

6 Training to ensure compliance with this guideline Multidisciplinary Annual JOT Training. Mandatory training on emergencies

7 References and associated documents

1. NICE guidelines :Management of hypertensive disorder during Pregnancy (Aug 2010).

2. Saving Mother’s Lives: Reviewing maternal deaths to make motherhood Safer 2003- 2005.

3. Eclampsia - Management of severe pre-eclampsia/eclampsia (10A), Mar 2006.


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4. Eclampsia Trial Collaborative Group. Which anticonvulsant for women

with eclampsia? Evidence from the collaborative trial. Lancet 1995; 345: 1455-

1463.

Hypertension in pregnancy Diagnosis & management; Green Top guidelines No.10A RCOG

Critical care guidelines Preterm labour guidelines Postpartum haemorrhage guidelines Casaerean section guidelines

8 Glossary / explanation of terms used in this document

Acronym/ Abbreviation/ Term

Meaning

CTG Cardiotocograph

DVT Deep vein thrombosis

ICU Intensive Care Unit

DIC Disseminating Intravascular Coagulation

AVPU Alert Voice, Pain Unresponsive

PCR Protein creatinine release

9 Document Control This procedural document supports:

Standard(s)/ Key Lines of Enquiry:

Para/ I.D. no.

Standard/title

NICE Guideline

Aug 2010

Management of hypertensive disorder duringpregnancy

NICE guidelines

Management of hypertensive disorder during Pregnancy (Aug 2010).


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Consultation record

Relevant service

Speciality, Sponsor or User Group name

Individual’s name

Job title Date consulted

Date feedback received

Pharmacy

Aggie Cedro-sogliani

Lead Pharmacist

12/12/16

WaCH maternity Adaline Smith

Matron 12/12/16

WaCH maternity Sarah Cowley

LW manager

12/12/16

WaCH Obstetrics Samantha Stimpson

LW manager

12/12/16

WaCH maternity Amanda Morgan

P/N manager 12/1216

WaCH Obstetrics All consultants

12/12/16


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9 Document Control Change History Version Date

Author/ Lead Job title Details of Change Ratificati

on body Archivin

5 Dec 2016

Ms.Sivarajan Eileen Lanzon

Obs Con Policy editor

Updated. Reviewed. Content & flow charts updated

WaCH Mat

4.5 November

2013

Sharmila Sivarajan

Consultant Obstetrician

Formatting changes to flow chart

WaCH Mat

4.4 June 2013

Michelle Cudjoe,

Head of Midwifery

(Minor change required by CNST assessor &

approved by Chief):

Amended to make

reference to the use

of a fluid balance

chart;

Formatting changes

WaCH Mat

4.3 Jan 2013

Michelle Cudjoe,

Head of Midwifery

Rearranging of sections

WaCH Mat

4.2 Jan 2013

Michelle Cudjoe,

Head of Midwifery

Associated Documents

section amended to include reference to current Training Guideline

WaCH Mat

4.1 Oct 2012

Ms Sharmila Sivarajan

Obstetric

Consulta

nt

Updated to reflect RCOG

guidelines. Transferred onto current Trust template

WaCH Mat

4 May

2012

Ms Sharmila Sivarajan, A.Durrel & S. Bone,

Obs

Consultant

Band 7 midwives

Updated evidence

Changes to medication &

infusion preparation PET proforma added

WaCH Mat

3 2009 S sivarajan, , B.Ajay, K. Jermy, S. Banerjee, Nada Bolad E. Lanzon M. Cudjoe.

Obs Cons

Anaeth

Guideline editor

Risk manager

Changes to medication and

flow chart

WaCH Mat

2 J. Penny, Consultant

Obstetrician

treatment for eclampsia

Medication Fluid flow chart. Emergency

WaCH Mat

1 Unknown


24

Appendix 1 Equality Analysis (EqA) By completing this document in full you will have gathered evidence to ensure, documentation, service design, delivery and organisational decisions have due regard for the Equality Act 2010. This will also provide evidence to support the Public Sector Equality Duty.

Name of the guideline Pre-eclampsia/ Eclapmsia/ postnatal care

Date last reviewed or created & version number

5

Briefly describe its aims and objectives:

To Involve obstetric and

anaesthetic consultants

early in the clinical

decision making progress.

To Involve the

multidisciplinary team

including the senior

midwife, obstetricians,

anaesthetists and

Neonatologists in the

management plan.

To recognise that a raised blood pressure is significant in women without a pre- existing diagnosis of hypertension at or beyond 20 weeks gestation

Directorate lead Obstetricians & Midwives

Target audience (including staff or patients affected)

Screening completed by (please include everyone’s name)

Organisation Date

Sharmila Sivarajan WaCH 15th Dec 2016

Eileen Lanzon


25

Equality Group (Or protected characteristic):

What evidence has been used for this assessment?

What engagement and consultation has been used

Identify positive and negative impacts

How are you going to address issues identified?

Lead and Timeframe

Age Maternity booking questionnaire -collects information and data locally. See references in guideline for national and international recommendations and good practice

Data collected on the maternity electronic system, MSLC Questionnaire for service users following delivery, & “Your care matters” feedback from service users Labour ward Forum

No None identified, however all service users are treated on an individual basis, recognising their specific needs

Disability

Gender reassignment

Marriage & Civil partnership

Pregnancy & maternity

Race

Religion & Belief

Sex

Sexual orientation

Carers