Eclampsia-Midwifery Emergencies

1- Introduction

  • Recognise time-critical emergency- Eclampsia
  • Definition: One or more convulsions associated with pre-eclampsia (NICE, 2010). 
  • Recognise that seizure may be the first presentation. In the postnatal period, most common in the first 24 hours following birth.
  • Call for help- SOAPS
  • Senior Midwife- Aware of workload on delivery suite, can keep theatre free/make theatre team aware, knowledge and expertise
  • Obstetrician- Prescribe and administer drugs, Plan of care, expedite birth (if pregnant)
  • Anaesthetist- Manage airway, IV access, analgesia
  • Paediatrician/Neonatologist- (if pregnant) Hypoxic episode- fetal compromise
  • Scribe- Document time of events such as drug administration, personelle in room, time and length of seizures.
  • Drug/Eclampsia box
  • Record time and length of seizure- Normally less than 90 seconds, self-limiting
  • DO NOT LEAVE WOMAN ALONE AT ANY POINT
  • Begin ABCDE approach
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2-Airway

  • Left lateral position
  • To open airway
  • To reduce aorta-caval compression (If pregnant)
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2-Breathing

  • High-flow Oxygen via mask with reservoir (12-15L/min)
  • Due to seizures- hypoxic episode
  • To improve oxygenated blood to vital organs i.e. brain 
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3- Circulation

  • 2x Large bore cannulas (14-16 gauge)- Fluids, drugs, transfer to theatre
  • Bloods
  • Full Blood Count-RBC's-haemolysing/clotting? Platelet count
  • Urea and Electrolytes- Kidney function- Detects creatinine clearance
  • Liver Function test- possible liver damage. Elevated liver enzymes.
  • Coagulation screen- Damage to capillaries- thrombi produced. 
  • Group and Save- Crossmatch blood incase of transfer to theatre. At risk of DIC (Disseminated intravascular coagulation-formation of blood clots in the small blood vessels throughout the body).
  • Catheter
  • Strict fluid balance
  • Leaky blood vessels could cause pulmonary oedema 
  • 100ml in 4 hours OR 0.5ml/kg/hr
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3-Disability

  • During the seizure, protect from injury
  • Use cot sides
  • Do not attempt to restrain or put anything in the mouth
  • Following seizure remain in L lateral to maintain an open airway
  • Maintain communication
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3-Exposure

  • Respect dignity
  • Minimise heat loss/exposure
  • Any injuries? Banged head, biting tongue
  • Obstetric Review
  • If pregnant, CTG 
  • Hypoxic episode- risk of bradycardia or placental abruption
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4-Drugs

  • Drug used to control seizures= Magnesium Sulphate
  • Magpie trial- Inhibits cerebral NMDA receptors and causes cerebral vasodilation
  • Loading Dose (administered by obstetrician- out of scope of practice of midwife)
  • 4g Magnesium Sulphate over 5 minutes
  • 8ml 50% Magnesium Sulphate in 12ml 0.9% normal saline
  • In 20ml syringe
  • Maintenance Dose (In syringe driver for safety. Set up to pump 5ml/hr)
  • 1g/hr
  • 20ml 50% Magnesium Sulphate in 30ml 0.9% normal saline
  • In 50ml syringe
  • Continue for 24 hours following birth or last seizure (whichever most recent)
  • Side Effects: Flushing, burning sensation up arm
  • Toxicity suspected? Call for help. Stop infusion. Administer oxygen and calcium glutonate IV 1g (100mls, 10%), start BLS
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5-Following Seizure

  • Monitor maternal observations- MAGNESIUM SULPHATE TOXICITY AND RISK OF RESPIRATORY DEPRESSION, RISK OF CARDIAC ARREST
  • Blood Pressure - Treat hypertension to keep BP <150/100mmHg
  • Maternal Pulse
  • Respiratory Rate- Risk of respiratory depression
  • Patellar reflexes- Hourly-to monitor for magnesium toxicity
  • Oxygen saturations
  • Level of consciousness- AVPU- Alert, Voice, Pain, Unresponsive- Risk of respiratory depression, magnesium toxicity
  • Level 2 critical care
  • Obstetric HDU chart (High dependency unit)
  • Fluid Balance Chart
  • Modified Early Warning Score (MEWS)
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5- Following seizure- if pregnant

  • Left lateral- use wedge- to avoid aorto-caval compression
  • Monitor FHR immediately post-seizure- compare with mat pulse
  • Commence continuous CTG
  • Maternal condition must be stabilised before transfer/ planning birth
  • Involve paediatricians
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6- Documentation, Debrief, Incident Report Form

  • Documentation- accurate record keeping, accountability (NMC, 2015)
  • Incident Report Form
  • Debrief: woman, family, staff. Psychological care- traumatic effect.
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6- Potential complications of eclampsia

  • Maternal:
  • Recurrent fits
  • Physical injury
  • More likely to develop HELLP syndrome- haemolysis, elevated liver enzymes, low platelet count
  • Fetal
  • Hypoxia
  • Prematurity
  • Compromised fetus
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Additional Information

  • Incidence: 2.7 per 10,000 births (Knight, 2007)

Risk Factors

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