Eclampsia-Midwifery Emergencies

• 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

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

• 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 

• 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

• 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

• 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

• 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

• 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)

• 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

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

• Maternal:
• Recurrent fits
• Physical injury
• More likely to develop HELLP syndrome- haemolysis, elevated liver enzymes, low platelet count

• Fetal
• Hypoxia
• Prematurity
• Compromised fetus

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

Risk Factors