Prevention and
management of
pre-eclampsia and
eclampsia
Facilitator’s Guide
Copyright © 2011, Jhpiego. All rights reserved. The material in this document may be freely
used for educational or noncommercial purposes, provided that the material is accompanied
by an acknowledgement line.
Suggested citation: MCHIP. Prevention of eclampsia: Facilitator’s Guide. Baltimore: Jhpiego;
2011.
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Prevention and management of pre-eclampsia and eclampsia
Version 1.0 / 10 January 2011
Facilitator’s Guide
Prevention and management of pre-eclampsia
and eclampsia
Facilitator’s Guide
2011
Maternal and Child Health Integrated Project
(MCHIP)
This project is made possible through support provided to MCHIP by the Office of Health, Infectious
Diseases and Nutrition, Bureau for Global Health, US Agency for International Development, under the
Cooperative Agreement No. GHS-A-00-08-00002-00. MCHIP is implemented by a collaborative effort
between Jhpiego, Save the Children, John Snow, Inc (JSI), MACRO, Johns Hopkins University Institute
for International Programs (IIP), Program for Appropriate Technology for Health (PATH), Broad Branch
Associates (BBA), Population Services International (PSI), Collaborating Organizations:
Communication Initiative (CI), CORE, and others.
Prevention and management of pre-eclampsia and eclampsia
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Table of contents
Introduction ........................................................................................................... 1
Training objectives ................................................................................................ 1
Materials .............................................................................................................. 1
Responsibilities of a facilitator ................................................................................. 2
Assessments of participants.................................................................................... 3
Lesson plans ......................................................................................................... 4
Training schedule .................................................................................................. 5
Understanding pre-eclampsia and eclampsia ......................................................... 7
Summary of the session ......................................................................................... 7
Learning objectives for the session .......................................................................... 7
Learning outline for the session............................................................................... 7
Group work: Factors influencing maternal and perinatal outcomes .............................. 9
Identifying pre-eclampsia .................................................................................... 13
Summary of the session ....................................................................................... 13
Learning objectives for the session ........................................................................ 13
Learning outline for the session............................................................................. 13
Puzzle game ....................................................................................................... 15
Prevention of pre-eclampsia and/or eclampsia .................................................... 23
Summary of the session ....................................................................................... 23
Learning objectives for the session ........................................................................ 23
Learning outline for the session............................................................................. 23
Management of pre-eclampsia and eclampsia ...................................................... 25
Summary of the session ....................................................................................... 25
Learning objectives for the session ........................................................................ 25
Learning outline for the session............................................................................. 25
Case study ......................................................................................................... 28
Clinical simulation ............................................................................................... 31
Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg
but < 110 mm Hg ............................................................................................... 33
Learning guide: Management of severe pre-eclampsia / eclampsia ............................ 36
Learning guide: Administering magnesium sulfate ................................................... 38
Management during a convulsion / fit .................................................................. 41
Summary of the session ....................................................................................... 41
Learning objectives for the session ........................................................................ 41
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Prevention and management of pre-eclampsia and eclampsia
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Learning outline for the session............................................................................. 41
Puzzle game ....................................................................................................... 43
Clinical simulation ............................................................................................... 50
Learning guide: Management during and after an eclamptic fit/seizure ...................... 52
Birth preparedness and complication readiness ................................................... 55
Summary of the session ....................................................................................... 55
Learning objectives for the session ........................................................................ 55
Learning outline for the session............................................................................. 55
Pre- and mid-course questionnaires ..................................................................... 57
Pre-course knowledge assessment questionnaire .................................................... 57
Key: Pre-course knowledge assessment questionnaire ............................................. 59
Mid-course knowledge assessment questionnaire .................................................... 61
Key: Mid-course knowledge assessment questionnaire ............................................. 65
Administrative Documents ................................................................................... 69
Registration Form ................................................................................................ 69
Training report form ............................................................................................ 71
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Acknowledgements
Susheela Engelbrecht led development of the learning materials, with technical assistance
and feedback from members of the MCHIP Training and Quality Assurance Task Force, one of the
five Task Forces formed under the Pre-Eclampsia/Eclampsia Technical Working Group. Members of the
task force include Patricia Gomez, Diane Sawchuck, Peter von Dadelszen, Abdelhadi Eltahir,
Frances Ganges, Ann Davenport, Deborah Armbruster, Nahed Matta, Jeffrey Smith, Annette
Briley, and Bridget Lynch. The writing team is grateful to the following people, who provided
invaluable assistance with this effort:
Contributing editors
Reviewers: Ahmet Metin Gulmezoglu
Proofreader
Illustrator .
About MCHIP
For more information or additional copies of this manual, please contact:
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Acronyms
BP
blood pressure
BPP
birth preparedness plan
CRP
complication readiness plan
dBP
diastolic blood pressure
DIC
disseminated intravascular coagulation
HELLP
Hemolysis, ELevated Liver enzymes, and low Platelet count
syndrome
HIP
hypertension in pregnancy
IUGR
intrauterine growth restriction
Magpie Trial
magnesium sulfate for prevention of eclampsia trial
MAP
mean arterial pressure
MCHIP
maternal and child health integrated project
MDG
Millennium Development Goals
RCT
randomized controlled trial
sBP
systolic blood pressure
STI
sexually transmitted infections
UTI
urinary tract infection
USAID
United States Agency for International Development
WHO
World Health Organization
Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor
vii
Facilitator’s Guide
Introduction
Training objectives
This three-day clinical training provides the information needed to manage pre-eclampsia /
eclampsia and help prevent pre-eclampsia/eclampsia. The following six topics are covered
during the training course:

Understanding pre-eclampsia and eclampsia

Identifying pre-eclampsia

Prevention of pre-eclampsia and/or eclampsia

Management of pre-eclampsia and eclampsia

Management during a convulsion / fit

Birth preparedness and complication readiness
Participants are encouraged to apply their knowledge and skills to improve clinical services
and train other providers. Ultimately, this training will help improve the quality of care for
women—mothers, wives, and vital members of the community—and help them stay
healthy.
Materials
The Reference Manual contains the theoretical content for the training course.
The Facilitator’s Guide assists facilitators conducting training activities on pre-eclampsia /
eclampsia. The guide has the following components:
 General information to assist the facilitator in conducting a training course
 A proposed agenda for the training program
 Lesson plans for each session to be presented
 Pre- and mid-course questionnaire forms with answer keys

Model forms to fill in for the training report
The Participant’s Notebook assists participants during training activities on pre-eclampsia
/ eclampsia. The notebook has the following components:

Training program agenda

Learning activities for each topic

Answers for learning activities

Learning guides and checklists for essential skills

Training evaluation form
If possible, each participant should receive a copy of the Participant’s Notebook and
Reference Manual on the first day of training activities. Each facilitator needs a copy of
the Facilitator’s Guide and Reference Manual.
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Responsibilities of a facilitator
Carefully selected facilitators are essential for a successful training program. An ideal
facilitator should be a practicing nurse, midwife, or physician competent and confident
in identifying and managing pre-eclampsia and eclampsia, who is also:

Trained in competency-based training and participatory learning methods

Trained in conducting clinical training programs

Able to use learning principles for an effective clinical training program

Able to provide care for women with pre-eclampsia and eclampsia according to the
checklist

Competent in care for women with pre-eclampsia and eclampsia
Before the training begins:
Facilitators should meet before training activities begin to discuss and assign the following
administrative responsibilities:
1. Assign facilitation of teaching sessions, demonstrations, return demonstrations, and
clinical simulations. [Each facilitator will be responsible for ensuring that all needed
resources, equipment, supplies, and medications are available for any sessions assigned
to him/her.]
2. Set the classroom up in a way that ensure interactive learning
3. Purchase flipcharts, markers, pens/pencils, notebooks, etc.
4. Read the Reference Manual thoroughly to be sure that it is in agreement with current
policies and practice guidelines in your country. The manual is based on globally
accepted, evidence-based information that countries should strive to adopt in their
guidelines. However, if this has not yet occurred for your setting, revisions may need to
be made.
5. Review the Facilitator’s Guide for other preparation details.
6. Make a copy for each facilitator of the:

Facilitator’s Guide

Reference Manual
7. Make a copy for each participant of the:

Participant’s Notebook

Pre- and mid-course questionnaire forms (in the Facilitator’s Guide).

Reverence Manual
Before each session:

Read the content of each session thoroughly.

Review any learning activities (case studies, role-plays, etc.) and skill learning checklists
for the session.

Review the materials and resources needed for the session and make sure they are
available.

Review the suggested lesson plan, learning objectives, and PowerPoint presentation for
the session. The lesson plan builds on the knowledge from the suggested readings in the
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Prevention and management of pre-eclampsia and eclampsia
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Reference Manual. Use those parts of the lesson plan that are relevant to your
participants’ learning needs. This will depend on the experience, skill, and knowledge
level of the participants and how much time is available.

Plan how much time to devote to each learning activity; lesson plans are included for
your guidance.
After each session:

Review what parts of the session went well and what parts require revision

Revise lesson plans, learning activities, and PowerPoint presentations as needed

Investigate any topics that were brought up during the session that you were not able to
adequately respond to
Assessments of participants
Facilitators evaluate the participants’ knowledge and skills during the training program using
a checklist to evaluate performance of skills, and pre- and mid-course questionnaires to
evaluate knowledge. Each topic has a set of learning activities, enabling the participant to
practice applying the presented information.
The facilitator records pre- and mid-course questionnaire scores on the Training Report
Form and completes checklists found in the Participant’s Notebooks for skills being
evaluated.
Pre-course questionnaire
Prior to beginning the training program, participants should complete the pre-course
questionnaire.
The objectives of this questionnaire are to:

Assess what the participant knows about the course topics.

Identify topics that may need additional emphasis during the course.

Alert the participant to the content that will be presented in the course.
Facilitators and participants may correct the pre-course questionnaire together using the
answers found in the key in the Facilitator’s Guide.
Mid-course questionnaire
After completing the session objectives, the facilitator will administer the mid-course
questionnaire. The objectives of this questionnaire are similar to the pre-course
questionnaire:

Assess what the participant has learned about the course topics.

Identify topics that may need additional emphasis during the clinical practicum.

Identify each participant’s individual learning needs.
Facilitators and participants may correct the mid-course questionnaire together using the
answers found in the key in the Facilitator’s Guide.
Participants should be encouraged to review course content for the questions they answered
incorrectly and to talk with facilitators if they have questions about any of the answers.
Prevention and management of pre-eclampsia and eclampsia
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Participants who do not achieve a score of at least 80% on the mid-course questionnaire will
have a second chance to take it on the last day of training activities. All participants must
achieve a score of at least 80% to receive certification.
Assessment in a simulated setting
After completing the mid-course questionnaire and before going to the clinical area, the
facilitator will use the checklist to evaluate each participant in a simulated setting. When the
facilitator determines a participant can competently perform the newly acquired skills in a
simulated setting, the participant can practice the skill in the clinical area to gain
competency and proficiency in the skills acquired.
After a participant has performed a skill in a simulated situation, give feedback immediately
using the checklist as a guide:

Always start feedback with one or two positive comments on what was done correctly.

The participant gives feedback on his/her performance.

Observers give feedback.

Finally, the facilitator gives feedback on any missed points and develops a plan with the
participant to improve his/her performance.
Clinical skills at the training site
There is a very small chance that a woman with pre-eclampsia or eclampsia presents at the
clinical site during training activities. It is thus imperative that there be a plan to evaluate
the participant at his/her place of work after training activities have been completed.
Participants will not receive a certificate of completion of the course until they have been
evaluated in the clinical area.
Participants and facilitators keep track of progress in gaining competence in the clinical skills
being taught by using the checklist found in the Participant’s Notebook.
Lesson plans
Preparation of what you will teach and how you will teach is just as important as the
actual teaching. Even though it takes time to do the preparation, it will help you to feel
not just competent, but also confident. Using a lesson plan can help to organize all of
the details of teaching. Reviewing a lesson plan will also help you discover what you
know and what you may have forgotten. It is your responsibility as a facilitator to
ensure your knowledge and skills are up to date. Review both your knowledge and
skill by teaching yourself again, or find someone who can help you.
There is a lesson plan for each of the sessions. The lesson plan is simply a guide and
should be adapted based on the needs or experience of the participants. For example,
some groups may need a more thorough review on taking blood pressure than others.
Make these decisions in advance, so an appropriate training plan and schedule can be
developed.
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Training schedule
Sample schedule for providers
Day 1
Day 2
Opening

Welcome

Participant introductions

Participant expectations

Workshop norms
Overview of the course

Goals, objectives, schedule

Approach to training

Review of course materials
Day 3
Mid-course questionnaire
Evaluation in simulated setting:
Session 4: Management of
hypertensive disorders in
pregnancy (4 hours)
1. Evaluation of women with
diastolic BP 90-110 mm Hg
2. Management of women with
severe pre-eclampsia/eclampsia
Pre-course questionnaire
3. Preparation and administration
of MgSO4
Session 1: Understanding preeclampsia and eclampsia (90
minutes)
4. Care during and after a
convulsion in a
pregnant/postpartum woman
Lunch
Session 2: Identifying preeclampsia and eclampsia (120
minutes)
Session 5: Management
during a convulsion/fit (90
minutes)
Session 3: Prevention of preeclampsia and/or eclampsia (75
minutes)
Session 6: Birth
preparedness and
complication readiness (75
minutes)
Read chapter 1-6.
Work on learning activities for
sessions 1-3.
Plan for final evaluation in a
clinical setting
Workshop evaluation
Closing session
Work on learning activities
for sessions 4-6.
Prepare for mid-course
questionnaire and skills
evaluation.
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Understanding pre-eclampsia and eclampsia
Summary of the session
During this session, you will review: 1) the evolution of pre-eclampsia and eclampsia, 2)
epidemiology of pre-eclampsia and eclampsia, 3) the pathophysiology of pre-eclampsia and
eclampsia, 4) factors that influence the survival of women with pre-eclampsia/eclampsia
and their fetuses/newborn, and 5) morbidity and mortality associated with severe preeclampsia and eclampsia.
Learning objectives for the session
At the end of the session, participants will be able to:

Describe the pathophysiology of pre-eclampsia and eclampsia

Describe the progression of gestational hypertension into severe pre-eclampsia
or eclampsia

List factors that may predispose some women to the disease

List maternal, community, and health service factors that influence the survival
of women and their newborns

List maternal and fetal complications associated with severe pre-eclampsia or
eclampsia
Estimated time: 90 minutes
Learning outline for the session
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 1: Describe the pathophysiology of pre-eclampsia and eclampsia.
 Cause
 Physiologic changes
in pregnancy
 Pathophysiologic
changes: Preeclampsia
 HELLP syndrome
Activities:
 Lecture
 Discussion
Reference Manual
Presentation Graphics:
Understanding pre-eclampsia and
eclampsia
Learning Objective 2: Describe the progression of gestational hypertension into severe
pre-eclampsia or eclampsia.
 Disease progression
Activities:
 Lecture
Prevention and management of pre-eclampsia and eclampsia
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Reference Manual
Presentation Graphics:
Understanding pre-eclampsia and
eclampsia
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CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 3: List factors that may predispose some women to the disease
 Epidemiology of preeclampsia
 Factors that may
predispose to preeclampsia /
eclampsia
Activities:
 Lecture
 Discussion
 Brainstorming
Reference Manual
Presentation Graphics:
Understanding pre-eclampsia and
eclampsia
White board and markers / Chalk
board and chalk / Flipchart and
markers
Learning Objective 4: List maternal, community, and health service factors that
influence the survival of women and their newborns.
 Factors affecting
positive outcome
 Factors influencing
maternal and
perinatal outcomes
Activities:
 Lecture
 Discussion
 Group work:
Factors
influencing
maternal and
perinatal
outcomes
Reference Manual
Presentation Graphics:
Understanding pre-eclampsia and
eclampsia
Participant’s Notebook
Pens / Pencils
Learning Objective 5: List maternal and fetal complications associated with severe preeclampsia or eclampsia.
 Mortality associated
with pre-eclampsia
and eclampsia
 Effects of PE/E on
the woman
 Effects of PE/E on
the fetus
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Activities:
 Lecture
 Discussion
Reference Manual
Presentation Graphics:
Understanding pre-eclampsia and
eclampsia
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Group work: Factors influencing maternal and perinatal
outcomes
1. List the factors that influence maternal and perinatal outcomes.
2. Mark the factors that are avoidable or can be anticipated.
3. State the steps that must be taken to prevent these avoidable factors, or to reduce the
risk.
[Please note that the steps to avoid occurrences are not exhaustive but illustrative.]
Maternal factors
Predisposing factors
Pre-existing medical
conditions
Avoidable? Yes / No
May be avoidable
Steps to avoid occurrence
 Prevent pregnancy until
condition is stable or
avoid pregnancy
Gestational age at which preeclampsia develops:
 In general, maternal and
perinatal outcomes are
usually favorable in women
with mild pre-eclampsia
developing beyond 36
weeks’ gestation who have
no other pre-existing
medical disorders.
 By contrast, maternal and
perinatal morbidities and
mortalities are increased in
women who develop the
disorder before 33 weeks’
gestation, in those with
pre-existing medical
disorders, and in those
receiving care in low
resource settings.

Most likely not avoidable
Prevention and management of pre-eclampsia and eclampsia
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
Not avoidable but all
women should receive
early and regular
antenatal visits during
which women are
screened for preeclampsia
Community sensitization
about danger signs and
importance of antenatal
care
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Community factors
Predisposing factors
Lack of awareness about
signs and symptoms of
pre-eclampsia, severe
pre-eclampsia and
eclampsia and the
importance of early and
regular antenatal care
Avoidable? Yes / No
Steps to avoid occurrence
Yes
 Good antenatal care
 Birth preparedness and
complication readiness
plans
 Community
sensitization
Transportation barriers
particular for obstetric
emergencies.
Yes
 Work with woman and
family to develop
complication readiness
plan
 Medical insurance schemes
 Collaborate with
transportation syndicates
and drivers
Low socioeconomic status
including lack of access to
information and low literacy
levels
Yes – but requires long-term
plan for economic
improvement and literacy
campaigns
 Strategies to improve
economic status of women
 Literacy campaigns
Financial hardship and
inability to pay for transport
and medical care
Yes – but requires long-term
plan for economic
improvement and planning
 Work with woman and
family to develop
complication readiness
plan
 Medical insurance schemes
Community distrust of health
care personnel
Yes – but requires long-term
plan for quality improvement
and work to build
relationships between the
community and health care
facilities
 Quality assurance
programs
 Health committees that
include members of the
community
 Sensitization of health care
personnel
 Sensitization of
communities about their
rights for health care and
treatment
Cultural barriers
Yes – but requires long-term
plan for community
sensitization
 Community sensitization
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Health service factors
Predisposing factors
Inadequate availability
and access to antenatal
care
Failure to monitor blood
pressure and urine during
antenatal care
Failure to counsel women
and families about
dangerous symptoms of
severe pre-eclampsia and
the importance of regular
antenatal care
Delay in referral of women
with symptoms and signs of
severe pre-eclampsia or
eclampsia
Lack of a clear-cut
management
strategy/clinical protocols for
dealing with pre-eclampsia
and eclampsia
Avoidable?
Steps to avoid occurrence
Yes
 Political commitment to increase access
to care
 Create alternatives to traditional health
care system
Yes
 Quality assurance programs
 Sensitization of health care personnel
 Where necessary, retraining of health care
personnel
 Sensitization of women about components
of antenatal care
 Work with administration / management to
ensure that necessary equipment, supplies,
and commodities are available
Yes
 Quality assurance programs
 Sensitization of health care personnel
 Where necessary, retraining of health care
personnel
 Sensitization of women about components
of antenatal care
Yes
 Quality assurance programs
 Sensitization of health care personnel
 Where necessary, retraining of health care
personnel
Yes
 Development of evidence-based clinical
protocols
 Dissemination of updated clinical protocols
 Where necessary, retraining of health care
personnel
Inadequately trained staff to
treat women with severe
eclampsia or eclampsia
Yes
Delay in identification and
management of severe preeclampsia
Yes
Lack of proper equipment
and drugs to treat preeclampsia and eclampsia
Yes
 Quality assurance programs
 Sensitization of health care personnel
 Where necessary, retraining of health care
personnel
 Quality assurance programs
 Sensitization of health care personnel
 Where necessary, retraining of health care
personnel
 Quality assurance programs
 Sensitization of health care personnel and
administration/management personnel
 Advocacy for procurement of essential
equipment and supplies
 Development of a plan for maintenance of
equipment
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Identifying pre-eclampsia
Summary of the session
During this session, you will review 1) screening for pre-eclampsia, 2) diagnosing
hypertensive disorders of pregnancy, and 3) the differential diagnosis of hypertensive
disorders in pregnancy and the postpartum.
Learning objectives for the session
At the end of the session, participants will be able to:

Describe routine screening for hypertensive disorders during pregnancy and the
postpartum

Correctly measure protein in the urine

Correctly measure blood pressure

Make a differential diagnosis of hypertensive disorders in pregnancy and the
postpartum

Test reflexes in women with elevated blood pressure
Estimated time: 2 hours
Learning outline for the session
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 1: Make a differential diagnosis of hypertensive disorders in
pregnancy and the postpartum
 Definition of
hypertension during
pregnancy
Activities:
Reference Manual
 Lecture
 Identifying preeclampsia
 Discussion
Presentation Graphics: Identifying
pre-eclampsia
 Hypertensive
disorders in
pregnancy
 Puzzle game –
hypertension in
pregnancy
Prevention and management of pre-eclampsia and eclampsia
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Print, paste together, and cut out the
clinical pictures for the puzzle game.
Print 1 copy of each clinical picture
for each group (if there are three
groups, print three copies, etc.)
13
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 2: Correctly measure protein in the urine
 Detecting proteinuria
 Reasons why detecting
protein in urine may be
inaccurate
Activities:
Reference Manual
 Lecture
Presentation Graphics:
Identifying pre-eclampsia
 Discussion
 Measures to reduce error
when checking urine for
protein
Test strips for checking
protein in urine
Learning Objective 3: Correctly measure blood pressure
 Reasons why BP reading
are inaccurate
Activities:
Reference Manual
 Measures to reduce
observer error when taking
BP measurements
 Lecture
 Discussion
Presentation Graphics:
Identifying pre-eclampsia
 Group work:
Checking BP
machines
BP machines – at least three
 Measures to reduce device
error when taking BP
measurements
 Measures to reduce
variability of BP
measurements
 Presentation of
photos to evaluate
how the BP is being
measured
Learning Objective 4: Describe routine screening for hypertensive disorders during
pregnancy and the postpartum
 Differentiating between
different hypertensive
disorders in pregnancy
Activities:
Reference Manual
 Lecture
 Routine screening for preeclampsia
 Discussion
Presentation Graphics:
Identifying pre-eclampsia
 If diastolic BP is >90 mmHg
 If there is greater than 1+
protein in the urine
 If there is greater than 1+
protein in the urine AND
dBP > 90 mmHg
Learning Objective 5: Test reflexes in women with elevated blood pressure
 Testing reflexes
 Grading reflexes
Activities:
Reference Manual
 Lecture
Presentation Graphics:
Identifying pre-eclampsia
 Discussion
 Demonstration /
Return
demonstration of
testing reflexes
14
Reflex hammers
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Puzzle game
“Adapted from: World Health Organization (WHO) Department of Making Pregnancy Safer.
Midwifery Education Modules (2nd Edition): Managing eclampsia. Geneva, Switzerland:
WHO; 2008.
“Why is her blood pressure elevated?”
Goal:
This exercise is intended to help participants identify hypertension during pregnancy.
Participants will learn to describe the clinical picture of most hypertensive disorders in
pregnancy.
It can be helpful to think of a diagnosis in terms of building up a picture.
Advance preparation:
Photocopy the following pages that have clinical pictures A-F on them.
Fold each paper such that the signs/symptoms are directly behind the picture of the woman.
Glue the two sides together, back-to-back.
Cut the puzzles into pieces along the lines indicated.
The clinical picture Divide participants into three groups to work on the puzzles. Give each
group three clinical pictures. Mix the three puzzles together. The participants will not know
the diagnosis before they work on the puzzle.
Clinical picture (A) is chronic hypertension
Clinical picture (B) is gestational hypertension
Clinical picture (C) is mild pre-eclampsia
Clinical picture (D) is severe pre-eclampsia
Clinical picture (E) is eclampsia
Clinical picture (F) is pre-eclampsia superimposed on chronic hypertension
Provide the participants with the Instructions for Group Work.
During the group work, check that participants are able to correctly put the pictures
together to discover the diagnosis.
Feedback After the group work, ask each group to report on:
1. the conditions they have diagnosed
2. the diagnostic criteria for each condition.
Prevention and management of pre-eclampsia and eclampsia
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INSTRUCTIONS FOR GROUP WORK
The Clinical Picture
1. You have been given many small pieces of card. Place them all on the table so that
the black dot(s) with small writing on each piece faces upwards.
1. Separate the cards from each other so that you can easily read the symptoms and
signs that are written on each one.
2. When the cards are fitted together correctly, they will form three complete clinical
pictures. Each clinical picture has a drawing of a woman in the centre. Clinical
symptoms and signs are written around the drawing.
3. Choose the cards which you think best fit together to describe the symptoms and
signs of a particular condition. Place the cards together to make a complete clinical
picture.
4. When you have completed your three clinical pictures, read again the symptoms and
signs and decide on the most likely diagnosis for the woman in each picture.
5. Write down your diagnosis for each clinical picture. Check your diagnosis by carefully
turning the picture over, piece by piece, and reading the diagnosis written on the
other side. The diagnosis can be seen only when all the correct cards are put together
in their right order.
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Facilitator’s Guide
Prevention of pre-eclampsia and/or eclampsia
Summary of the session
During this session, you will review interventions for 1) primary, 2) secondary, and 3)
tertiary prevention of pre-eclampsia and/or eclampsia.
Learning objectives for the session
At the end of the session, participants will be able to:


Define the different levels of prevention

Describe evidence-based interventions to promote for secondary prevention of
pre-eclampsia / eclampsia

Describe evidence-based interventions to promote for tertiary prevention of
pre-eclampsia / eclampsia
Describe evidence-based interventions to promote for primary prevention of
pre-eclampsia / eclampsia
Estimated time: 75 minutes
Learning outline for the session
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 1: Define the different levels of prevention
 Primary prevention of pre-eclampsia
 Secondary prevention (Screening
and Detection)
 Tertiary prevention (management)
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Prevention of
pre-eclampsia and/or eclampsia
Learning Objective 2: Describe evidence-based interventions to promote for primary prevention
of pre-eclampsia / eclampsia
 Prevention of too early and too late
pregnancies with family planning
 Prevention and/or treatment of
obesity





Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Prevention of
pre-eclampsia and/or eclampsia
Prevention of IUGR
Smoking
Use of low-dose aspirin
Calcium supplementation
Interventions with insufficient
evidence to promote for primary
prevention
 Interventions to promote for primary
prevention of PE/E
Prevention and management of pre-eclampsia and eclampsia
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23
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 3: Describe evidence-based interventions to promote for secondary
prevention of pre-eclampsia / eclampsia
 Secondary prevention (Screening
and Detection)
 Elements needed to ensure access to
secondary prevention
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Prevention of
pre-eclampsia and/or eclampsia
Learning Objective 4: Describe evidence-based interventions to promote for tertiary prevention
of pre-eclampsia / eclampsia
 Management of severe preeclampsia and eclampsia
 Anti-convulsant therapy
 Anti-hypertensive treatment
 Induction of labor
24
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Prevention of
pre-eclampsia and/or eclampsia
Prevention and management of pre-eclampsia and eclampsia
Version 1.0 / 10 January 2011
Facilitator’s Guide
Management of pre-eclampsia and eclampsia
Summary of the session
During this session, you will review management of: 1) gestational hypertension, 2) mild
pre-eclampsia, and 3) severe pre-eclampsia / eclampsia.
Learning objectives for the session
At the end of the session, participants will be able to:

Describe management of gestational hypertension and mild pre-eclampsia

Describe management of severe pre-eclampsia and eclampsia

Describe the appropriate level of care to manage hypertensive disorders in
pregnancy

Provide care for women with severe pre-eclampsia and eclampsia according to
recommended standards

Appropriately refer women to tertiary care facilities
Estimated time: 4 hours
Learning outline for the session
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 1: Describe management of gestational hypertension and mild pre-eclampsia
 Gestational hypertension
 Mild pre-eclampsia - Gestation less
than 37 weeks
 Mild pre-eclampsia - Gestation 37
weeks or more
Activities:
Reference Manual
 Lecture
 Discussion
 Puzzle game –
Presentation Graphics: Management
of pre-eclampsia and eclampsia
hypertension in
pregnancy
Use puzzle pieces prepared for the
session on identifying pre-eclampsia
 Group work –
Management of
gestational
hypertension
and mild preeclampsia
Learning Objective 2: Describe management of severe pre-eclampsia and eclampsia
 Severe pre-eclampsia and
eclampsia
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Management
of pre-eclampsia and eclampsia
Prevention and management of pre-eclampsia and eclampsia
Version 1.0 / 10 January 2011
25
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 3: Describe the appropriate level of care to manage hypertensive disorders in
pregnancy
 Level of care
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Management
of pre-eclampsia and eclampsia
Learning Objective 4: Provide care for women with severe pre-eclampsia and eclampsia
according to recommended standards
 Demonstration: Bedside clotting
test
 Anti-convulsive therapy
 Demonstration: MgSO4 – Loading
dose
 MgSO4 kit - Loading dose
 Magnesium intoxication
 Administering maintenance dose of
MgSO4
 Withhold or delay magnesium
sulfate dose if














Antidote for MgSO4 toxicity
MgSO4 kit - Maintenance dose
Use of diazepam (Valium)
IV administration of diazepam
Rectal administration of diazepam
Anti-hypertensive therapy
Nifedipine
Labetolol
Activities:
Reference Manual
 Lecture
 Discussion
 Demonstration
Presentation Graphics: Management
of pre-eclampsia and eclampsia
– bedside
clotting test
 Demonstration
/ Return
demonstration
– Preparation
of MgSO4
 Group work –
Case study
 Clinical
simulation:
Management of
headache, high
blood pressure,
blurred vision
 Skills stations
Hydralazine
Delivery
Materials for bedside clotting
demonstration: Tourniquet, sterile
needle/syringe, examination gloves,
alcohol wipes, sharps disposal box,
plain glass test tube (approximately
10 mm x 75 mm)
Materials for preparation of MgSO4:
Three MgSO4-Loading dose kits and
three MgSO4-Maintenance dose kits
Samples of the following: valium,
nifedipine, labetolol, and hydralazine
Materials for the clinical simulation:
examination gloves, sharps disposal
box, BP machine, watch,
thermometer, stethoscope, fetal
stethoscope, MgSO4 kits, Normal
Saline or Ringer’s Lactate 500 mL, IV
giving set, urinary catheter, fluid
balance chart, urine dipsticks
Mode of delivery
Plan for vaginal delivery
Plan for cesarean operation
Postpartum care
Learning Objective 5: Appropriately refer women to tertiary care facilities
 Referral for tertiary level care
26
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Management
of pre-eclampsia and eclampsia
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Always check expiration dates before using any
medications in the kit.
Replenish the kit immediately after using and store in the
designated area.
Always check expiration dates before using any
medications in the kit.
Replenish the kit immediately after using and store next to
the woman’s bed.
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Case study
Source: All learning activities for this session were copied from: MNH/Jhpiego. Managing
Complications in Pregnancy and Childbirth: Learning Resource Package - Guide for
Facilitators.
Available at:
http://www.reproline.jhu.edu/english/2mnh/2mcpc/5_Learning_Pkg/C_05_Headaches_etc/
05-CS-5.2.htm
Case study #1
Mrs. B. is 16 years old. She is 30 weeks pregnant and has attended the antenatal clinic
three times. All findings were within normal limits until her last antenatal visit 1 week ago.
At that visit it was found that her blood pressure was 130/90 mm Hg. Her urine was
negative for protein. The fetal heart sounds were normal, the fetus was active and uterine
size was consistent with dates. She has come to the clinic today, as requested, for followup.
ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory
Tests)
1. What will you include in your initial assessment of Mrs. B., and why?

Mrs. B. should be greeted respectfully and with kindness.

She should be told what is going to be done and listened to carefully. In
addition, her questions should be answered in a calm and reassuring
manner.

Mrs. B. should be asked how she is feeling and whether she has had
headache, blurred vision or upper abdominal pain since her last clinic visit.

She should be asked whether fetal activity has changed since her last visit.

Her blood pressure should be checked and her urine tested for protein (the
presence of proteinuria, together with a diastolic blood pressure greater
than 90 mm Hg, is indicative of pre-eclampsia).
2. What particular aspects of Mrs. B.'s physical examination will help you make a diagnosis,
and why?

Blood pressure should be measured.

An abdominal examination should be done to check fetal growth and to
listen for fetal heart sounds (in cases of pre-eclampsia/eclampsia reduced
placental function may lead to low birth weight; there is an increased risk of
hypoxia in both the antenatal and intranatal periods, and an increased risk
of abruptio placentae).
3. What screening procedures/laboratory tests will you include (if available) in your
assessment of Mrs. B., and why?

As mentioned above, urine should be checked for protein.
DIAGNOSIS (Identification of Problems/Needs)
You have completed your assessment of Mrs. B. and your main findings include the
following:
Mrs. B.'s blood pressure is 130/90 mm Hg, and she has proteinuria 1+.
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Facilitator’s Guide
She has no adverse symptoms (headache, visual disturbance, upper abdominal pain,
convulsions or loss of consciousness.
The fetus is active and fetal heart sounds are normal. Uterine size is consistent with dates.
4. Based on these findings, what is Mrs. B.'s diagnosis, and why?

Mrs. B.'s signs and symptoms (e.g., diastolic blood pressure 90110 mm Hg
after 20 weeks gestation and proteinuria up to 2+) are consistent with mild
pre-eclampsia.
CARE PROVISION (Planning and Intervention)
5. Based on your diagnosis, what is your plan of care for Mrs. B., and why?

Mrs. B. should be provided reassurance and counseled about the danger
signs related to severe pre-eclampsia and eclampsia (severe headache,
blurred vision, upper abdominal pain, and convulsions or loss of
consciousness) and the need to seek help immediately if any of these occur.
She should be advised of the possible consequences of pregnancy-induced
hypertension.

She should be encouraged to take additional periods of rest and to eat a
normal diet (salt restriction should be discouraged as this does not prevent
pregnancy-induced hypertension).

Mrs. B. should be asked to return to the clinic twice weekly to have her
blood pressure, urine and fetal condition monitored.

Mrs. B.'s management should not include the use of anticonvulsives,
antihypertensives, sedatives or tranquilizers (these should not be given
unless the blood pressure or urinary protein level increases).

Basic antenatal care (early detection and treatment of problems,
prophylactic interventions, birth plan development/revision, plan for
newborn feeding) should be provided, as needed.

She should be advised to plan for childbirth in the hospital.
EVALUATION
Mrs. B. attends antenatal clinic on a twice-weekly basis, as requested. Her blood pressure
remains the same; she continues to have proteinuria 1+. Fetal growth is normal. Four
weeks later, however, her blood pressure is 130/110 mm Hg and she has proteinuria 2+.
Mrs. B. has not suffered headache, blurred vision, upper abdominal pain, convulsions or loss
of consciousness and says that she feels well. However, she finds it very tiring to have to
travel to the clinic by bus twice weekly for followup and wants to come only once a week.
6. Based on these findings, what is your continuing plan of care for Mrs. B., and why?

Mrs. B. needs to be monitored on a twice-weekly basis, especially since her
diastolic blood pressure and proteinuria have increased. Since this will be
difficult on an outpatient basis because travel to the clinic twice weekly is
making Mrs. B. very tired, she should be admitted to the district hospital.

The need for close followup should be explained to Mrs. B. In relation to
this, she should be encouraged to express her concerns, listened to
carefully, and provided emotional support and reassurance.

Her care in hospital should be as follows:
o
Normal diet
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30
o
Blood pressure monitored twice daily
o
Urine tested for protein daily
o
Fetal condition monitored twice daily
o
No anticonvulsants, antihypertensives, sedatives or tranquilizers
o
If Mrs. B.'s blood pressure returns to normal or her condition is stable,
she could be discharged, providing arrangements can be made for
twice-weekly followup (e.g., it may be possible for her to attend
antenatal clinic once a week and be monitored at home once a week by
a community midwife).
o
If her condition remains unchanged, she should remain in the hospital
and be monitored as described above.
o
Basic antenatal care should continue to be provided, as needed.
o
If Mrs. B. develops signs of fetal growth restriction, early childbirth
should be considered.
o
If fetal and maternal condition are stable, she should be allowed to go
into spontaneous labor and may deliver vaginally without the need for
vacuum extraction or forceps.
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Clinical simulation
Management of headache, high blood pressure, blurred vision, loss of
consciousness
A clinical simulation is an activity in which the learner is presented with a carefully planned,
realistic re-creation of an actual clinical situation. The learner interacts with persons and
things in the environment, applies previous knowledge and skills to respond to a problem,
and receives feedback about those responses without having to be concerned about real-life
consequences. The purpose of using clinical simulations is to develop learners' clinical
decision-making skills.
The clinical simulations included in the learning resource package therefore provide learners
with the opportunity to develop the skills they need to address complex, rare or lifethreatening situations before moving into the clinical practice area. The clinical simulations
may, in fact, be the only opportunity learners have to experience some rare situations and
therefore may also be the only way that a facilitator can assess learners' abilities to manage
such situations.
The simulations in this package combine elements of case studies, role plays and skills
practice using anatomic models (if available). The situations they present were selected
because they are clinically important, require active participation by the learners, and
include clinical decision-making and problem-solving skills. The simulations are structured
so that they accurately reflect how clinical situations develop and progress in real life.
Learners are provided with only a limited amount of information initially. As they analyze
this information and identify additional information that is needed, it is provided. Learners
may also perform any procedures or other skills as needed if the appropriate models and
equipment are available. Based on the data they collect, learners make decisions regarding
diagnoses, treatment and further information needed. The facilitator asks the learners
questions about what they are doing, why a particular choice was made, what the other
alternatives might be, what might happen if circumstances or findings were to change, and
so forth. In other words, the facilitator explores the learners' decision-making process and
depth of their knowledge and understanding, and provides feedback and suggestions for
improvement.
The simulation should be conducted in as realistic a setting as possible, meaning that the
models, equipment and supplies needed for managing the situation should be available to
the learner. Because many of the situations addressed in simulations are clinically complex,
providing the models and other equipment often requires creativity and ingenuity.
Learners will need time and repeated practice to achieve competency in the management of
the complex situations presented in the simulations. They should be provided with as many
opportunities to participate in simulations as possible. The same simulation can be used
repeatedly until the situation it presents is mastered. It can also be adapted to address
different causes for the problem it presents, different treatment options or different
outcomes, to provide learners with as wide a variety of experiences as possible. When a
simulation is used for assessment, one standard version should be used with all learners to
ensure the consistency of assessment standards and allow comparison of the performance
of individual learners.
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Scenario 1
Mrs. H. is 20 years old. She is 38 weeks
pregnant. This is her second pregnancy. Her
mother-in-law has brought Mrs. H. to the
health center this morning because she has
had a severe headache and blurred vision for
the past 6 hours. Mrs. H. says she feels very
ill.
1. What will you do?
Key Reactions/Responses




Mrs. H.’s diastolic blood pressure is 96 mm
Hg, her pulse 100 beats/minute and
respiration rate 20 breaths/minute. She has
hyper-reflexia. Her mother-in-law tells you
that Mrs. H. has had no symptoms or signs of
the onset of labor.

2. What is Mrs. H.’s problem?
3. What will you do now?
4. What is your main concern at the
moment?





After 15 minutes, Mrs. H. is resting quietly.
She still has a headache and hyper-reflexia.
5. What will you do now?
6. What will you do during the next hour?




It is now 1 hour since treatment for Mrs. H.
was started. Her diastolic blood pressure is
still 96 mm Hg, pulse 100 beats/minute and
respiration rate 20 breaths/minute. She still
has hyper-reflexia. You detect that the fetal
heart rate is 80.
7. What is your main concern now?
8. What will you do now?
32



Shouts for help to urgently mobilize all available
personnel
Places Mrs. H. on the examination table on her
left side
Makes a rapid evaluation of Mrs. H.’s condition,
including vital signs (temperature, pulse, blood
pressure, and respiration rate), level of
consciousness, color and temperature of skin
Simultaneously asks about the history of Mrs.
H.’s present illness
States that Mrs. H.’s symptoms and signs are
consistent with severe pre-eclampsia
Has one of the staff who responded to her shout
for help start oxygen at 4–6 L/minute
Prepares and gives magnesium sulfate 20%
solution, 4 g IV over 5 minutes
Follows promptly with 10 g of 50% magnesium
sulfate solution, 5 g in each buttock deep IM
injection with 1 mL of 2% lignocaine in the same
syringe
At the same time, tells Mrs. H. (and her motherin-law) what is going to be done, listens to them
and responds attentively to their questions and
concerns
States that the main concern at the moment is to
prevent Mrs. H. from convulsing
Has one of the staff assisting with the emergency
insertion of an indwelling catheter to monitor
urinary output and proteinuria
Starts an IV infusion of normal saline or Ringer’s
lactate
Listens to the fetal heart
States that during the next hour will continue to
monitor vital signs, reflexes and fetal heart, and
maintain a strict fluid balance chart
States that main concern now is fetal heart
abnormality
States that Mrs. H. should be prepared to go the
operating room for cesarean section
Tells Mrs. H. (and her mother-in-law) what is
happening, listens to their concerns and provides
reassurance
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Learning guide for hypertension in pregnancy: Diastolic
Blood Pressure is >90 mm Hg but < 110 mm Hg
Training facilitators or participants can use the following learning guide to gauge progress
while learning to care for pregnant women with diastolic BP between 90-110 mm Hg.
Directions
Rate the performance of each step or task using the following rating scale:
1 = Performs the step or task completely and correctly.
0 = Unable to perform the step or task completely or correctly or the step/task was not
observed.
N/A (not applicable) = Step was not needed.
Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but
< 110 mm Hg
STEP/TASK
OBSERVATIONS
GETTING READY
1. Greet the woman respectfully and with kindness.
2. Tell the woman what is going to be done and encourage her to ask
questions.
3. Listen to what the woman has to say.
4. Provide emotional support and reassurance.
Initial assessment
1. Take a good personal and family history of:
 Epilepsy
 Hypertension
 Renal or heart disease
 Cerebro-vascular accident (CVA)
2. Take a good symptom history (danger signs). ASK if she has or had
any:
 Epigastric pain (heartburn)
 Headaches
 Visual problems (double vision, partial vision, rings around lights)
3. Calculate gestational age
4. Check that the right size BP cuff was used and that the BP machine is
functioning properly
5. Have the woman lie on her left side for 20 minutes, then recheck it
again with her sitting up
– If the blood pressure is normal, this is not hypertension.
– the blood pressure is still elevated, plan to check the BP again in
– If
4
– hours.
– If
– the BP is still elevated 4 hours after the first reading, this is
considered hypertension.
6. Check a mid-stream “clean catch” urine sample for protein regardless
of subsequent BP measurement.
Prevention and management of pre-eclampsia and eclampsia
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33
Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but
< 110 mm Hg
STEP/TASK
OBSERVATIONS
7. If there is greater than 1+ protein in the urine:
– Verify that the sample was a mid-stream/clean-catch sample.
Make sure the urine is not contaminated by vaginal secretion.
– Check for sexually transmitted infections (STI)
– Rule out a urinary tract infection, schistosomiasis (in endemic
areas), and kidney infections.
– Rule-out anemia
8. If diastolic BP is >90 mm Hg, gestational age is at least 20 weeks,
and there is proteinuria, check the biceps and patellar reflexes.
9. If the reflexes are brisk (+3 or +4), refer her to a hospital/doctor
regardless of BP and/or proteinuria.
Identify problems / needs
1. Analyse the data collected and make a differential diagnosis:

Chronic hypertension: Diastolic BP >90 but <110 without
proteinuria, detected before 20 weeks gestation

Gestational hypertension: Diastolic BP >90 without proteinuria,
detected after 20 weeks gestation

Mild pre-eclampsia: Diastolic BP >90 but <110 with 1+ proteinuria
2. Make a decision about management or referral.
3. Assess educational needs of the woman and make plan for
counselling and follow-up.
Make a plan of care
1. Share your findings with the woman:
 State of health
 Blood pressure
2. Discuss any complications / problems detected during the visit:
 Complications / problems
 Possible cause(s)
 Preventive measures
3. Explain management, based on diagnosis, and the importance for
pregnancy, labor, and delivery
4. Write and / or explain any prescriptions:
 How and when to use
 Contraindications
 Possible reactions
4. If the woman has to be referred, explain the need for referral and, if
possible, accompany her.
5. Determine where the woman should deliver, and assist her in
developing a birth preparedness and complication readiness plan.
6. Counsel the woman.
Follow-up
1. Inform the woman about next steps – either arrange for
hospitalisation, referral, or follow-up as an outpatient.
2. Check the woman’s understanding of findings and next steps.
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but
< 110 mm Hg
STEP/TASK
OBSERVATIONS
3. Remind the woman to report any time she has
questions/concerns/danger signs and not to wait for the scheduled
visit
4. Record drug administration and findings on the woman’s record
5. Give the woman her antenatal and / or appointment cards.
6. Bid the woman farewell.
Prevention and management of pre-eclampsia and eclampsia
Version 1.0 / 10 January 2011
35
Learning guide: Management of severe pre-eclampsia /
eclampsia
Training facilitators or participants can use the following learning guide to gauge progress
while learning to care for women with severe pre-eclampsia and eclampsia.
Directions
Rate the performance of each step or task using the following rating scale:
1 = Performs the step or task completely and correctly.
0 = Unable to perform the step or task completely or correctly or the step/task was not
observed.
N/A (not applicable) = Step was not needed.
Learning guide: Management of severe pre-eclampsia / eclampsia
STEP/TASK
OBSERVATIONS
Getting ready [These steps should be occurring at the same time as immediate
management]
1. Greet the woman respectfully and with kindness.
2. Tell the woman what is going to be done and encourage her to ask
questions.
3. Listen to what the woman has to say.
4. Provide emotional support and reassurance.
Immediate management
1. Urgently mobilise available personnel.
2. Encourage the woman to lie on her side to reduce the risk of
aspiration of secretions, vomit and blood.
3. Ensure the woman’s airway is open.
4. Observe color for cyanosis and need for oxygen
5. If available, give oxygen at 4–6 L per minute by mask or cannulae.
6. Check pulse, respirations, temperature, and fetal heart
10. Check the biceps or patellar reflexes.
7. Auscultate the lung bases for rales.
8. Start an intravenous drip of normal saline or Ringer’s lactate
9. If diastolic blood pressure remains above 110 mm Hg, give
antihypertensive drugs. Reduce the diastolic blood pressure to less
than 100 mm Hg but not below 90 mm Hg.
10. Give anti-convulsive drugs to prevent or treat convulsions / fits (see
Learning Guide for administering magnesium sulfate)
11. Insert an indwelling urinary catheter to monitor urine output and
proteinuria
12. Check urine for proteinuria.
13. Assess clotting status with a bedside clotting test. Failure of a clot to
form after 7 minutes or a soft clot that breaks down easily suggests
coagulopathy
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Learning guide: Management of severe pre-eclampsia / eclampsia
STEP/TASK
OBSERVATIONS
14. If the woman begins having a convulsion, provide for care during the
convulsion (see Learning Guide for care during a convulsion)
15. Never leave the woman alone. A convulsion followed by aspiration
of vomit may cause death of the woman and fetus.
16. Check for signs of labor (see Learning Guide for vaginal examination
of a pregnant woman)
17. Record drug administration, interventions, and findings on the
woman’s record
Communicate with the woman
1. Share your findings with the woman and, as appropriate, her partner
or family member
2. Discuss any complications / problems detected:
 Complications / problems
 Possible cause(s)
3. Explain management, based on diagnosis, and the importance for
pregnancy, labor, and delivery
7. If the woman has to be referred, explain the need for referral
8. Check the woman’s understanding of findings and next steps and
answer any questions.
9. Inform the family that the woman should never be left alone.
Monitor women with severe pre-eclampsia / eclampsia
1. Maintain a strict fluid balance chart and monitor the amount of fluids
administered and urine output to ensure that there is no fluid
overload.
2. Check BP, pulse, and respirations hourly, or more frequently as
needed.
3. Check fetal heart rate hourly, or more frequently as needed
4. Check urinary output hourly, or more frequently as needed
5. Check reflexes hourly, or more frequently as needed
6. Observe color for cyanosis and need for oxygen hourly.
7. Auscultate the lung bases hourly for rales indicating pulmonary edema
8. If rales are heard, withhold fluids
9. If rales are heard, give furosemide 40 mg IV once.
10. Check temperature every four hours (hyperpyrexia may occur).
11. Check for signs of labor.
12. Never leave the woman alone. A convulsion followed by aspiration
of vomit may cause death of the woman and fetus.
13. Record all findings on the woman’s record
14. Share findings with the woman and, as appropriate, her
partner/family member.
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Learning guide: Administering magnesium sulfate
Training facilitators or participants can use the following learning guide to gauge progress
while learning to administer magnesium sulfate and care for women receiving it.
Directions
Rate the performance of each step or task using the following rating scale:
1 = Performs the step or task completely and correctly.
0 = Unable to perform the step or task completely or correctly or the step/task was not
observed.
N/A (not applicable) = Step was not needed.
Learning guide: Administering magnesium sulfate
STEP/TASK
OBSERVATIONS
Administering Loading Dose of Magnesium Sulfate
1. Wash hands thoroughly with soap and water and dry with a clean, dry
cloth or air dry.
2. Put clean exam gloves on both hands.
Prepare magnesium sulfate 20% solution, 4 g
3. Take one 20 mL sterile syringe
4. Draw 4 ampoules of MgSO4 50% (8 mL = 4 gm) into the
syringe
5. Add 12 mL of sterile water for injection to make it 20%
6. Tell the woman that she may experience a feeling of warmth when
magnesium sulfate is given.
7. Carefully clean the injection site with an alcohol wipe.
8. Give magnesium sulfate 20% solution, 4 g by IV injection SLOWLY
over 5 minutes.
9. Dispose of used needle and syringe in a sharps disposal box
Prepare 2 syringes with 5 g of 50% magnesium sulfate solution with 1 mL
of 2% Lignocaine in the same syringe.
10. Take two 20 mL sterile syringes
11. Draw 5 ampoules of MgSO4 50% (10 mL = 5 gm) into each
syringe.
12. Add 1 mL of 2% Lignocaine in each syringe
13. Carefully clean the injection site with an alcohol wipe.
14. Give 5 g by DEEP IM injection in one buttock.
15. Dispose of used needle and syringe in a sharps disposal box
16. Carefully clean the injection site in the alternate buttock with an
alcohol wipe.
17. Give 5 g by DEEP IM injection into the other buttock.
18. Dispose of used needle and syringe in a sharps disposal box
19. Dispose of gloves in a 0.5% decontamination solution
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Learning guide: Administering magnesium sulfate
STEP/TASK
OBSERVATIONS
20. Wash hands thoroughly with soap and water and dry with a clean, dry
cloth or air dry.
21. Record drug administration and findings on the woman’s record.
22. Explain findings and drug administration to the woman
If convulsions recur AFTER 15 minutes, give 2 g magnesium sulfate (50%
solution) IV over 5 minutes.
23. Wash hands thoroughly with soap and water and dry with a
clean, dry cloth or air dry.
24. Put clean exam gloves on both hands.
25. Take one 10 mL sterile syringe
26. Draw 2 ampoules of MgSO4 50% (4 mL = 2 gm) into each
syringe.
27. Carefully clean the injection site with an alcohol wipe.
28. Give magnesium sulfate 50% solution, 2 g by IV injection
SLOWLY over 5 minutes.
29. Dispose of used needle and syringe in a sharps disposal box
30. Dispose of gloves in a 0.5% decontamination solution
31. Wash hands thoroughly with soap and water and dry with a clean, dry
cloth or air dry.
32. Record drug administration and findings on the woman’s record.
33. Explain findings and drug administration to the woman
34. Plan to monitor the woman at least hourly (see Learning Guide for
management of women with severe pre-eclampsia/eclampsia)
Monitoring women for toxicity
Before repeating the 4-hourly dose of magnesium sulphate:
1. Count respiration rate for one minute
2. Calculate urinary output over the last 4 hours
3. Check patellar reflexes
4. WITHHOLD or DELAY drug if:
· Respiratory rate falls below 16 per minute.
· Patellar reflexes are absent.
· Urinary output falls below 30 ml per hour over the preceding 4
hours.
5. If respiratory arrest occurs:
· Assist ventilation.
· Give calcium gluconate 1 g (10 mL of 10% solution) by IV injection
SLOWLY until respiration begins.
6. Record findings on the woman’s record.
7. Explain findings to the woman
Administering Maintenance Dose of Magnesium Sulfate
1. Provide maintenance dose of magnesium sulphate (5 g magnesium
sulfate (50% solution) + 1 mL lignocaine 2% IM every 4 hours) if:
· Respiratory rate is at least 16 per minute.
· Patellar reflexes are present.
· Urinary output is at least 30 ml per hour over 4 hours.
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Learning guide: Administering magnesium sulfate
STEP/TASK
OBSERVATIONS
2. Wash hands thoroughly with soap and water and dry with a clean, dry
cloth or air dry.
3. Put clean exam gloves on both hands.
Prepare 5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2% :
4. Take one 20 mL sterile syringe
5. Draw 5 ampoules of MgSO4 50% (10 mL = 5 gm) into each
syringe.
6. Add 1 mL of 2% Lignocaine in each syringe
7. Verify in which buttock the last magnesium sulfate injection was
given.
8. Carefully clean the injection site with an alcohol wipe.
9. Give 5 g by DEEP IM injection [Make sure that this injection is given in
the alternate buttock from the most previous injection].
10. Dispose of used needle and syringe in a sharps disposal box
11. Dispose of gloves in a 0.5% decontamination solution
12. Wash hands thoroughly with soap and water and dry with a clean, dry
cloth or air dry.
13. Record drug administration and findings on the woman’s record
14. Explain findings and drug administration to the woman
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Management during a convulsion / fit
Summary of the session
Not all women with pre-eclampsia will develop eclampsia, but both her life and the life of
her baby are in danger when a pregnant woman has fits. During this session, you will
review how to care for pregnant and postpartum women who are fitting.
Learning objectives for the session
At the end of the session, participants will be able to:

Describe stages of an eclamptic fit

Describe steps to follow for managing convulsions / fits in a pregnant or
postpartum woman

Make a differential diagnosis of fits / convulsions during pregnancy and the
postpartum
Estimated time: 90 minutes
Learning outline for the session
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 1: Describe stages of an eclamptic fit
 Eclamptic fits
 Stages of an eclamptic fit
Activities:
Reference Manual
 Lecture
 Discussion
Presentation Graphics: Management during a
convulsion / fit
Learning Objective 2: Describe steps to follow for managing convulsions / fits in a pregnant or
postpartum woman
 Management during a
convulsion
 Care after the convulsion
Activities:
Reference Manual
 Lecture
 Discussion
 Demonstration
Presentation Graphics: Management during a
convulsion / fit
/ Return
demonstration
 Clinical
simulation
Prevention and management of pre-eclampsia and eclampsia
Version 1.0 / 10 January 2011
Samples of the following: nifedipine,
labetolol, and hydralazine
Materials for the clinical simulation: materials
for bedside clotting test, examination gloves,
sharps disposal box, BP machine, watch,
thermometer, stethoscope, fetal stethoscope,
MgSO4 kits, Normal Saline or Ringer’s Lactate
500 mL, IV giving set, urinary catheter, fluid
balance chart, urine dipsticks
41
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 3: Make a differential diagnosis of fits / convulsions during pregnancy
and the postpartum
 Differential diagnosis of
convulsions/fits during
pregnancy
 Tests to make a
differential diagnosis
42
Activities:
Reference Manual
 Lecture
 Discussion
 Puzzle game
Presentation Graphics: Management during a
convulsion / fit
Print, paste together, and cut out the clinical
pictures for the puzzle game. Print 1 copy of
each clinical picture for each group (if there are
three groups, print three copies, etc.)
Prevention and management of pre-eclampsia and eclampsia
Version 1.0 / 10 January 2011
Facilitator’s Guide
Puzzle game
Adapted from: World Health Organization (WHO) Department of Making Pregnancy Safer.
Midwifery Education Modules (2nd Edition): Managing eclampsia. Geneva, Switzerland:
WHO; 2008.
Learning puzzle: “Why is she having a fit?”
This exercise is intended to help participants identify other conditions which may cause fits
and which may have to be distinguished from eclampsia. Participants will learn to describe
the clinical picture of these other conditions, outline the details that may be noted when
taking a history, and list the tests and investigations that may be used to confirm diagnosis.
Advance preparation:
Photocopy the following pages that have clinical pictures A-E on them.
Fold each paper such that the signs/symptoms are directly behind the picture of the woman.
Glue the two sides together, back-to-back.
Cut the puzzles into pieces along the lines indicated.
The clinical picture In order to help participants practice putting together pieces of
information which will help them make a diagnosis, divide them into groups to work on the
puzzles.
Give each group clinical picture (A) plus two other pictures. Mix the three puzzles together.
The participants will not know the diagnosis before they work on the puzzle.
Clinical picture (A) is eclampsia .
Clinical picture (B) is tetanus
Clinical picture (C) is epilepsy
Clinical picture (D) is severe / complicated malaria
Clinical picture (E) is meningitis or encephalitis
Provide the participants with the Instructions for Group Work.
During the group work, check that participants are able to correctly put the pictures
together to discover the diagnosis.
Feedback After the group work, ask each group to report on:
1. the conditions they have diagnosed
2. the tests/investigations which would help confirm diagnosis in the condition studied.
Ask each group in turn to present to the rest of the class the symptoms and signs of a
woman with the condition indicated on their paper and explain how they were able to
differentiate the diagnosis from eclampsia..
When each group has presented its case, summarize the main findings and ask if there are
any questions.
Emphasize that when the clinical picture is not clear, a range of tests must be used to make
a differential diagnosis.
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43
INSTRUCT IONS FOR GROUP WORK
The Clinical Picture
1) You have been given many small pieces of card. Place them all on the table so that
the black dot(s) with small writing on each piece faces upwards.
2) Separate the cards from each other so that you can easily read the symptoms and
signs that are written on each one.
3) When the cards are fitted together correctly, they will form three complete clinical
pictures. Each clinical picture has a drawing of a woman in the centre. Clinical
symptoms and signs are written around the drawing. These may be experienced by a
woman who has a fit.
4) Choose the cards which you think best fit together to describe the symptoms and
signs of a particular condition which may be accompanied by a fit. Place the cards
together to make a complete clinical picture.
5) When you have completed your three clinical pictures, read again the symptoms and
signs and decide on the most likely diagnosis for the woman in each picture.
6) Write down your diagnosis for each clinical picture. One is marked A, and you have
two others, B, C, D, E or F. Check your diagnosis by carefully turning the picture
over, piece by piece, and reading the diagnosis written on the other side. The
diagnosis can be seen only when all the correct cards are put together in their right
order.
7) For each of the three clinical pictures, discuss and write down the tests or
investigations which would help to confirm the diagnosis.
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Clinical simulation
Scenario 2
Key Reactions/Responses



Mrs. G. is 16 years old and is 37 weeks
pregnant. This is her first pregnancy. She has
presented to the labor unit with contractions
and says that she has had a bad headache all
day. She also says that she cannot see
properly. While she is getting up from the
examination table she falls back onto the
pillow and begins to have a convulsion.
1. What will you do?





Discussion Question 1: What would you do
if there was no magnesium sulfate in the
hospital?
Expected Response: Use diazepam 10 mg slowly
over 2 minutes.

After 5 minutes, Mrs. G. is no longer
convulsing. Her diastolic blood pressure is
110 mm Hg and her respiration rate is 20
breaths/minute.
2. What is Mrs. G.’s problem?
3. What will you do next?
4. What should the aim be with respect to
controlling Mrs. G.’s blood pressure?
5. What other care does Mrs. G. require
now?





50
Shouts for help to urgently mobilize all available
personnel
Checks airway to ensure that it is open, and turns
Mrs. G. onto her left side
Protects her from injuries (fall) but does not
attempt to restrain her
Has one of the staff members who responded to
her shout for help take Mrs. G.’s vital signs
(temperature, pulse, blood pressure and
respiration rate) and check her level of
consciousness, color and temperature of skin
Has another staff member start oxygen at 4–6
L/minute
Prepares and gives magnesium sulfate 20%
solution, 4 g IV over 5 minutes
Follows promptly with 10 g of 50% magnesium
sulfate solution, 5 g in each buttock deep IM
injection with 1 mL of 2% lignocaine in the same
syringe
At the same time, explains to the family what is
happening and talks to the woman as appropriate
States that Mrs. G.’s symptoms and signs are
consistent with eclampsia
Gives hydralazine 5 mg IV slowly every 5
minutes until diastolic blood pressure is lowered
to between 90–100 mm Hg
States that the aim should be to keep Mrs. G.’s
diastolic blood pressure between 90 mm Hg and
100 mm Hg to prevent cerebral hemorrhage
Has one of the staff assisting with the emergency
insertion of an indwelling catheter to monitor
urinary output and proteinuria
Has a second staff member start an IV infusion of
normal saline or Ringer’s lactate and draws blood
to assess clotting status using a bedside clotting
test
Maintains a strict fluid balance chart
Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Scenario 2
Key Reactions/Responses
Discussion Question 2: Would you give
additional hydralazine after the first dose?
Expected Response: Repeat hourly as needed, or
give 12.5 mg IM every 2 hours as needed.
After another 15 minutes, Mrs. G.’s blood
pressure is 94 mm Hg and her respiration
rate is 16 breaths/minute.

6. What will you do now?
It is now 1 hour since treatment was started
for Mrs. G. She is sleeping but is easily
roused. Her blood pressure is now 90 mm Hg
and her respiration rate is still 16
breaths/minute. She has had several more
contractions, each lasting less than 20
seconds.





Stays with Mrs. G. continuously and monitors
blood pressure, pulse, respiration rate, patella
reflexes and fetal heart
Checks whether Mrs. G. has had any further
contractions
Continues to monitor blood pressure, pulse,
respiration rate, reflexes and fetal heart
Monitors urine output and IV fluid intake
Monitors for the development of pulmonary
edema by auscultating lung bases for rales
Assesses Mrs. G.’s cervix to determine whether it
is favorable or unfavorable
7. What will you do now?
It is now 2 hours since treatment was started
for Mrs. G. Her blood pressure is still 90 mm
Hg and her respiration rate is still 16
breaths/minute. All other observations are
within expected range. She continues to sleep
and rouses when she has a contraction.
Contractions are occurring more frequently
but still last less than 20 seconds. Mrs. G.’s
cervix is 100% effaced and 3 cm dilated.
There are no fetal heart abnormalities.



Continues to monitor Mrs. G. as indicated above
States that membranes should be ruptured using
an amniotic hook or a Kocher clamp and labor
induced using oxytocin or prostaglandins
States that childbirth should occur within 12
hours of the onset of Mrs. G.’s convulsions
8. What will you do now?
9. When should childbirth occur?
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51
Learning guide: Management during and after an eclamptic
fit/seizure
Training facilitators or participants can use the following learning guide to gauge progress
while learning to administer magnesium sulfate and care for women receiving it.
Directions
Rate the performance of each step or task using the following rating scale:
1 = Performs the step or task completely and correctly.
0 = Unable to perform the step or task completely or correctly or the step/task was not
observed.
N/A (not applicable) = Step was not needed.
Learning guide: Management during and after an eclamptic fit/seizure
STEP/TASK
OBSERVATIONS
Immediate management during a convulsion
1. SHOUT FOR HELP to urgently mobilize available personnel.
2. Gather equipment (airway, suction, mask and bag, oxygen)
3. Airway: Turn the woman onto her left side to reduce the risk of
aspiration of secretions, vomit and blood.
4. Ensure the woman’s airway is open
5. Breathing: Assess breathing
6. If the woman is not breathing, begin resuscitation measures
7. Give oxygen at 4–6 L per minute by mask or cannulae.
8. Circulation: Evaluate pulse
9. If absent, initiate CPR and call arrest team
10. Protect her from injury but do not actively restrain.
Care after the convulsion
1. Aspirate the mouth and throat as necessary.
2. Encourage the woman to lie on her side to reduce the risk of
aspiration of secretions, vomit and blood.
3. Ensure the woman’s airway is open.
4. Observe color for cyanosis and need for oxygen
5. If available, contiinue oxygen at 4–6 L per minute by mask or
cannulae.
6. Check for aspiration: Lungs should always be auscultated after the
convulsion has ended
7. Check vital signs and fetal heart rate
8. Start an intravenous of normal saline or Ringer’s lactate, if not yet
started
9. Give anticonvulsive drugs (see Learning Guide for administering
magnesium sulfate), if not yet started or due
10. If diastolic blood pressure remains above 110 mm Hg, give
antihypertensive drugs, if not yet started or due
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Facilitator’s Guide
Learning guide: Management during and after an eclamptic fit/seizure
STEP/TASK
OBSERVATIONS
11. Insert an indwelling urinary catheter to monitor urine output and
proteinuria, if one has not yet been placed
12. Do a bedside clotting test, if not yet done
13. Never leave the woman alone. A convulsion followed by aspiration
of vomit may cause death of the woman and fetus.
14. Check for signs of labor (see Learning Guide for vaginal examination
of a pregnant woman)
15. If this was the woman’s first convulsion and eclampsia has not yet
been diagnosed, make a differential diagnosis.
16. Provide specific management based on diagnosis. A small proportion
of women with eclampsia have normal blood pressure. Treat all
pregnant/postpartum women with convulsions as if they have
eclampsia until another diagnosis is confirmed
17. Record drug administration and findings on the woman’s record.
Share findings with the woman
1. Share your findings with the woman and, as appropriate, her partner
or family member
2. Discuss any complications / problems detected:
 Complications / problems
 Possible cause(s)
3. Explain management, based on diagnosis, and the importance for
pregnancy, labor, and delivery
4. If the woman has to be referred, explain the need for referral
5. Check the woman’s understanding of findings and next steps and
answer any questions.
6. Inform the family that the woman should never be left alone.
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Prevention and management of pre-eclampsia and eclampsia
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Facilitator’s Guide
Birth preparedness and complication readiness
Source: JHPIEGO/MNH. Birth Preparedness and Complication Readiness. Baltimore, MD:
JHPIEGO/MNH, 2001.
Summary of the session
When delays occur in recognizing problems and referring women to appropriate health care
facilities, the result can lead to maternal and newborn deaths. One solution to combat these
problems is to work with the pregnant woman and her family to develop two plans: a birthpreparedness plan and a complication-readiness plan.
Because all pregnancies carry risks, providers must work with all pregnant women and their
families to develop a birth-preparedness plan. This planning helps women receive highquality, timely care for both normal and complicated pregnancy, labor, and childbirth. The
following topic provides information on developing a birth-preparedness plan (BPP) and a
complication-readiness plan (CRP).
Learning objectives for the session
At the end of the session, participants will be able to:

List elements of the birth preparedness plan

List elements of the complication-readiness plan.
Estimated time: 75 minutes
Learning outline for the session
CONTENT
ACTIVITIES
MATERIALS/RESOURCES
Learning Objective 1: List elements of the birth preparedness plan
 Elements of a birthpreparedness plan
Activities:
Reference Manual
 Lecture
 Discussion
 Brainstorming
Presentation Graphics: Birth preparedness and
complication readiness
Learning Objective 2: List elements of the complication-readiness plan
 Elements of a
complication- readiness
plan
Activities:
Reference Manual




Presentation Graphics: Birth preparedness and
complication readiness
Lecture
Discussion
Brainstorming
Role play
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Facilitator’s Guide
Pre- and mid-course questionnaires
Pre-course knowledge assessment questionnaire
Instructions: Read each statement and then decide if it is TRUE or FALSE. Circle either
“True” or “False”.
Understanding pre-eclampsia
1. Eclampsia can occur during the antepartum, intrapartum, and postpartum periods.
True / False
2. Pre-eclampsia and/or eclampsia can usually be predicted using risk factors.
True / False
Identifying pre-eclampsia
3. A woman's urine may test positive for protein if the urine has been contaminated by
vaginal discharge.
True / False
4. The BP measure may be inaccurate if the woman’s legs are dangling off the table when
BP is measured.
True / False
5. A small proportion of women with eclampsia have normal blood pressure.
True / False
6. The difference between a diagnosis of gestational hypertension and pre-eclampsia is the
presence of proteinuria.
True / False
7. Elevated blood pressure and proteinuria in pregnancy define acute pyelonephritis.
True / False
8. Pulmonary edema in a woman who has pre-eclampsia is considered a sign of heart
failure.
True / False
Prevention
9. The drug of choice for preventing and treating convulsions in severe pre-eclampsia and
eclampsia is diazepam.
True / False
10. Primary prevention is difficult to achieve for pre-eclampsia because the cause is not well
understood and most factors associated with it are difficult to avoid or manipulate.
True / False
Prevention and management of pre-eclampsia and eclampsia
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Management of pre-eclampsia and eclampsia
11. A woman who has gestational hypertension should have her blood pressure, urine for
protein, and fetal condition monitored once a month.
True / False
12. Women with mild pre-eclampsia should not receive anticonvulsive and antihypertensive
therapy
True / False
13. Diazepam should only be given if magnesium sulfate is not available.
True / False
14. Repeat administration of magnesium sulfate may be given if respiratory rate is greater
than 16 /minute, patellar reflexes are absent, and urine output has been approximately
30 mL/hour over the preceding 4-hour period.
True / False
15. Anticonvulsive therapy for severe pre-eclampsia or eclampsia should be discontinued
immediately after childbirth.
True / False
16. A G1P0 15 year old women, at 24 weeks gestation, should be given an antihypertensive
drug if diastolic blood pressure is 102 mm Hg.
True / False
17. The goal of antihypertensive therapy for severe pre-eclampsia or eclampsia is to keep
the diastolic blood pressure below 80 mm Hg
True / False
Management of convulsions / fits
18. The most probable diagnosis for a pregnant woman presenting with convulsions,
headache, chills/rigor, muscle/joint pain, anemia, and diastolic blood pressure of 90 mm
Hg or more is eclampsia.
True / False
19. Treat all pregnant/postpartum women with convulsions as if they have eclampsia until
another diagnosis is confirmed.
True / False
Birth preparedness and complication readiness
20. Developing a birth preparedness and complication readiness plan will not improve
maternal and perinatal outcomes due to health service factors.
True / False
Name: ______________________________________
Score: _____/ 20 = ______%
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Facilitator’s Guide
Key: Pre-course knowledge assessment questionnaire
Understanding pre-eclampsia
1. Eclampsia can occur during the antepartum, intrapartum, and postpartum periods.
True
2. Pre-eclampsia and/or eclampsia can usually be predicted using risk factors.
False
Identifying pre-eclampsia
3. A woman's urine may test positive for protein if the urine has been contaminated by
vaginal discharge.
True
4. The BP measure may be inaccurate if the woman’s legs are dangling off the table when
BP is measured.
True
5. A small proportion of women with eclampsia have normal blood pressure.
True
6. The difference between a diagnosis of gestational hypertension and pre-eclampsia is the
presence of proteinuria.
True
7. Elevated blood pressure and proteinuria in pregnancy define acute pyelonephritis.
False
8. Pulmonary edema in a woman who has pre-eclampsia is considered a sign of heart
failure.
False
Prevention
9. The drug of choice for preventing and treating convulsions in severe pre-eclampsia and
eclampsia is diazepam.
False
10. Primary prevention is difficult to achieve for pre-eclampsia because the cause is not well
understood and most factors associated with it are difficult to avoid or manipulate.
True
Management of pre-eclampsia and eclampsia
11. A woman who has gestational hypertension should have her blood pressure, urine for
protein, and fetal condition monitored once a month.
False
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12. Women with mild pre-eclampsia should not receive anticonvulsive and antihypertensive
therapy
True
13. Diazepam should only be given if magnesium sulfate is not available.
True
14. Repeat administration of magnesium sulfate may be given if respiratory rate is greater
than 16 /minute, patellar reflexes are absent, and urine output has been approximately
30 mL/hour over the preceding 4-hour period.
False
15. Anticonvulsive therapy for severe pre-eclampsia or eclampsia should be discontinued
immediately after childbirth.
False
16. A G1P0 15 year old women, at 24 weeks gestation, should be given an antihypertensive
drug if her diastolic blood pressure is 102 mm Hg.
False
17. The goal of antihypertensive therapy for severe pre-eclampsia or eclampsia is to keep
the diastolic blood pressure below 80 mm Hg
False
Management of convulsions / fits
18. The most probable diagnosis for a pregnant woman presenting with convulsions,
headache, chills/rigor, muscle/joint pain, anemia, and diastolic blood pressure of 90 mm
Hg or more is eclampsia.
False
19. Treat all pregnant/postpartum women with convulsions as if they have eclampsia until
another diagnosis is confirmed.
True
Birth preparedness and complication readiness
20. Developing a birth preparedness and complication readiness plan will not improve
maternal and perinatal outcomes due to health service factors.
True
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Mid-course knowledge assessment questionnaire
Instructions: Circle the letter of the single best answer to each question.
Understanding pre-eclampsia
1. Eclampsia can occur during :
a) the antepartum period
b) the intrapartum period
c) the postpartum periods
d) only A and B
e) all of the above
2. Pre-eclampsia and/or eclampsia:
a) can be predicted if women’s risk factors are identified during pregnancy
b) may occur in women who have no risk factors
c) can be predicted if a thorough history is taken when the woman comes to the
health facility in labor
d) can be predicted by experienced skilled birth attendants
Identifying pre-eclampsia
3. A woman's urine can test positive for protein if:
a) she is severely anemic
b) she has kidney disease
c) has pre-eclampsia or eclampsia
d) the urine has been contaminated by vaginal discharge
e) all of the above
f)
only C and D
4. Which of the following may cause an inaccurate blood pressure measure:
a) The woman’s legs are dangling off the table
b) The woman smoked a cigarette 10 minutes before getting her BP checked
c) The length of the bladder on the BP measuring device is 80 percent of the
circumference of the upper arm
d) The woman’s sleeves are loose
e) all of the above
f)
only A and B
5. Hypertension in pregnancy can be associated with
a) headaches and blurred vision
b) convulsions and loss of consciousness
c) protein in the urine
d) all of the above
Prevention and management of pre-eclampsia and eclampsia
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6. Diastolic blood pressure 90 mm Hg or more before 20 weeks of gestation without
proteinuria is symptomatic of
a) mild pre-eclampsia
b) chronic hypertension
c) superimposed mild pre-eclampsia
d) gestational hypertension
7. Elevated blood pressure and proteinuria in pregnancy define
e) pre-eclampsia
f)
chronic hypertension
g) pyelonephritis
h) none of the above
8. Pulmonary edema in a woman who has pre-eclampsia should be considered a sign of
a) tuberculosis
b) heart failure
c) severe pre-eclampsia
d) pneumonia
Prevention
9. The drug of choice for preventing and treating convulsions in severe pre-eclampsia and
eclampsia is
a) diazepam
b) hydralazine
c) magnesium sulfate
d) labetolol
10. The following is/are recommended for secondary prevention of pre-eclampsia and/or
eclampsia
a) Calcium 1 G daily from 12 weeks gestation until birth
b) 75-150 of aspirin daily from 12 weeks gestation until birth
c) Checking BP at every antenatal and postnatal visit
d) All of the above
e) Only A and B
Management of pre-eclampsia and eclampsia
11. A woman who has gestational hypertension should have her blood pressure, urine for
protein, and fetal condition monitored
a) weekly
b) every 2 weeks
c) every 3 weeks
d) once a month
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12. The management of mild pre-eclampsia should include
a) anticonvulsive and antihypertensive therapy
b) sedatives and tranquilizers
c) sedatives only
d) no anticonvulsive and antihypertensive medications
13. The loading dose of magnesium sulfate is given via
a) IV over 5 minutes, followed by deep im injection into each buttock
b) IV over 5 minutes, followed by deep IM injection into one buttock
c) simultaneous IV and IM injections
d) IV bolus, followed by deep IM injection into each buttock
14. Repeat administration of magnesium sulfate should be withheld if
a) respiratory rate is 18/minute, patellar reflexes are 1+, urinary output is 250 mL
over the preceding 4-hour period
b) respiratory rate is 20/minute, patellar reflexes are 2+, urinary output is 180 mL
over the preceding 4-hour period
c) the woman is breastfeeding
d) respiratory rate is 18/minute, patellar reflexes are absent, urinary output is 100
mL over the preceding 4-hour period
15. Anticonvulsive therapy for severe pre-eclampsia or eclampsia should be
a) discontinued immediately after childbirth
b) discontinued immediately before childbirth
c) maintained for 12 hours after childbirth or the last convulsion, whichever occurs
last
d) maintained for 24 hours after childbirth or the last convulsion, whichever occurs
last
16. An antihypertensive drug should be given for hypertension in severe pre-eclampsia or
eclampsia if diastolic blood pressure is
a) between 80 mm Hg and 90 mm Hg
a) between 90 mm Hg and 100 mm Hg
b) between 100 and 110 mm Hg
c) 110 mm Hg or more
17. The goal of antihypertensive therapy for severe pre-eclampsia or eclampsia is to keep
the diastolic blood pressure
b) below 70 mm Hg
c) below 80 mm Hg
d) between 80 mm Hg and 90 mm Hg
e) between 90 mm Hg and 100 mm Hg
Prevention and management of pre-eclampsia and eclampsia
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Management of convulsions / fits
18. The presenting signs and symptoms of eclampsia include
a) convulsions, diastolic blood pressure of 90 mm Hg or more after 20 weeks
gestation and proteinuria of 2+ or more
b) convulsions, headache, stiff neck, fever, photophobia, drowsiness, diastolic blood
pressure of 90 mm Hg or more
c) convulsions, headache, chills/rigor, muscle/joint pain, anemia, and diastolic blood
pressure of 90 mm Hg or more
d) none of the above
19. If a pregnant woman presents with convulsions / fits and a BP of 142/78, when will you
give her magnesium sulfate?
a) Immediately
b) Only after eclampsia has been diagnosed
c) After performing a thick drop blood slide to rule-out complicated malaria
d) none of the above
Birth preparedness and complication readiness
20. Developing a birth preparedness and complication readiness plan could improve
outcomes by addressing:
a) Maternal factors influencing maternal and perinatal outcomes
b) Community factors influencing maternal and perinatal outcomes
c) Health service factors influencing maternal and perinatal outcomes
d) None of the above
e) Only A and B
Name: ______________________________________
Score: _____/ 20 = ______%
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Prevention and management of pre-eclampsia and eclampsia
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Key: Mid-course knowledge assessment questionnaire
Some questions were copied from:
http://www.reproline.jhu.edu/english/2mnh/2mcpc/5_Learning_Pkg/C_05_Headaches_etc/
05-KAQ-KEY.htm
Instructions: Circle the letter of the single best answer to each question.
Understanding pre-eclampsia
1. Eclampsia can occur during :
a) the antepartum period
b) the intrapartum period
c) the postpartum periods
d) only A and B
e) ALL OF THE ABOVE
2. Pre-eclampsia and/or eclampsia:
a) can be predicted if women’s risk factors are identified during pregnancy
b) MAY OCCUR IN WOMEN WHO HAVE NO RISK FACTORS
c) can be predicted if a thorough history is taken when the woman comes to the
health facility in labor
d) can be predicted by experienced skilled birth attendants
Identifying pre-eclampsia
3. A woman's urine can test positive for protein if:
a) she is severely anemic
b) she has kidney disease
c) has pre-eclampsia or eclampsia
d) the urine has been contaminated by vaginal discharge
e) ALL OF THE ABOVE
f)
only C and D
4. Which of the following may cause an inaccurate blood pressure measure:
a) The woman’s legs are dangling off the table
b) The woman smoked a cigarette 10 minutes before getting her BP checked
c) The length of the bladder on the BP measuring device is 80 percent of the
circumference of the upper arm
d) The woman’s sleeves are loose
e) all of the above
f)
ONLY A AND B
5. Hypertension in pregnancy can be associated with
e) headaches and blurred vision
f)
convulsions and loss of consciousness
g) protein in the urine
h) ALL OF THE ABOVE
Prevention and management of pre-eclampsia and eclampsia
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6. Diastolic blood pressure 90 mm Hg or more before 20 weeks of gestation without
proteinuria is symptomatic of
a) mild pre-eclampsia
b) CHRONIC HYPERTENSION
c) superimposed mild pre-eclampsia
d) gestational hypertension
7. Elevated blood pressure and proteinuria in pregnancy define
a) PRE-ECLAMPSIA
b) chronic hypertension
c) pyelonephritis
d) none of the above
8. Pulmonary edema in a woman who has pre-eclampsia should be considered a sign of
a) tuberculosis
b) heart failure
c) SEVERE PRE-ECLAMPSIA
d) pneumonia
Prevention
9. The drug of choice for preventing and treating convulsions in severe pre-eclampsia and
eclampsia is
a) diazepam
b) hydralazine
c) MAGNESIUM SULFATE
d) labetolol
10. The following are recommended for secondary prevention of pre-eclampsia and/or
eclampsia
a) Calcium 1 G daily from 12 weeks gestation until birth
b) 75-150 of aspirin daily from 12 weeks gestation until birth
c) CHECKING BP AT EVERY ANTENATAL AND POSTNATAL VISIT
d) All of the above
e) Only A and B
Management of pre-eclampsia and eclampsia
11. A woman who has gestational hypertension should have her blood pressure, urine for
protein, and fetal condition monitored
a) WEEKLY
b) every 2 weeks
c) every 3 weeks
d) once a month
12. The management of mild pre-eclampsia should include
a) anticonvulsive and antihypertensive therapy
b) sedatives and tranquilizers
c) sedatives only
d) NO ANTICONVULSIVE AND ANTIHYPERTENSIVE MEDICATIONS
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Prevention and management of pre-eclampsia and eclampsia
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13. The loading dose of magnesium sulfate is given via
a) IV OVER 5 MINUTES, FOLLOWED BY DEEP IM INJECTION INTO EACH
BUTTOCK
b) IV over 5 minutes, followed by deep IM injection into one buttock
c) simultaneous IV and IM injections
d) IV bolus, followed by deep IM injection into each buttock
14. Repeat administration of magnesium sulfate should be withheld if
a) respiratory rate is 18/minute, patellar reflexes are 1+, urinary output is 250 mL
over the preceding 4-hour period
b) respiratory rate is 20/minute, patellar reflexes are 2+, urinary output is 180 mL
over the preceding 4-hour period
c) the woman is breastfeeding
d) RESPIRATORY RATE IS 18/MINUTE, PATELLAR REFLEXES ARE ABSENT,
URINARY OUTPUT IS 100 ML OVER THE PRECEDING 4-HOUR PERIOD
15. Anticonvulsive therapy for severe pre-eclampsia or eclampsia should be
a) discontinued immediately after childbirth
b) discontinued immediately before childbirth
c) maintained for 12 hours after childbirth or the last convulsion, whichever occurs
last
d) MAINTAINED FOR 24 HOURS AFTER CHILDBIRTH OR THE LAST
CONVULSION, WHICHEVER OCCURS LAST
16. An antihypertensive drug should be given for hypertension in severe pre-eclampsia or
eclampsia if diastolic blood pressure is
a) between 80 mm Hg and 90 mm Hg
d) between 90 mm Hg and 100 mm Hg
e) between 100 and 110 mm Hg
f)
110 MM HG OR MORE
17. The goal of antihypertensive therapy for severe pre-eclampsia or eclampsia is to keep
the diastolic blood pressure
a) below 70 mm Hg
b) below 80 mm Hg
c) between 80 mm Hg and 90 mm Hg
d) BETWEEN 90 MM HG AND 100 MM HG
Management of convulsions / fits
18. The presenting signs and symptoms of eclampsia include
a) CONVULSIONS, DIASTOLIC BLOOD PRESSURE OF 90 MM HG OR MORE
AFTER 20 WEEKS GESTATION AND PROTEINURIA OF 2+ OR MORE
b) convulsions, headache, stiff neck, fever, photophobia, drowsiness, diastolic blood
pressure of 90 mm Hg or more
c) convulsions, headache, chills/rigor, muscle/joint pain, anemia, and diastolic blood
pressure of 90 mm Hg or more
d) none of the above
Prevention and management of pre-eclampsia and eclampsia
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19. If a pregnant woman presents with convulsions / fits and a BP of 142/78, when will you
give her magnesium sulfate?
a) IMMEDIATELY
b) Only after eclampsia has been diagnosed
c) After performing a thick drop blood slide to rule-out complicated malaria
d) none of the above
Birth preparedness and complication readiness
20. Developing a birth preparedness and complication readiness plan could improve
outcomes by addressing:
a) Maternal factors influencing maternal and perinatal outcomes
b) COMMUNITY FACTORS INFLUENCING MATERNAL AND PERINATAL
OUTCOMES
c) Health service factors influencing maternal and perinatal outcomes
d) None of the above
e) Only A and B
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Administrative Documents
MCHIP: PREVENTON AND MANAGEMENT OF PREECLAMPSIA/ECLAMPSIA
Registration Form
General Information
Name______________________________________________________
Surname
Title: Mrs. ( ) Miss ( )
First
Ms. ( )
Mr. ( )
Middle
Dr. ( )
Sex: Male____ Female_____
Contact Address _______________________________________________
____________________________________________________________
Home or mobile telephone_______________ E-mail________________
Place of work ________________________________________________
Address____________________________________________________
Telephone__________________
Work E-mail__________________
Professional Qualification
Please tick all that apply
Registered Nurse____
Registered Midwife____
Public Health Nurse____
Obstetrical Nurse ____
Obstetrician/Gynecologist____ Physician____
Clinical Officer______
Medical Assistant____
Other (please specify) _________________________________________
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Prevention and Management of Pre-Eclampsia/Eclampsia
Training Registration Form
- Page 2 Job Title/Designation ______________________________________
Position _____________________
Primary Responsibility
Clinical teaching___________
Clinical practice________
Administration_________
Other (please specify) ___________________________________________
Main area of clinical work or teaching (tick the area where you
spend most of your time as a provider or tutor/facilitator)
Antenatal clinic___________
Labor ward________
Postpartum ward_______
Family planning clinic_________
Other (please specify) _______________________
Number of births you have attended in the last 3 months:
None ( )
0-10 births ( )
11-20 births ( )
>20 births ( )
Experience with managing cases of pre-eclampsia/eclampsia
Previous training in prevention and management of PE/E: Yes ( ) No ( )
If yes: Date of training: ______/______ (mm/yyyy)
Organization that provided training:
Pre-Service Education ( ) MOH ( ) NGO ( ) UNICEF ( )
UNFPA ( ) Other (please specify) _____________ ( )
Number of times you have provided magnesium sulfate: Never provided ( )
0-10 times ( ) 11-20 times ( ) >20 times ( )
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Prevention and management of pre-eclampsia and eclampsia
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Training report form
Training Dates: ___/___/___–___/___/___
Knowledge
Assessment
Place of work
Prevention and management of pre-eclampsia and eclampsia
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PreCourse
Final
Care for
women during
and after a
convulsion /
fit
Profession
Evaluation of
dBP 90-110
Name
Skill Assessment
Care for
women with
severe preeclampsia /
eclampsia
Administering
magnesium
sulfate
Participants and Results
71
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References
World Health Organization (WHO) Mother-Baby Package: Implementing Safe Motherhood in Countries.
WHO/FHE/MSM/94.11. Geneva: WHO; 1994.
1
AbouZahr C. Antepartum and postpartum haemorrhage. In: Murray CJL, Lopez AD, eds. Health Dimensions of Sex
and Reproduction. Boston, MA: Harvard University Press; 1998:165–190.
2
Stephenson P. Active Management of the Third Stage of Labor: A Simple Practice to Prevent Postpartum
Hemorrhage. USAID Global Health Technical Brief. June 2005. MAQ website. Available at:
http://www.maqweb.org/techbriefs/tb13activemgmt.shtml. Accessed April 2, 2007.
3
World Health Organization (WHO). Biennial Report 2000–2001: Research on Reproductive Health at WHO.
Geneva: WHO; 2002. Available at: http://www.who.int/reproductive-health/publications/
biennial_reports/2000-01/Chapter_2.PDF. Accessed April 2, 2007.
4
Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus
physiological management of the third stage of labour. British Medical Journal. 1988;297:1295–1300.
5
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