Pre-eclampsia and high blood pressure in pregnancy
Making decisions about labour, induction and birth
Pre-eclampsia or HELLP syndrome can affect how long a pregnancy lasts and decisions about labour and birth. These decisions depend on lots of factors, such as when the condition starts and how severe it becomes. The impact varied greatly for those people we spoke to; sometimes the mother was very ill and her baby needed delivering prematurely, other times the condition was controlled and it had little impact on the progress of her pregnancy.
For women diagnosed with pre-eclampsia or HELLP syndrome, doctors usually explained that the only way to stop the condition getting more serious was to deliver the baby and the placenta connecting mother and baby. This often meant cutting the pregnancy short if it looked like the pregnant woman or her unborn baby were becoming extremely unwell. Kate had HELLP syndrome and initially thought she would have to put up with her severe epigastric pain until her due date, before she realised her baby would be born early. Kay’s consultant was very direct about the fact that, in an emergency situation, she would need a caesarean or otherwise “you could die”.
The situation changed quickly for Samantha X – she went from expecting to stay in hospital for many weeks to being told she would need a caesarean section very soon.
The situation changed quickly for Samantha X – she went from expecting to stay in hospital for many weeks to being told she would need a caesarean section very soon.
Betty had to sign forms consenting to her caesarean section, but she also felt there were no alternatives and that she was not in the best frame of mind to process information.
Betty had to sign forms consenting to her caesarean section, but she also felt there were no alternatives and that she was not in the best frame of mind to process information.
Well I don’t think there were any options. It was get baby out as soon as possible. They were trying to gauge the approach to take to get baby out. We weren’t given the option not to do it, only forms to consent to doing what needed to be done.
So I didn’t think there were any options but I can't imagine myself ever saying, "No, don’t do that," because obviously the risk is that the baby's going to die.
And what was the role of your husband in all this? So, it must be a very challenging situation?
Yes, yes. He did ask about the blood pressure; what should it be. He kept a very close eye on it. He would answer a lot of the questions on my behalf and I'd correct him [laughs]. He didn’t actually look at the consent papers I don’t think, that was given to me which is right but equally I don’t think I was really in the right position to sort of digest it properly, but at the same time what options what are there? They can't… my husband shouldn’t be reading and signing on my behalf, and unless I didn’t want to go ahead with it there was little option other than to sign it. Dr Khan explains that doctors and midwives must balance different risks and benefits when advising women with pre-eclampsia about birth.
Dr Khan explains that doctors and midwives must balance different risks and benefits when advising women with pre-eclampsia about birth.
For some women, serious problems with pre-eclampsia or HELLP syndrome meant that babies born prematurely could be very unwell and unable to survive at such a young age. As Kay explained, having pre-eclampsia from 25 weeks into her pregnancy meant lots of extra risks for her baby compared to if she had developed it in the last few weeks before the due date. Some women met with a paediatrician or neonatologist who helped explain the impact and long-term prospects for babies born early. Women said this was really important to help them and their partners know more about what lay ahead – although, as Josie said, “nothing really prepares you” for the real thing.
But, having pre-eclampsia does not mean that a woman will definitely have her baby early or that the baby will be very poorly. Some women we spoke to had reached full term (9 months [40 weeks]) and a few had been overdue.
When women are ill, decisions have to be made about how long it is safe to keep a pregnancy going. This can be a balance between, firstly, giving the unborn baby more time to grow and, secondly, delivering the baby before the health problems become very dangerous and potentially fatal for both mother and baby. Of the women we talked to who had been in this situation, they were usually already staying in the hospital and being monitored for signs of a shift in this balance. Julie gave birth at 41 weeks and thought the situation might have escalated less if she had been induced earlier.
Josie thought there was a balance of risks in the run-up to her caesarean section. She had recently had an injection to prevent clotting, which meant delaying the operation.
Josie thought there was a balance of risks in the run-up to her caesarean section. She had recently had an injection to prevent clotting, which meant delaying the operation.
I think that again, you know I just wonder about those decisions that were made at the time about [son’s name] welfare and my welfare, and whether they were having to… having to balance somehow the fact that I was needing this blood clotting thing to work. Had they given me blood clotting… probably I can't remember, I don’t know. That they were, you know just waiting for my blood count to rise was it? My blood count to rise, something, I can't… again I can't remember the technical aspects of it. And that was what was actually holding it up in the end. So, I was having, you know consent forms put at me; I had something in my arm here and something in my arm… you know it was literally… it was so much happening and I was on my own – it was… you know I'd had a lot of friends and family visiting all the time but here I was just on my own surrounded by a lot of doctors, a lot of nurses, a lot of midwives.For Kay, seeing the neonatal unit helped her come to terms with the situation. It was still a huge shock but she also found it reassuring that there was an incubator and neonatal nurses ready to look after her baby.
For Kay, seeing the neonatal unit helped her come to terms with the situation. It was still a huge shock but she also found it reassuring that there was an incubator and neonatal nurses ready to look after her baby.
And Imogen’s little incubator was sitting – it was a giraffe, it was empty – and it was sitting, just waiting on her, and I think that’s when it really hit me, I'm really ill. This…I'm not going full term with this baby.
I'm kidding myself that I am because I was in denial you know, I feel fine. But then I was like, 'This baby's coming early and this baby's going to be tiny,' and I'd seen the size of the incubator and I thought, 'Oh, oh my goodness she's… she is going to be tiny,' you know and it was quite frightening.
But they show you, and there was no tiny babies in the ward at the time, but they have different stages – you know they’ve got an intensive care and then a high dependency and a family kind environment, the room that’s next down, and then they’ve got individual rooms and then they’ve got… they have got a family room where you can go and see where baby in preparation for coming home. And they went through it all with me and a lot of it I didn’t take in because I was… I was very much in shock. And I was under the impression that babies born at 24… over 24 weeks they can live can't they, and they're like, "Yeah, but there is a lot of complications and a lot of them don’t." And I think the media, because you see so many success stories, you think everyone's a success and actually, no they're not.
And I didn’t know that, I was kind of kidding myself that she was going to be just fine.
Deciding factors in birth choices
Some women were induced and some others had a caesarean section as soon as it was decided their baby needed to be born. A few women we spoke to had naturally gone into labour. These decisions could be prompted by signs that the pregnancy was becoming very dangerous for mother and baby – the mother might have extremely high blood pressure or blood tests results showing a serious problem (e.g. very ‘off’ platelets for Paige and Helen X indicating risks of serious bleeding; severe liver problems for Tracey and Emma). Claire was induced when she started to feel very unwell, but then given a caesarean section when her condition deteriorated with an irregular heartbeat, blood poisoning and fluid on her lungs: “there was just a million and one things that they were just like ‘right, we’re not happy’”. How the illness might develop varies widely. So doctors advised women about when it would be best to deliver their baby at very different stages. While Mairi reached 39 weeks, Aileen in her second pregnancy had her baby at the end of 30 weeks.
It was often signs that their unborn baby was struggling (sometimes called fetal distress) which led to a decision that a caesarean section would be the safest course of action. Some of the women found out that their high blood pressure had caused the placenta to detach from the uterine wall (placental abruption). As Betty’s doctors explained, this is serious: “if they don’t get the baby out quickly enough there won't be enough oxygen”.
Tracey was frightened when the decision was suddenly made that she needed a caesarean section. She had a general anaesthetic and so she was asleep for the operation.
Tracey was frightened when the decision was suddenly made that she needed a caesarean section. She had a general anaesthetic and so she was asleep for the operation.
Horrific.
Their illness often meant women felt they lost control over birth options; this could be disappointing and frightening. While women had different preferences about the kind of birth they wanted (some had hoped for a vaginal delivery, including options such as water birth, and others had wanted a caesarean section), pre-eclampsia often meant that the reality of birth ended up being very different to what they had hoped for. Julie “was hoping for a natural water birth. I thought it was just going to all beautiful and lovely”. Mairi remembered asking her consultant if a water birth would be possible: “he looked at me in horror and said that there was no way I was going anywhere else other than a bed, and I remember thinking, 'It's a bit unfair,' but now I realise why”.
Lots of women said they had tried to keep an open mind about birth options, knowing that things may not go to plan. Aileen was happy to go with “whatever is best for my baby and for myself”. Betty’s preference had always been for a caesarean so she wasn’t “fazed” when she was told it would be. One consideration for some women was that a caesarean operation would mean that they could not drive for six weeks afterwards.
Dominie didn’t want to have a caesarean section as she knew she wouldn’t be able to drive for six weeks after the operation and this would make visiting her baby in hospital difficult. She opted for an induction and had a vaginal birth.
Dominie didn’t want to have a caesarean section as she knew she wouldn’t be able to drive for six weeks after the operation and this would make visiting her baby in hospital difficult. She opted for an induction and had a vaginal birth.
That I was the top priority and I was going to be the first on the section list. And they were kind of talking about it amongst themselves, and they said, "How do you feel about that?" and I said, "I don’t want to have a section." For me it was because I lived too far away.
And I knew that he was going to be in special care and I knew I wouldn’t be able to drive for six weeks, so how was… that was all going through my mind – how was I going to get in and out from hospital to see him. So, I begged and they agreed to induce me. So, the hospital that I work at we use a drug that you… it stays in the cervix for 24 hours and after 24 hours they take it out and then they kind of reassess. So, I was given four hours with this drug on the Friday morning. So, they put it in for four hours, and then they had obviously gone out of the room and had a discussion, and they decided that at that point my blood pressure was under control, and that they would see what the 24 hours would do. So, I was really pleased about that.
And I'm really pleased with my decision because then on the Saturday they took it out, they managed to break my waters and within about four hours I'd had him.
So, I do believe that if I wasn’t a midwife and I didn’t know what I was talking about, that I would have had a section regardless, which I think is major surgery for, you know someone of my age that isn’t… wasn’t… it wasn’t necessary. I mean, if my blood pressure was amazingly dangerous at that point, and they were really worried about him, I would have done; I would have done anything. But in my mind, and through discussion with the midwife I felt like I was… that was the right path to go down. But I had not been a midwife things could have been very different yeah.Hanna wanted the expert advice of the consultant she saw when she was first admitted to hospital. It was also helpful to talk to her mum about the options available.
Hanna wanted the expert advice of the consultant she saw when she was first admitted to hospital. It was also helpful to talk to her mum about the options available.
So, when I told my mum, she advised me against it and she said, “Go for natural birth. They’re there, the medical experts to help you and you, they wouldn’t give you those two options if they weren’t safe for the baby to be delivered naturally.” So I said, “I’d rather to have a natural birth.” So they said, “Okay. We’ll wait until the 35th week.”
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