Situation: A nurse works at a Rural Health Unit (RHU) that provides prenatal care, a birthing facility, and a clinic for sick young infants. A 26-year-old woman at 34 weeks of gestation comes in with a severe headache and blurred vision. Her blood pressure is 164/112 mmHg on two readings 15 minutes apart, and she has not had a convulsion. The RHU physician is away, and the nearest physician is at the referral hospital, 1 hour away. The nurse is trained and certified to give emergency obstetric drugs under DOH protocols. Which action is BEST?

Severe-range blood pressure with a severe headache and blurred vision points to pre-eclampsia with severe features, which needs urgent referral to a hospital with comprehensive emergency obstetric care. Referral is not a reason to go without treatment: the woman is stabilized first. Under the Responsible Parenthood and Reproductive Health Act (RA 10354), a trained and certified nurse may give a lifesaving drug such as magnesium sulfate in an emergency when no physician is available, so the nurse gives the loading dose to prevent eclampsia and then refers her without delay. Her severe-range blood pressure also needs an antihypertensive, given by physician order or the facility's standing protocol, before or during transfer.

Clinical situation
A pregnant woman at 34 weeks of gestation presents with a severe headache, blurred vision, and blood pressure of 164/112 mmHg on two readings 15 minutes apart. She has not convulsed. These findings meet the criteria for pre-eclampsia with severe features, a condition that can progress rapidly to eclampsia and maternal death if untreated.

Why the correct action is to give magnesium sulfate first, then refer
The best action is to administer the magnesium sulfate loading dose and then refer urgently. Severe-range hypertension combined with neurological symptoms indicates that seizure risk is high. Referral without stabilization leaves the woman unprotected during the one-hour transport, when an eclamptic convulsion could occur. Magnesium sulfate is the drug of choice for preventing eclampsia in severe pre-eclampsia, and its benefit is greatest when given before a seizure develops.

The legal basis in the Philippines supports this action. Under the Responsible Parenthood and Reproductive Health Act (RA 10354), a nurse who is trained and certified in emergency obstetric drug administration may give a lifesaving drug such as magnesium sulfate when no physician is available. The nurse in this scenario has that certification, so giving the loading dose is within scope of practice and is not a delay of care.

Magnesium sulfate: mechanism and clinical role
Magnesium sulfate is a central nervous system depressant that raises the seizure threshold and blocks neuromuscular transmission. In severe pre-eclampsia, it reduces the risk of progression to eclampsia. The Pritchard regimen is a widely used intramuscular protocol: a loading dose of 14 g (10 g IM plus 4 g IV), followed by maintenance doses of 5 g IM every 4 hours. In resource-limited primary care settings, a simplified 10 g IM loading dose has also been studied as a practical alternative when IV access or close monitoring is limited.

The evidence supports using a loading dose even before transfer. A study in Northwest Nigeria compared a 10 g IM loading dose with the standard 14 g Pritchard loading dose in women with severe pre-eclampsia or eclampsia. The primary outcomes included occurrence of fits, further fits, and maternal death. The findings suggested that the 10 g IM loading dose could be considered for use at the primary health level, which is directly relevant to a rural health unit setting ^[2][3]. This supports the principle that a loading dose given before referral provides seizure prophylaxis during transport, which is the highest-risk window for deterioration.

A cohort study in Uganda also examined magnesium sulfate administration patterns in women with pre-eclampsia with severe features. The study reinforced that magnesium sulfate is used to prevent eclampsia and to treat women who have already convulsed, with the goal of avoiding severe maternal and infant illness and death ^[4]. This aligns with the priority of preventing the first seizure rather than waiting for one to occur.

Why the other options are incorrect

Option	Problem
1. Refer at once, giving no drug on the way	Leaves the woman unprotected during a one-hour transport. Seizure risk remains high, and an eclamptic fit in transit is dangerous and difficult to manage.
2. Recheck blood pressure in 4 hours before deciding	Delays care for a condition that can deteriorate within minutes to hours. Severe-range blood pressure with neurological symptoms is already an emergency.
3. Start magnesium sulfate and keep her at the RHU until it settles	Magnesium sulfate prevents seizures but does not treat the underlying pre-eclampsia or the severe hypertension. Definitive care requires delivery and comprehensive emergency obstetric care, which the RHU cannot provide.
4. Give the magnesium sulfate loading dose, then refer urgently	Correct. Stabilizes the woman with seizure prophylaxis before transfer, then ensures she reaches a facility with comprehensive emergency obstetric care.

Key point! In severe pre-eclampsia, the priority is to prevent the first seizure with magnesium sulfate, not to wait for convulsions to begin. Referral and stabilization are not competing actions; they are sequential steps in the same emergency response.

Watch out! Magnesium sulfate prevents eclampsia but does not lower blood pressure. The severe-range blood pressure of 164/112 mmHg also requires an antihypertensive, given by physician order or the facility’s standing protocol, before or during transfer. Both interventions are part of stabilizing the woman for safe referral.

Nursing implications for the referral process
Before transfer, the nurse should confirm that magnesium sulfate has been given, monitor vital signs and deep tendon reflexes, assess respiratory rate and urine output, and ensure a patent IV line if available. Calcium gluconate should be available as an antidote for magnesium toxicity. During transport, the woman should be positioned to prevent aspiration if a seizure occurs, and the receiving facility should be notified in advance so that definitive care can begin immediately upon arrival ^[1][4].