Cases/Urgent & Unscheduled care

Headache and High Blood Pressure After Giving Birth — Free SCA Practice Case

Woman five days after giving birth with a headache and high blood pressure

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Try 5 free cases

Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Mairead Colquhoun

Age

30 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Urgent appointment requested by the patient.

Reason for Encounter

"I've had a bad headache since last night and my ankles are really swollen. I had the baby five days ago."

Medical Records

●PMH: Nil of note. Normal vaginal delivery of her second baby, five days ago. Antenatal blood pressures all within normal limits.
●Medications: Paracetamol as needed. Nothing regular.
●Allergies: NKDA.
●Social: Court clerk on maternity leave. Lives with partner and two children. Breastfeeding.

Recent Notes

●Community midwife home visit, this morning: BP 158/102. Pulse 84.

Patient Script

For the friend playing the patient role

Character Overview: You are Mairead Colquhoun, a 30 year old court clerk on maternity leave. Five days ago you had your second baby, Finlay, a straightforward vaginal birth with gas and air only. You live with your partner Euan, who works in IT support about 35 minutes away, and your daughter Ferne, who is 2. Your sister Ailsa lives 15 minutes away. You are exhausted, running on broken sleep, and used to being the one who copes. Since last night you have had a thumping headache and your ankles have swollen up. You assume it is tiredness and dehydration from feeding. A midwife visited this morning, took your blood pressure and said she would let the GP know, but you did not take in what the number meant. Above all you do not want to leave Finlay, who feeds every two hours and has never taken a bottle. You are polite, brisk and a little embarrassed to be bothering anyone. You speak quickly when you are worried and go quiet when someone suggests you are not coping.

Opening Sentence: "Hello, doctor. I'm sorry to ring, I know it's probably just tiredness, but I've had a horrible headache since last night and my ankles have blown up. I had my baby five days ago and the midwife said to speak to you."

History if Asked (Data Gathering Phase)

●The headache: "It started yesterday evening. It's across my forehead and behind my eyes, a heavy thumping. About seven out of ten. It's there all the time and I wake up with it. I took paracetamol this morning and it took the edge off for about an hour, then it came back."
●Previous headaches: "I don't get migraines. I get the odd tension headache when I'm tired, but nothing like this."
●Worse or better: "Bright light makes it a bit worse. Lying in a dark room helps a little but not much. Bending down makes it throb."
●Swelling: "My ankles and feet are puffy and my shoes won't go on. My hands feel tight and my wedding ring is snug. It's much worse than after Ferne."
●Vision: "This morning I had a few flickering spots for a minute or two, like when you look at a light and then away. It cleared. I didn't think much of it. My vision is fine now."
●Pain under the ribs, nausea, vomiting: "I've had a dull ache just under my ribs on the right since yesterday. I thought it was indigestion. I feel a bit queasy but I haven't been sick."
●The midwife's reading: "She said it was a bit high and wrote it down. I think she said one fifty something. She said she'd tell the GP."
●Blood pressure history: "It was always normal in pregnancy, even with Ferne. Nobody ever said anything about it."
●Delivery: "Finlay was born at 39 weeks and two days. It was quick. No epidural, only gas and air. I lost a bit of blood but not a lot, and we were home the next day."
●Bleeding, discharge, temperature: "The bleeding is like a heavy period and getting lighter. No clots bigger than a coin. It doesn't smell. I haven't felt feverish or shivery."
●Chest, breathing, legs: "No chest pain and no breathlessness. My legs are swollen on both sides but there's no one calf that's sore or red."
●Fits, weakness, speech, confusion: "No. Nothing like that. I'm tired but I know where I am and my speech is fine. No weakness or numbness."
●Feeding and baby: "I'm breastfeeding and it's going well. Finlay is feeding every two hours or so and has plenty of wet nappies. He won't take a bottle. We tried once and he screamed."
●Sleep and mood: "Maybe three hours broken sleep a night. My mood is okay, just tired and a bit teary. I'm not low and I'm not having dark thoughts."

Ideas, Concerns, Expectations

Gating note: Mairead does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks the headache is tiredness and dehydration from breastfeeding, and the swelling is fluid left over from the pregnancy. She wonders if the blood pressure reading was high because she was rushing about when the midwife called. "I'd just run upstairs with Ferne, so I thought that's why it was up."
●Concerns: Her main worry is being taken away from Finlay. She is afraid that he will not feed, that he will be left with a bottle he refuses, and that she will be kept in hospital. She also worries about Ferne, who has never been away from her overnight. Underneath she is a little frightened because her mother was told her blood pressure was raised after she had Mairead and was never followed up. "I can't leave him, he won't take a bottle. And Ferne has never been without me."
●Expectations: She hoped for stronger painkillers, or perhaps a water tablet for the swelling, and to be told to rest. She had not expected to be told to go anywhere. "I was hoping you could give me something for the headache and I'd put my feet up."

If Asked: Medical History and Medications

Gating note: Mairead answers each of these plainly when the doctor asks about it.

●Other health problems: "Nothing. I'm usually very healthy."
●Medicines: "Paracetamol, one gram, a couple of times since yesterday. I take nothing else, apart from vitamin D."
●Previous pregnancy: "Ferne's was normal. A normal delivery too, and my blood pressure was fine."
●Allergies: "None."
●Family history: "My mum says her blood pressure went up when she had me. Dad had a stroke at seventy. Nobody in the family has had fits or clots that I know of."
●Smoking and alcohol: "I've never smoked. I don't drink."

Social History and Lifestyle Impact

●Work: Court clerk at the local magistrates court, on maternity leave until next autumn.
●Home: Lives in a terraced house with Euan and the children. Euan went back to work three days ago and is in the office today. He can leave straight away if she rings him and be home in about 35 to 40 minutes. He has the car.
●Support: Her sister Ailsa lives 15 minutes away and has offered to help. She could take Ferne at short notice. Her mum lives two hours away.
●Transport: She has not driven since the birth and would not drive herself. The nearest maternity unit is 25 minutes away by car.
●Right now: Finlay is asleep in the next room and Ferne is watching television beside her. She is alone with both children until Euan returns.
●Availability: She can leave the house within the hour if she is told it matters and someone is with her.

If Asked: Associated Symptoms

Gating note: Mairead answers these only when asked. Every one is negative unless stated.

●If asked about calf pain, leg redness, or one leg more swollen than the other: "No. Both ankles are puffy but neither calf is sore."
●If asked about breathlessness, chest pain, or palpitations: "No. I'm just tired."
●If asked about fever, shivering, a painful breast, or foul discharge: "No."
●If asked about a spinal or epidural injection during labour: "No. I only had gas and air."
●If asked about neck stiffness, rash, or a headache that came on like a thunderclap: "No. It built up over a few hours yesterday evening."
●If asked about medicines or drugs that could raise blood pressure, such as anti inflammatory painkillers: "I haven't taken ibuprofen. I wasn't sure whether I could while feeding."

Responses to Management (The Negotiation Phase)

●
If the doctor explains that she needs to be seen at the maternity unit today:
- ●Reaction: Taken aback. "Today? Can't I just have something for the headache and come to the surgery tomorrow?" If the doctor explains clearly that the blood pressure together with the headache and swelling needs checking now, she goes quiet, then agrees. "Is it serious? I felt fine in my pregnancy." If the doctor is vague, she keeps trying to delay.
●
If the doctor discusses Finlay and breastfeeding:
- ●Reaction: Tearful. "He won't take a bottle. What if they keep me in?" She relaxes when told that Finlay can go with her, that she can keep feeding, and that the medicines used are compatible with breastfeeding. If told to leave him at home, she says: "I can't, he won't feed."
●
If the doctor asks how she will get there and who can help:
- ●Reaction: Practical. She gives the transport details and offers to ring Euan and Ailsa. "Euan can be here in about forty minutes. Do I wait for him?" If asked whether she should wait at home alone, she accepts that she should not, and asks whether to call an ambulance if she cannot get there safely. She agrees to arrange it so Euan takes her, with Ailsa collecting Ferne.
●
If the doctor explains what they are worried about:
- ●Reaction: Anxious. "So you think it could be something with my blood pressure after the birth? I thought that was just in pregnancy." If told it can happen after delivery and needs treating, she accepts. She asks what they will do there. "Will they give me tablets? Can I still feed?"
●
If the doctor offers painkillers or something to take now:
- ●Reaction: Relieved to be helped. "Can I take ibuprofen? I wasn't sure while feeding." She accepts advice about what to take and is reassured that the hospital team will decide on any treatment. "So I shouldn't just take extra paracetamol and wait?"
●
If the doctor gives safety netting while she arranges the journey:
- ●Reaction: Wants specifics. "What would make you call an ambulance?" She repeats back clearly when given specific symptoms, such as worsening vision, vomiting, a fit, chest pain or breathlessness, confusion or collapse, and what to do. If the safety netting is vague, she asks: "Worse how? It's already bad."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Mairead is five days after a normal delivery with a severe headache, new swelling, and a midwife reading of 158/102. She apologises for ringing, blames tiredness, and does not want to leave a breastfed baby who refuses a bottle. The station tests recognising postnatal pre eclampsia, not being reassured by a reading just under the severe threshold, and arranging same day assessment in a way a reluctant mother can accept.
●The model plan has six parts. Take a focused history that finds the visual symptoms and right upper abdominal pain and screens for other causes. Say clearly that this needs checking today. Arrange same day assessment in the maternity service and telephone ahead. Make sure she is accompanied and does not drive, with an ambulance if that is not possible. Advise that she takes Finlay and keeps feeding. Give specific safety netting and make sure someone confirms she was seen.
●Acceptable alternatives: referring directly to the maternity unit or obstetric team, or an in person check at the surgery that is followed immediately by referral, provided there is no delay. Calling an ambulance is appropriate if she cannot be accompanied promptly, if she worsens, or if the candidate judges the picture to be severe. Starting a tablet at home and waiting is not a safe plan.

Recognising Postnatal Pre Eclampsia

●Pre eclampsia is new hypertension after 20 weeks with proteinuria or another new feature such as severe headache, visual disturbance, epigastric pain, raised liver enzymes or low platelets. It can first appear or worsen after delivery, so a normal pregnancy blood pressure is no reassurance. NICE NG133 tells clinicians to ask women who have had pre eclampsia about severe headache and epigastric pain each time blood pressure is measured, because these are the warning features. NICE CKS (hypertension in pregnancy, revised January 2025) adds that suspected postpartum pre eclampsia, which can first appear up to 4 weeks after birth even with no earlier hypertension, should be admitted to hospital for immediate assessment, and lists a severe headache not relieved by regular analgesics, flashing lights or floating spots, persistent right upper quadrant pain and sudden swelling of the face, hands or feet as triggers.
●Mairead has several: a new thumping headache that paracetamol only briefly touches, flickering spots this morning, a dull ache under the right ribs, queasiness, and swelling of the hands as well as the ankles. Swelling alone is common after birth and means little; it counts here because it sits alongside the others.
●Her mother's raised blood pressure after her own birth is a small family risk marker. She has no major risk factor, which is a reminder that postnatal pre eclampsia is not confined to high risk women.

Why 158/102 Is Not Reassuring

●NICE NG133 defines severe hypertension as a systolic pressure over 160 or a diastolic over 110 mmHg, and says such women should be admitted and treated. A trap is to reason that 158/102 falls just below the line and can be watched. The threshold marks the level at which treatment must start immediately; it does not mark the point below which a woman with symptoms is safe.
●For women who have given birth and are not on treatment, NG133 advises starting antihypertensive treatment at 150/100 mmHg or higher. Her reading is above that, taken once by a midwife, and accompanied by symptoms that suggest evolving disease. Blood pressure can rise further over hours.
●A single reading can be affected by exertion, as Mairead suggests she had been running about. The answer is not to wait for a better number but to recheck under controlled conditions in a unit, where urine protein and blood tests can be done at the same visit.

Why Same Day Assessment Matters and What Happens Next

●Postnatal pre eclampsia can progress to eclampsia, stroke, liver and kidney injury, and pulmonary oedema. The risk is highest when severe headache and visual symptoms are present, which is why she needs measurement, urine testing and bloods today and not at a routine appointment.
●The assessing team will repeat her blood pressure, test for proteinuria and send blood tests including full blood count, liver function and renal function. NG133 asks for blood pressure to be measured at least four times a day while an inpatient and at least once between day 3 and day 5. Severe hypertension is treated with labetalol or oral nifedipine, and magnesium sulfate is considered if features of severe pre eclampsia such as recurring severe headache, visual scotomata or epigastric pain are present. The primary care candidate does not treat at home; the decision is for the unit. A call to the unit gives them time to prepare.
●If assessment confirms pre eclampsia, NG133 advises that women who remain on antihypertensive treatment have a GP or specialist review 2 weeks after transfer to community care, and that all women who have had pre eclampsia have a medical review 6 to 8 weeks after birth, with a further review at 3 months if proteinuria of 1+ or more persists. This is the follow up the practice should expect.

Other Serious Causes the Candidate Should Keep in Mind

●A new severe headache within days of birth has other dangerous causes. Cerebral venous thrombosis is more likely after birth because of the prothrombotic state. Stroke, reversible vasoconstriction, a post dural puncture headache after an epidural or spinal, and pulmonary embolism with its own symptoms all enter the differential. Meningitis is unlikely without fever.
●The history screens for these: Mairead had no spinal or epidural, no thunderclap onset, no neck stiffness, no fits, weakness, speech change, chest pain, breathlessness or calf signs, and no fever. All of these are negative. Hospital assessment, with neuroimaging if indicated, is the right place to settle the question, so the same plan serves every diagnosis.
●Do not fix on migraine or tension headache. A woman with no previous migraines who has a new severe headache after birth needs a serious cause excluded before it is labelled primary.

Why the Assessment Cannot Be Done by Telephone

●Blood pressure, urine protein and bloods cannot be measured over the phone, and a patient's own home reading, if she had a machine, would not replace an assessment. Asking her to judge her own swelling or vision is not reliable. This station is a telephone consultation, so the candidate should say plainly that she needs to be seen and measured today.
●A sensible candidate arranges to telephone the maternity unit with a concise handover: age, days since delivery, the midwife's blood pressure and time, headache, visual symptoms, upper abdominal pain, no spinal injection, breastfeeding, and plan for arrival. A call from the practice means she is expected rather than waiting in a general queue.

Breastfeeding, Analgesia and Medication

●NG133 advises that women who need antihypertensive medication can breastfeed, because most medicines pass into milk in very small amounts and need not stop feeding. The candidate should say this directly, because it removes her main reason for refusing. Offering that Finlay goes with her is the practical answer.
●For postnatal hypertension, NICE offers enalapril as first line with monitoring of kidney function and potassium, and, for women of Black African or Caribbean family origin, nifedipine or amlodipine as the option to consider first; labetalol is a later add on option. NG133 advises avoiding diuretics and angiotensin receptor blockers where possible in women who are breastfeeding. The MHRA says ACE inhibitors are generally not recommended in breastfeeding but are not absolutely contraindicated, and that clinicians may prescribe them if essential. The candidate does not need to quote doses, and does not need to start these at home.
●For interim pain relief, plain paracetamol is reasonable. A diuretic for the swelling or a stronger painkiller to get through the day is a mistake because it delays assessment and masks the picture. Whether other analgesics can be taken is a decision for the assessing team.

Practical Safety, Communication, and Common Mistakes

●She is alone with a newborn and a toddler. A safe plan covers who is with her, who takes Ferne, and how she gets there. Her partner is 35 to 40 minutes away, so it is reasonable to ask him to leave now, and to call an ambulance if she worsens or cannot be accompanied. She should not drive herself.
●Safety netting should be specific: call 999 for a fit, worsening vision, vomiting, severe pain under the ribs, confusion, weakness, chest pain, breathlessness or collapse, and not wait for her partner. The practice should confirm she has been seen and tell the community midwife.
●Common mistakes: accepting tiredness as the explanation; being reassured by 158/102 being under 160/110; offering a surgery appointment tomorrow; prescribing tablets by phone and waiting; telling her to drive herself; suggesting that she leave the baby or stop breastfeeding; vague safety netting; and talking over her worries about her children, which makes her less likely to go.

Mapped to the RCGP curriculum topic: Urgent & Unscheduled care.

← Back to Free SCA Practice Cases