Guideline 3

Process  

• Blood Pressure should be measured manually and recorded at each visit prenatally and at least until 6 weeks postpartum. If the first postpartum visit is later than 6 weeks, at least one blood pressure should be taken. 
• In hypertensive clients, BP should be monitored at least 6 weeks postpartum and further until hypertension is resolved. 
• Measure blood pressure after client has been sitting quietly for five minutes with arm resting at heart level. Back should be straight and legs should be uncrossed with feet flat on the floor. Attempt to take a blood pressure reading at least 30 minutes after the client has exercised, consumed caffeine, or used tobacco. Client should not be talking at the time of the reading. 
• Assess size of cuff required. A cuff that is too large will give a falsely low reading, and a cuff that is too small will give a falsely high reading. The bladder length should be 75% to 100% of the arm circumference, and bladder width should be 37% to 50% of the arm circumference. (https://www.aafp.org/pubs/afp/afp-community-blog/entry/for-accurate-blood-pressure-measurement-cuff-size-matters.html#:~:text=The%20bladder%20length%20should%20be,(40.1%20to%2055%20cm).)
• Ideally, a reading should be taken on both arms and the higher reading should be recorded. If only one arm is measured, use the left arm unless contraindicated. 
• The use of a wrist cuff for the measuring of blood pressure is not recommended at this time. If one is used, using a validated device and utilizing proper technique will contribute to more accurate readings. While wrist cuffs have potential as a reliable method, further evaluation is needed. 
• Per the 2017 American College of Cardiology/American Heart Association (ACC/AHA), blood pressure categories during pregnancy are: normal (< 120/< 80), elevated (120-129/ < 80 mmHg), stage 1 hypertension (130-139 and/or diastolic 80-89), and stage 2 hypertension (prior diagnosis of chronic hypertension or systolic ≥ 140 or diastolic ≥ 90 mmHg). 
• The risk of preeclampsia increases with increasing BP at <20 weeks pregnant (7)
•  Stage 1 hypertension (130-139/80-89) is associated with a 2.7 fold increased risk of preeclampsia     
• (95% CI 2.2-3.4), with a prevalence of 15.1% compared to 4.5% prevalence among normotensive patients.
• If the blood pressure is >129/79 for either systolic or diastolic measurement, reassess in 15 minutes. Ensure proper cuff and client positioning (see above). Prenatal or postnatal blood pressure readings greater than 130 mmHg systolic or 80 mmHg diastolic x2 15 minutes apart should be immediately reported to the prenatal care provider. 
• Prenatal or postnatal acute onset of blood pressure readings of 160 mmHg systolic or 110 mmHg diastolic (sustained 15 minutes or more) constitutes a medical emergency and should be immediately reported to the provider. If the provider is not able to be reached, consider emergency department evaluation, per nursing judgement. 
• Take a blood pressure, and alert prenatal care provider if client reports any of these symptoms (may indicate preeclampsia**): Persistent severe headaches, changes in vision, right upper quadrant abdominal pain, or sudden weight gain of more than 2 pounds in a week. 
• If blood pressure is <90/60 or significantly below baseline confirmed with at least two measurements or 15 minutes apart, evaluate for tachycardia, vaginal bleeding, clots, fundal height and consistency, chest pain, abdominal pain, hydration status (mucus membranes, urine output), numbess or weakness, dizziness or orthostasis. Notify primary care provider for further assessment and follow up plan. 

*Note: the BP recommendation for adults was updated by the American College of Cardiology and the American Health Association in 2017. Many on-line resources still reference the BP of 140/90. (140/90 mmHg two times more than 4 hours apart, or 160/110 mmHg) 
** Note: Preeclampsia is defined as gestational hypertension combined with proteinuria after 20 weeks gestation. A 24-hour urine specimen is necessary to reliably measure urine protein excretion for a diagnosis of proteinuria; a conventional urine dipstick test is not adequate. Severe headaches are the most common indicator of a postpartum eclamptic seizure. The development of HELLP Syndrome most commonly occurs within 72 hours postpartum. (see the ACOG Practice Bulletin for more detailed information on preeclampsia). 
*** Pre-eclampsia is a risk factor or delayed Lactogenesis II (transition from colostrum to mature milk).  

References 

1. Institute for Clinical Systems Improvement. (2012). Hypertension in pregnancy. National Institutes of Health. 
2. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov;122(5):1122-1131. doi: 10.1097/01.AOG.0000437382.03963.88. PMID: 24150027. 
3. American College of Cardiology, American Heart Association, American Academy of Physician Assistants, American College of Preventive Medicine, American Geriatrics Society, American Pharmacists Association, American Society of Hypertension, American Society for Preventive Cardiology, National Medical Association, & Preventive Cardiovascular Nurses Association. (2018). Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248. https://doi.org/10.1016/j.jacc.2017.11.006 
4. American College of Obstetricians and Gynecologists. (2017). Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period: Committee opinion no. 692. Obstetrics & Gynecology, 129(e90–e95). 10.1097/AOG.0000000000002019 
5. American College of Obstetricians and Gynecologists. (2019). Interpregnancy care: Obstetric care consensus no. 8. Obstetrics & Gynecology, 133(e51–e72). doi: 10.1097/AOG.0000000000003025. PMID: 30575677. 
6. Tesfalul, M. A., Sperling, J. D., Blat, C., Parikh, N. I., Gonzalez-Velez, J. M., Zlatnik, M. G., & Norton, M. E. (2022). Perinatal outcomes and 2017 ACC/AHA blood pressure categories. Pregnancy Hypertension, 28, 134–138. https://doi.org/10.1016/j.preghy.2022.03.004