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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 1 - Clinical Principles

Antibiotic therapy

Infection during pregnancy and the postpartum period may be caused by a combination of organisms, including aerobic and anaerobic cocci and bacilli. Antibiotics should be started based on observation of the woman. If there is no clinical response, culture of uterine or vaginal discharge, pus or urine may help in choosing other antibiotics. In addition, blood culture may be done if septicaemia (bloodstream invasion) is suspected. 

Uterine infection can follow an abortion or childbirth and is a major cause of maternal death. Broad spectrum antibiotics are often required to treat these infections. In cases of unsafe abortion and non-institutional delivery, anti-tetanus prophylaxis should also be provided 
(Box S-5). 



Performing certain obstetrical procedures (e.g. caesarean section, manual removal of placenta) increases a woman’s risk of infectious morbidity. This risk can be reduced by:

Prophylactic antibiotics are given to help prevent infection. If a woman is suspected to have or is diagnosed as having an infection, therapeutic antibiotics are more appropriate.

Give prophylactic antibiotics 30 minutes before the start of a procedure, when possible, to allow adequate blood levels of the antibiotic at the time of the procedure. An exception to this is caesarean section, for which prophylactic antibiotics should be given when the cord is clamped after delivery of the baby. One dose of prophylactic antibiotics is sufficient and is no less effective than three doses or 24 hours of antibiotics in preventing infection. If the procedure lasts longer than 6 hours or blood loss is 1 500 mL or more, give a second dose of prophylactic antibiotics to maintain adequate blood levels during the procedure.



  • As a first defense against serious infections, give a combination of antibiotics:

- ampicillin 2 g IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours.

Note: If the infection is not severe, amoxicillin 500 mg by mouth every 8 hours can be used instead of ampicillin. Metronidazole can be given by mouth instead of IV.

  • If the clinical response is poor after 48 hours, ensure adequate dosages of antibiotics are being given, thoroughly re-evaluate the woman for other sources of infection or consider altering treatment according to reported microbial sensitivity (or adding an additional agent to cover anaerobes, if not yet given).

  • If culture facilities are not available, re-examine for pus collection, especially in the pelvis, and for non-infective causes such as deep vein and pelvic vein thrombosis. Consider the possibility of infection due to organisms resistant to the above combination of antibiotics:

- If staphylococcal infection is suspected, add:

- cloxacillin 1 g IV every 4 hours;

- OR vancomycin 1 g IV every 12 hours infused over 1 hour;

- If clostridial infection or Group A haemolytic streptococci is suspected, add penicillin 2 million units IV every 4 hours;

- If neither of the above are possibilities, add ceftriaxone 2 g IV every 24 hours.

Note: To avoid phlebitis, the infusion site should be changed every 3 days or at the first sign of inflammation.

  • If the infection does not clear, evaluate for the source of infection.

For the treatment of metritis, combinations of antibiotics are usually continued until the woman is fever-free for 48 hours. Discontinue antibiotics once the woman has been fever-free for 48 hours. There is no need to continue with oral antibiotics, as this has not been proven to have additional benefit. Women with blood-stream infections, however,
will require antibiotics for at least 7 days.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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