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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 


How to use the manual

A woman presenting with a life-threatening obstetric complication is in an emergency situation requiring immediate diagnosis and management. Therefore, the main text of the manual is arranged by symptom (e.g. vaginal bleeding in early pregnancy). Because this symptom-based approach is different than most medical texts which are arranged by disease, a list of diagnoses with the page number of the corresponding diagnosis table is provided.

The emphasis of the manual is on rapid assessment and decision making. The clinical action steps are based on clinical assessment with limited reliance on laboratory or other tests and most are possible in a variety of clinical settings (e.g. district hospital or health centre).

Section 1 outlines the clinical principles of managing complications in pregnancy and childbirth and begins with a table that the health care worker can use to rapidly assess the woman’s condition and initiate appropriate treatment. This section includes the general principles of emergency, general and operative care, including infection prevention, the use of blood and replacement fluids, antibiotics and anaesthesia and analgesia. A description of normal labour and childbirth, including use of the partograph and active management of the third stage, is included in this section in order to provide the health care worker the information needed to differentiate between the normal process and a complication.  Guidance on the initial care of the normal newborn is also provided. Section 1 also includes information on providing emotional support to the woman and her family and outlines the linkage between the providers and their community.

Section 2 describes the symptoms by which women with complications of pregnancy and childbirth present. The symptoms reflect the major causes of mortality and morbidity. For each symptom there is a statement of general, initial management. Diagnosis tables then lead to identifying the diagnosis which is causing the symptom. Simplified management protocols for these specific diagnoses then follow. Where there are several choices of therapy, the most effective and inexpensive is chosen. Also in this section is information on management for immediate (within the first 24 hours) conditions or problems of the newborn.

Section 3 describes the procedures that may be necessary in the management of the condition. These procedures are not intended to be detailed “how-to” instructions but rather a summary of the main steps associated with each procedure. Because general operative care principles are summarized in Section 1, these are not repeated for each procedure, unless there is care required specific to the procedure (e.g. post-procedure care for ketamine anaesthesia). Clear guidance is provided on drugs and dosages, a wide variety of anaesthesia options (e.g. safe caesarean section under local anaesthesia) and safe, effective and lower cost techniques (e.g. single layer closure of the uterus). 

Section 4 contains a list of essential drugs and an index. The index is organized so that it can be used in an emergency situation to find relevant material quickly. The most critical information including diagnosis, management and steps for a procedure are listed first in bold. Other relevant entries follow in alphabetical order. Only the pages containing critical or relevant information are included, rather than listing every page that contains the word or phrase.

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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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