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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 2 - Symptoms

Difficulty in breathing


  • A woman is short of breath during pregnancy, labour or after delivery.


  • Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).

  • Prop up the woman on her left side.

  • Start an IV infusion and infuse IV fluids.

  • Give oxygen at 4–6 L per minute by mask or nasal cannulae.

  • Obtain haemoglobin estimates using haemoglobinometer or other simple method.


TABLE S-18   Diagnosis of difficulty in breathing

Presenting Symptom and Other Symptoms and Signs Typically

Symptoms and Signs Sometimes Present

Probable Diagnosis

• Difficulty in breathing

• Pallor of conjunctiva, tongue, nail beds and/or palms

• Haemoglobin 7g per dL or less

• Haematocrit 20% or less

• Lethargy and fatigue

• Flat or concave nails

Severe anaemia

• Symptoms and signs of severe anaemia

• Oedema

• Cough

• Rales

• Swelling of legs

• Enlarged liver

• Prominent neck veins

Heart failure due to anaemia

• Difficulty in breathing

• Diastolic murmur and/or

• Harsh systolic murmur with palpable thrill 

• Irregular heart beat

• Enlarged heart

• Rales

• Cyanosis (blueness)

• Cough

• Swelling of legs

• Enlarged liver

• Prominent neck veins

Heart failure due to heart disease

• Difficulty in breathing

• Fever

• Cough with expectoration

• Chest pain

• Consolidation

• Congested throat

• Rapid breathing

• Rhonchi/rales


• Difficulty in breathing

• Wheezing

• Cough with expectoration

• Rhonchi/rales

Bronchial asthma

• Difficulty in breathing

• Hypertension

• Proteinuria

• Rales

• Frothy coughIMPAC

Pulmonary oedema associated with pre-eclampsiaa

a Withhold fluids and give frusemide 40 mg IV once 



- Use packed cells;

- If blood cannot be centrifuged, let it hang until the cells have settled. Infuse the cells slowly and dispose of the remaining serum;

- Give frusemide 40 mg IV with each unit of packed cells.

  • If Plasmodium falciparum malaria is suspected, manage as severe malaria.

  • Give ferrous sulfate or ferrous fumerate 120 mg by mouth PLUS folic acid 400 μg by mouth once daily for 6 months during pregnancy. Continue for 3 months postpartum.

  • Where hookworm is endemic (prevalence of 20% or more), give one of the following anthelmintic treatments:

- albendazole 400 mg by mouth once; 

- OR mebendazole 500 mg by mouth once or 100 mg two times per day for 3 days;

- OR levamisole 2.5 mg/kg body weight by mouth once daily for 3 days;

- OR pyrantel 10 mg/kg body weight by mouth once daily for 3 days.

• If hookworm is highly endemic (prevalence of 50% or more), repeat the anthelmintic treatment 12 weeks after the first dose.



  • Transfusion is almost always necessary in heart failure due to anaemia:

- Use packed or sedimented cells as described for severe anaemia (above);

- Give frusemide 40 mg IV with each unit of packed cells.


  • Treat acute heart failure. Drugs used may include:

- morphine 10 mg IM as a single dose; 

- OR frusemide 40 mg IV, repeated as necessary;

- OR digoxin 0.5 mg IM as a single dose;

- OR nitroglycerine 0.3 mg under the tongue, repeated in 15 minutes, if necessary.

  • Refer to a higher level if needed.


  • Prop up the woman on her left side.

  • Limit infusion of IV fluids to decrease the risk of circulatory overload and maintain a strict fluid balance chart.

  • Ensure adequate analgesia

  • If oxytocin infusion is required, use a higher concentration at a slower rate while maintaining a fluid balance chart (e.g. the concentration may be doubled if the drops per minute is decreased by half, Table P-7).

Note: Do not give ergometrine.

Heart failure is not an indication for caesarean section. 



Inflammation in pneumonia affects the lung parenchyma and involves respiratory bronchioles and alveoli. There is loss of lung capacity that is less tolerated by pregnant women. 

  • A radiograph of the chest may be required to confirm the diagnosis of pneumonia. 

  • Give erythromycin base 500 mg by mouth four times per day for 7 days.

  • Give steam inhalation.

  • Consider the possibility of tuberculosis in areas where it is prevalent.



Bronchial asthma complicates 3–4% of pregnancies. Pregnancy is associated with worsening of the symptoms in one-third of affected women. 

  • If bronchospasm occurs, give bronchodilators (e.g. salbutamol 4 mg by mouth every 4 hours or 250 μg aerosol every 15 minutes for 3 doses).

  • If there is no response to bronchodilators, give corticosteroids such as hydrocortisone IV 2 mg/kg body weight every 4 hours as needed.

  • If there are signs of infection (bronchitis), give ampicillin 2 g IV every 6 hours.

  • Avoid the use of prostaglandins. For prevention and treatment of postpartum haemorrhage, give oxytocin 10 units IM or give ergometrine 0.2 mg IM.

  • After acute exacerbation has been managed, continue treatment with inhaled bronchodilators and inhaled corticosteroids to prevent recurrent acute episodes.

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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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