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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

Loss of  fetal movements


  • Fetal movements are not felt after 22 weeks of gestation or during labour.


- If the mother has had sedatives, wait for the effect of the drugs to wear off and then recheck;

- If the fetal heart cannot be heard, ask several other persons to listen or use a Doppler stethoscope, if available. 


Table S-19

Diagnosis of loss of fetal movements 

Presenting Symptom and Other Symptoms and Signs Typically Present

Symptoms and Signs Sometimes Present

Probable Diagnosis

• Decreased/absent fetal movements

• Intermittent or constant abdominal pain

• Bleeding after 22 weeks gestation (may be retained in the uterus)

• Shock

• Tense/tender uterus

• Fetal distress or absent fetal heart sounds

Abruptio placentae

• Absent fetal movements and fetal heart sounds

• Bleeding (intra-abdominal and/or vaginal)

• Severe abdominal pain (may decrease after rupture)

• Shock

• Abdominal distension/ free fluid

• Abnormal uterine contour

• Tender abdomen

• Easily palpable fetal parts

• Rapid maternal pulse

Ruptured uterus

• Decreased/absent fetal movements

• Abnormal fetal heart rate (less than 100 or more than 180 beats per


• Thick meconium-stained fluid

Fetal distress

• Absent fetal movements and fetal heart sounds

• Symptoms of pregnancy cease

• Symphysis-fundal height decreases

• Uterine growth decreases

Fetal death



Intrauterine death may be the result of fetal growth restriction, fetal infection, cord accident or congenital anomalies. Where syphilis is prevalent, a large proportion of fetal deaths are due to this disease.

  • If x-ray is available, confirm fetal death after 5 days. Signs include overlapping skull bones, hyper flexed spinal column, gas bubbles in heart and great vessels and oedema of the scalp.

  • Alternatively, if ultrasound is available, confirm fetal death. Signs include absent fetal heart activity, abnormal fetal head shape, reduced or absent amniotic fluid and doubled-up fetus.

  • Explain the problem to the woman and her family. Discuss with them the options of expectant or active management. 

  • If expectant management is planned

- Await spontaneous onset of labour during the next 4 weeks;

- Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complications. 

  • If platelets are decreasing or 4 weeks have passed without spontaneous labour, consider active management.

  • If active management is planned, assess the cervix

- If the cervix is favourable (soft, thin, partly dilated), induce labour using oxytocin or prostaglandins

- If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or a Foley catheter;

Note: Do not rupture the membranes due to risk of infection.

- Deliver by caesarean section only as a last resort.

  • If spontaneous labour does not occur within 4 weeks, platelets are decreasing and the cervix is unfavourable (firm, thick, closed), ripen the cervix using misoprostol:

- Place misoprostol 25 μcg in the upper vagina. Repeat after 6 hours if required;

- If there is no response after two doses of 25 μcg, increase to 50 μcg every 6 hours;

Note: Do not use more than 50 μcg at a time and do not exceed 4 doses.

Do not use oxytocin within 8 hours of using misoprostol. Monitor uterine contractions and fetal heart rate of all women undergoing induction of labour with prostaglandins. 

  • If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for metritis.

  • If a clotting test shows failure of a clot to form after 7 minutes or a soft clot that breaks down easily, suspect coagulopathy.

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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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