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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

Emotional and psychological support

Emergency situations are often very disturbing for all concerned and evoke a range of emotions that can have significant consequences. 

Emotional and psychological reactions

  • How each member of the family reacts to an emergency situation depends on the:

  • marital status of the woman and her relationship with her partner;

  • social situation of the woman/couple and their cultural and religious practices, beliefs and expectations;

  • personalities of the people involved and the quality and nature of social, practical and emotional support;

  • nature, gravity and prognosis of the problem and the availability and quality of the health care services.

Common reactions to obstetric emergencies or death include:

  • denial (feelings of “it can’t be true”);

  • guilt regarding possible responsibility;

  • anger (frequently directed towards health care staff but often masking anger that parents direct at themselves for “failure”);

  • bargaining (particularly if the patient hovers for a while between life and death);

  • depression and loss of self-esteem, which may be long-lasting;

  • isolation (feelings of being different or separate from others), which may be reinforced by care givers who may avoid people who experience loss;

  • disorientation.

General principles of communication and support

While each emergency situation is unique, the following general principles offer guidance. Communication and genuine empathy are probably the most important keys to effective care in such situations.

At the time of the event

  • Listen to those who are distressed. The woman/family will need to discuss their hurt and sorrow. 

  • Do not change the subject and move on to easier or less painful topics of conversation. Show empathy.

  • Tell the woman/family as much as you can about what is happening. Understanding the situation and its management can reduce their anxiety and prepare them for what happens next.

  • Be honest. Do not hesitate to admit what you do not know. Maintaining trust matters more than appearing knowledgeable.

  • If language is a barrier to communication, find a translator.

  • Do not pass the problem on to nursing staff or junior doctors.

  • Ensure that the woman has a companion of her choice and, where possible, the same care giver throughout labour and delivery. Supportive companionship can enable a woman to face fear and pain, while reducing loneliness and distress.

  • Where possible, encourage companions to take an active role in care. Position the companion at the top of the bed to allow the companion to focus on caring for the woman’s emotional needs.

  • Both during and after the event, provide as much privacy as possible for the woman and her family.

After the event

  • Give practical assistance, information and emotional support. 

  • Respect traditional beliefs and customs and accommodate the family’s needs as far as possible.

  • Provide counselling for the woman/family and allow for reflection on the event.

  • Explain the problem to help reduce anxiety and guilt. Many women/families blame themselves for what has happened.

  • Listen and express understanding and acceptance of the woman’s feelings. Nonverbal communication may speak louder than words: a squeeze of the hand or a look of concern can say an enormous amount. 

  • Repeat information several times and give written information, if possible. People experiencing an emergency will not remember much of what is said to them.

  • Health care providers may feel anger, guilt, sorrow, pain and frustration in the face of obstetric emergencies that may lead them to avoid the woman/family. Showing emotion is not a weakness.

  • Remember to care for staff who themselves may experience guilt, grief, confusion and other emotions.

Maternal mortality and morbidity 

Maternal mortality 

Death of a woman in childbirth or from pregnancy-related events is a devastating experience for the family and for surviving children. In addition to the principles listed above, remember the following:

At the time of the event

  • Provide psychological care as long as the woman is awake or even vaguely aware of what is or might be happening to her.

  • If death is inevitable, provide emotional and spiritual comfort rather than focusing on the emergency (now futile) medical care.

  • Provide dignity and respectful treatment at all times, even if the woman is unconscious or has already died.

After the event 

  • Allow the woman’s partner or family to be with her. 

  • Facilitate the family’s arrangements for the funeral, if possible, and see that they have all the necessary documents.

  • Explain what happened and answer any questions. Offer the opportunity for the family to return to ask additional questions. 

Severe maternal morbidity

Childbirth sometimes leaves a woman with severe physical or psychological damage. 

At the time of the event

  • Include the woman and her family in the proceedings of the delivery if possible, particularly if this is culturally appropriate.

  • Ensure that a staff member cares for the emotional and informational needs of the woman and her partner, if possible.

After the event

  • Clearly explain the condition and its treatment so that it is understood by the woman and her companions. 

  • Arrange for treatment and/or referral, when indicated.

  • Schedule a follow-up visit to check on progress and discuss available options.

Neonatal mortality or morbidity 

While general principles of emotional support for women experiencing obstetrical emergencies apply, when a baby dies or is born with an abnormality some specific factors should be

Intrauterine death or stillbirth

Many factors will influence the woman’s reaction to the death of her baby. These include those mentioned above as well as:

  • the woman’s previous obstetric and life history;

  • the extent to which the baby was “wanted”;

  • the events surrounding the birth and the cause of the loss;

  • previous experiences with death.

At the time of the event

  • Avoid using sedation to help the woman cope. Sedation may delay acceptance of the death and may make reliving the experience later—part of the process of emotional healing—more difficult. 

  • Allow the parents to see the efforts made by the care givers to revive their baby.

  • Encourage the woman/couple to see and hold the baby to facilitate grieving. 

  • Prepare the parents for the possibly disturbing or unexpected appearance of the baby (red, wrinkled, peeling skin). If necessary, wrap the baby so that it looks as normal as possible at first glance.

  • Avoid separating the woman and baby too soon (before she indicates she is ready), as this can interfere with and delay the grieving process.

After the event

  • Allow the woman/family to continue to spend time with the baby. Parents of a stillborn still need to get to know their baby.

  • People grieve in different ways, but for many remembrance is important. Offer the woman/family small mementos such as a lock of hair, a cot label or a name tag.

  • Where it is the custom to name babies at birth, encourage the woman/family to call their baby by the name they have chosen.

  • Allow the woman/family to prepare the baby for its funeral if they wish. 

  • Encourage locally-accepted burial practices and ensure that medical procedures (such as autopsies) do not preclude them.

  • Arrange a discussion with both the woman and her partner to discuss the event and possible preventive measures for the future.

Destructive operations

Craniotomy or other destructive operations on the dead fetus may be distressing and call for additional psychosocial care.

At the time of the event

  • It is crucial that you explain to the mother and her family that the baby is dead and that the priority is to save the mother.

  • Encourage the partner to provide support and comfort for the mother until she is anaesthetized or sedated. 

  • If the mother is awake or partially awake during the procedure, protect her from visual exposure to the procedure and to the baby.

  • After the intervention, arrange the baby so it can be seen and/or held by the woman/family if they wish, especially if the family is going to take care of the dead baby for burial.

After the event

  • Allow unlimited visiting time for the woman’s companion.

  • Counsel the mother and her companion and reassure them that an alternative was not available. 

  • Arrange a follow-up visit several weeks after the event to answer any questions and to prepare the woman for a subsequent pregnancy (or the inability/inadvisability of another pregnancy).

  • Family planning should be provided, if appropriate

Birth of a baby with an abnormality

The birth of a baby with a malformation is a devastating experience for the parents and family. Reactions may vary.

  • Allow the woman to see and hold the baby. Some women accept their baby immediately while others may take longer.

  • Disbelief, denial and sadness are normal reactions, especially if the abnormality is unpredicted. Feelings of unfairness, despair, depression, anxiety, anger, failure and apprehension are common.

At the time of the event

  • Give the baby to the parents at delivery. Allowing the parents to see the problem immediately may be less traumatic.

  • In cases of severe deformity, wrap the baby before giving it to the mother to hold so that she can see the normality of the baby first. Do not force the mother to examine the abnormality.

  • Provide a bed or cot in the room so the companion can stay with the woman if she chooses.

After the event

  • Discuss the baby and its problem with the woman and her family together, if possible. 

  • Allow the woman and her partner free access to their baby. Keep the baby with its mother at all times. The more the woman and her partner can do for the baby themselves, the more quickly they will accept the baby as their own.

  • Ensure access to supportive professional individuals and groups.


Psychological morbidity

Postpartum emotional distress is fairly common after pregnancy and ranges from mild postpartum blues (affecting about 80% of women), to postpartum depression or psychosis.
Postpartum psychosis can pose a threat to the life of the mother or baby.

Postpartum depression

Postpartum depression affects up to 34% of women and typically occurs in the early postpartum weeks or months and may persist for a year or more. Depression is not necessarily one of the leading symptoms although it is usually evident. Other symptoms include exhaustion, irritability, weepiness, low energy and motivational levels, feelings of helplessness and hopelessness, loss of libido and appetite and sleep disturbances. Headache, asthma, backache, vaginal discharge and abdominal pain may be reported. Symptoms may include obsessional thinking, fear of harming the baby or self, suicidal thoughts and depersonalization.  

The prognosis for postpartum depression is good with early diagnosis and treatment. More than two-thirds of women recover within a year. Providing a companion during labour may prevent postpartum depression. 

Once established, postpartum depression requires psychological counselling and practical assistance. In general:

  • Provide psychological support and practical help (with the baby and with home care).

  • Listen to the woman and provide encouragement and support.

  • Assure the woman that the experience is fairly common and that many other women experience the same thing.

  • Assist the mother to rethink the image of motherhood and assist the couple to think through their respective roles as new parents. They may need to adjust their expectations and activities.

  • If depression is severe, consider antidepressant drugs, if available. Be aware that medication can be passed through breastmilk and that breastfeeding should be reassessed.

Care can be home-based or can be offered through day-care clinics. Local support groups of women who have had similar experiences are most valuable. 


Postpartum psychosis

Postpartum psychosis typically occurs around the time of delivery and affects less than 1% of women. The cause is unknown, although about half of the women experiencing psychosis also have a history of mental illness. Postpartum psychosis is characterized by abrupt onset of delusions or hallucinations, insomnia, a preoccupation with the baby, severe depression, anxiety, despair and suicidal or infanticidal impulses. 

Care of the baby can sometimes continue as usual. Prognosis for recovery is excellent but about 50% of women will suffer a relapse with subsequent deliveries. In general:

  • Provide psychological support and practical help (with the baby as well as with home care).

  • Listen to the woman and provide support and encouragement. This is important for avoiding tragic outcomes.

  • Lessen stress. 

  • Avoid dealing with emotional issues when the mother is unstable. 

  • If antipsychotic drugs are used, be aware that medication can be passed through breastmilk and that breastfeeding should be reassessed.

Top of page

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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