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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

General care principles


  • Infection prevention (IP) has two primary objectives:

- prevent major infections when providing services;

- minimize the risk of transmitting serious diseases such as hepatitis B and HIV/AIDS to the woman and to service providers and staff, including cleaning and housekeeping personnel.

  • The recommended IP practices are based on the following principles:

- Every person (patient or staff) must be considered potentially infectious;

- Handwashing is the most practical procedure for preventing cross-contamination;

- Wear gloves before touching anything wet—broken skin, mucous membranes, blood or other body fluids (secretions or excretions);

- Use barriers (protective goggles, face masks or aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated;

- Use safe work practices, such as not recapping or bending needles, proper instrument processing and proper disposal of medical waste.


  • Vigorously rub together all surfaces of the hands lathered with plain or antimicrobial soap. Wash for 15–30 seconds and rinse with a stream of running or poured water.

  • Wash hands:

- before and after examining the woman (or having any direct contact);

- after exposure to blood or any body fluids (secretions or excretions), even if gloves were worn;

- after removing gloves because the gloves may have holes in them.

  • To encourage handwashing, programme managers should make every effort to provide soap and a continuous supply of clean water, either from the tap or a bucket, and single-use towels. Do not use shared towels to dry hands.

  • To wash hands for surgical procedures


  • Wear gloves:

- when performing a procedure (Table C-2);

- when handling soiled instruments, gloves and other items;

- when disposing of contaminated waste items (cotton, gauze or dressings).

  • A separate pair of gloves must be used for each woman to avoid cross-contamination.

  • Disposable gloves are preferred, but where resources are limited, surgical gloves can be reused if they are:

- decontaminated by soaking in 0.5% chlorine solution for 10 minutes;

- washed and rinsed;

- sterilized by autoclaving (eliminates all microorganisms) or high-level disinfected by steaming or boiling (eliminates all microorganisms except some bacterial endospores).

Note: If single-use disposable surgical gloves are reused, they should not be processed more than three times because invisible tears may occur.

Do not use gloves that are cracked, peeling or have detectable holes or tears. 

  • A clean, but not necessarily sterile, gown should be worn during all delivery procedures:

- If the gown has long sleeves, the gloves should be put over the gown sleeve to avoid contamination of the gloves;

- Ensure that gloved hands (high-level disinfected or sterile) are held above the level of the waist and do not come into contact with the gown. 

Table C-2  

Glove and gown requirements for common obstetric procedures



Gloves a


Gloves b


Blood drawing, starting IV infusion

Exam c

High-level disinfected surgical d


Pelvic examination


High-level disinfected surgical


Manual vacuum aspiration, dilatation and curettage, colpotomy, repair of cervical or perineal tears

High-level disinfected surgical

Sterile surgical


Laparotomy, caesarean section, hysterectomy, repair of ruptured uterus, salpingectomy, uterine artery ligation, delivery, bimanual compression of uterus, manual removal of placenta, correcting uterine inversion, instrumentaldelivery

Sterile surgical

High-level disinfected surgical

Clean, high-level disinfected or sterile

Handling and cleaning instruments

Utility e

Exam or surgical


Handling contaminated waste


Exam or surgical


Cleaning blood or body fluid spills


Exam or surgical



a Gloves and gowns are not required to be worn to check blood pressure or temperature, or to give injections.

b Alternative gloves are generally more expensive and require more preparation than preferred gloves.

c Exam gloves are single-use disposable latex gloves. If gloves are reusable, they should be decontaminated, cleaned and either sterilized or high-level disinfected before use.

d Surgical gloves are latex gloves that are sized to fit the hand.
e Utility gloves are thick household gloves.



Operating theatre and labour ward

Hypodermic needles and syringes

  • Use each needle and syringe only once.

  • Do not disassemble needle and syringe after use.

  • Do not recap, bend or break needles prior to disposal.

  • Dispose of needles and syringes in a puncture-proof container.

  • Make hypodermic needles unusable by burning them.

Note: Where disposable needles are not available and recapping is practiced, use the “one-handed” recap method:

- Place the cap on a hard, flat surface;

- Hold the syringe with one hand and use the needle to “scoop up” the cap;

- When the cap covers the needle completely, hold the base of the needle and use the other hand to secure the cap.


  • The purpose of waste disposal is to:

- prevent the spread of infection to hospital personnel who handle the waste;

- prevent the spread of infection to the local community;

- protect those who handle waste from accidental injury.

  • Noncontaminated waste (e.g. paper from offices, boxes) poses no infectious risk and can be disposed of according to local guidelines. 

  • Proper handling of contaminated waste (blood- or body fluid-contaminated items) is required to minimize the spread of infection to hospital personnel and the community. Proper handling means:

- wearing utility gloves;

- transporting solid contaminated waste to the disposal site in covered containers;

- disposing of all sharp items in puncture-resistant containers;

- carefully pouring liquid waste down a drain or flushable toilet;

- burning or burying contaminated solid waste;

- washing hands, gloves and containers after disposal of infectious waste. 



  • Start an IV infusion (two if the woman is in shock) using a large-bore (16-gauge or largest available) cannula or needle.

  • Infuse IV fluids (normal saline or Ringer’s lactate) at a rate appropriate for the woman’s condition.

Note: If the woman is in shock, avoid using plasma substitutes (e.g. dextran). There is no evidence that plasma substitutes are superior to normal saline in the resuscitation of a shocked woman and dextran can be harmful in large doses.

  • If a peripheral vein cannot be cannulated, perform a venous cut-down Fig S-1



Figure C-1 

The lithotomy position


  • Wash hands with soap and water and put on gloves appropriate for the procedure (Table C-2)

  • If the vagina and cervix need to be prepared with an antiseptic for the procedure (e.g. manual vacuum aspiration):

- Wash the woman’s lower abdomen and perineal area with soap and water, if necessary;

- Gently insert a high-level disinfected or sterile speculum or retractor(s) into the vagina;

- Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the vagina and cervix using a high-level disinfected or sterile ring forceps and a cotton or gauze swab.

  • If the skin needs to be prepared with an antiseptic for the procedure (e.g. symphysiotomy):

- Wash the area with soap and water, if necessary; 

- Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the area using a high-level disinfected or sterile ring forceps and a cotton or gauze swab. If the swab is held with a gloved hand, care must be taken not to contaminate the glove by touching unprepared skin;

- Begin at the centre of the area and work outward in a circular motion away from the area;

- At the edge of the sterile field discard the swab.

  • Never go back to the middle of the prepared area with the same swab. Keep your arms and elbows high and surgical dress away from the surgical field.

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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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