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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

Provider and community linkages


The district hospital should strive to create a welcoming environment for women, communities and providers from peripheral health units. It should support the worthy efforts of other providers and work with them to correct deficiencies.

When dealing with other providers, doctors and midwives at the district hospital should:

  • encourage and thank providers who refer patients, especially in the presence of the woman and her family;

  • offer clinical guidance and corrective suggestions in private, so as to maintain the provider’s credibility in the community; 

  • involve the provider (to an appropriate extent) in the continued care of the woman.

When dealing with the community, doctors and midwives at the district hospital should:

  • invite members of the community to be part of the district hospital or health development committee;

  • identify key persons in the community and invite them into the facility to learn about its role and function, as well as its constraints and limitations;

  • create opportunities for the community to view the district hospital as a wellness facility (e.g. through vaccination campaigns and screening programs).


To enhance its appeal to women and the community, the district hospital should be willing to examine its own service delivery practices. The facility should create a culturally sensitive and comfortable environment which:

  • respects the woman’s modesty and privacy;

  • welcomes family members;

  • provides a comfortable place for the woman and/or her newborn (e.g. lower delivery bed, warm and clean room).

With careful planning, the facility can create this environment without interfering with its ability to respond to complications or emergencies.


Improving referral patterns

Each woman who is referred to the district hospital should be given a standard referral slip containing the following information:

  • general patient information (name, age, address);

  • obstetrical history (parity, gestational age, complications in the antenatal period);

  • relevant past obstetrical complications (previous caesarean section, postpartum haemorrhage); 

  • the specific problem for which she was referred; 

  • treatments applied thus far and the results of those treatments.

The referral slip should also include the outcome of the referral. The referral slip should be sent back to the referring facility with the woman or the person who brought her. Both the district hospital and the referring facility should keep a record of all referrals as a quality assurance mechanism:

  • Referring facilities can assess the success and appropriateness of their referrals;

  • The district hospital can review the records for patterns indicating that a provider or facility needs additional technical support or training. 


District hospitals should offer clinical training for peripheral providers that is high-quality and participatory. Participatory training is skill- focused and is more effective than classroom-based training because it:

  • improves the relationship between providers at the district hospital and the auxiliary and multipurpose workers from peripheral units;

  • increases the familiarity of the peripheral providers with the clinical care provided at the district hospital;

  • promotes team building and facilitates supervision of health workers once they return to their community to implement the skills they have learned.


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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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