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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 3 - Procedures

Culdocentesis and colpotomy

Figure P-37

Diagnostic puncture of the cul-de-sac

  • Pull back on the syringe to aspirate the cul-de-sac (the space behind the uterus).

  • If non-clotting blood is obtained, suspect ectopic pregnancy.

  • If clotting blood is obtained, a vein or artery may have been aspirated. Remove the needle, re-insert it and aspirate again.

  • If clear or yellow fluid is obtained, there is no blood in the peritoneum. The woman may, however, still have an unruptured ectopic pregnancy and further observations and tests may be needed

  • If no fluid is obtained, remove the needle, re-insert it and aspirate again. If no fluid is obtained, the woman may have an unruptured ectopic pregnancy.
    If pus is obtained, keep the needle in place and proceed to colpotomy (see below).


If pus is obtained on culdocentesis, keep the needle in place and make a stab incision at the site of the puncture:

  • Remove the needle and insert blunt forceps or a finger through the incision to break loculi in the abscess cavity (Fig P-38);

Figure P-38

Colpotomy for pelvic abscess 


  • Allow the pus to drain;

  • Insert a high-level disinfected soft rubber corrugated drain through the incision;

Note: A drain can be prepared by cutting off the fingertips of a high-level disinfected rubber glove.

  • If required, use a stitch through the drain to anchor it in the vagina;

  • Remove the drain when there is no more drainage of pus.

  • If no pus is obtained, the abscess may be higher than the pouch of Douglas. A laparotomy will be required for peritoneal lavage (wash-out).

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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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