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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


  • Review for indications.

Episiotomy should be considered only in the case of: 

  • complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum);

  • scarring from female genital cutting or poorly healed third or fourth degree tears;

  • fetal distress.

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer seizures and death if IV injection of lignocaine occurs.

  • At the conclusion of the set of injections, wait 2 minutes and then pinch the incision site with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.

Anaesthetize early to provide sufficient time for effect. 


Figure P-39

Infiltration of perineal tissue with local anaesthetic

  • Wait to perform episiotomy until:

- the perineum is thinned out; and

- 3–4 cm of the baby’s head is visible during a contraction. 

Performing an episiotomy will cause bleeding. It should not, therefore, be done too early. 

  • Wearing high-level disinfected gloves, place two fingers between the baby’s head and the perineum.

  • Use scissors to cut the perineum about 3–4 cm in the mediolateral direction (Fig P-40). 

  • Use scissors to cut 2–3 cm up the middle of the posterior vagina.

  • Control the baby’s head and shoulders as they deliver, ensuring that the shoulders have rotated to the midline to prevent an extension of the episiotomy.

  • Carefully examine for extensions and other tears and repair (see below).

Figure P-40

 Making the incision while inserting two fingers to protect the baby’s head




Note: It is important that absorbable sutures be used for closure. Polyglycolic sutures are preferred over chromic catgut for their tensile strength, non-allergenic properties and lower probability of infectious complications and episiotomy breakdown. Chromic catgut is an acceptable alternative, but is not ideal.

- Start the repair about 1 cm above the apex (top) of the episiotomy. Continue the suture to the level of the vaginal opening;

- At the opening of the vagina, bring together the cut edges of the vaginal opening;

- Bring the needle under the vaginal opening and out through the incision and tie.

  • Close the perineal muscle using interrupted 2-0 sutures (Fig P-41 B).

  • Close the skin using interrupted (or subcuticular) 2-0 sutures (Fig P-41 C).

Figure P-41

Repair of episiotomy 



  • If a haematoma occurs, open and drain. If there are no signs of infection and bleeding has stopped, reclose the episiotomy.

  • If there are signs of infection, open and drain the wound. Remove infected sutures and debride the wound:

- If the infection is mild, antibiotics are not required;

- If the infection is severe but does not involve deep tissues, give a combination of antibiotics:

- ampicillin 500 mg by mouth four times per day for 5 days;

- PLUS metronidazole 400 mg by mouth three times per day for 5 days.

- If the infection is deep, involves muscles and is causing necrosis (necrotizing fasciitis), give a combination of antibiotics until necrotic tissue has been removed and the woman is fever-free for 48 hours:

- penicillin G 2 million units IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours;

- Once the woman is fever-free for 48 hours, give:

- ampicillin 500 mg by mouth four times per day for 5 days;

- PLUS metronidazole 400 mg by mouth three times per day for 5 days;

Note: Necrotizing fasciitis requires wide surgical debridement. Perform secondary closure in 2–4 weeks (depending on resolution of the infection).

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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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