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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

External version

  • Review for indications. Do not perform this procedure before 37 weeks.

  • Have the woman lie on her back, and elevate the foot of the bed.

  • Listen to and note the fetal heart rate. If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), do not proceed with external version.

  • Palpate the abdomen to confirm presentation and position of the fetal head, back and hips.

  • To mobilize the breech, gently lift the lowest part of the fetus from the pelvic inlet by grasping above the pubic bone (Fig P-5 A).

  • Bring the head and buttocks of the fetus closer to each other to achieve forward rotation. Rotate the fetus slowly by guiding the head in a forward roll as the buttocks are lifted 
    (Fig P-5 B–C). 

  • Listen to the fetal heart rate. If an abnormality is detected:

- Have the woman turn on to her left side;

- Give oxygen at 4-6 L per minute by mask or nasal cannulae;

- Reassess every 15 minutes.

  • If the procedure is successful, have the woman remain lying down for 15 minutes. Counsel her to return if bleeding or pain occurs or if she believes the baby has returned to the previous presentation.

  • If the procedure is unsuccessful, try again using a backward roll (Fig P-5 D). 

  • If the procedure is still unsuccessful and fetal heart rate is good, tocolytics may increase the chances of successful version. Give:

- terbutaline 250 mcg IV slowly over 5 minutes;

- OR salbutamol 0.5 mg IV slowly over 5 minutes.

  • If the procedure is still unsuccessful, attempt version again after 1 week or if the woman presents in early labour with breech or transverse lie.

  • If they are fetal heart abnormalities:

- Turn the woman onto her left side;

- Reassess the fetal heart rate every 5 minutes;

- If the fetal heart rate does not stabilize within the next 30 minutes, deliver by caesarean section.

Figure P-5

 External version of a breech presentation.


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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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