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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


TABLE P-5 Indications and precautions for ketamine anaesthesia 



  • Any procedure that is relatively short (less than 60 minutes) and where muscle relaxation is not required (e.g. repair of perineal tears or extensive cervical tears, manual removal of placenta, caesarean section, drainage of breast abscess)

  • Suitable as a back-up if inhalation apparatus (or gas supply for a Boyle’s anaesthesia machine) fails or for general anaesthesia is used without inhalation apparatus

  • When used alone, ketamine can cause unpleasant hallucinations. Avoid use in women with a history of psychosis. To prevent hallucinations, give diazepam 10 mg IV after the baby is delivered

  • By itself ketamine does not provide muscular relaxation, so the incision for caesarean section may need to be longer

  • Ketamine should not be used in women with elevated blood pressure, pre-eclampsia, eclampsia or heart disease


- Most women will require 6–10 mg/kg body weight IM. Surgical anaesthesia is reached within 10 minutes and lasts up to 30 minutes;

- Alternatively, give 2 mg/kg body weight IV slowly over 2 minutes (in which case the action lasts for only 15 minutes); 

- Infusion of ketamine is described below. This is suitable for caesarean section;

- When additional pain relief is needed, give ketamine 1 mg/kg body weight IV.

Ketamine anaesthesia should not be used in women with elevated blood pressure, pre-eclampsia, eclampsia or heart disease. 




  • Give atropine sulfate 0.6 mg IM 30 minutes prior to surgery. 

  • Give diazepam 10 mg IV at the time of induction to prevent hallucinations (for caesarean section, give diazepam after the baby is delivered).

  • Give oxygen at 6–8 L per minute by mask or nasal cannulae.



  • Check the woman’s vital signs (pulse, blood pressure, respiration, temperature). 

  • Insert a mouth gag to prevent airway obstruction by the tongue.

  • Induction of anaesthesia is achieved by slowly administering ketamine 2 mg/kg body weight IV slowly over 2 minutes. For short procedures lasting less than 15 minutes, this will provide adequate anaesthesia. 

  • For longer procedures, infuse ketamine 200 mg in 1 L dextrose at 2 mg per minute (i.e. 20 drops per minute).

  • Check the level of anaesthesia before proceeding with the surgery. Pinch the incision site with forceps. If the woman feels the pinch, wait 2 minutes and then retest.

  • Monitor vital signs (pulse, blood pressure, respiration, temperature) every 10 minutes during the procedure.


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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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