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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

Manual removal of placenta

- ampicillin 2 g IV PLUS metronidazole 500 mg IV;

- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.

  • Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor.

  • Wearing high-level disinfected gloves, insert a hand into the vagina and up into the uterus (Fig P-42).

Figure P-42

 Introducing one hand into the vagina along cord


  • Let go of the cord and move the hand up over the abdomen in order to support the fundus of the uterus and to provide counter-traction during removal to prevent inversion of the uterus (Fig P-43).

Note: If uterine inversion occurs, reposition the uterus.

  • Move the fingers of the hand laterally until the edge of the placenta is located.

  • If the cord has been detached previously, insert a hand into the uterine cavity. Explore the entire cavity until a line of cleavage is identified between the placenta and the uterine wall.

Figure P43

  Supporting the fundus while detaching the placenta 


  • Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall.

  • Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall.

  • If the placenta does not separate from the uterine surface by gentle lateral movement of the fingertips at the line of cleavage, suspect placenta accreta and proceed to laparotomy and possible subtotal hysterectomy

  • Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with it (Fig P-44).

  • With the other hand, continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn. 

Figure P-44

 Withdrawing the hand from the uterus


  • Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed.

  • Give oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute.

  • Have an assistant massage the fundus of the uterus to encourage a tonic uterine contraction.

  • If there is continued heavy bleeding, give ergometrine 0.2 mg IM or prostaglandins (Table S-8).

  • Examine the uterine surface of the placenta to ensure that it is complete. If any placental lobe or tissue is missing, explore the uterine cavity to remove it.

  • Examine the woman carefully and repair any tears to the cervix or vagina, or repair episiotomy


  • If the placenta is retained due to a constriction ring or if hours or days have passed since delivery, it may not be possible to get the entire hand into the uterus. Extract the placenta in fragments using two fingers, ovum forceps or a wide curette.


  • Observe the woman closely until the effect of IV sedation has worn off.

  • Monitor the vital signs (pulse, blood pressure, respiration) every 30 minutes for the next 6 hours or until stable. 

  • Palpate the uterine fundus to ensure that the uterus remains contracted.

  • Check for excessive lochia.

  • Continue infusion of IV fluids.

  • Transfuse as necessary.

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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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