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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

Uterine and utero-ovarian artery

- ampicillin 2 g IV;

- OR cefazolin 1 g IV.

  • Open the abdomen:

- Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia;

- Make a 2–3 cm vertical incision in the fascia;

- Hold the fascial edge with forceps and lengthen the incision up and down using scissors;

- Use fingers or scissors to separate the rectus muscles (abdominal wall muscles);

- Use fingers to make an opening in the peritoneum near the umbilicus. Use scissors to lengthen the incision up and down in order to see the entire uterus. Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum; 

- Place a bladder retractor over the pubic bone and place self-retaining abdominal retractors.

  • Pull on the uterus to expose the lower part of the broad ligament.

  • Feel for pulsations of the uterine artery near the junction of the uterus and cervix. 

  • Using 0 chromic catgut (or polyglycolic) suture on a large needle, pass the needle around the artery and through 2–3 cm of myometrium (uterine muscle) at the level where a transverse lower uterine segment incision would be made. Tie the suture securely.

  • Place the sutures as close to the uterus as possible, as the ureter is generally only 1 cm lateral to the uterine artery.

  • Repeat on the other side.

  • If the artery has been torn, clamp and tie the bleeding ends.

  • Ligate the utero-ovarian artery just below the point where the ovarian suspensory ligament joins the uterus (Fig P-53).

  • Repeat on the other side.

  • Observe for continued bleeding or formation of haematoma.

Figure P-53

 Sites for ligating uterine and utero-ovarian arteries



  • Close the abdomen:

- Ensure that there is no bleeding. Remove clots using a sponge.

- Examine carefully for injuries to the bladder and repair any found.

- Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture.

Note: There is no need to close the bladder peritoneum or the abdominal peritoneum.

- If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared.

- If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.


- ampicillin 2 g IV every 6 hours; 

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

- PLUS metronidazole 500 mg IV every 8 hours.

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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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