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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 2 - Symptoms

Labour with an overdistended uterus


  • A woman in labour has an overdistended uterus or symphysis-fundal height more than expected for the period of gestation. 


  • Prop up the woman.

  • Confirm accuracy of calculated gestational age, if possible.


  • If only one fetus is felt on abdominal examination, consider wrong dates, a single large fetus  or an excess of amniotic fluid.

  • If multiple fetal poles and parts are felt on abdominal examination, suspect multiple pregnancy. Other signs of multiple pregnancy include:

- fetal head small in relation to the uterus;

- uterus larger than expected for gestation;

- more than one fetal heart heard with Doppler fetal stethoscope. 

Note: An acoustic fetal stethoscope cannot be used to confirm the diagnosis, as one heart may be heard in different areas. 

  • Use ultrasound examination, if available, to:

- identify the number, presentations and sizes of fetuses;

- assess the volume of amniotic fluid.

  • If ultrasound service is not available, perform radiological examination (anterio-posterior view) for number of fetuses and presentations.




  • Allow labour to progress and monitor progress using a partograph.

  • If the woman is uncomfortable because of uterine distension, aspirate excess amniotic fluid:

- Palpate for location of fetus;

- Prepare the skin with an antiseptic;

- Under aseptic conditions, insert a 20-gauge spinal needle through the abdominal and uterine walls and withdraw the stylet;

- Aspirate the fluid using a large syringe. Alternatively, attach an infusion set to the needle and allow the fluid to slowly drain into a container;

- When the woman is no longer distressed because of overdistension, replace the stylet and remove the needle.



- If a vertex presentation, allow labour to progress as for a single vertex presentation and monitor progress in labour using a partograph;

- If a breech presentation, apply the same guidelines as for a singleton breech presentation and monitor progress in labour using a partograph;

- If a transverse lie, deliver by caesarean section.

Leave a clamp on the maternal end of the umbilical cord and do not attempt to deliver the placenta until the last baby is delivered. 


  • Immediately after the first baby is delivered:

- Palpate the abdomen to determine lie of additional baby;

- Correct to longitudinal lie by external version;

- Check fetal heart rate(s).

  • Perform a vaginal examination to determine if:

- cord has prolapsed;

- the membranes are intact or ruptured.


  • If the head is not engaged, manoeuvre the head into the pelvis manually (hands on abdomen), if possible.

  • If the membranes are intact, rupture the membranes with an amniotic hook or a Kocher clamp.

  • Check fetal heart rate between contractions.

  • If contractions are inadequate after birth of first baby, augment labour with oxytocin using rapid escalation (Table P-8, page P-23) to produce good contractions (three contractions in 10 minutes, each lasting more than 40 seconds).

  • If spontaneous delivery does not occur within 2 hours of good contractions or if there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), deliver by caesarean section.



  • If the baby is estimated to be no larger than the first baby, and if the cervix has not contracted, consider vaginal delivery:

- If there are inadequate or no contractions after birth of first baby, escalate oxytocin infusion at a rapid rate (Table P-8) to produce good contractions (three contractions in 10 minutes, each lasting more than 40 seconds);

- If the membranes are intact and the breech has descended, rupture the membranes with an amniotic hook or a Kocher clamp;

- Check fetal heart rate between contractions. If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), deliver by breech extraction;


  • If the membranes are intact, attempt external version;

  • If external version fails and the cervix is fully dilated and membranes are still intact, attempt internal podalic version:

Note: Do not attempt internal podalic version if the provider is untrained, the membranes have ruptured and the amniotic fluid has drained, or if the uterus is scarred. Do not persist if the baby does not turn easily.

- Wearing high-level disinfected gloves, insert a hand into the uterus and grasp the baby’s foot;

- Gently rotate the baby down;

- Proceed with breech extraction.

  • Check fetal heart rate between contractions;

  • If external version fails and internal podalic version is not advisable or fails, deliver by caesarean section.
  • Give oxytocin 10 units IM or give ergometrine 0.2 mg IM within 1 minute after delivery of the last baby and continue active management of the third stage to reduce postpartum blood loss


  • Maternal complications of multiple pregnancy include:

- anaemia;

- abortion;

- pregnancy-induced hypertension and pre-eclampsia;

- excess amniotic fluid;

- poor contractions during labour;

- retained placenta;

- postpartum haemorrhage.

  • Placental/fetal complications include:

- placenta praevia;

- abruptio placentae;

- placental insufficiency;- preterm delivery;

- low birth weight;

- malpresentations;

- cord prolapse;

- congenital anomalies.

Top of page

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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