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Uterus, Acute inversion

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

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Second degree inversion of the uterus

This is a rare but potentially life-threatening complication of the third stage of labour.

Classification of inversion

Inversion can be classified according to severity as follows:

First-degree. The fundus reaches the internal os.

Second-degree. The body or corpus of the uterus is inverted to the internal os.

Third-degree. The uterus, cervix and vagina are inverted and are visible.

Causes

Causes of acute inversion are associated with uterine atony and cervical dilatation, and include:

  • Mismanagement in the third stage of labour, involving excessive cord traction to manage the delivery of the placenta actively
  • Combining fundal pressure and cord traction to deliver the placenta
  • Use of fundal pressure while the uterus is atonic, to deliver the placenta
  • Pathologically adherent placenta
  • Spontaneous occurrence of unknown cause
  • Short umbilical cord
  • Sudden emptying of a distended uterus.

Warning signs and diagnosis

  • There is haemorrhage, the amount of which will depend on the degree of placental adherence to the uterine wall.
  • There is shock and sudden onset of pain.
  • The fundus will not be palpable on abdominal examination.
  • A mass may be felt on vaginal examination.
  • The fundus may be visible at the introitus.

Management

Management of acute inversion of the uterus

Immediate action

  • Summon appropriate medical support
  • Attempt to replace the uterus by pushing the fundus with the palm of the hand, along the direction of the vagina, towards the posterior fornix. The uterus is then lifted towards the umbilicus and returned to position with a steady pressure (Johnson's manoeuvre)
  • Give hydrostatic pressure with warm saline
  • Insert an intravenous cannula and commence fluids. Take blood for cross-matching prior to starting the infusion
  • If the placenta is still attached, it should be left in situ as attempts to remove it at this stage may result in uncontrollable haemorrhage
  • Once the uterus is repositioned, the operator should keep the hand in situ until a firm contraction is palpated. Oxytocics should be given to maintain the contraction

Medical management

If manual replacement fails, then medical or surgical intervention is required

Further reading

Hostetier DR, Bosworth MF. (2000)Uterine inversion J Am Board Fam Med, 13(2):120-123 http://www.medscape.com/viewarticle/405770_4

Patient. Payne J. 2015. Uterine inversion (Professional reference). http://patient.info/doctor/uterine-inversion

UpToDate. Repka JT. (2016) Puerperal uterine inversion. http://www.uptodate.com/contents/puerperal-uterine-inversion

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