uterine inversion

2. Introduction
This is Rare.But Potentially Life
Threatening Complication of the Third
Stage Of Lobour.
It Occurs in Approximately 1 in 20,000
Deliveries
The Obstetric Inversion is almost always
an Acute One & Usually Complete.

3. DEFINITION
‘‘ When Uterus Turns Inside Out, It Is
Called Uterine Inversion.”
‘‘Inversion of Uterus means Uterus is
Turned Inside Out Partially OR
Completely.
Uterine inversion is the folding of the
fundus into the uterine cavity in varying
degrees.

4. CLASSIFICATION
Inversion Of Uterus is Classified in
Mainly 3 Types :
A. According to its Types
B. According to the Degrees
C. According to the Timing of Event

5. A. Types
1) Incomplete Inversion :
When fundus of uterus has turned
inside out, like toe of socks, but inverted
fundus has not descended through Cx…
2) Complete Inversion :
When the inverted fundus has
passed completely through Cx to lie
within the vagina or lie often outside the
Vaginal Wall.

7. B. Degrees
 First degree: The uterus is partially
turned out
 Second degree: The fundus has passed
through the cervix but not outside the
vagina
 Third degree: The fundus is prolapsed
outside the vagina
 Fourth degree: The uterus, cervix and
vagina are completely turned inside out
and are visible

8. Universally….
 First Degree : Incomplete Inversion
 Second Degree : Complete inversion in
the vagina
 Third Degree : Complete inversion
outside the Vagina

9. 1st Degree
- Inverted fundus
up to cervix
2nd Degree
- Body of uterus
protrudes through
cervix into vagina
3rd Degree
- Prolapse of
inverted uterus
outside vulva

11. C. According to Timing of
Event
 Acute : It occurs within 24 hrs of
delivery.
 Sub-acute : It presents between 24 hrs
& 4 wks of delivery.
 Chronic : It presents beyond 4 wks of
delivery or in non pregnant stage.

12. CAUSES
Excessive cord traction (esp. with an
unseparated placenta)
Excessive fundal pressure (esp. when
uterus is poorly contracted Atonic)
Placenta accreta
Congenital predisposition
 Fundal implantation of placenta
 Either Spontaneous OR Iatrogenic
causes.

13. Conti…
Spontaneous (40%) :


 Abnormal short umbilical cord or
functionally shortened by being wrapped
around the fetal body.
 Sudden rise in intra abdominal pressure
due to maternal coughing or vomiting.
Morbid adherence of fundally implanted
placenta
Connective tissue disorder such as
Marphan’s syndrome.

14. Conti…
Latrogenic:
Due to mismanagement of third stage of labor…
 Pulling the cord when the uterus is atonic while
combined with fundal pressure
 Crede’s Expression while the uterus is relaxed
 Faulty technique in manual removal of placenta
While separating retained placenta from the wall, a
portion may remain attached and as the placenta
is withdrawn, the fundus is also withdrawn.

15. RISK FACTORS
uterine over enlargement
prolonged labor
fetal macrosomia
uterine malformations
morbid adherent placenta
short umbilical cord
Tocolysis and manual removal of placenta.
It is more common in women with collagen
disease like Ehler-Danlos syndrome.
( connective tissue disorder affects skin,joints
and blood vessels)

16. PATHOPHYSIOLOGY
a portion of uterine wall prolapses through the
dilated cervix or indents forward
relaxation of part of the uterine wall
simultaneous downward traction on the fundus
leading to inversion of the uterus.

17. Sign & Symptoms
Hemorrhage (94%)
Severe abdominal pain in 3rd stage
Hypotension with Bradycardia: shock out of
proportion to the blood loss (neurogenic due to
increased vagal tone)
Uterine fundus not palpable abdominally
Mass in the vagina on vaginal examination.
Sudden cardiovascular collapse
Lump in the vagina
Abdominal tenderness
Absence of uterine fundus on abdominal palpation

18. Conti…
 Shock
Shock is initially out of proportion with the amount
of blood loss.
Woman becomes sweaty with bradycardia,
profound hypotension and rarely cardiac arrest.
 In short time there is marked hemorrhage and
Hypovolemic shock.

19. DIAGNOSIS
The diagnosis of uterine inversion is based
upon clinical findings:
Bleeding, which may be severe and result in
Hemorrhagic Shock
Palpation of the prolapsed uterine fundus:
Lower uterine segment =
Vagina =
INCOMPLETE
COMPLETE
By Intra Uterine Manual Examination

20. DIAGNOSIS
Symptoms: Acute lower abdominal pain with bearing
down sensation.
Signs:
(1) Varying degree of shock is a constant feature,
(2) Abdominal examination—(a) Cupping or dimpling of
the fundal surface, (b) Bimanual examination not only
helps to confirm the diagnosis but also the degree. In
complete variety, a pear-shaped mass protrudes
outside the vulva with the broad end pointing
downward and looking reddish purple in color, (c)
Sonography can confirm the diagnosis when clinical
examination is not clear.

21. Dr Shashwat Jani. 9909944160 22
Management

22. Uterine Inversion
Remove placenta
Oxytocic infusion
(40 units/500mls
NS)
Antibiotics observe
O’Sullivan hydrostatic method
-dependent part replace into
vagina
-5L or more physiological
solution deposited onto
posterior fornix
-assistant create water tight
seal
Manual reduction
-apply pressure to
dependent part of
uterus
-simultaneous
pressing with other
hand on other part
which inverted last
GA/ stabilize
patient
UTERUS
REPLACED
Immediate
replacement
Resuscitate, IV
access, fluids/ bolus
replacement
NO
YES

23. Conti…
Teamwork = resuscitation + uterine
repositioning simultaneously
postpartum hemorrhage drill.
The quickest way to treat neurogenic
shock - to replace the uterus.

24. BEFORE SHOCK DEVEOPS
Call for extra help
Before the shock develops, urgent manual replacement
even without anesthesia can be done in emergent situation.
Principal steps: The patient is under general anesthesia.
(1) To replace that part first, which is inverted last with the
placenta attached to the uterus by steady firm pressure
exerted by the fingers.
(2) To apply counter support by the other hand placed on the
abdomen.
(3) After replacement, the hand should remain inside the
uterus until the uterus becomes contracted by parenteral
oxytocin or PGF2α.

25. (1) The placenta is to be removed manually
only after the uterus becomes contracted.
The placenta may however be removed
prior to replacement—(a) to reduce the bulk
which facilitates replacement or (b) if
partially separated to minimize the blood
loss,
(2) Usual treatment of shock including blood
transfusion should be arranged
simultaneously.

26. AFTER SHOCK DEVEOPS
Principal Steps:
(1) The treatment of shock should be instituted with an
urgent normal saline infusion and blood transfusion.
(2) The inverted fundus lies on the palm of the hand with
the fingers placed near the utero cervical junction.
When pressure is exerted on the fundus, it gradually
returns into the vagina. The vagina is packed with
antiseptic roller gauze.
(3) Foot end of the bed is raised
(4) Replacement of the uterus using hydrostatic method
(O’Sullivan’s) under general anesthesia is to be done
along with resuscitative measures. Hydrostatic
method is quite effective and less shock producing. of
the uterus.

27. Hydrostatic method: The inverted uterus is replaced into
the vagina. Warm sterile fluid (up to 5 liters) is gradually
instilled into the vagina through a douche nozzle. The
vaginal orifice is blocked by operator’s palms
supplemented by labial apposition around the palm by
an assistant. Alternatively, a silicon cup (vacuum
extraction cup) is placed into the vagina. The douche
can be placed at a height of about 3 feet above the
uterus. The water distends the vagina and the
consequent increased intra vaginal pressure leads to
replacement.

28. SUBACUTE STAGE
(1) To improve the general condition by blood
transfusion,
(2) Antibiotics are given to control sepsis,
(3) Reposition of the uterus either manually or by
hydrostatic method may be tried,
(4) If fails, reposition may be done by abdominal
operation (Haultain’s operation).

31. Mx of Acute Inversion of Uterus
Delay in treatment increases the mortality, So
number of steps are taken immediately and
simultaneously.
Before shock develops :
When one is on the spot when the inversion happens
TRY IMMEDIATE MANUAL REPLACEMENT, even
without anesthesia if not easily available.
Principle :
“ The part of the uterus which has come
down last , should go back first. “

32. Procedure
If the diagnosis is made immediately after
the inversion has occurred, then that same
degree of relaxation of myometrium and
cervix (which is required for the inversion to
occur) will allow uterine replacement
easily…
1. The gloved hand is lubricated with suitable
antiseptic cream and placed inside the vagina.
2. The uterine fundus with or without the
attached placenta, is cupped in the palm of the
hand. The fingers and thumb of the hand are
extended to identify margins of the cervix.

33. 3. The whole uterus is
lifted upwards towards
and beyond umbilicus
4. Additional pressure is
exerted with the
fingertips systematically
and sequentially to
push and squeeze the
uterine wall back
through the cervix.
29
Dr Shashwat Jani. 9909944160

34. 5. Sustained pressure for 3-5 mins to achieve
complete replacement
6. Apply counter support by the other hand
placed on the abdomen
7. Once the fundus has been replaced keep
the hand in the uterus while rapid infusion
of oxytocin is given to contract the uterus.
Initially, bimanual compression aids in
control of further hemorrhage until uterine
tone is recovered.

35. 8. When the uterus is felt contracting, the hand
is slowly withdrawn.
If placenta is attached, it is to be removed only
after the uterus becomes contracted.
If the placenta is partially attached , it should
be peeled out before replacement of uterus.

37. 1) Starting from the edge of placenta ,
2) The placenta is separated by
a)keeping the back of the hand in contact with the
uterine wall.
b) with slicing movement of the hand.
33
Dr Shashwat Jani. 9909944160

38. O’Sullivan’s hydrostatic
method
Tube passed into the
posterior fornix
Assistant close vulva
around operator’s wrist
Warm saline run in
until pressure gradually
restores position of
uterus

39. Silicon Vacuum cup

41. Alternatively the tubing can be attached to
sialistic vacuum extracter cup which is placed
inside introitus and may provide better seal.
As the vaginal wall distends, there is increase
in intravaginal pressure, the fundus of uterus
rises and inversion is corrected
Once this is achieved, fluid is allowed to escape
slowly from vagina.
Dr Shashwat Jani. 9909944160 37

43. Conti…
If this technique fails, Haultain's Operation
can done.
In this following steps are taken:
Exteriorize the uterus
Cervical ring may be stretched

45. Spinellis’s method
Kustner’s method
Hysterectomy
41
Vaginal route

46. SPINELLI’S METHOD
Anterior Colpotomy is done and incision
on the constricting cervical ring is given
for the replacement of uterus .

47. KUSTNER’S METHOD
Posterior Colpotomy is done and incision of the
cervix similar to that of spinelli’s method.
43

48. Hysterectomy
 Failure of conservative surgery
 Family is completed
 sepsis
Dr Shashwat Jani. 9909944160 44

49. MANEUVERS : TO BE AVOIDED
Excessive traction on the umbilical cord
Excessive fundal pressure
Excessive intra-abdominal pressure
Excessively vigorous manual removal of
placenta.
45
Dr Shashwat Jani. 9909944160

51. Prevention
 Do not employ any method to expel the
placenta when the uterus is relaxed
 Patient should not be instructed to change her
position.
 Pulling the cord simultaneously with fundal
pressure should be avoided
 Manual removal of placenta should be done in
proper manner.
47
Dr Shashwat Jani. 9909944160

52. DANGERS
(1) Shock is extremely profound mainly of neurogenic
origin due to—(a) tension on the nerves due to
stretching of the infundibulopelvic ligament, (b)
pressure on the ovaries as they are dragged with the
fundus through the cervical ring and (c) peritoneal
irritation.
(2) Hemorrhage, especially after detachment of placenta,
(3) Pulmonary embolism
(4) If left uncared for, it may lead to—(a) infection, (b)
uterine sloughing and (c) a chronic one.

53. PROGNOSIS
The prognosis is extremely gloomy. Even if the
patient survives, infection, sloughing of the uterus
and chronic inversion with ill health may occur

54. Bibliography
1. D.C. DUTTA’S ; ‘‘A TEXT BOOK OF OBSTETRICS’’
SEVENTH EDITION;PUBLISHED BY NEW CENTRAL BOOK AGENCY
MEDICAL PUBLISHERS (P) LIMITED;KOLKATA;
P.NO.420 TO 421.
2. PV BOOKS; ‘‘ A TEXT BOOK OF MATERNAL HEALTH NURSING’’
FIFTH EDITION;EDITED BY R.K.GUPTA;P.NO. TO 500.
3. MYLES; ‘‘A TEXT BOOK FOR MIDWIVES’’ SIXTEENTH EDITION;
INTERNATIONAL EDITION;PUBLISHED BY SAUNDERS ELSEVIER;
EDITED BY JAYNE MARSHALL & MAUREEN RAYNOR
P NO.- 510 TO 515
4. WEBPAGE; ‘‘WWW.WIKIPEDIA.COM & WWW.ENCYCLOPEDIA.COM’’;
TOPIC OF UTERINE INVERSION ;TEXT AND PICTURES OF ANAEMIA BY
DR.KIRAN SADHU,R.N.R.M PROFESSOR.
5. WEBPAGE;‘‘WWW.GOOGLE.COM & WWW.SLIDESHARE.COM”;
TOPIC OF UTERINE INVERSION;TEXT AND PICTURES;BY
RUCHITA BHATT,R.N.R.M.LECTURER