On successfully completing this topic, you will be able to:
recognise and manage uterine inversion.
Introduction
Reported incidence ranges from 1/2000 to 1/6400. Although it has often been thought to be related to mismanagement of the third stage, uterine inversion was found even in an institution that did not use the Crede’s manoeuvre, where they strongly discourage vigorous cord traction and where oxytocin was not given until after placental separation. Brar et al. found a fundal placenta in the majority of women.1 Other associated obstetric conditions include a short cord, a morbidly adherent placenta and uterine anomalies.
Inversion of the uterus can be puerperal and nonpuerperal. However, chronic nonpuerperal uterine inversions are rare. In a study by Mwinyoglee et al., only 77 cases were reported; 75 (97.4%) were tumour-produced and 20% of these tumours were malignant.2
Puerperal uterine inversions can follow vaginal delivery or occur at CS. Usual causes are cord traction before the uterus has contracted, but especially when there is a short umbilical cord, fundal insertion of placenta or an adherent placenta. Prompt understanding and repositioning by manual replacement will prevent further complications.
Immediate, nonsurgical measures are successful in the vast majority of cases of uterine inversion. The pooled experience of Brar et al.1 and Watson3 demonstrated only three laparotomies requiring surgical reposition out of a total of 102 uterine inversions.
Recognition
Early recognition of uterine inversion is vital to enable prompt treatment and to reduce morbidity and mortality.
Symptoms and signs
These include:
severe lower abdominal pain in the third stage
shock that is out of proportion to the blood loss, owing to parasympathetic stimulation
haemorrhage (present in 94% of cases)
placenta may or may not be attached
uterine fundus not palpable per abdomen (in milder degrees there may be a dimple in the fundal area)
pelvic examination showing a mass in the vagina (in milder degrees) or at/outside the introitus; if the placenta is still attached then it is palpable/visible as above.
Prevention
Mismanagement of the third stage should be avoided, and cord traction should not be applied until the signs of placental separation are apparent.
Management
1 Call for help (experienced obstetrician/anaesthetist/midwives).
2 Arrange replacement of uterus concurrently with antishock measures, as resuscitation may not be successful until the inversion is corrected. Sometimes the delivering attendant may be successful at immediate replacement, within seconds of the inversion.
3 Insert two wide-bore intravenous cannulae.
4 Collect blood for full blood count, coagulation studies and group and crossmatch (4–6 units).
5 Start fluid replacement immediately (colloids and crystalloids).
6 Continuously monitor blood pressure, pulse, respiratory rate, urine output, O2 saturation.
7 If the bradycardia is pronounced, atropine can be administered.
8 Arrange appropriate analgesia.
9 Transfer to theatre.
10 If oxytocin has been running it should be stopped, as replacement requires the uterus to be relaxed.
11 If the placenta is still attached, it should be left as such until after repositioning. Attempts to remove the placenta may result in major bleeding, as there will be no uterine muscular contraction to constrict blood vessels in the placental bed.
12 Attempt to reposition the uterus; the earlier the restoration, the more likely the success.
Replace the uterus using one of the following techniques:
Manual replacement
Manual replacement should be performed preferably under general anaesthesia. The uterus may require relaxation for manual replacement to succeed, and the aim should be to reduce the uterus in the order of ‘last out first back in’, gradually progressing such that the first bit out (the fundus) is replaced last. Once the replacement is complete the hand should be left inside the uterus while a uterotonic is administered and only when the uterus has contracted should a manual removal of the placenta ensue, with precautions for and treatment of postpartum haemorrhage.
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