Learning Objectives
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List risk factors for uterine inversion.
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Recognize clinical presentation of uterine inversion.
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Describe management of uterine inversion.
Uterine inversion occurs when the fundus of the uterus collapses after delivery and, in its most severe form, delivers through the vagina ( Fig. 19.1 A-B ) . If not quickly recognized, it has a reported maternal mortality rate as high as 15%.
Risk Factors
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Fundal placenta
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Uterine atony (or use of medications such as magnesium that reduce uterine tone)
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Placenta accreta
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Short cord
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Connective tissue disorders
Diagnosis
Complete uterine inversion is easily diagnosed by palpation of the uterine fundus within or beyond the vaginal introitus. More subtle cases of uterine inversion can be diagnosed by heavy postpartum bleeding with a nonpalpable uterine fundus. Uterine inversion can also be visualized sonographically with the inverted fundus directed caudally instead of the usual cephalad orientation.
Management
The priority in management is to replace the uterine fundus to its correct anatomic position ( Table 19.1 ).
| Stepwise Maneuvers for Uterine Inversion |
|---|
|
| Time | Comments | ||
|---|---|---|---|
| Call for help | Emergency call bell | ||
| Clearly stated the problem | |||
| Requested specific personnel and supplies | |||
| Circulation | Inserted IV cannula (needs 2 large bore IV’s) | ||
| Took blood pressure | |||
| Requested blood—considered giving O negative if indicated | |||
| Measured blood loss | |||
| Replacement of uterus | Stopped uterotonics | ||
Considered uterine relaxant:
| |||
| Placenta left in situ until uterus replaced | |||
| Attempted to manually replace uterus | |||
| If necessary, consideration given to laparotomy | |||
| Uterotonics given after uterus replaced | |||
| Documentation | Timing of events | ||
| Medication administered | |||
| Persons present | |||
| Communication | Call-out | ||
| Directed communication | |||
| Closed-loop communication |
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