Acute inversion of the uterus

a rare but potentially life-threatening complication of the third stage of labour. - A midwife's awareness of the precipitating factors enables her to take preventive measures to avoid this emergency.

Classification of inversion according to severity : 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 fundus protrudes to or beyond the introitus and is visible fourth degree: this is total uterine and vaginal inversion where both the uterus and vagina are inverted beyond the introitus. Inversion is also classified according to the timing of the event: acute inversion: occurs within the first 24 hours subacute inversion: occurs after the first 24 hours, and within 4 weeks

chronic inversion: occurs after 4 weeks and is rare

Causes associated with uterine atony and cervical dilatation, and include: mismanagement in the third stage of labour, involving excessive cord traction to manage the birth of the placenta combining fundal pressure and cord traction to expel the placenta use of fundal pressure to expel the placenta while the uterus is atonic pathologically adherent placenta spontaneous occurrence, of unknown cause primiparity fetal macrosomia

short umbilical cord sudden emptying of a distended uterus. Careful management of the third stage of labour is needed to prevent inversion of the uterus. In active management of the third stage of labour, palpation of the fundus is essential to confirm that contraction has taken place, prior to undertaking controlled cord traction.

Warning signs and diagnosis profound shock and usually haemorrhage. The blood loss is within a range of 800–1800 ml. severe abdominal pain. On palpation of the uterus, the midwife may feel an indentation of the fundus. Where there is a major degree of inversion the uterus may not be palpable abdominally but may be felt upon vaginal examination or, in a severe case, the uterus may be seen at the vulva.

The pain is thought to be caused by the stretching of the peritoneal nerves and the ovaries being pulled as the fundus inverts. Bleeding may or may not be present, depending on the degree of placental adherence to the uterine wall.

Management Immediate action. vital signs, including level of consciousness Urgent medical help. to replace the uterus. If replacement is delayed the uterus can become oedematous and replacement will become increasingly difficult.

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 known as Johnson's manoeuvre.

If replacement cannot be achieved immediately the foot of the bed can be raised to reduce traction on the uterine ligaments and ovaries cannula should be inserted and blood taken for cross-matching prior to commencing an infusion. Analgesia such as morphine may be given to the woman. 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 midwife or obstetrician should keep their hand in situ until a firm contraction is palpated. Oxytocics should be given to maintain the contraction

Medical management The hydrostatic method of replacement involves the instillation of several litres of warm saline infused through a giving set into the vagina. The pressure of the fluid builds up in the vagina and restores the uterus to the normal position, while the midwife or obstetrician seals off the introitus by hand or using a soft ventouse cup.

If the inversion cannot be replaced manually, a cervical constriction ring may have developed. Drugs can be given to relax the constriction and facilitate the return of the uterus to its normal position. Surgical correction via a laparotomy may be needed to correct inversion.

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