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Uterine Inversion


Learning Objectives

  • List risk factors for uterine inversion.

  • Recognize clinical presentation of uterine inversion.

  • 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%.

Fig. 19.1
Uterine inversion with placenta (A) ; Uterine inversion with placenta and umbilical cord (B) .

Risk Factors

  • Fundal placenta

  • Uterine atony (or use of medications such as magnesium that reduce uterine tone)

  • Placenta accreta

  • Short cord

  • 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 ).

Table 19.1
Stepwise Maneuvers for Uterine Inversion

  • Manual replacement of uterus with fist/fingers

  • Transvaginal hydrostatic pressure

  • Perform laparotomy

  • Replacement of uterus with traction on round ligaments

  • Posterior colpotomy with digital replacement of uterus

Simulation Checklist
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:

  • Terbutaline 0.25 mg SQ

  • Nitroglycerin 50–500 mcg IV in aliquots of 50–100 mcg

  • Halothane general anesthesia

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

Uterine Inversion Simulation

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