1) Uterine inversion occurs when the uterus turns inside out, and can range from partial to complete. It has a very low incidence rate of about 1 in 20,000 deliveries. 2) The main classifications are by type (incomplete or complete), degree (how far the inversion has progressed), and timing (acute within 24 hours or chronic beyond 4 weeks postpartum). 3) Risk factors include excessive cord traction, fundal pressure, placenta accreta, and connective tissue disorders. Symptoms include hemorrhage, abdominal pain, and shock. 4) Treatment of acute inversion involves immediate manual repositioning if possible, IV fluids, antibiotics, and surgical re

1. Edna Dahir

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
‘‘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 Types
B. According Degrees
C. According 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.

6. 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

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

8. 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.

9. CAUSES
Excessive cord traction (esp. with an
unseparated placenta)
Excessive fundal pressure (esp. when
uterus is poorly contracted Atonic)
Placenta accreta
Congenital predisposition

10. 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.
Connective tissue disorder such as
Marphan’s syndrome.

11. Conti…
Latrogenic:
Due to mismanagement of third stage of labor…
 Pulling the cord when the uterus is atonic while
combined with fundal pressure
 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.

12. Sign & Symptoms
Hemorrhage (94%)
Severe abdominal pain in 3rd stage
Hypotension with Bradycardia
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

13. 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.

14. 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

15. DIFFRENTIAL DIAGNOSIS
 Inversion of uterus
 Uterine rupture.
 Prolapse of uterine tumor (submucous
fibroid).

16. 22
Management

17. Prevention
17
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.

18. 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.
18

19. Management of Acute Inversion of Uterus
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• 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. “

20. 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.

21. 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.
29Dr Shashwat Jani. 9909944160

22. 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.

23. 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.

25. 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.
33Dr Shashwat Jani. 9909944160

26. If the patient comes late :
Within 1 -2 minutes, from the occurrence of inversion, the
cervix and lower segment clamps down inverted part of
the uterus.
increasing congestion, Edema of the inverted fundus.
makes manual replacement without anesthesia difficult.
If first attempt at immediate manual replacement of
uterus fails, move to the following sequence …
1. Call assistance
Anesthesiologist (assistance of nurse and obstetricians)
2. Elevation of the foot of the delivery table may relieve the
tension on the viscera and reduce the pain and shock
26

27. 3. Establish two wide bore i.v. cannulae.
Send blood for for grouping and cross match.
Rapidly run in 1-2 L of normal saline.
Because though initially shock is neurogenic
type, hypovolumia will follow due to hemorrhage.
4. Catheterize.
5. Prophylactic antibiotics are given
6. If pain is a dominant symptom, small doses of i.v.
Morphine is given.
7. If the inverted uterus is prolapsed beyond the vagina,
it is replaced within the vagina
8. Patient is shifted to OT.
9. Anaesthesia
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28. COMPLICATIONS OF
INVERSION OF UTERUS.
 Postpartum hemorrhage due to uterine atony.
 Hypovolaemic shock and all its consequence.
 Vasovagal shock (due to severe pain).
 Endometritis (sepsis).
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29.  Infection of adnexa.
 Necrosis of adnexa (ovaries)
 Damage to intestine .
 Chronic inversion.
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30. • Recurrence of inversion.
• Increased risk of rupture of uterus in next
pregnancy (when surgical procedure
done for inversion).
• Increased risk of C-section in
subsequent delivery.
• Chronic pelvic pain -> if chronic inversion is
not treated.
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31. PREVENTION
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• Many cases of acute
uterine inversion result
mainly from mismanagement
of the third stage of labour in
women who are already at
risk.

32. MANEUVERS : TO BE AVOIDED
• Excessive traction on the umbilical cord
• Excessive fundal pressure
• Excessive intra-abdominal pressure
• Excessively vigorous manual removal of
placenta.
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