Uterine inversion occurs when the uterus turns inside out, most commonly during the third stage of labor. It has an incidence of 1 in 2000 deliveries. The main causes are mismanagement of the third stage through excessive cord traction or fundal pressure. Uterine inversion can be first, second, or third degree depending on how far the inversion has progressed. Clinical presentation includes abdominal pain, postpartum hemorrhage, and shock. Management involves prompt recognition and replacement of the inverted uterus manually or through hydrostatic replacement, with tocolytics as needed. Prevention focuses on controlled cord traction and avoiding fundal pressure before signs of placental separation.

1. Uterine inversion SALSO Course Sarawak General Hospital Uterine inversion

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3. Uterine inversion Incidence : 1 in 2000 deliveries Causes : Mismanagement of 3 rd stage Excessive cord traction (esp. with an unseparated placenta) Excessive fundal pressure (esp. when uterus is poorly contracted @ atonic) Placenta accreta Congenital predisposition Fundal implantation of placenta

4. Classification 1 st Degree - Inverted fundus up to cervix 2 nd Degree - Body of uterus protrudes through cervix into vagina 3 rd Degree - Prolapse of inverted uterus outside vulva

5. Clinical presentation Abdominal pain Post-partum haemorrhage Sudden collapse – degree of shock may be inconsistent with the amount of blood loss Absence of uterine fundus @ depression over fundus Fleshy mass at or outside the introitus (dark red-blue bleeding mass)

6. Management Prompt recognition and treatment Should be suspected if profound shock without obvious explanation Treat vasovagal shock (i.e. ABC, IV access, GXM) Placental should not be detached until the uterus is replaced and contracted Replace uterus immediately- several techniques Manual or hydrostatic replacement Surgical replacement May require tocolytics, anaesthesia, or both

7. Manual replacement of uterus Replace by pressing first on that part of the uterus which inverted last Once replaced, keep hand inside uterus until ergotmetrine or oxytocin has produced a firm contraction

8. O’Sullivan’s hydrostatic method Tube passed into the posterior fornix Assistant close vulva around operator’s wrist Warm saline run in until pressure gradually restores position of uterus

9. Surgical replacement of uterus Constricting ring stretched Posterior part of ring divided Fundus hooked up and resutured

10. Prevention Controlled Cord Traction – avoid excesive traction Wait - Signs of placental separation NO Fundal Pressure