NOTES FOR UNDERGRADUATES AND POSTGRADUATES IN GYNE

1. DR.PRIYA SAXENA

2. CLASSIFICATION
 According to extent of inversion:
 First degree: dimpling of fundus, fundus well above the internal os.
 Second degree: fundus passes through the internal os but not upto the
introitus
 Third degree: fundus extends to the introitus
 Fourth degree: uterus completely turned inside out and lies partly outside
the vulva

3.  On the basis of time of diagnosis:
 Acute inversion: detected within 24 hours of delivery
 Subacute: after 24 hours but within 4 weeks of delivery
 Chronic: after 4 weeks of delivery

4. ETIOLOGY
 Spontaneous inversion: can occur with atonic uterus due to raised intra-
abdominal pressure like coughing or sneezing
 Iatrogenic: occurs due to mismanagement of placental delivery like use of
crede’s method

5. SYMPTOMS
 Severe pain in lower abdomen and pelvis with feeling of something coming
out.
 Immediate life threatening hemorrhage
 Shock- excessive
 Sudden postpartum collapse
 If untreated, it may cause:
o Uterine sloughing
o Chronic inversion
o Infection

6. SIGNS
 Hemorrhage
 Shock
 Abdominal examination: dimpling of uterine fundus
 Vaginal examination: confirms the diagnosis and severity of inversion
 Complete inversion- a soft globular reddish purple mass visible outside the
vulva or vagina
 Portable ultrasound: can confirm the diagnosis

7. TREATMENT
 Call for assistance including an anesthetic
 Two iv infusion systems are started with two large bone cannulae and
dextrose saline or ringer lactate solution and blood is given to treat
hypovolemia.
 Manual reposition of the uterus:
 The palm of the hand is placed against the inverted fundus as if holding a
tennis ball with the finger tips exerting upward pressure circumferentially at
the uterocervical junction.
 The principle of reduction is that the part which comes down first is the last
to go. Hence fundus is last to go.

8.  Once the uterus is restored to its normal position, the anesthetic agent used
to provide relaxation is stopped and oxytocin drip is started to contract the
uterus while the operator manually keeps the fundus in normal position.
 Uterus may also be reposed with placenta attached to it.
 When uterus becomes contracted with oxytocin drip, placenta is removed
manually.

9. OTHER METHODS
 O’Sullivan’s hydrostatic method:
 The operator occludes the vaginal introitus with his hand and a large volume
of warm saline upto 5L is infused with a douche nozzle to distend the
vagina which pushes the fundus back to its position.

10. SURGICAL METHODS
 Vaginal
 Spinelli’s method
 Kustner’s method
 Abdominal
 Huntington’s method
 Robinson’s operation
 Haultain’s technique

11. VAGINALAPPROACH
 Spinelli’s method: Cutting the ring anteriorly and repositioning the uterus
is the most common surgical procedure.
 Kustner’s method: Cutting the ring posteriorly and repositioning the uterus

12. ABDOMINALAPPROACH
 Huntington’s method:
 Allis forcep placed at the dimple of the inverted fundus
 Gentle upward traction is applied
 Forceps are further advanced till fundus is reposited
 Robinson’s operation:
 Cutting the ring anteriorly and repositioning the fundus back
 Haultain’s technique:
 If constriction ring prohibits repositioning it is incised posteriorly with
longitudinal incision
 Fundus is reposited by operator using his fingers and uterus repaired in 2
layers.

13. THANK YOU