Inversion of the uterus is a life-threatening complication where the uterus turns inside out, partially or completely. It occurs in about 1 in 20,000 deliveries. Prevention involves avoiding fundal pressure and pulling on the cord when the uterus is relaxed. Treatment depends on the degree of shock - for mild shock, manual replacement is attempted without anesthesia; for severe shock, replacement methods under anesthesia like hydrostatic replacement are used. Antibiotics are given to prevent infection.

1. INVERSION OF THE UTERUS

2. INVERSION OF THE UTERUS
• It is an extremely rare but a life-threatening complication in third
stage in which the uterus is turned inside out partially or
completely.
• The incidence is about 1 in 20,000 deliveries.

3. VARIETIES
• First degree—There is dimpling of the fundus, which still remains
above the level of internal os.
• Second degree—The fundus passes through the cervix but lies inside
the vagina.
• Third degree (complete)—The endometrium with or without the
attached placenta is visible outside the vulva. The cervix and part of
the vagina may also be involved in the process.

6. ETIOLOGY
The inversion may be spontaneous or more commonly induced.
Spontaneous (40%):
• This is brought about by localized atony on the placental site over the
fundus associated with sharp rise of intraabdominal pressure as in
coughing, sneezing or bearing down effort.
• Fundal attachment of the placenta (75%)
• short cord
• placenta accreta
• weakness of uterine wall at the placental site are often associated.

7. • Iatrogenic: This is due to the mismanagement of third stage of labor.
• Pulling the cord when the uterus is atonic especially when combined
with fundal pressure
• Fundal pressure while the uterus is relaxed
• Faulty technique in manual removal.

8. Common risk factors are
uterine over enlargement
prolonged labor
fetal macrosomia,
Uterine malformations
morbid adherent placenta
short umbilical cord
tocolysis
manual removal of placenta.

9. DANGERS:
(1) Shock is extremely profound mainly of neurogenic origin
(2) Hemorrhage, especially after detachment of placenta
(3) Pulmonary embolism
(4) If left uncared for, it may lead to—
(a) Infection
(b) uterine sloughing
(c) a chronic one.

10. DIAGNOSIS:
Symptoms: Acute lower abdominal pain with bearing down sensation.
Signs:
(1) Varying degree of shock is a constant feature
(2) Abdominal examination—
(a) Cupping or dimpling of the fundal surface
(b) Bimanual examination not only helps to confirm the diagnosis but also the degree. In
complete variety, a pear-shaped mass protrudes outside the vulva with the broad end
pointing downward and looking reddish purple in color
(c) Sonography

11. PREVENTION:
• Do not employ any method to expel the placenta out when the
uterus is relaxed.
• Pulling the cord simultaneous with fundal pressure should be avoided.
• Manual removal should be done in a manner, as it should be

12. MANAGEMENT:
• Call for extra help
• Before the shock develops- urgent manual replacement even without
anesthesia

13. Principal steps:
• The patient is under general anesthesia.
(1) To replace that part first, which is inverted last.
(2) To apply counter support by the other hand placed on the abdomen.
(3) After replacement, the hand should remain inside the uterus until the
uterus becomes contracted by parenteral oxytocin or PGF2α.

14. (4) The placenta is to be removed manually only after the uterus becomes
contracted.
The placenta may however be removed prior to replacement—
(a) to reduce the bulk which facilitates replacement
(b) if partially separated to minimize the blood loss
(5) Usual treatment of shock including blood transfusion should be
arranged simultaneously.

15. After the shock develops
Principal Steps:
(1) The treatment of shock should be instituted with an urgent NS infusion
and blood transfusion .
(2) The inverted fundus lies on the palm of the hand with the fingers placed
near the uterocervical junction. When pressure is exerted on the fundus,
it gradually returns into the vagina. The vagina is packed with antiseptic
roller gauze.
(3) Foot end of the bed is raised

16. • (4) Replacement of the uterus using hydrostatic method (O’Sullivan’s)
under general anesthesia

17. • The inverted uterus is replaced into the vagina.
• Warm sterile fluid (up to 5 liters) is gradually instilled into the vagina through a
douche nozzle.
• The vaginal orifice is blocked by operator’s palms supplemented by labial
apposition around the palm by an assistant.
• Alternatively, a silicon cup (vacuum extraction cup) is placed into the vagina.
• The douche can be placed at a height of about 3 feet above the uterus.
• The water distends the vagina and the consequent increased intravaginal pressure
leads to replacement of the uterus.

18. Sub acute stage:
(1) To improve the general condition by blood transfusion
(2) Antibiotics are given to control sepsis
(3) Reposition of the uterus either manually or by hydrostatic method
may be tried
(4) If fails, reposition may be done by abdominal operation