Guidelines for the Management of Acute Inversion of the Uterus The Queen Mothers Hospital

Acute inversion of the uterus is a very rare complication occurring in approximately 1:25,000 deliveries. Causes: Fundal insertion of the placenta is reported in 75% of cases and this accompanied by uterine atony are considered to be the important underlying factors. Cord traction before placental separation, abnormal placental adhesion, raised abdominal pressure and a shortened cord are precipitating factors. There are four stages of inversion: Stage 1 - The fundus begins to turn inside out but does not pass through the cervical ring. Stage 2 - The fundus passes through the cervical ring, enters the vagina but does not protrude from the introitus. Stage 3 - The inverted fundus protrudes from the introitus. Stage 4 - The vagina is inverted also. Patients with Stage 1 may present with constant uterine pain and early signs of shock. Patients with Stage 2 & 3 may present with unexplained postpartum collapse and severe clinical shock. Uterine inversion pulls the ovaries into the inverted space and can cause sudden shock. Reduction of the inversion results in a rapid improvement in the patients condition. To diagnose inversion, palpate the fundus. In Stage 1 you may feel a dimple in the mid-line. In Stages 2 and 3 you will be unable to palpate the fundus abdominally. The diagnosis of Stage 2 must be confirmed by vaginal examination, in Stage 3 there is an obvious mass at the vulva. Management: Immediately summon the obstetric emergency team Gain IV access and send bloods for FBC and cross-match 4 units & catheterise the bladder Establish the diagnosis & determine whether the placenta is attached to the uterus. It is recommended that no attempts be made to remove the placenta as this can lead to a severe PPH.

Inverted Uterus Author(s): Labour Suite Review Date: October 2007

Version: 1.1 Approved: Labour Suite Forum Ref No: YOR-LBS-022

Page 1 of 2 Issue Date: October 2004

Manual Replacement: If you are present at the inversion, immediately attempt to push the uterus upwards into the vagina, controlling the upward force bi-manually. This should return the uterus through the cervix while the uterine atony persists and relieve the shock. Keep the hand in the uterine fundus. Sustained pressure lasting several minutes is usually required. After replacement of the uterus, give Syntocinon 10iu IV followed by 40 units in 500mls over 4hrs. Manually remove the placenta if attached. Transient tocolysis with Terbutaline (A SC injection of 0.25mgs or infusion as per manufacturers data sheet) or Ritodrine 5mgs IV may be required to relax the cervical ring. If this fails elevate the foot of the bed and push the inverted mass into the vagina. DO NOT give oxytocic agents. Treat shock as required by volume expanding fluids, oxygen and continuous monitoring of patients vital signs. Keep an accurate record of fluid balance. If the inversion cannot be reduced immediately, proceed to the intravaginal hydrostatic pressure method. Insert a detached silastic ventouse cup into the vagina towards the posterior fornix and hold it there with your hand. Attempt to close the area around the introitus with the labia and pour copious warm sterile fluid through the ventouse cup tubing. The hydrostatic pressure created can dramatically reduce the inversion. When the uterus is replaced, give oxytocic drugs as above and manually remove the placenta if still attached. Surgical Correction: Huntington Procedure: Allis forceps are placed within the dimple of inverted fundus & gentle upward traction exerted with the clamps with further placement of forceps on the advancing fundus. Haultain Procedure: Make a posterior incision in the cervical ring and manually reduce the inversion. Repair the incision after giving oxytocin and manually remove the placenta. *All these procedures should be covered by IV Antibiotics. Document all findings and actions in detail within the case record.

Inverted Uterus Author(s): Labour Suite Review Date: October 2007

Version: 1.1 Approved: Labour Suite Forum Ref No: YOR-LBS-022

Page 2 of 2 Issue Date: October 2004