INVERSION OF UTERUS

Mrs. Shwetha Rani C.M.

Associate Professor & H.O.D.
Department of Obstetric & Gynecological Nursing
SCPM College Of Nursing & Paramedical Sciences,
Gonda. U.P.
OBJECTIVES
• To learn about uterine inversion
• To learn how to diagnose uterine inversion
• To Learn what are the causes of uterine inversion
• To learn What are the Treatment of Uterine Inversion
• Steps to manage uterine inversion
Content
• Introduction Of Topic
• Definition
• Classification of Inversion of Uterus
• Degrees
• Causes
• Pathophysiology
• Sign & Symptoms
• Diagnosis
• Management
• Prevention
Introduction
• This is Rare. But Potentially Life. Threatening Complication of the
Third Stage Of Labour.
• It Occurs in Approximately 1 in 20,000 Deliveries
• The Obstetric Inversion is almost always an Acute One & Usually
Complete.
DEFINITION
• ‘‘ When Uterus Turns Inside Out, It Is Called Uterine Inversion.”
• ‘‘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.
CLASSIFICATION
• Inversion Of Uterus is Classified in Mainly 3 Types :

A. According Types
B. According Degrees
C. According the Timing of Event
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.
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
Universally….
• First Degree : Incomplete Inversion.
• Second Degree : Complete inversion in the vagina.
• Third Degree : Complete inversion outside the Vagina.
• 1st Degree • 2nd Degree • 3rd Degree
- Inverted fundus up - Body of uterus - Prolapse of
to cervix protrudes through inverted uterus
cervix into vagina outside vulva
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.
CAUSES
• 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
• Either Spontaneous OR Iatrogenic causes.
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.
• Morbid adherence of fundally implanted placenta
• Connective tissue disorder such as Marphan’s syndrome.
Conti…
• Latrogenic:
• Due to mismanagement of third stage of labor…
❑ Pulling the cord when the uterus is atonic while combined with
fundal pressure.
❑ Crede’s Expression while the uterus is relaxed.
❑ 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.
PATHOPHYSIOLOGY
• a portion of uterine wall prolapses through the
dilated cervix or indents forward

• relaxation of part of the uterine wall

• simultaneous downward traction on the fundus

• leading to inversion of the uterus.

Sign & Symptoms
• Hemorrhage (94%)
• Severe abdominal pain in 3rd stage
• Hypotension with Bradycardia: shock out of proportion to the blood loss
(neurogenic due to increased vagal tone)
• 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
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.

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 = INCOMPLETE
• Vagina = COMPLETE
• By Intra Uterine Manual Examination
DIFFRENTIAL DIAGNOSIS
• Inversion of uterus
• Uterine rupture.
• Prolapse of uterine tumor (submucous fibroid).
• Large endometrial polyp.
• Passage of succenturiate lobe of placenta.
 Management Uterine Inversion

Resuscitate, IV access, fluids/ bolus replacement

Immediate replacement

UTERUS REPLACED NO
YES
GA/ stabilize patient
Remove placenta Manual reduction - O’Sullivan hydrostatic
Oxytocic infusion apply pressure to method -dependent part
(40 units/500mls dependent part of replace into vagina -5L or
uterus –simultaneous more physiological solution
NS) pressing with other deposited onto posterior
Antibiotics observe hand on other part fornix -assistant create water
which inverted last tight seal
Conti…
• Teamwork = resuscitation + uterine repositioning simultaneously
• postpartum hemorrhage drill.
• The quickest way to treat neurogenic shock - to replace the uterus.
Mx of Acute Inversion of Uterus
• 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. “
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.
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.
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.
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.
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.
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
• Alternatively the tubing can be attached to sialistic vacuum extracter
cup which is placed inside introitus and may provide better seal.
• As the vaginal wall distends, there is increase in intravaginal pressure,
the fundus of uterus rises and inversion is corrected
• Once this is achieved, fluid is allowed to escape slowly from vagina.
Conti…
• If this technique fails, Haultain's Operation can done.
• In this following steps are taken:

❑ Exteriorize the uterus

❑ Cervical ring may be stretched
Vaginal route
• Spinellis’s method
• Kustner’s method
• Hysterectomy
SPINELLI’S METHOD
• Anterior Colostomy is done and incision on the constricting
cervical ring is given for the replacement of uterus .

KUSTNER’S METHOD
• Posterior Colpotomy is done and incision of the cervix similar to that
of spinelli’s method.

Hysterectomy
• Failure of conservative surgery
• Family is completed
• Sepsis
MANEUVERS : TO BE AVOIDED
• Excessive traction on the umbilical cord
• Excessive fundal pressure
• Excessive intra-abdominal pressure
• Excessively vigorous manual removal of placenta.
Prevention
• 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.
 Bibliography
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EDITION;EDITED BY R.K.GUPTA;P.NO. TO 500.
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JAYNE MARSHALL & MAUREEN RAYNOR P NO.- 510 TO 515
• 4. WEBPAGE; ‘‘WWW.WIKIPEDIA.COM & WWW.ENCYCLOPEDIA.COM’’;
TOPIC OF UTERINE INVERSION ;TEXT AND PICTURES OF ANAEMIA BY
DR.KIRAN SADHU,R.N.R.M PROFESSOR.
• 5. WEBPAGE;‘‘WWW.GOOGLE.COM & WWW.SLIDESHARE.COM”; TOPIC OF
UTERINE INVERSION;TEXT AND PICTURES;BY RUCHITA
BHATT,R.N.R.M.LECTURER