Inversion Of Uterus

Joshi Abhishek
F.Y.P.B.B.SC.Nursing
Govt College of Nursing
Jamnagar

OBJECTIVES
1. To learn about uterine inversion
2. To learn how to diagnose uterine inversion
3. To Learn what are are the causes of
uterine inversion
4. To learn What are the Treatment of Uterine
Inversion
5. 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 Lobour.
 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
- Inverted fundus
up to cervix
2nd Degree
- Body of uterus
protrudes through
cervix into vagina
3rd Degree
- Prolapse of
inverted uterus
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.

Dr Shashwat Jani. 9909944160 22
Management

Uterine Inversion
Remove placenta
Oxytocic infusion
(40 units/500mls
NS)
Antibiotics observe
O’Sullivan hydrostatic method
-dependent part replace into
vagina
-5L or more physiological
solution deposited onto
posterior fornix
-assistant create water tight
seal
Manual reduction
-apply pressure to
dependent part of
uterus
-simultaneous
pressing with other
hand on other part
which inverted last
GA/ stabilize
patient
UTERUS
REPLACED
Immediate
replacement
Resuscitate, IV
access, fluids/ bolus
replacement
NOYES

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.
29Dr Shashwat Jani. 9909944160

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

 Spinellis’s method
 Kustner’s method
 Hysterectomy
41
Vaginal route

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.
43

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
1. D.C. DATTA’S ; ‘‘A TEXT BOOK OF OBSTETRICS’’
SEVENTH EDITION;PUBLISHED BY NEW CENTRAL BOOK AGENCY
MEDICAL PUBLISHERS (P) LIMITED;KOLKATA;
P.NO.420 TO 421.
2.PV BOOKS; ‘‘ A TEXT BOOK OF MATERNAL HEALTH NURSING’’
FIFTH EDITION;EDITED BY R.K.GUPTA;P.NO. TO 500.
3.MYLES; ‘‘A TEXT BOOK FOR MIDWIVES’’ SIXTEENTH EDITION;
INTERNATIONAL EDITION;PUBLISHED BY SAUNDERS ELSEVIER;
EDITED BY 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

49Dr Shashwat Jani. 9909944160.

Inversion Of Uterus

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