Uterine Inversion
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Direct answer
When the uterine fundus turns inside-out, the inner surface of the uterus protrudes into the cavity or through the cervix — uterine inversion, a rare but dramatic cause of shock and postpartum haemorrhage in which the collapse is often out of proportion to visible bleeding, because a neurogenic component adds to haemorrhage. The commonest mechanism is cord traction with fundal pressure on a placenta implanted over the fundus in a hypotonic uterus. Treatment is immediate manual replacement, ideally with the placenta still attached, using a uterine relaxant if needed, with oxytocin withheld until after the uterus is restored.
What you must remember
- Predisposing factors — fundal placental implantation, improper cord traction with fundal pressure (misapplied Crede manoeuvre), uterine atony, primigravidity, short cord, rapid delivery and connective tissue disorders.
- Degrees — first: fundus inverts into the cavity but does not cross the internal os; second: the inverted fundus passes through the cervix into the vagina; third: fundus prolapses to or through the introitus; total inversion including vaginal walls is called fourth degree in some classifications.
- Shock is classically disproportionate to bleeding in the early stage — a favourite exam point; later, haemorrhagic shock dominates.
- Johnson's manual replacement — the whole palm pushes the fundus along the long axis of the uterus towards the umbilicus, with the wall lifted rather than pushed at one point.
- O'Sullivan's hydrostatic method — warm saline run into the vagina from a height while the introitus is sealed with the operator's palm or a silicone cup; the generated pressure reverts the fundus.
- Uterine relaxants before replacement — terbutaline, magnesium sulphate, glyceryl trinitrate or deep halogenated anaesthesia; oxytocin follows correction, not precedes it.
- Surgical fallbacks — Huntington's operation (traction on the round ligaments through a small incision) and Hautain's operation (posterior incision of the retraction ring to release the fundus).
- Recurrence in a subsequent pregnancy is well recognised, so delivery should occur in hospital with an experienced team.
How the replacement actually proceeds
Picture a woman who collapses just after a delivery where the birth attendant pulled hard on the cord while an assistant pushed the fundus. On examination a dark, boggy mass fills the vagina and the uterus cannot be felt abdominally — the diagnosis is clinical, made in seconds, and no time is wasted on imaging.
Resuscitate while you act: two wide-bore cannulae, cross-match, and anaesthetic help. With the woman tilted and relaxed, the operator's palm is placed on the inverted fundus and the part that inverted last (nearest the cervix) is replaced first, pushing along the axis of the uterus as if toward the umbilicus. Do not peel the placenta off before correction if it can be avoided — removal first enlarges the raw surface and worsens bleeding. Steady sustained pressure over a minute or two usually succeeds; if the cervix grips tightly, a relaxant is given and the push repeated.
Once the uterus is in place, the hand stays inside to hold the fundus while an oxytocin infusion is started and the placenta is then delivered. Antibiotics are commonly given and uterotonics continue after replacement to prevent re-inversion and atony. If the ring defeats manual effort, hydrostatic correction is attempted before surgery. Afterwards the placenta is examined, blood loss replaced, and the woman counselled about recurrence risk.
The viva trap
Examiners love two reversals of routine teaching. First, oxytocin before replacement is wrong — contracting the inverted organ locks it in place; tocolysis first, oxytocin after. Second, the traditional advice is to replace the uterus with the placenta attached, because hurried removal from the inverted fundus can precipitate massive haemorrhage. A third trap is misreading the mass as a prolapsed fibroid or the placenta itself; a uterus that cannot be felt abdominally with a mass in the vagina after delivery settles it.
Frequently asked questions
What is the commonest cause of acute puerperal inversion?
Improper management of the third stage — cord traction combined with fundal pressure, especially with a fundally implanted placenta and an atonic uterus.
How is Johnson's method of replacement performed?
The palm pushes the inverted fundus upward along the long axis of the uterus toward the umbilicus, replacing the part that inverted last, ideally before removing the placenta.
What is O'Sullivan's hydrostatic method?
Warm saline is poured into the vagina from a height with the introitus sealed by the operator's palm or a cup, so the fluid pressure pushes the inverted fundus back.
Why should oxytocin be withheld until after replacement?
An oxytocin-induced contraction tightens the cervical ring around the inverted fundus and makes reduction harder; relaxants help before, uterotonics follow correction.
Which operations treat irreducible inversion?
Huntington's operation, with traction on the round ligaments through a small incision, and Hautain's operation, which incises the retraction ring posteriorly to release the fundus.