1. INVERSION OF THE UTERUS
PRESENTEDBY
Mrs.Simarjeet Kaur
Associate Professor
Obstetrics and Gynaecological Nursing
M.M.College of Nursing Mullana

2. DEFINITION
 It is an extremely rare but a life
threatening complication in third
stage in which the uterus is turned
out partially or completely.

3. Inversion of Uterus

4. Type of Inversion
 Incomplete inversion describes an
inverted fundus that lies within the
endometrial cavity without extending
beyond the external os.
 Complete inversion describes an
inverted fundus that extends beyond the
external os

5.  A prolapsed inversion is one in which
the inverted uterine fundus extends
beyond the vaginal introitus .
 A total inversion, usually nonpuerperal
and tumor related, results in inversion of
the uterus and vaginal wall as well.

6. INCIDENCE
 The incidence is about 1 in 20,000
deliveries.
 The obstetric inversion is always an
acute one and usually complete.

7. CLASSIFICATION
 Based on the degree of inversion
 First degree — There is dimpling of the
fundus which still remains above the
level of internal os.

8.  Second degree — The fundus passes
through the cervix but lies inside the
vagina.

9.  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 .
 It may occur before or after separation
of placenta.

10. Third degree (complete)

11. Based on the time of onset:
 Acute- occurs immediately after
delivery and before the cervix constricts
 Sub-acute- once cervix constricts
 Chronic- noted >4/52 after delivery, or
non-puerperal

12. ETIOLOGY:
 Principle behind its occurrence:
 Cervix must be dilated. Uterine fundus
must be relaxed.Many cases of acute
uterine inversion results from
mismanagement of third stage of labour
in women who already are at risk.

13. ETIOLOGY(cont....)
 Spontaneous (40%): This is brought
about by localised atony on the
placental site over the fundus
associated with sharp rise of intra
abdominal pressure as in coughing,
sneezing or bearing down effort. Fundal
attachments of the placenta (75%),
short cord and placenta accreta are
often associated.

14. ETIOLOGY(cont....)
 Iatrogenic: This is due to the
mismanagement of third stage of
labour.
 Pulling the cord when the uterus is
atonic specially when combined with
fundal pressure
 Fundal pressure while the uterus is
relaxed
 Faulty technique in manual removal

15. Risk Factors
 uterine over enlargement,
 prolonged labour,
 fetal macrosomia,
 uterne formations,
 short umbilical cord,
 tocolysis
 Strong fundal pressure

16. Risk Factors....
 Rapid emptying of uterus
 Fundal implantation of the placenta
 Previous uterine inversion
 manual removal of placenta more
common in women with collagen
disease like Ehler Danlos Syndrome.

17. Risk Factors....
 Vaginal birth after previous caeserean
section
 Protracted labour
 Certain drugs such as magnesium
sulphate
 Tumors- submucuos myomas
 Cervical incompetence

18. Risk Factors....
 Abnormal adherence of the placenta(e.g
placenta accreata)
 Uterine anomalies(e.g unicornuate
uterus)
 Congenital or acquired weakness of the
myometrium
 Chronic endometritis

19. SIGNS AND SYMPTOMS
 Symptoms
 Pain in the lower abdomen
 Sensation of vaginal fullness: with a
desire to bear down after delivery of the
placenta
 Vaginal bleeding: unless the placenta is
not separated

20. Signs
 General examination ;
 Shock: out of proportion to blood loss.
 More neurogenic due to traction on the
peritoneum & press On the tubes ,
ovaries, & maybe, the intestine.
Parasympathetic effect of traction on
the ligaments supporting the uterus &
maybe associated with bradycardia.

21.  Abdominal examination
 Cupping of the fundus-1st &2nd degree
 Absence of the uterus-3rd degree
 Vaginal examination :Soft purple(dark
bluish-red) mass in the vagina or vulva

22. DANGERS :
 Shock is extremely profound mainly of
neurogenic origin due to —
– tension oo the nerves due to stretching of
the infundibulo-pelvic ligament
– pressure on the ovaries as they are
dragged with the fundus through the
cervical ring and
– peritoneal irritation.

23. Dangers....
 hemorrhage, specially after
detachment of placenta
 Pulmonary embolism
 If left uncared lead to —
 (a) infection
 (b) uterine slough
 c) a chronic one.

24. INVESTIGATIONS :
 Diagnosis is usually based on clinical
symptoms and signs.
 If not clinically very obvious, imaging is
useful if patient is clinically stable to
undergo such evaluation; USG & MRI

25. CONT...
 USG:
 Transverse image- a hypoechoic mass
in the vagina with a central hypoechoic
H-shaped cavity.
 Longitudinal- U-shaped depressed
longitudinal groove from the uterine
fundus to the centre of the inverted part
 MRI- Findings are more conspicuous

26. PREVENTION :
 Do not employ any method to expel
the placenta out when the uterus is
relaxed.
 Pulling the cord simultaneous with
fundal pressure avoided.
 Manual removal should be done .

27. PROGNOSIS
 As it is commonly met in unfavourable
surroundings, the prognosis is
extremely gloomy. Death may be occur
suddenly due to shoc, hemorrhage or
embolism. Even if the patient survives,
infection, sloughing of the uterus and
chronic inversion with ill health may
occur.

28. MANAGEMENT :
 Call for extra help
 Before the shock develops urgent
manual replacement is necessary

29. Before the shock develops....
 Principal steps :
 (1) To replace that part first which is
inverted last with the placenta attached
to the uterus become contracted by
steady firm pressure exerted by the
fingers.
 (2) To apply counter support by the
other hand placed on the abdomen.

30. Before the shock develops....

32. Before the shock develops....
 (3) After replacement, the hand
should remain inside the uterus until
the uterus becomes contracted by
parenteral oxytocin or PGF2α.

33. Before the shock develops....
 (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 or
 (b) if partially separated to minimise the
blood loss

34. Before the shock develops....
 (5) Usual treatment of shock including
blood transfusion should be arranged
simultaneously.

35. After the shock develops
 Principal steps :
 (1) The treatment of shock should be
instituted with an urgent dextrose saline
drip and blood transfusion
 (2) To push the uterus inside the vagina
if possible and pack the vagina with
antiseptic roller guaze.

36. After the shock develops....
 (3) Foot end of the bed is raised
 (4) Replacement of the uterus either
manually or hydrostatic method
(O’Sullivan's) under general
anaesthesia is to be done along with
resuscitative measures.
 Hydrostatic method is quite effective
and less shock producing.

37. Hydrostatic method :
 The inverted uterus is replaced into the
vagina. Warm sterile fluid (up to 5 litres)
is gradually instilled in to 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.

38. Hydrostatic method ....
 Alternatively a silicon cup (Vacuum
extraction cup) is placed into the vagina.
The douch can be placed at a height of
about 3 feet above the uterus. The
water distends the vagina and the
consequent intravaginal pressure leads
to replacement of the uterus.

39. Subacute 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
Huntington procedure and
abdominal operation (Haultain's
operation).

40. Huntington procedure
 Locate the cup of the uterus formed by
the inversion
 Dilate the constricting cervical ring
digitally
 Place clamps in the cup of the inversion
below the cervical ring and gentle
upward traction is applied
 Repeated clamping and traction
continue until the inversion is corrected.

41. Haultaim’s procedure
 Incision is made in the posterior portion
of the inversion ring, to increase the
size of the ring and allow repositioning
of the uterus
 Further steps as in huntington
procedure

42. NURSING CARE

43. NURSING CARE....
 "Massage the uterus while supporting
the lower uterine segment. Express
clots.
 Insert an indwelling catheter to empty
the bladder and allow accurate measure
of output.
 Place the woman in supine position.
Avoid Trendelenburg position which
may interfere with respiratory and
cardiac function.

44. NURSING CARE....
 Maintain IV access and start a second
IV with large-bore catheter capable of
carrying whole blood.
 Draw blood (per protocol or orders) for
hemoglobin and hematocrit, type and
crossmatch, platelets, prothrombin time,
activated partial thromboplastin time
(aPTT), fibrinogen, fibrin degradation
products, and fibrin split products.

45. NURSING CARE....
 Administer IV fluids, volume expanders,
and blood as directed.
 Administer prescribed drugs, such as
oxytocin, prostaglandins, or
methylergonovine maleate.
 Apply a pulse oximeter to determine the
oxygen saturation; administer oxygen
by snug face mask at 8 to 10 L/min or
as directed by the physician or facility
protocol.

46. NURSING CARE....
 Anticipate further medical interventions
(uterine packing, ligation or
embolization of uterine, ovarian, or
hypogastric arteries, or hysterectomy if
other measures fail to control bleeding.

47. NURSING CARE....
 In addition, the nurse will:
– Monitor the condition of the woman, and
communicate with the health care provider.
– Provide explanations and emotional
support for the woman and her family.
– Obtain signed consents for specific
surgical procedures or blood transfusions."


48. assessment and
physical examination
 Ask if the patient has perineal pain.
Although some discomfort is expected
after a vaginal delivery, severe pain or
pressure is uncommon and often
indicates a hematoma.

49. Cont.....
 Observe the amount and characteristics
of blood loss; sometimes there is a
pooling of blood and the passage of
large clots.
 Usually, complete saturation of one
perineal pad within 15 minutes or
saturation of two or more pads in 1 hour
suggests hemorrhage.

50. Cont.....
 Palpate the fundus, noting if it is firm or
boggy, if it is midline or deviated
laterally, and if it is above or below the
umbilicus.
 Normally, after delivery, the fundus is
firm, midline, and at the level of the
umbilicus.

51. Cont.....
 A fundus above the umbilicus and
deviated laterally may indicate a full
bladder.
 A boggy uterus is indicative of uterine
atony and, if it is not corrected, results
in a PPH.
 If the fundus is firm, midline, and at or
below the umbilicus and if there is
steady, bright red bleeding, further
assessment for trauma is necessary.

52. Cont.....
 If a hematoma is suspected, the patient
is placed in lithotomy position, and the
vagina and perineal area are carefully
inspected.
 A bulging and discoloration of the skin is
noted if a hematoma is present. Assess
the patient’s vital signs.

53. Cont.....
 A temperature above 100.4°F may
indicate uterine infection, which
decreases the myometrium’s ability to
contract and makes the patient more
susceptible to PPH.
 Note any foul vaginal odor that may
accompany the fever with infection.

54. Cont.....
 Elevated heart rate, delayed capillary
refill, decreased blood pressure, and
increased respiratory rate may be noted
if PPH is occurring.
 Assess the patient’s color and skin
temperature; pallor and cool, clammy
skin also indicate hypovolemic shock.

55. Cont.....
 Assess the anxiety level of the patient;
the patient going into hypovolemic
shock is highly anxious and then may
lose consciousness. The significant
others experience a high level of anxiety
as well and need a great deal of
support.

56. Nursing care plan
 primary nursing diagnosis:
 Fluid volume deficit related to blood
loss.

57. Intervention
 The goal of treatment is to correct the
cause and replace the fluid loss.
 Patients should have nothing by mouth
until hemostasis is established.
 Expedient diagnosis and treatment of
the cause reduce the likelihood of a
blood transfusion.

58. Intervention....
 Treatment for uterine atony involves
performing frequent fundal massage,
sometimes bimanual massage (by the
medical clinician only), and
pharmacologic therapy.

59. Intervention....
 Fluid replacement with normal saline
solution, lactated Ringer’s injection,
volume expanders, or whole blood may
be necessary.
 Multiple venous access sites, 100%
oxygen, and a Foley catheter are often
needed. If uterine atony is not corrected
quickly, a lifesaving hysterectomy is
indicated.

60. Intervention....
 Monitor the hematocrit and hemoglobin
to determine the success of fluid
replacement and the patient’s intake
and output.
 If an infection is the cause of the atony,
the physician prescribes antibiotics.
 PPH caused by trauma requires
surgical repair with aseptic technique.

61. Intervention....
 Hematomas may absorb on their own;
however, if they are large, an incision,
evacuation of clots, and ligation of the
bleeding vessel are necessary.
 Administer analgesics for perineal pain.
If retained fragments are suspected at
the time of delivery, the uterine cavity
should be explored.

62. Intervention....
 Monitor for hypertension if oxytocics
and prostaglandins are used.
 Encourage the patient to void; a full
bladder interferes with contractions and
normal uterine involution. If the patient
is unable to void on her own, a straight
catheterization is necessary.

63. Intervention....
 Monitor vaginal bleeding; the lochia is
usually dark red and should not saturate
more than one perineal pad every 2 to 3
hours. Notify the physician if the
bleeding is steady and bright red in the
presence of a normal firm fundus; this
usually indicates a laceration.
 Ice packs and sitz baths may relieve
perineal discomfort.

64. Intervention....
 The patient is usually on complete
bedrest. Rooming in with the infant may
be difficult; provide for safe care for the
infant while it is in the mother’s room.
 Assist the patient and significant others
as much as possible with newborn care
to facilitate quality time between the
mother and her newborn.

65. Intervention....
 Assist the patient with ambulation the
first few times out of bed; syncope is
common after a large blood loss.
 Ensure adequate rest periods.

66. discharge and home health care
guidelines
 Teach the patient how to check her own
fundus and do a fundal massage; this is
especially important for patients at risk
who are discharged early from the
hospital.

67. cont,.....
 Advise the patient to contact the
physician for the following: a boggy
uterus that does not become firm with
massage, excessive bright red or dark
red bleeding, many large clots, fever
above 100.4°F, persistent or severe
perineal pain or pressure.

68. Cont....
 If iron supplements are provided, teach
the patient to take the drug with orange
juice and expect some constipation and
a dark-colored stools.
 If oxytocics are ordered, emphasize the
importance of taking them around the
clock as prescribed.

69. Cont....
 If antibiotics are ordered, teach the
patient to finish the prescription, even
though the symptoms may have
ceased.

70. THANK YOU...