Uterine inversion

Uterus turns inside out after birth — appears as red raw mass in vagina or coming out of birth canal. Uterus must immediately be pushed back up vagina into correct position

Consider in woman with sudden collapse or shock after birth

Do not

  • Do not remove placenta if still attached to uterus
  • Do not give oxytocin until uterus replaced

Check

  • Signs of shock
    • Increased RR
    • Pulse weak and fast (more than 100bpm) or difficult to feel
    • Central capillary refill longer than 2 seconds
    • Pale, cool, moist skin
    • Restless, confused, drowsy, occasionally unconscious
    • Low BP for age or relative to person's previously recorded values
  • Check for top of fundus (uterus) abdominally
    • If severe inversion — can't be felt
    • If mild inversion — feels 'dimpled' in fundal area
  • Check for red raw mass in vagina or coming out of birth canal

Do

  • Call for help — have helper do medical consult to send to hospital straight away
  • Resuscitate mother — give oxygen to
    • Target O2 sats 94–98%
    • OR if moderate/severe COPD — 88–92%
  • Put in IV cannula — largest possible, if not already in
  • Give IV fluids as directed by doctor
  • Try manual replacement of uterus

Manual replacement

  • Put on sterile gloves and cover with obstetric cream or water-based lubricant
  • Gently grasp fundus of uterus in one hand, palm up — Figure 1.52
  • Put hand inside vagina and push fundus up the vagina toward the umbilicus — Figure 1.53. This may take a few minutes of constant firm pressure

Figure 1.52   

Figure 1.53   

Figure 1.54   
  • If uterus returns to normal position — leave hand inside until you feel a firm contraction — Figure 1.54
    • Give oxytocin IM or slow IV push — 10 international units straight away, single dose
    • THEN Start oxytocin infusion (40 international units in 1L normal saline) at 250mL/hr over 4 hours
    • If no infusion pump — monitor carefully
    • Medical consult about how long to continue

Further management

  • If total blood loss 500mL (2 cups) or more OR if signs of shock — see Postpartum haemorrhage
    • 1 soaked pad holds about 100mL
  • If continuing to bleed heavily — perform bimanual compression
  • Once replaced — keep uterus contracted
    • Massage uterus
  • Put in indwelling urinary catheter
  • Explain to woman what has happened and reassure her
  • Medical consult about
    • Pain relief
    • Antibiotics — cefazolin IV — adult 2g, single dose AND metronidazole IV — adult 500mg, single dose
    • If allergy — medical consult
  • Continue observations until evacuated to hospital