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Essay 268 - uterine inversion

Posted by H H.
This is a case of uterine inversion as there is unexpected hypotension with normal pulse or bradycardia following vaginal delivery, but I should exclude other causes of vasovagal attacks and ay medications taken during labour that could cause this.On examination of the abdomen might find no uterus or cupping of fundus.Vaginally there would be vaginal bleeding and the inverted uterus present and placenta attached . If placenta was removed I might find the inverted uterus or not if there is partial inversion in such case it can be felt as a mass in the vagina. The amount of bleeding is not matching with the degree of hypotension. All the previous are done swiftly and if diagnose uterine inversion I would call for help and apply resuscitative measures, airway, breathing with oxygen supplementation, and apply 2 widebored cannulas and give iv fluids. Anaesthetist will be of help in giving analgesia and in raising blood pressure and patient transferred to theatre. I would not remove placenta if attached.Senior staff is informed.


In theatre every attempt is done to manually reposit the uterus is done.If patient has an epidural it is topped up, if not reposition is done under general anaesthesia.Reposit the parts of the uterus near the vaginal wall first.This is done wether placenta is attached or not.When replaced the hand is left in the cavity while oxytocics are given to ensure uterus contracted . If manual reposition fails the O’sullivan technique is applied which include reposting the inverted uterus using water pressure. If this fails surgery is needed via a laparotomy .A vertical incision is done in the ring encircling the inverted uterus in the abdomen and the fundus is cupped up.

In the postnatal period all procedures done are explained to the patient specially if there was no time to take her consent as we acted in patient best interest.An incident report is written for risk management and audit procedures to improve service. Patient is supplied with written information and given cotact details of us and support groups. Recurrence risk is low.
Posted by Srivas  P.
a) If there are signs of collapse without obvious signs of external or internal bleeding, inversion of uterus is a possibility.

This is a life threatening emergency. Swift diagnosis and acting quickly can save a life. Immediately call senior obstetrician, senior anesthetist, senior midwife, Operation Theatre, Blood bank, Porters. Treatment of hypovolaemia and shock is the first priority. Start two I/V access with large bore cannula and draw blood for FBC, cross matching and clotting screen and start crystalloids rapidly while 4 units of blood is being crossmatched. Up to 2 litres of crystalloids, 1.5 litres colloids and o-ve blood can be given until blood ready. Monitor Pulse, B.P, oxygen saturation by pulse oximetry and apply oxygen 15 l/min via face mask. Atropine I/V may correct bradycardia.

Examination should be done to look for dimpled uterus and mass in vagina and this along with shock out of proportion to blood loss and bradycardia strongly suggest an inversion uterus as most likely diagnosis. Per speculum examination should be done to see any active bleeding from any trauma or tear to vagina or cervix following vacuum delivery.

Relatives should be explained about the condition, need for anesthesia, possible laprotomy while arrangements are made for quick reposition of the uterus as the results are best if it is attempted early.

b) An attempt can be done in the labor ward under sedation to reposit the uterus. The part of the uterus that came in last is pushed in first. I/V terbutaline 0.25 mg or 2 gm MgSo4 can help in aiding the procedure. Once the uterus is in position the attendant’s hand should remain in the endometrial cavity until a firm contraction occurs with intravenous oxytocin. Manual removal of the placenta is then performed.

If uterus cannot be reposited under sedation, further attempts should be done in the theatre under GA and the above procedure is repeated. If it is still unsuccessful, O’Sullivan’s technique of hydrostatic replacement is tried. Two litres of warm sterile saline is instilled into the vagina while the introitus is manually sealed using surgeons fore arm. A silastic vacuum cup can be used to accomplish a seal. This procedure may result in resolution of the inversion.

If the above fails, abdominal correction via a laparotomy using Huntington’s technique is carried out-Identifying the uterine dimple and traction on round ligaments while assistant pushes from below.

Haultains technique is the last resort-this involves incision on post wall of the cervix to release the constriction on cervix and then reposit the uterus. All these procedures require quick action and excellent support staff. Patient should have prophylactic antibiotics due to intra uterine manipulations.

The relatives should be constantly kept informed by the supporting staff throughout the process. Detailed debriefing should be done in post partum period to relatives and patient and if necessary a meeting arranged with consultant obstetrician for further explanations. An incident report should be written. The chance of recurrence of inversion in next pregnancy is difficult to foresee.
Posted by Hethere D.
a-

We inquire about other symptoms like chest pain, shortness of breath, haemptysis or frothy secretion from the mouth to exclude other causes of collapse like myocardial infarction or pulmonary embolism. Rapidly we do general assessment of the patient , we look for pallor which reflect circulatory collapse also we look for cyanosis as it may reflect patient hypoxia. Abdominal examination is done to check site and integrity of the uterus, we exclude uterine inversion or notching, also we check position, if the uterus is shifted laterally there might be an intra-abdominal heamatoma. Pelvic examination is done to exclude external blood loss , also we look for any perineal tears and their extent. We look also for any lump protruded through vagina to exclude inversion also. Immediate and prompt resuscitation is done to maintain airway, breathing and circulation. Oxygen saturation is measured. Two iv line inserted and blood is taken for FBC and cross matching. ECG is done also. Hartman solution is started. Subsequent management will depend on the underlying cause of collapse. We call for help of other colleagues and keep the family aware about the whole situation.

b-

We try to replace the uterus back to its position manually even if the placenta still attached and not separated. We replace first the last point of the uterus that came out.
Oxytocin infusion is started and uterine massage is done. If the uterus start to contract , we look for signs of placental separation. The patient vital signs and general condition usually improve enormously with uterine replacement. After than we try to deliver the placenta by controlled cord traction while putting our left hand over the uterus and trying to push it upward. The placenta is checked carefully to assure it is delivered completely with continuation of oxytocin infusion. Ergotamine injection can be given intramuscularly to maintain sustained contraction of the uterus. Alternatively carboprost can be given.
If manual replacement fail, we try to replace the uterus by hydrostatic pressure, we put the rubber cup of the ventose over the interoitus then let 2 Liters of worm saline pass through its tube , this maneuver can help gradual replacement of uterus. If the uterus is not replaced immediately, an edematous ring occasionally formed and this necessitates incision of that ring under anesthesia, the uterus replaced then suturing is done of that incision. This procedure is associated with increase maternal morbidity. Clear documentation is done with filling of incident form. The patient is followed up closely for 24 hours. If patient general condition is not improved, other causes of collapse should be excluded.
Posted by Shabana M.
Symptoms of shock in absence of bleeding while delivering placenta indicates toward uterine inversion .It is an acute obstetric emergency and should be dealt quickly and swiftly which occur due to mismanagement of third stage,short cord or due to increased intra abdominal pressure while uterus is relaxed.
Call for senior help including anesthetist , senior obstetrician and midwife Inform ODA and theater staff to stand by for examination under anesthesia and lapratomy. Two large iv canula should be installed and draw 20 ml blood for CBC to check Hb ,cross match 4 unit blood and base line renal function and liver function, clotting profile. Maintain airway and if breathing is normal and patient responding to verbal command assess for pain .Ask midwife to summarize the event and if placenta is still in or removed already. Try to replace uterus manually if placenta is separated and Oxytocin should be started hand should be kept inside till contraction is achieved and then removed slowly.Keep oxytocin infusion running to ensure good uterine tone..

b) If placenta is still attached no further attempts to be made to remove placenta and attempt to replace uterus with the help of hand in a form of fist. Oxytocin should be started and while hand is still in should wait for contraction to occur .
Patient should be
O sullvian method is attempted which is replacing uterus by hydrostatic pressure.In this procedure vagina is sealed with the help of hand or a vacuum cup and 4 liter of iv fluid is filled in vagina by keeping IV stand at 2 meter height..Uterus will be replaced slowly with this. If these attempts failed patient should be transferred to OT for examination under anesthesia. Haultin or Huntington procedure is carried out at lapratomy that is uterus is pushed from vagina while traction on round ligament is given to correct inversion .If required small incision is given at contraction ring in posterior muscular wall of uterus to release this ring .
Documentation of events in file should be done.
Risk management forms should be filled and patient should be debriefed in post natal ward in detail.

Posted by Shabana M.
Symptoms of shock in absence of bleeding while delivering placenta indicates uterine inversion .It is an acute obstetric emergency and should be dealt quickly and swiftly which occur due to miss-management of third stage, short cord or due to increased intra abdominal pressure while uterus is relaxed.in multiparous woman.
Other causes of shock such as amniotic fluid embolisam,myocardial infarction ,pulmonary embolisam and vaso- vagul suncopy should also be kept in mind while resuscitating the patient
Call for senior help including anesthetist , senior obstetrician and midwife .Inform ODA and theater staff to stand by for examination under anesthesia and lapratomy.

Two large iv canula should be installed and draw 20 ml blood for CBC to check Hb.ABG,cross match 4 unit blood and base line renal function and liver function, clotting profile. Maintain airway and if breathing is normal and patient responding to verbal command assess for pain .Follys catheter should be inserted.No further attempt should be made to pull on placenta Try to replace uterus manually . Oxytocin should be started hand should be kept inside till contraction is achieved and then removed slowly.Keep oxytocin infusion running to ensure good uterine tone.


b)O sullvian method is attempted which is replacing uterus by hydrostatic pressure.In this procedure vagina is sealed with the help of hand or a vacuum cup and 4 liter of iv fluid is filled in vagina by keeping IV stand at 2 meter height..Uterus will be replaced slowly with this. If these attempts failed patient should be transferred to OT for examination under anesthesia. Haultin or Huntington procedure is carried out at lapratomy that is uterus is pushed from vagina while traction on round ligament is given to correct inversion .If required small incision is given at contraction ring in posterior muscular wall of uterus to release this ring .
Documentation of events in file should be done.
Risk management forms should be filled and patient should be debriefed in post natal ward in detail.

Posted by Farina A.
a)This is an obstetrical emergency. I would like to call for help from a senior midwife, obstetrician and anaesthetist. Meanwhile I would like to ensure two IV lines with wide bore canulae. Airway is maintain with oxygen blood is sent for cross matching and transfusion is requested for at least four unit of blood and its product. Shock is usually neurogenic, but haemorrhagic shock may be present. Patient is kept in head down position, colloids and crystalloids can be used for volume expansion before the blood is available CVP line should be maintained. Abdominal palpation may show an indented uterus or the uterus may not be palpable at all. Vaginal examination is carried out to search for the site of bleeding if any and to estimate the degree of uterine inversion that is grade-1 – fundus reaching the os, grade-2 – fundus past the os, grade-3 – fundus reaching the introitus and grade-4 – fundus past the introitus with associated vaginal inversion.

b)Rapid replacement of uterus is required as the patient is in shock, preferably under regional anaesthesia. GA may be harmful as it may lead to hypotension. Manual replacement is first line of management in the way that the last part of the descended fundus goes back first and the first part goes back at the end. Pressure is sustained by a fist for 3 to 5 minutes. Attempts to remove the placenta should not be done before replacement of uterus as it can further aggreviate the condition. Cervical constriction ring may need to be relaxed by topolytics. If this method failed O’ Sullivan’s hydrostatic pressure method is applied by infusing warm saline 37°C, with pressure and obliterating the introitus. After successful replacement of uterus placenta should be removed. Manual removal may be required under GA. If all these methods fail laprotomy is indicated and the indented uterus is pulled up by allis forceps. Haultains technique divides the cervical ring by giving a posterior longitudinal incision and then replacing the fundus later on the uterus is repaired in two layers. This is done in case of a very tight cervical ring. It is very important to note that patient’s state of shock may not improve before successful replacement. Postpartum, patient should be told about the events. Written information should be provided. Incident form should be filled.
Posted by Priti T.
a]The patient should be initially assessed by doing pelvic examination.Presence of mass of inverted uterus attached to placenta confirms the diagnosis of uterine inversion which is a obstetric emergency.Additionally vaginal examination rules out other causes of bleeding like supralevator haematoma,trumatic PPH causing obstetric shock.Vasovagal attacks,amniotic fluid embolism and iatrogenic causes following drug administration of the commonly used drugs Oxytocin,ergometrine and lignocaine causing post partum collapse should be ruled out.

Patient should be dealt on the emergency basis and 2 large bore Intravenous cannula inserted,group and save 2-4 units of blood crossmatched and other investigations like FBC,clotting screen sent.Emergency help should be sent for the senior midwife/Obstetrician/Anasthetist.Airway and breathing should be maintained;oxygen given and pulse oximetry done.

b]Management of inverted uterus with attached placenta is based on managing the shocked patient and replacing the uterus as soon as possible without trying to remove the placenta first.I would like to try the manual replacement under general anasthesia with the hand in the endometrial cavity till the uterus contracts with i/v Oxytocin infusion given.Once the uterus inverts the surrounding tissue constricts and prevents its replacement easily.
If this method fails then O\'Sulivan\'s hydrostatic technique should be tried.The vagina is filled with warm saline while being blocked at the interoitus by the attendent\'s fist/sialstic vaccum cup.The hydrostatic pressure resulting from the installation of 4-5 lit of saline may be sufficient to balloon vagina and reverse the inversion of the uterus.
In case neither of the technique works,we have to try Lapratomy and the Haultains or Huntington\'s procedure before the uterus becomes ischaemic from the obstruction to its blood supply.At Laparatomy traction is placed at the round ligaments and the incision is made through the muscular ring in the posterior uterine wall.[Haultain\'s technique].Continued manual pressure on the fundus from the vagina and traction of the round ligament will allow the replacement of the uterus;and the incision is closed.As described previously the oxytocin infusion should be continued to encourage the contraction of the uterus.
Clinical risk management is done by the proper documentation of this rare case and filling up of the incident report form.Post natally patient should be explained in written about this complication and the 30% risk of recurrence in the future pregnancies as reported in the literature.
Posted by Asma kamal K.
(a)If I haven’t delivered the placenta yet ill stop. This is an obstetric emergency associated with significant maternal morbidity and mortality. The detection of 65/35mmHg B.P and 70bpm pulse will prompt a call for help. senior obstetrician , anesthetist registrar, senior midwife nurses and obstetric SHO(if not already there) will be called. Consultant obstetrician ,anesthetist and hematologist will be informed. Blood bank, operation theater staff and laboratory technician alerted as urgent investigations, blood transfusion and operative procedure may be needed. I will talk to the patient and ask her how she feels to assess her consciousness level and to alleviate her anxiety. if she gives response and the response is coherent then I will ask the nurse/midwife to give her oxygen via face mask at a rate of 15-20 litter/min and monitor her pulse, blood pressure and respiratory rate. mean while i will ask another nurse to maintain an intravenous access with two large bore cannula preferably 14G and draw 20ml blood for investigations like blood grouping (if not done antenatally),cross match(arrange 4-6 units red cell concentrate),FBC, clotting profile (fibrinogen, PT, fibrinogen degradation product) and base line RFTs. I will ask the nurse to start up intravenous fluids preferably Ringer lactate solution and catheterize the urinary bladder. I will assign a midwife/nurse to keep a record of all the events, pulse , B.P, respiratory rate,urine output,type and quantity of fluids given,timing and dose of drugs given.i will do visual assessment of the blood loss. If she is not hemorrhaging profusely and placenta still in situ in view of her sudden marked hypotension without tachycardia appearing during an attempt at delivering the placenta(vagal shock) ill look for the signs of uterine inversion which seems the most probable cause. i will palpate the abdomen for the presence of the uterus, any dimple in the fundus and will do vaginal examination.i will look for any mass in the vagina, look for vaginal and cervical tears/lacerations as she was delivered by ventouse though it seems less likely to be the cause of her shock. if placenta is delivered I will look for the signs of uterine atony(soft non contracted uterus) and will rub up a contraction. if placenta is delivered than I will assess whether it is complete or not.


As soon as I identify an inverted uterus I will stop delivering the placenta and ask the nurse/midwife to stop the oxytocin drip if in progress. prompt recognition is the main stay of treatment. provided I have done all the initial assessment and intervention needed ill start to treat the cause. Making sure that all the concerned seniors been called and blood arranged. I will try to do manual replacement of the uterus with placenta in situ as soon as possible.usually this helps and if I am able to replace the uterus then I will remove the placenta manually and keep my hand in the uterus and ask the nurse to give her syntomtrine(syntocinon + ergometrine) and start an infusion of syntocinon 40i.u in 500ml R/L solution to keep the uterus contracted. when the uterus starts contracting then I will take my hand out. if I am unsuccessful then I will try again with tocolytic agents like magnesium sulphate 2-4Grams i.v over 5min or ritrodine i.v bolus.if this also fails then I will try hydrostatic reversion of uterus (O, sullviens method) with warm saline held 2 meters above the pelvis via a rubber tube and blocking the vagina manually or a silicon ventouse cup can be used to create a good seal. Before going for the hydrostatic pressure I will rule out uterine rupture by vaginal examination.if this fails I will shift the patient to the theater as the theater staff has been already informed about the emergency. in the theater manual replacement can be tried again with volatile anesthetic gases like halothain. if all fails then she will need laparotomy to correct the inversion by huntingdon,s or haultains method by a consultant obstetrician. meanwhile I will ask for the result of investigation sent earlier. she is at high risk of developing DIC ,hemorrhage and Venous thrombo-embo-embolism.which will be managed with fresh frozen plasma , red cell concentrate and Low molecular weight heparin in liaison with hematologist.i will make sure that all the documentation is complete. in the end at an appropriate time as soon as possible the patient and her husband should be briefed.
Posted by Vaishali Sriniv J.
a)I will alert the midwife in charge and first line medical staff. Head down tilt should be given to the patient. I will do quick assessment of the vital parameters. Two wide bore I/V cannulas are to be inserted and blood should be sent for grouping and cross matching, complete blood count and coagulation profile. Patient is started on I/V crystalloids. Nasal oxygen should be given by mask. One staff is to be assigned for monitoring of vitals every 15 minutes. I will do clinical examination to identify the cause of collapse. The most likely cause is inversion of uterus. I will do per abdominal examination to note dimpling of uterus. Per vaginal blood loss is to be noted. Any evidence of uterus at introitus should be noted. Per vaginal examination should be done to note inversion of uterus and rule out supralevator haematoma.
B)Once diagnosis of invesion is confirmed then i will inform the consultant obstetrician, consultant anaesthetist, haematologist . I/V crystalloids can be given up to 3.5 litres till blood is ready. I will try to replace uterus with placenta in situ by giving sustained pressure at fundus vaginally. If attempt to replace is successful then I/V oxytocin drip is to be started. If not successful then replacement of uterus under GA along with manual removal of plancenta can be carried out. If it is unsuccessful then Osullivans method of hydrostatic pressure can be tried. 4 to 5 litres of warm saline is to be instilled in vagina and introitus should be blocked with the fist. The hydrostatic pressure due to ballooning of vagina with saline can replace the uterus. If this technique fails then laparotomy for Houstans procedure should be carried out by consultant. Incision is to be given on the muscular ring on the backside of the uterus and pressure should be applied on the fundus vaginally, simultaneously pressure is to be applied on the round ligaments to pull the uterus. Once inversion is corrected incision should be closed. Placenta should be removed manually. I/V oxytocin drip is to be started to contract the uterus. Patient is to be monitored for postpartum haemorrhage. Incident form should be filled up. Before discharge patient should be explained the events in detail . She should be told that there is about 20- 30% chance of recurrence.

Posted by Manoj M.

a) This is maternal shock which is a life threatening situation and can cause her death. Initial assessment involves stabilising her. As she is complaining of feeling unwell her airway and breathing is maintained, next measure is to stabilise her blood pressure with large intravenous acess and hydrating her with crystalloids so that this improves circulation and maintains oxygenation to all endorgans. Take bloods for coagulation screen to look for any coagulopathy as amniotic fluid embolism may be a cause of her shocked state and also do baseline liver function and renal function tests and at the same time look for anaemia and look for any blood indices suggestive of preeclampsia. Put a foley cather into urinary bladder which can help in maintaining fluid balance and can look for preteinuria which can suggest preeclampsia. Look for signs of bleeding associated which is common after assisted deliveries as a cause for her shock. As this event was precipitated with an attempt to deliver the placenta this could be due to cervical shock from acute inversion of uterus which is life threatening and will need immediate correction.
It is also important to involve the anaesthetist, midwives, consultant obstetritian because this needs team work to resusitate and treat this patient.

b) acute uterine inversion is a relatively rare condition but when associated with delivery especially with delivery of placenta can cause significant morbidity and mortality.
The immediate principle of management is stabilise the patient first and then try to correct the inversion manually leaving the placenta insitu, as immediate correction can correct the cervical shock state and also usually corrrects it with higher sucess. This may also need good pain relief and for the same reason a general anaesthesia is preferable as this can give complete muscle relaxation and aid quick correction. If this method fails other option which are helpful are hydrostatic correction which uses fluid pressure to correct the inversion.
If this is not sucessful she may need more complicated surgical correction with Laparotomy.
Once the uterine inversion is corrected she should be started on oxytocic infusion so that the uterus contracts and then digitally seperate and remove the placenta so that post partum haemorrhage is minimised. she can be given further oxytocics depending on her uterine contractile state and she should be kept in a high dependency area for observation as she is at high risk for post partum haemorrhage. Antibiotics should be given to minimise the risk of infection. She should be fully debriefed of the incident and also explained regarding its a rare occurance and the risk of recurrance is rare, all events should be documented in the patient case notes and a risk management document filed so that we learn from this exercise and minimise the risk in future.
Posted by H P.
(a) Blood pressure of 65/35 mmHg in the third stage of labour is an obstetric emergency. I would immediately call for help and stop attempting to deliver the placenta. All available junior staff on ward, a senior midwife, senior obstetrician, anesthetist and porters will be called. I would ask to assess her oxygen saturation and start oxygen at the rate of 15litres/ min through face mask. I would ask to start her on intravenous (IV) fluids like Hartmann’s solution from existing canula at the rate of 150ml/hour. I would ask one staff nurse to continuously monitor and document her pulse, blood pressure, respiratory rate, oxygen saturation. I would ask to insert another wide bore canula and collect blood samples for complete blood count, baseline renal and liver function tests , clotting profile (PT, APTT, serum fibrinogen, fibrin degradation products), and cross- match for 4-6 units of blood. I would ask the operation theatre to be on standby and blood bank and laboratory alerted for the need for urgent investigations and blood products.
I would assess the patient’s level of consciousness and inform her about the proceedings and try to relieve her anxiety. If her consciousness level has deteriorated, she should be resuscitated by trained staff and anaesthetist.
Meanwhile, I would attempt to find out her cause of collapse. I would assess the amount of bleeding per vaginum, presence of trauma to vagina, check whether the placenta has separated and rule out uterine atony. I would insert a Foley’s catheter. I would rule out an anaphylactic shock and look for any bleeding diathesis. I would look for any signs of uterine inversion like inability to palpate uterus or dimpling of the uterine fundus per abdomen, mass in the vagina or at the introitus.
I would ask a senior midwife to continuously inform the relatives about the patient’s condition and the need for further interventions.
(b) On identifying uterine inversion, all oxytocic agents should be withheld and management of shock started. Simultaneously an immediate attempt should be made reposit the uterus by Johnson’s maneuver. If the patient is haemodynamically stable, the initial attempt will be made in the delivery suite.

After explaining the patient, I will ensure adequate analgesia by intravenous pethidine or a top-up dose if epidural catheter is in place. I will thoroughly clean the inverted uterus with antiseptic solution and apply compression with a moist, warm, sterile towel until ready for procedure. The part of the uterus that came out first will go in first. I would push the inverted fundus through the cervical ring with pressure directed towards the umbilicus. To assist repositioning, uterine relaxant like IV terbutaline 0.25mg may be given .Once the uterus is in position, I will leave the hand inside till it is well contracted. The placenta is removed manually after correction.
If manual repositioning fails, O’sullivan’s hydrostatic method should be attempted. Place the patient in deep trendlenberg’s position and prepare a douche system with large nozzle, long tubing and warm saline. An IV administration set or a Rush/ Foley’s catheter tube can be used. I will place the nozzle at the level of posterior fornix and seal the labia over it with my other hand or using a silicone vacuum cup. An assistant will start flow at full pressure by raising the drip stand to 3 meters and using pressure cuffs on bottles.
After correction by any method, I will give oxytocics to maintian uterine contraction and prevent postpartum haemorrhage. Slow IV infusion of Oxytocin 10 IU followed by drip of 20 IU oxytocin in 500ml Hartmann’s solution at the rate of 30 drops/min and IV ergometrine 0.2mg or intramuscular carboprost 250ug can be given.
If the above method fails or if she is haemodynamically unstable at any stage, she should be immediately transferred to the operating theatre. Informed written consent should be taken from the patient and/ or relatives. An attempt to manually reposition the uterus should be made under general anesthesia using halothane to provide uterine relaxation.
If all above methods fail, surgical correction by Huntington or Haultaim procedure is attempted after laparotomy. Huntington’s procedure involves placing clamps in the cup of inversion below the cervical ring followed by gentle upward traction until the inversion is corrected. In Haultaim’s procedure, an incision is made in the posterior part of the inversion ring to increase the size of the ring to allow repositioning uterus.
Single dose IV antibiotics like ampicillin + metronidazole should be given prophylactially and appropriate analgesia should be given. Monitor for post partum hemorrhage. In post partum period, detailed debriefing of the patient and relatives should be done by a senior obstetrician. Incident report should be written.

Posted by g.b. D.
A
This is a medical emergency. staff has to be alerted. The first step is stabilizing the patient and second is to diagnose etiology.
The platient should be placed in flat position if she was in propped up position. This will improve the bloodflow to heart and brain.oxygen started with face mask at 10it/min. Iv crystalloids should be infused in the existing canula to increase the circulatory volume .Continous monitering of pulse, blood pressure and oxygen saturation and ecg should be done with moniter.This will diagnose other causes of shock like amniotic fluid embolism(particularly important here as she has had a prolong labour) . Another wide bore (18 no) veinflow has to be inserted in other arm. blood investigations for cbc and crossmatch for 4units blood, coagulation profile, liver and renal function tests with electrolytes as baseline should be sent.iv fluid commenced. Blood bank has to be alerted regarding the emergency. if the patient is conscious and oriented then she should be informed about the situation and that she may need bloodtransfusions and examination in OT.
If she collapses then anesthetist should be called in for help and further resucitation.Consultant obstetrician should be informed.
A typical situation of shock in third stage while delivering placenta should alert us of possibility of uterine inversion.Hypovolumia is unlikely because there is no associated tachycardia. Midwife should be told not to give ergometrin. Delivery of placenta should not be attempted.A quick per abdominal palpation of uterine fundus may show dimpling of fundus . pv examination to check for bleeding from the placenta if partially separated or from genital tract trauma or hematomas to cause profound shock.

B
After initial stabilization and requesting for x match,first step is to repose the uterus irrespective of the placental status.the earlierdone is easier. It should be done in ot.consultant obsterician should be called in.
The patient if conscious or the partner should be informed and consent taken for EUA, laprotomy and sos hysterectomy.
In ot under GA, preferably under halothane, which causes uterine relaxation manual reposition is tried with a outstretched palm directed upwards and posteriorly.most of the time in early or partial inversions this is successful. Then 20 u syntocinon infusion started. After uterus is well contracted placental removal attempted with controlled cord traction.
If manual removal fails then O Sullievans hydrostatic method shouldbe used. The vagina is inflated with 2-3 lit of warm saline with wide nossle delivery system and manually occluding the vaginal introitus to avoid leak . The hydrostaic pressure will help repose the uterus.If this fails the laparatomy needs to be done. Haultains technique can be attempted. The cervical rim is incised posteriorly and uterus is reposed, placenta removed and then cervical incision closed. However in late cases where the cervix and inverted part is odematous and thickened this is difficult. In such cases or where this techniq fails or when associated with continued hemorrage the last resort is hysterectomy. This decision should not be delayed.the acute severe blood loss may cause DIC which is a life threatening condition.
Blood loss has to be assessed and transfusions with fresh blood arranged .
If coagulation is deranged hematologist needs to be involved.

Post operative maternal debriefing and clear documentation of time and sequence of events has to be done .Risk management form has to be filled.
Posted by N K.
(a) Justify your initial assessment and interventions [8 marks].
My initial assessment and interventions will be based on the possible differential diagnoses of post partum collapse/shock i.e. uterine inversion, ruptured uterus, vasovagal syncope or amniotic fluid embolism.
First of all I will call for immediate help of midwives, team leader, SHO and if any of the above life threatening emergencies idedntified this will include consultant Obstetritian and Anaesthetist. If possible I will enquire about any pain, shortness of breath or chest tightness to make more accurate diagnosis. Thereafter, I will assess the airway and breathing and look for airway patency and give oxygen if low saturation and, intubation by anaesthetist if necessary. As pulse and blood pressure is low her circulation should be stabilised. She will need 2 large IV cannulae for fluids and blood if necessary to maintain her BP and circulation. She will be put on ECG leads and automatic BP and saturation monitor for continuous monitoring. I will also elevate the leg end of the bed to increase cerebral perfusion.
Meanwhile, I will carryout a general examination to look for signs of pallor, cyanosis, respiratory rate and dyspnoea which may point towards the diagnosis. An abdominal examination is necessary to look for distension –internal bleeding after ruptured uterus or to check whether the uterus is palpable or any presence of depression in the uterus to rule out uterine inversion. Vaginal examination is necessary to look for presence of uterus in the vagina and to assess the bleeding. My subsequent management will depend on the most likely diagnosis.

(b) You identify an inverted uterus and the placenta has not separated. Justify your subsequent management [12 marks].
Inverted uterus is a life threatening emergency. I will summon immediate help of consultant Obstetrician, Anaesthetist, theatre team and midwives. I will not remove the placenta which will cause bleeding and compromise the patient more and it is essential not to give sytocion which will make the reduction impossible. I will attempt to replace the uterus if the patient is not shocked, as it will become more difficult with time, through a contracting cervix. I will attempt manual replacement first and if this fails I will try hydrostatic replacement i.e. filling the vagina with a nozzle of tubing whilst occluding the vaginal introitus with the forearm or silastic Ventouse cup. Tocolytics may be helpful.
If these methods fail, patient will be moved to theatre for laparotomy. Two methods can be used to correct the inversion. I will first attempt Huntingdon technique i.e. applying 2 Allis clamps to the dimpling below the ring and apply gentle upward traction. Vaginal pressure may also be helpful. If still not successful, Haultain Technique can be employed which is posterior (to avoid bladder trauma) longitudinal incision over the constriction ring and Huntingdon technique to replace the fundus.
The management after replacement of the uterus will be to manage hypotonus and possible bleeding. After the incision is closed (2 layers), uterus needs to be rubbed up for contraction and Uterotonics such as Syntocinon infusion (40U in 500 mls over 4 hours), ergometrin or Misoprostol if necessary. Mannual removel is essential at this point by an experienced person followed by IV antibiotics.
Patient needs to be monitored in High dependency unit of the labour ward for atleast next 24 hours.
Adequate documentation is vital and Incident report form needs to be filled in. Debriefing of the patient and the family is essential.
Posted by R M.
a) I’ll have a high index of suspicion if uterine inversion as it happened while trying to deliver the placenta and the falling blood pressure is out of proportion to the clinical situation. But I need to exclude other causes like vasovagal attack, haemorrhage or cardiac cause such as aortic dissection or MI. Also I’ve to rule out the possibility of pulmonary embolism or amniotic fluid embolism.

Patient will be asked whether she has any associated symptoms like chest pain, shortness of breath or abdominal pain and its duration and radiation if any. I’ll check with the midwife regarding the amount of blood loss and medications given such as a bolus dose of oxytocin which can cause sudden hypotension.

Initial assessment will include assessing whether the airway is patent and oxygen is in situ. Auscultation of the lung fields to assess her breathing and will see whether air entry is equal bilateral. I’ll also look for the cardiac sounds, its rhythm and regularity – an irregular cardiac rhythm is suggestive of a cardiac cause. I’ll look for pallor indicative of massive blood loss and cyanosis suggestive of hypoxia. I’ll look for capillary refill which gives an index of the severity of shock. Abdominal palpation will be done to see the tone of uterus as atonic uterus can cause massive blood loss leading to hypotension and shock. Failure to feel the uterus per abdomen or a fundal dimpling is suggestive of uterine inversion. A quick vaginal examination will be done to see the amount of bleeding, any vaginal or cervical tears. A mass in the vagina or protruding through the cervix is suggestive of an inverted uterus.

I’ll call for help from senior obstetrician, anesthetist and senior midwife as it is an obstetric emergency. I’ll insert two large bore venflons, collect blood for investigations, and will start intravenous fluids. I’ll send blood for FBC, cross matching, coagulation screen, U & E. I’ll alert the blood bank regarding the need for blood. I’ll get one bedside ECG done and will closely monitor the patient while she is being resuscitated.

b) This is an obstetric emergency. Management will be based on the principles of managing shock and replacing uterus as soon as possible. Local protocols and guidelines will be followed. Intravenous fluids will be given and blood loss will be assessed and corrected as nearly 90% cases of uterine inversion are associated with haemorrhage.

I’ll try to replace the uterus immediately without attempting to remove the placenta if it is still attached to the uterus. Delay in replacement is associated with formation of cervical ring and increasing edema and congestion if uterus making replacement more difficult. Tocolytic drugs like magnesium sulphate, ritodrine or terbutaline may be used to relax the uterus. I’ll prefer manual replacement under GA if it requires the uterus to be relaxed. Once the uretus is in position I’ll try to separate the placenta. Even after separation of placenta hand should remain inside uterus until a firm contraction occurs with intravenous oxytocin.

If the above method fails O’Sullivan’s technique of hydrostatic repositioning of uterus will be tried. Hydrostatic pressure resulting from instillation of 3-4 litres of warm saline may be sufficient to balloon the vagina and reverse the inversion.
Should neither of these techniques result in replacement of uterus, correction of inversion via a laparotomy is carried out by either Huntington’s or Haultain’s technique. In Huntington’s, allis forceps are placed within the dimple of the inverted uterus, gentle traction is applied on the clamps with further placement of forceps on the advancing fundus. In Haultain’s, cervical ring is posteriorly incised with a longitudinal incision facilitating repositioning of the uterus. The incision is then sutured.

Oxytocics should be administered to prevent recurrence. I’ll document the series of events in patient records and risk management forms will be filled. Patient will be given debriefing of the events. I’ll tell her there is a recurrence risk of nearly 30%.
Posted by Farkhanda A.
Just after assisted vaginal delivery for prolonged second stage of labour, patient is complaining of unwell and in shock, during an attempt to deliver placenta may be due to uterine inversion. There is a need to exclude other causes of unexplained shock such as vasovagal, myocardial infarction , uterine rupture and pulmonary embolism.
I will call for help. I will inform obstetrician consultant on call, anaesthetist to help in resuscitation, senior midwife to communicate haematologist, theatre and blood bank. The patient will be given oxygen by mask and send her blood for group & cross match 4 units. Full blood counts and clotting profile and check her oxygen saturation. I will do abdomen examination to palpate uterus. Prim Para is immune to rupture uterus. I will check any risk factor for myocardial infarction and pulmonary embolism. Incomplete inversion of uterus, funds of the uterus will be dimpled but due guarding of abdominal wall it is difficult to feel it. I will do per vaginal examination to exclude any excessive bleeding, but in uterine inversion bleeding is insufficient to give us any association with shock. In incomplete uterine inversion, we can feel a mass in upper vagina, but complete uterine inversion funds can be seen at intritos or even outside the vulva.
B
Uterine inversion is an acute obstetric complication and carries high risk of mortality. It needs to replace it as soon as possible. If patient goes into shock then first resuscitate her . Resuscitative measures will not be successful until inverted uterus will be replaced.
I will try to replace the uterus after resuscitation and insertion of indwelling urinary catheter. The part of the funds which was last to come out will be replaced first with out removing the placenta. Before my attempt to replace, I will ask Anaesthetist to give tocolytics like terbutaline 0.25mg intramuscular. If this attempt is unsuccessful in the room , I will shift the patient in the theatre.
I will do next attempt under anaesthesia and after replacement, I will keep my hand in the uterus and weight for the contraction start after oxytocin infusion and then I will do manual removal of placenta and check for any tear or deep laceration. If this is not successful, then I will do O; Sullivan technique. In this method, I will seal the opening of vagina either by my closed fist or by ventuse cup. By blood giving set tube, I will put 4-5 litres of warm sterile fluid into vagina which by hydrostatic pressure will push the inverted uterus back into abdominal cavity.
Last option is laparotomy, in which incision in posterior cervical wall be given to release the constriction ring and inverted uterus will be pushed up from the vagina. After dealing with this scenario, keep the patient in high dependence unit to observe her. Fill the incidence form. Documentation should be complete. Before discharging her , make an appointment in 6 weeks time . Discuss all events and answer all her questions and also risk in subsequent pregnancy
Posted by J P.
a.This is an acute emergency which needs immediate management. I will have a thorough and quick assessment of the patient. I will ask for any breathlessness, cough, chest pain which may suggest the possible causes of postpartum shock amniotic fluid embolism, myocardial infarction, drug allergy. The other possible causes like uterine inversion and uterine rupture will also be looked into by pelvic examination.I will look for any pallor, respiratory system for crepitations and wheeze. Abdominal examination whether uterus felt, contracted or not. Bleeding from uterus & cervix for the possibility of uterine atony and post partum haemorrhage.. Speculum examination to rule out cervical and vaginal tears will be done.
2 14 Gauge needles for intravenous access for fluid administration and blood investigation will be used. Oxygen should be administered by facial mask. Blood to be sent for full blood count to rule out anaemia, urea and electrolytes to be done for baseline assessment. Intravenous crystalloids to be started and blood will be sent for cross matching for 4 units of blood. Patient will be monitored by pulsoximeter, ECG. Bladder should be catheterised for the Urine output & for calculation of administration of fluids.

b.Inversion of uterus is an obstetric emergency. I will call for help from consultant obstretician .Theatre staff, anaesthetist will be informed of the situation and the possible need for laparotomy..With the intravenous fluids on flow for correction of shock manual reposition of uterus will be attempted.Tocolytics may be used for this.This will be followed by oxytocin administration to allow contraction of uterus. Hand should not be removed until contraction begins with oxytocin. Placental removal will not be attempted till manual reposition is complete since this may cause severe bleeding and shock.. O’sullivan’s method of hydrostatic repositioning may be tried if this fails. If this fails with informed consent and 4 units of blood kept ready laparotomy will be proceeded by Haultain,s and Huntington’s method. Patient will be managed in ITU post operatively. I will inform patient and her attenders of the entire course of events. The events should be carefully documented and incident report form will be filled. Psychological support in the form of counselling will be arranged.Thrombo prophylaxis risk assessment will be made post operatively.
Posted by Iffat ara M.
a):As symptoms of shock with out visible blood loss are suggestive of uterine inversion. Which is a acute obstetrical emergency. Which should deal quickly without delay to avoid necrosis of uterus due to obliteration of its blood supply. So I will call for help & involve MDC which include Obstetrical consultant, anesthetist, hematologist, senior midwife, obstetric team, ICU specialist & porter. I will review her & asses airway, breathing circulation. If needed start CPR in the Meantime l/V line with two 14G cannulas. Start l/V crystalloids to stabilize her B.P & to improve circulation. I will take blood samples for FBC, urea, electrolytes, coagulation profile, for cross matching of 4-6 pints of blood. After resuscitation & stabilization of the patient I will examine her thoroughly .On abdominal examination I will see her fundal height, if not palpable I will do pelvic examination. If the mass is felt in vagina this will conform the diagnosis of inversion of uterus so I will try to shift her in theatre where replacement of uterus will be done so theatre team will be informed in advance.
b):After confirmation of inversion of uterus & Pt is heamodynamically stable then I will try to replace uterus followed by removal of placenta. Replacement is attempted manually under general anesthesia(by pushing up funds with the palm of hand & fingers in direction of long axis of vagina). If fail to achieve replacement manually, I will proceed with O,sullivan maneuver. If this fails then proceeds to laparotomy & haultain operation will be option. After replacement of uterus I will start infusion of syntocinon(40 units of sytocinon in 500ml of ringer lactate). Then I will shift to HDU/ITU. After recovery of patient I will arrange a sitting with a patient & her husband/family. They will be informed about the all events. I will provide them written information. Documentation of all events on medical record is necessary. Incident report should be filled up properly. As their is 30% rate of recurrence Pt will be informed about this.
Posted by hoping ..
You are undertaking a ventouse delivery on a healthy 30 year old primigravida for delay in the second stage of labour. During an attempt to deliver the placenta, she complains of feeling unwell with a blood pressure of 65/35 mmHg and a pulse of 70 bpm. (a) Justify your initial assessment and interventions [8 marks]. (b) You identify an inverted uterus and the placenta has not separated. Justify your subsequent management [12 marks].
This pateint needs urgent assesment and stabilisation to avoid maternal morbidity or mortality. Her severe hypotensive state with normal pulse rate suggest neurogenic shock and therefore initial assesment directed towards these causes. Commonest reason is vasovagal episode secondary to pain or pooling of blood in legs. Uterine inversion should always be suspected when shock occurs during attempts to deliver placenta and is out of proportion to visible blood loss. This is diagnosed when uterus is either not palpable abdominally or had a fundal dimple. Vaginal examination may reveal inverted uterus in vagina. Inadvertant intravascular injection of local anaesthetic should be considered.Hypovolemic shock should also be considered and possibility of broad ligament haematoma. Patient should be layed flat on bed with legs slightly elevated to improve return of blood towards heart and brain and would also improve vasovagal symptoms. Help should be summoned for anaesthetist, obstetric resident doctors and senior midwife as resusitation can be effectively instituted with team effort. Patients airway and breathing should be assesed and iv access obtained.Bloods should be sent for fullblood count , grouping and crossmatching as bloodtransfusion may be required.If inverted uterus is diagnosed, attempts to replace uterus should be tried without separating placenta to reduce further traction on nerves and worsening compromise.
Uterine inversion while uncommon is not unexpected in this patient. This is Obstetric emergency and after initial assesment and intervention , subsequent management involves replacing uterus into pelvis. Attempts to deliver placenta prior to replacement must not be made as it will increase traction and thus increase parasympathetic outflow lading to further deteroration in condition. Manual replacement of fundus involves replacing everted uterus in order of sidewalls first and fundus last ie reverse order of eversion. This allows uterus to spring back to position and reduce peroration. These attempts could cause extreme discomfort or pain to patient and thus necessitate pain relief or anaesthesia. Regional anaesthesia is unsuitable in view of hypotension and thus general anaesthesia considered. Thus patient should be transferred to theatre.Replacement should be done as early as possible because delay couls lead to formation of constriction ring making it more difficult to replace. Other options like sealing introitus with hands or vacuum and pushing normal saline at high flow may help replace uterus. If vaginal attempts fail then laparotomy to replace uterus should be done. Hysterectomy may become necessary as life saving procedure.
Once replacement acheived , placenta should be carefully removed with controlled traction or manual removal while oxytocin infusion running. Uterotonics should be continued for 12- 24 hour to maintain contraction. Blood transfusion should be guided by her clinical condition and haemoglobin results. Coagulation abnormalities could be precipitated by this episode and thus corrected in liason with haematologist. As this is risk management issue and thus reporting should be done to improve patient care and develop strategies to prevent this type of event as this is iatrigenic in majority of cases with significant maternal mortality risk. Patient should be reviewed before discharge and events explained. She should be advised of low reccurrence risk in future pregnancies.
Posted by Sabahat S.
a) Postpartum collapse is an obstetric emergency with significant maternal morbidity and mortality. I will start resuscitation immediately to stabilize her, and at the same time look for the cause of her collapse/shock. Possibilities are vasovagal episode, uterine rupture, uterine inversion or amniotic fluid embolism. I will call for help of senior colleague, senior midwife, and anaesthtist.I will ask her about feeling of any chest pain, chest tightness or breathing difficulty. I will assess for airway, breathing. Oxygen will be given by facial mask .Pulse, B.P, respiratory rate,O2 saturation will be checked and monitored. Two wide bore cannulaewill be passed to establish circulation. Blood will be taken for FBC, blood group, cross match and clotting studies.IV fluids will be started in the form of crystalloids initially, colloids or Rh o-ve blood if needed. Abdominal examination will be done to see any distension, tenderness, rigidity to see signs of internal haemorrhage.Uterus will be palpated to see is it contracted or relaxed. A dimple in the fundus or absence of feeling of fundus will denote inversion of uterus. Amount of bleeding per vaginum will be assessed .Vaginal examination can reveal tears in the cervix or rent in the uterus, in case of uterine rupture or cervical tears extending to lower uterine segment .A pelvic mass will be felt in the vagina or protruding out of introitus, in case of uterine inversion. Internal hemorrhage will reveal signs of hypotension along with tachycardia with abdominal signs of internal bleeding. In vasovagal syncopal episode clinical findings will be normal except finding of transitory hypotension which will respond to resuscitation. I will explain the patient about the possible diagnosis and need for intervention.
b) Once discovered inversion, I with not continue with the removal of placenta as it may aggravate the condition. I will inform consultant on duty and theatre staff and anaesthetist .I will arrange to transfer the patient to theatre to proceed for replacement of uterus as well as placental removal .I will attempt to replace the uterus as soon as possible, because it is more likely to be successful if done immediately as with time, tissue oedema develops and makes it difficult. If It is difficult, I will ask for inj. ritrodine or terbutaline iv bolus to relax the uterus. If manual replacement fails, then OSullivan’s hydrostatic technique will be done to reposition the uterus. Two liters of warm normal saline are hanged on a stand at a level of 2 meters above the ground and fluid is instilled into the vagina.Vaginal introitus is sealed by hands or a sialistic vacuum cup. The uterus is replaced by pressure of fluid in the vagina. Once it is repositioned, sytometrine iv bolus will be given and syntocinon infusion started and I will keep my hand inside till a firm contraction is achieved. If the procedure fails then laparotomy will be proceeded and reposition can be done either by Huntington or Haultain\'s method .Written informed consent will be taken for possible laparotomy and correction of inversion before moving to theatre.Following successful replacement by any means , placenta will be removed manually.
Oxytocics infusion will be continued to keep uterus contracted. I will fill incident report following the event. I will explain the intervention done to the patient and her family . Possibility of recurrence in next delivery will be informed to her. A clear documentation will be done in the patient’s notes.
Posted by R M.
Dear Dr Paul,
It\'ll be helpful if you could please tell us the pass mark needed for individual questions at the end along with the key
Thanks....
Posted by Shabana M.
This is a very serious situation as woman is going into shock and in order to mange it effectively and with timely interventions unit protocol will be followed ands extra help will be summoned from senior consultant ,anesthetist ,midwife and senior house officer .If placenta is undeliverered then further attempt to remove it will be abonded as it will aggrevate the shock.
If woman is conciouss and well oriented then I will briefly explain the situation and if she is collapsed then i will start resuscitation immediately by following principles of ABC .airway will be assessed secured and patency will be maintained oxygen will be started via facial mask and intravenous line will be secured with two wide bore iv cannula and iv fluid will be started preferably crystalloid.Vitals (BP ,pulse nd temperature) will be assessed and monitored Bladder will be ctheterized.Blood will be collected for FBC group and save and coagulation profile .Blood bank and hematologist will be alerted for possible need of blood and blood products.A mid wife will be ssigned to keep the fmily and partner informed. Most probable diagnosis in this case is uterine inversion and will be confirmed by non palpable uterine fundus on abdominal examination and further confirmation will be achieved by vaginal examination
AS soon as diagnosis of inversion is confirmed I will stop oxytocin infusion if it is in progress and will made an attempt to replace the uterus as delay will lead to edema and swelling of uterus and will render repositioning difficult .Adequate analgesia (IV pethidine or inhalational analgesia entonox) is essential as shock in this situation is mainly neurogenic .If repositioning is not achieved then i will shift the patient to the theater I will try to do it with the help of uterine relaxation with iv terbutline and failing this will need osullivan hydrostatic replacement method utilizing hydrostatic pressure by filling vagina with warm saline and sealing introitus manually and resultant pressure reverses the inversion in most of the cases.Failure to achieve that will need leprotomy under GA.Haultain,s
procedure will be done before uterus become ischemic from obstruction of its blood supply .This involve traction of round ligament and incision is made through muscular ring in the posterior uterine wall continued traction on round ligament and manual pressure on fun dus from vagina will allow replacement of uterus and incision can then be closed .once repositioning is achieved oxytocin infusion will be restarted and and vaginal hand will not be removed till a tonic contraction is achieved .At this stage I will try to remove the placenta manually if still it is present.and will stich episiotomy or perinel tear if there Oxytocin infusion will be continued for 24 hours TO achieve good uterine conration
.I will keep the family informed and will fill an incident form as a part of risk management and documentionwill be made in the patients record Unit consultant will be informed of the event and patient will be given debriefing

Posted by SHAGUFTA T.
Anti shock measures should be undertaken immediately to avoid associated morbidity and mortality. Check the woman\'s breathing, secure the airway, oxygen administration, commence two large bore cannulae collecting the blood for CBC, coagulation, urea and electrolyte, cross match 4 - 6 unit and start crystaloid/ colloid fluid till cross match is available if needed. Simultaneously call for help the most senior obstretician, anaethestist and senior midwife. In somecases, patient get spontaneous recovery without any further intervention related to postural hypotension. If the lady still compromised careful assessment to address the cause with continuos monitoring of vital signs. The reading which is given above denote hypotension with normal pulse, this make high suggestion of uterine inversion. Rub up the uterus to assess the contraction with uterine inversion,the uterus will be unfelt or dimppling at the fundal area the diagnosis is confirmed with vaginal examination or it could be obviously protruded from the introitus at the same time evaluate the amount of bleeding any laceration or tear at the lower genitalia related to the operative delivery which can further compromise the condition. The most senior obstretician will take incharge the situation, trying to reduce the uterus manually starting from most outer part gradually the quicker this done the higher the success rate and avoid the tissue swelling and congestion. Intravenous muscle relaxant can be used it to facilitate the procedure. The placenta should not be removed before the replacement of the uterus as this can cause further bleeding and put the patient in profund shock. If this failed, O\'Sullivan\'s method should be implemented by filling the vagina with 2 liters of sterile saline rapidly infuse it hold 2 meters above the ground and the introitis sealed with the operator hand / vacuum silastic cup. This hydrostetic pressure will reposit prolapse uterus. If this failed laparatomy under GA is needed using Haultains procedure before uterine ischemia occured, incision in the posterior wall of the muscular ring of the uterus is made, traction on the roud ligament accompanied with pushing the uterine fundus from the vagina, then the incision sutured, at any trial when the uterus placing in position manual removal of the placenta is performed and the hand of the operator should be kept in a place with administration of IV oxytocyn till firm contraction is obtain it. If all above measures failed hysterectomy is indicated as a life saving prcedure. Filling incidental report as a part of effective risk management, clear careful documentation is of paramount importance. Post natal close monitoring to the patient clear explanation to the lady and her family regarding the events and all measures which is undertaken. Make note in her file for future pregnancy as this complication has recurrence rate as high as 30 percent.
Posted by SHAGUFTA T.
A) This Patient developed shock which is an obstetric emergency, I will take quick actions. I will call for help from senior obstetrician, anaesthetist registrar, senior midwife, SHO if not there. I will alert Consultant Obstetrician, anaesthetist, haematologist, theatre staff. I will quickly do clinical assessment of patient and check if she is conscious and responding. Iwill explain her & try to alleviate her anxiety. I will ask SHO, midwife & anaesthetic registrar to help me in resuscitation. We will check airway, start oxygen inhalation by facial mask, start IV fluids (crystalloid/colloids) by 2 large bore cannulae, same time take blood for FBC, coagulation, Group & cross match (4-6 units blood), baseline LFT,RFT, I will assign SHO to continue monitoring for vital signs, input/output chart, and check for availability of blood. Low BP without tachycardia goes in favour of uterine inversion.
I will examine the lady to look for cause of shock. I will do general examination, abdominal examination to see uterine tone, any dimpling/ cupping of fundus, then vaginal examination for amount of bleeding, any tears/ lacerations in vagina or cervix, or hematoma. I will look for any mass in vagina (suggestive of uterine inversion). After initial management of shock, subsequent management will depend upon cause identified.

B)
Inverted uterus with attached placenta is identified. This is acute obstetric emergency with high maternal morbidity & mortality if not identified and managed quickly. I will try to reposit the uterus manually by applying pressure on fundus through vagina as early as possible to avoid ischemia of tissues. If not successful, repeat trial after giving tocolytics like magnesium sulphate or terbutaline/ ritrodrine, I will try to reposit last part first, then rest and then keep my hand inside till good uterine contraction occurs. I will ask assistant to give syntometrine if not on syntocinon infusion from before. After successful reposition & good contraction only I will attempt delivery of placenta by MROP. This all I will do after shifting the patient to Operation Room
If manual reposition fails, I will try Hydrostatic pressure -- O’ Sullivans method by instilling 2 litres of warm normal saline through a bag kept at 2Metre height stand with a tubing. I will ask assistant to seal the introitus with fist or with sialastic ventouse cup. If this successful, synto will be given for goog contraction and then placenta removed. If this method also failed, then senior Obstetrician preferably consultant to do Laparotomy with Haultains or Huntingtons method of surgical reposition. In this method a vertical incision is given on post wall of uterus, to release constriction ring, then traction applied on B/L round ligament to pull uterus, same time assistant will push fundus through vagina. In case this also fails life saving hysterectomy to be performed
Once all procedures done, patient stabilized, debriefing should be done to patient and her family regarding her situation, the complications and what all procedures done. Incident form is filled clearly and all documentation done. She will be informed about the risk of recurrence in future pregnancy which is around 30%
Posted by San S.
a) I would call for help from senior obstetrician, anaesthetist and coordinator. Basic resuscitation with oxygen and 2 large bore iv access for administration of iv colloid and crystalloid is important. It is also important to check for the amount of blood loss form tears or atonic uterus. FBC, clottings and crossmatch for 2 units of blood initially. FBC and clottings would estimate her haemoglobin levels and identify any clotting problems. If there is excessive blood loss due to atonic uterus, uterine massage, syntometrine i.v or i.m and syntocinon infusion sould be started. Her pulse, BP and oxygen saturation should be monitor regularly to monitor her response to the resuscitation.
b)I would liase with the anaesthetist, senior obstetrician and coordinator to transfer the patient to theatre to correct the inverted uterus under general anaesthesia. Resuscitation should continue thorughout the event. Once patient is asleep, I wouls attempt to manually replace the uterus. All oxytoxic medications eg synocinon infusion if was administered should be stopped. Tocolysise.g. terbutaline 250micrograms i.m may be useful if there is difficulty in manually replacing of uterus. Packing the uterus and hydrostatic or cook\'s balloon may be helpful if manual replacement has failed. Once, uterus is reverted, the placenta can be removed manually.
She is still at risk of post partum haemorrhage and management has to continue with fluids or blood resuscitation and with response observed with her pulse and blood pressure. Syntocinon infusion can be restarted and carboprost can be considered if she continues to bleed or have atonic uterus.Pack, hydrostatic and Cook\'s balloon can be left in-situ if oxytoxics failed to control the bleeding. A laparotomy in view of a hysterectomy would be the last resort if all above has failed. Other perineal trauma should be checked and repaired.