II. Epidemiology

  1. Incidence: 1 in 2500 deliveries (0.04%)
  2. More commonly affects Multiparous patients
  3. Iatrogenic cause most often

III. Pathophysiology

  1. Serious complication of Vaginal Delivery
  2. Rare, but life threatening if not replaced

IV. Signs

  1. Placenta appears at introitus attached to mass
    1. Inverted Uterus appears as bluish-gray mass protruding from vagina
  2. Shock
    1. Bradycardia associated with vagal response
    2. Excessive Hemorrhage may be absent

V. Grading

  1. First Degree: Incomplete inversion
  2. Third Degree: Complete inversion to perineum

VI. Management

  1. Treat shock and blood loss
    1. Immediate Intravenous Access
    2. Intravenous Fluid Replacement
  2. Call for emergent Consultation
    1. Obstetrics
    2. General Anesthesia (consider Halothane)
  3. Immediate Manual Replacement (Johnson Maneuver)
    1. Replace Uterus in non-inverted position
      1. Replace last part out first (last out, first in)
      2. Leave placenta in place if still attached (removal increases bleeding)
      3. Johnson Method
        1. Grasp protruding uterine fundus with palm of hand and fingers toward posterior fornix
        2. Lift the Uterus back up into vagina, through Pelvis and into Abdomen
    2. Administer Terbutaline or Nitroglycerin as below as needed to relax Uterus
    3. Consider General Anesthesia
    4. Repeat trial of Manual Replacement
    5. Surgical Replacement
  4. Pre-replacement uterine relaxants (Tocolytics) if contraction ring prevents replacement
    1. Magnesium Sulfate
    2. Terbutaline 0.25 mg SC
    3. Nitroglycerin
      1. Intravenous: 50 to 200 mcg IV
      2. Sublingual (200 mcg per spray): 2 sprays sublingual
  5. Post-Replacement Uterine Hemorrhage Management options
    1. Pitocin IV 40 u/L at 100-250 cc/h
    2. Hemabate 0.25mg IM Myometrium q15 minutes (max: 2 mg)
    3. Methergine 0.2 mg IM or PO q6-8h
  6. Consider exploratory laparotomy if needed

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