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OG16.1-3 | Third Stage Complications — PBL Case

CLINICAL SETTING

It is 2:30 AM at a district hospital. Dr Meena, a first-year postgraduate resident in obstetrics, is the only doctor on the labour ward. A 22-year-old primigravida (Mrs Sunita) was admitted in active labour at 10 PM, progressed normally, and delivered a live female baby (3.1 kg, Apgar 8/9) at 2:15 AM. AMTSL was performed: oxytocin 10 IU was given intramuscularly within one minute of delivery. The midwife performed controlled cord traction. The placenta was delivered intact at 2:22 AM. At 2:28 AM, the midwife calls Dr Meena urgently: Mrs Sunita has gone pale, is clutching her lower abdomen in pain, and has a heart rate of 50/min — paradoxically low despite appearing shocked. There is no visible mass initially at the introitus, but the midwife has not yet performed a vaginal examination. The uterine fundus cannot be felt on abdominal palpation. Dr Meena calls for help and begins her assessment.

Trigger 1: Initial Presentation: Sudden Collapse After Placental Delivery

Dr Meena examines the patient: BP 74/50 mmHg, HR 50/min, GCS 14/15. On inspection of the perineum, she sees a smooth, dark-red mass protruding 2 cm beyond the vaginal introitus. On gentle bimanual assessment, there is no palpable uterine fundus at or above the umbilicus. Visible blood loss is approximately 300 mL — less than expected given the degree of haemodynamic collapse.

DISCUSSION POINTS

  • What is the diagnosis? What are the three clinical features in this case that confirm it?
  • Why is the patient bradycardic when she appears to be in shock — explain the physiological mechanism.
  • Grade this inversion by degree. What does the grade imply for urgency and approach?
  • Why is the visible blood loss disproportionately low given the degree of cardiovascular collapse?
Click to reveal Trigger 2: Immediate Management — Resuscitation and First Attempt at Reduction (discuss previous trigger first!)

Trigger 2: Immediate Management — Resuscitation and First Attempt at Reduction

Two large-bore IV cannulae are inserted. One litre of Ringer's lactate is running. Dr Meena calls the consultant at home. She notes that the placenta was delivered intact, and no placenta is attached to the inverted fundus. She attempts the Johnson manoeuvre (placing her palm on the exposed fundus and pushing steadily upward through the vagina toward the umbilicus) — but cannot reduce the inversion. The cervical ring feels firm and contracted around the inverted uterus.

DISCUSSION POINTS

  • What immediate resuscitation steps should run in parallel with attempting reduction?
  • Describe the Johnson manoeuvre — what is the correct technique?
  • The cervical ring is tight and is preventing reduction. What pharmacological intervention is needed, and what class of drug does it belong to? Name two agents that can be used.
  • At this moment, is oxytocin indicated? Justify your answer.
Click to reveal Trigger 3: Tocolysis and Successful Manual Reduction (discuss previous trigger first!)

Trigger 3: Tocolysis and Successful Manual Reduction

The anaesthetist arrives and gives intravenous glyceryl trinitrate (GTN) 300 mcg as a bolus. Within 90 seconds, the cervical ring relaxes perceptibly. Dr Meena reattempts the Johnson manoeuvre: this time, the fundus gradually reduces — she feels it return through the cervix and resume its normal position. The uterus is now palpable as a well-defined fundus at the umbilicus. Total elapsed time from inversion to reduction: 18 minutes.

DISCUSSION POINTS

  • What is the mechanism of action of GTN in this context? Which smooth muscle receptor pathway does it act on?
  • Now that the inversion is reduced, what is the FIRST pharmacological step? What would happen if you did NOT take this step immediately?
  • What should be done about the placenta? Should it be removed before or after reduction, and why? (What would have happened had the placenta been still attached at the time of reduction?)
  • What monitoring parameters should be tracked over the next 2 hours?
Click to reveal Trigger 4: Post-Reduction PPH and Blood Product Decision (discuss previous trigger first!)

Trigger 4: Post-Reduction PPH and Blood Product Decision

Thirty minutes after successful reduction, Mrs Sunita develops renewed bleeding — approximately 600 mL in 20 minutes. The uterus is well-contracted (confirmed by fundal palpation). The midwife reports the placenta was complete. Examination under a good light shows a 3 cm posterior vaginal wall laceration extending to the perineum, actively oozing. Blood test results: Hb 8.1 g/dL, platelets 110,000/mm³, PT normal, APTT normal, fibrinogen 2.8 g/L.

DISCUSSION POINTS

  • Which of the 4 Ts is now responsible for the ongoing bleeding? How does this differ from the initial presentation?
  • The coagulation screen is normal. Does this patient need blood product transfusion at this point? What are the transfusion thresholds in obstetric haemorrhage?
  • What is the definitive treatment for this laceration?
  • What would you look for on re-examination to ensure you have not missed additional lacerations (cervical, periurethral, vault)?
Click to reveal Trigger 5: Systemic Debrief and Prevention (discuss previous trigger first!)

Trigger 5: Systemic Debrief and Prevention

It is 5 AM. Mrs Sunita is stable after surgical repair of the laceration under spinal anaesthesia. Total blood loss was approximately 1400 mL. She received 2 units of packed RBC. The consultant reviews the case with Dr Meena: the uterine inversion likely occurred because AMTSL was performed correctly, but when the midwife applied controlled cord traction, the uterus was unsupported and the fundus was not adequately countered — a brief, inadvertent, strong traction caused the fundus to invert. The consultant asks: 'What should we change in our practice to prevent this next time?'

DISCUSSION POINTS

  • What are the iatrogenic and patient-related causes of uterine inversion? Which is more preventable?
  • Describe the correct technique of controlled cord traction in AMTSL — what specific manoeuvre prevents inversion?
  • If manual reduction had completely failed at this district hospital and no surgical expertise was available, what would the next step be — and what is the risk of delayed management?
  • What are the maternal complications of delayed or inadequately treated uterine inversion? What outcomes might Mrs Sunita have faced if the resident had not recognised the diagnosis promptly?

Group Task Assignments

  • As a group, construct a timeline of all management steps from 2:28 AM to 5:00 AM, marking each decision point with the correct pharmacological or procedural action and its justification.
  • Prepare a 3-minute brief for the morning handover explaining the diagnosis, how it was made, and the two pivotal decision points (tocolysis before reduction; oxytocin immediately after reduction).
  • List the uterotonic contraindications relevant to this case — had Mrs Sunita had hypertension, which uterotonic given post-reduction would have been contraindicated, and what would you substitute?
  • Identify three systems-level changes at a district hospital that would improve outcomes for a case like this (examples: AMTSL protocol audit, 24-hour obstetric cover, blood bank access).

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG16.3] What are the degrees of uterine inversion and how does degree influence management?
  2. [OG16.3] What is the correct sequence of management for acute uterine inversion: resuscitate → tocolyse → reduce → restore tone? Why is this sequence non-negotiable?
  3. [OG16.3] What are the mechanisms of the vasovagal component of uterine inversion shock, and why does it cause bradycardia rather than the tachycardia expected in haemorrhagic shock?
  4. [OG16.1] How do the 4 Ts explain the two separate haemorrhagic episodes in this case (inversion phase vs post-reduction laceration phase)?
  5. [OG16.1] What are the uterotonic contraindications (carboprost/asthma; ergometrine/hypertension) and how would comorbidities in this patient have changed the post-reduction uterotonic choice?
  6. [OG16.2] What non-surgical mechanical techniques are available if PPH persists after reduction, and what is the criterion for proceeding to surgical intervention?