OG16.3 | Uterine Inversion — Summary & Reflection

KEY TAKEAWAYS

Uterine inversion is the turning inside-out of the uterine fundus, classified by degree: 1st (fundal dimpling within cavity), 2nd (fundus in vagina), 3rd (fundus beyond introitus), 4th (uterus + vaginal walls inverted). By timing: acute (<24 h), subacute (24 h–4 weeks), chronic (>4 weeks).

Presentation: Shock disproportionate to blood loss (vasovagal mechanism — traction on broad ligament → massive parasympathetic discharge), absent fundus on abdominal palpation, vaginal or perineal mass.

Causes: Spontaneous (fundal placentation, short cord) or iatrogenic (premature/forceful cord traction, fundal pressure — the leading cause in practice).

Prevention: Correct AMTSL — Brandt-Andrews cord traction (suprapubic counter-pressure + cord traction only when uterus is contracted); never apply fundal pressure.

Management sequence:
1. IV access + resuscitation; DO NOT remove placenta before reduction; DO NOT give oxytocin before reduction
2. Johnson manoeuvre — cup fundus, sustained upward pressure through vagina toward umbilicus
3. Tocolysis if cervical ring contracted: GTN 100–200 µg IV, or terbutaline 0.25 mg SC, or MgSO₄ 4–6 g IV
4. Surgical reduction if Johnson manoeuvre fails: Huntington procedure (laparotomy + stepwise forceps traction of round ligaments); Haultain procedure (adds posterior cervical incision for tight constriction ring)
5. Oxytocin infusion after successful reduction to prevent re-inversion

REFLECT

Reflect on the sequence of events in the hook scenario at the beginning of this module. The house officer performed cord traction without waiting for uterine contraction — a technical error with catastrophic consequences. In Kolb's reflective cycle: what experience (real or observed) do you have of third-stage management that might have led to a similar sequence? What is the abstract principle that explains why the timing of cord traction matters so much mechanically? How would you actively experiment with applying correct AMTSL technique in your next supervised delivery — and how would you recognise, in real time, the signs of placental separation that tell you cord traction is safe? Discuss your reflection with the supervising consultant at your next obstetric placement.