Uterine Inversion: Rare but Life-Threatening Obstetric Emergency

Uterine inversion—the uterine fundus collapses through the cervix into the vagina—occurs in ~1/2,500–1/20,000 deliveries. It's a medical emergency requiring immediate recognition and manual reduction.

Risk Factors

• Prolonged labor (>18 hrs), precipitous labor
• Multiparity, macrosomia (>4 kg)
• Fundal placental implantation + vigorous cord traction
• Manual placental removal
• Uterine anomalies (bicornuate, septate)
• Short umbilical cord, connective tissue disorders

Signs and Symptoms

• Sudden severe lower abdominal pain
• Massive hemorrhage (often concealed)
• Shock (tachycardia, hypotension, altered mental status) disproportionate to visible bleeding
• Palpable vaginal mass (inverted fundus)
• Absent uterine fundus on abdominal exam

Immediate Management

1. Call for help (OB, anesthesia, blood bank).
2. Manual reduction: Johnson's maneuver—push fundus through cervix with fist, palm toward umbilicus, steady pressure. Do not remove placenta first if still attached.
3. If placenta attached → reduce uterus → then deliver placenta.
4. IV fluids, blood products, uterotonics (oxytocin, methylergonovine, carboprost) after reduction.
5. If manual fails → hydrostatic (O'Sullivan) or surgical (Huntington, Haultain) reduction under GA.

Prevention

• Controlled cord traction only after signs of separation.
• Fundal counter-pressure during placental delivery.
• Avoid excessive fundal pressure.

Mortality 5–15% if delayed; near 0% with prompt reduction.