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Difficulty: Very hardLabor, Delivery, and Puerperium

A 29-year-old primiparous woman at 4040 weeks gestation undergoes a spontaneous vaginal delivery. The infant weighs 41004100 g. Active management of the third stage of labor is performed using controlled cord traction. Shortly after the placenta delivers, a firm, smooth, red mass is observed protruding from the vaginal introitus, accompanied by profuse hemorrhage. The patient becomes lethargic, and her blood pressure drops to 70/4070/40 mm Hg with a heart rate of 135135/min. Arrange the following steps in the correct chronological order for the optimal management of this complication.

  1. 1Request multidisciplinary assistance, establish large-bore intravenous access, and begin aggressive fluid resuscitation.
  2. 2Discontinue all currently infusing uterotonic medications.
  3. 3Administer a rapidly acting uterine relaxant (e.g., intravenous nitroglycerin).
  4. 4Perform manual replacement of the uterine fundus into its correct anatomic position.
  5. 5Administer high-dose uterotonic agents to maintain sustained uterine contraction.

Answer

The correct chronological management of a firmly contracted uterine inversion is: call for multidisciplinary assistance and begin resuscitation, discontinue infusing uterotonics, administer a uterine relaxant, perform manual replacement of the uterus, and finally administer high-dose uterotonics.
Uterine inversion is a life-threatening obstetric emergency characterized by the fundus collapsing into the endometrial cavity, often caused by excessive umbilical cord traction. The patient's profound hemorrhagic shock is driven by bleeding and vagal stimulation from the stretched infundibulopelvic ligaments. The algorithmic priority is restoring normal anatomy. Initially, help must be summoned and fluids started. Crucially, any ongoing uterotonics must be stopped, and a uterine relaxant (e.g., nitroglycerin) must be given to relax the firmly contracted cervical ring. Only after the uterus is relaxed can the fundus be manually replaced (Johnson maneuver). Once the uterus is successfully replaced, uterotonics are aggressively restarted to maintain a firm, contracted uterus that will compress bleeding vessels and prevent reinversion.

Step-by-Step Solution

1
Recognize acute uterine inversion with hemorrhagic shock and initiate stabilization.
The maternal cardiac arrest/hemorrhage team is activated and fluid resuscitation begins.
The patient is hypotensive and tachycardic, requiring immediate life-saving support before definitive anatomical correction.
2
Stop any ongoing uterotonic infusions.
Oxytocin or other contracting agents are halted.
Uterotonics will worsen the constriction ring around the inverted fundus, making manual repositioning impossible.
3
Administer a uterine relaxant (such as IV nitroglycerin, terbutaline, or inhaled halogenated anesthetics).
The firm lower uterine segment and constriction ring relax.
The stem describes the mass as 'firm', meaning attempting to push it back without relaxation will likely fail and exacerbate hemorrhage.
4
Execute the Johnson maneuver.
The inverted fundus is manually pushed upward along the axis of the vagina and back into the pelvic cavity.
This is the definitive treatment to restore normal pelvic anatomy and stop the primary source of bleeding.
5
Administer aggressive uterotonic therapy (e.g., oxytocin, carboprost, methylergonovine).
The uterus becomes firmly contracted in its normal anatomical position.
A firm, contracted uterus is required post-replacement to compress myometrial blood vessels and prevent the fundus from prolapsing again.

Key Concept

Stepwise algorithmic management of acute postpartum uterine inversion
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Topics

Labor, Delivery, and Puerperium

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