Examkin

Question

Difficulty: Very hardLabor, Delivery, and Puerperium

A 28-year-old primiparous woman experiences significant vaginal bleeding immediately following the vaginal delivery of a 4100-g neonate. The delivery was complicated by a prolonged second stage, and aggressive umbilical cord traction was applied before complete placental separation. On physical examination, a firm, beefy-red mass is visualized protruding through the vaginal introitus, and the uterine fundus is no longer palpable transabdominally. The patient's blood pressure is 78/40 mmHg and her heart rate is 132/min. Intravenous fluid resuscitation and massive transfusion protocols are initiated.

Assuming each conservative measure fails to achieve resolution, arrange the following interventions in the correct chronological sequence for the optimal management of this patient's condition.

  1. 1Discontinue all active uterotonic infusions
  2. 2Attempt immediate manual replacement of the uterus
  3. 3Administer a uterine relaxant such as intravenous nitroglycerin
  4. 4Perform laparotomy for surgical correction
  5. 5Administer uterotonic agents such as oxytocin and methylergonovine

Answer

The correct chronological sequence is to first discontinue uterotonic agents, attempt manual replacement, administer uterine relaxants if the manual attempt fails, perform a laparotomy if the condition remains refractory, and finally administer uterotonic agents only after successful anatomical replacement.
Uterine inversion is a life-threatening obstetric emergency characterized by the collapse of the uterine fundus into the uterine cavity, often protruding through the cervix. The stepwise algorithmic management prioritizes avoiding the entrapment of the fundus. Therefore, any infusing uterotonics must be immediately discontinued. The clinician should then promptly attempt to manually replace the uterus (Johnson maneuver). If this is unsuccessful because the cervical ring has contracted around the inverted fundus, uterine relaxants (such as intravenous nitroglycerin, terbutaline, or halogenated general anesthetics) are administered to facilitate a second manual attempt. If pharmacological relaxation fails, surgical correction via laparotomy (e.g., Huntington or Haultain procedure) is indicated. Importantly, uterotonics (e.g., oxytocin, methylergonovine) are strictly contraindicated until the uterus is anatomically reverted. Once the uterus is confirmed to be in its normal position, uterotonics must be administered to establish firm uterine tone, prevent reinversion, and control ongoing hemorrhage.

Step-by-Step Solution

1
Discontinue active uterotonics
Prevents cervical ring constriction
Uterotonics would trap the inverted uterus, making non-surgical replacement impossible.
2
Attempt manual replacement
Restores normal uterine anatomy non-surgically
Early intervention before tissue edema sets in provides the best chance of resolution.
3
Administer uterine relaxants
Relaxes the constricting cervical ring
Required when the initial manual attempt fails due to cervical spasm.
4
Perform laparotomy for surgical correction
Surgical repositioning of the uterus
Necessary when pharmacological relaxation combined with manual traction is insufficient.
5
Administer uterotonics
Promotes sustained uterine contraction
Prevents reinversion and controls postpartum hemorrhage, but is safe only after the uterus is correctly positioned.

Key Concept

Management algorithm for acute puerperal uterine inversion
Rate this question

Topics

Labor, Delivery, and Puerperium

More questions from this topic