A -year-old woman, gravida , para , at weeks gestation undergoes an uncomplicated vaginal delivery of a g neonate. During the third stage of labor, excessive umbilical cord traction is applied before complete placental separation. Shortly after, a firm, purple, globular mass is noted protruding from the introitus, and the uterine fundus is no longer palpable in the abdomen. The patient experiences sudden, severe vaginal bleeding and her blood pressure drops to mmHg. Arrange the following steps in the optimal chronological order for the acute management of this obstetric emergency.
- 1Discontinue all ongoing uterotonic infusions
- 2Attempt immediate manual replacement of the uterus
- 3Administer intravenous nitroglycerin or terbutaline
- 4Reinitiate a continuous oxytocin infusion
Answer
The correct sequence for managing acute uterine inversion is to first discontinue uterotonics, then attempt immediate manual replacement, use uterine relaxants if the initial manual attempt fails, and finally restart uterotonics once the uterus is successfully replaced.
Uterine inversion is a life-threatening obstetric emergency characterized by the collapse of the fundus into the uterine cavity, classically presenting with a vaginal mass, absent fundus on abdominal exam, and rapid hemorrhagic shock. The first crucial step is to stop all uterotonics to prevent cervical constriction. Next, immediate manual replacement should be attempted by applying steady pressure to the inverted fundus. If this fails due to a cervical constriction ring, uterine relaxants (such as nitroglycerin or terbutaline) or general anesthetics are given to relax the uterus and allow replacement. Finally, once the uterus is successfully reverted to its normal position, uterotonics (e.g., oxytocin) are restarted to ensure the uterus remains firmly contracted, preventing both recurrent inversion and ongoing hemorrhage.
Step-by-Step Solution
Key Concept
Algorithm for the acute management of puerperal uterine inversion