Uterine Inversion & Uterine Rupture: Recognition, Replacement & Surgery

Two third-stage and intrapartum catastrophes in one place: how to recognise and replace an inverted uterus, and how to manage a uterine rupture. Based on the OLSS (Obstetric Life Saving Skills) lecture on uterine inversion at Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh.

Uterine inversion

The uterine fundus collapses into the endometrial cavity, with or without the placenta attached, turning the uterus partly or completely inside out. It is extremely rare and life-threatening, and happens in the third stage of labour.

Degrees

Degree	What happens	What you find
First	The fundus descends into the cavity, not beyond the cervical ring	A dimple at the top of the fundus; may not be obvious, as the fundus doesn't pass the internal os
Second	The fundus protrudes through the cervical ring into the vagina	The entire uterus is still within the vagina
Third	The fundus protrudes through the introitus	The fundus can't be felt per abdomen; the inverted uterus protrudes outside the vulva
Fourth	Complete inversion of the uterus and vagina	The vagina is inverted too

Risk factors

Excessive traction on the umbilical cord and inappropriate fundal pressure.
Short umbilical cord.
Multiparity.
Abnormally adherent placenta, and manual removal of the placenta.
Vaginal birth after caesarean (VBAC).
Uterine abnormalities, and a previous uterine inversion.
Fetal macrosomia.
Precipitate labour.
Connective tissue disorders (e.g. Marfan or Ehlers-Danlos syndrome).

Diagnosis

Sudden profuse bleeding and/or abdominal pain.
Hypotension and shock, before or after placental delivery. The shock is often vasovagal (neurogenic): bradycardia with hypotension.
No fundus on abdominal palpation, or a dimple felt at the fundus.
On VE, a mass protruding through or from the vagina.

Prevention

Don't try to expel the placenta while the uterus is relaxed.
Avoid pulling on the cord at the same time as applying fundal pressure.
Do manual removal of the placenta carefully.

Remark: VE = vaginal examination; VBAC = vaginal birth after caesarean.

Managing inversion

Call for help, control the haemorrhage and restore haemodynamic stability, and replace the uterus as soon as possible. Treat shock, including blood transfusion, at the same time.

The placenta: remove it manually only after the uterus has contracted.

Manual replacement: Johnson manoeuvre

Last part out, first part in.

Replace the part of the uterus that inverted last, first, with the other hand supporting the fundus and helping push the uterus in.
Replace the lower part of the uterus gradually; the fundus is not yet replaced.
Once the uterus is in the abdomen, use the supporting hand to hold the uterus on the abdomen.
The fundus, the first part to invert, is the last part replaced.
Keep your hand in the uterus and give oxytocics. Once you feel the uterus contracting, do the MRP.
Keep your hand in the uterus until it is firmly contracted on your hand, then gradually remove it.

Hydrostatic replacement: O'Sullivan technique

Run 2 L or more of warm saline into the vagina through a large rubber tube, with the bag held 1-2 metres above the patient.
Place the end of the tube in the posterior fornix; an assistant seals the introitus to stop leakage.
A silicone vacuum cup attached to the tubing (or to IV tubing) gives a better seal.

Tocolytics

To relax the cervical ring during replacement:

IV salbutamol 75-150 mcg bolus, or
SC terbutaline 0.25 mg.

After replacement

Keep your hand in the uterine cavity until a firm contraction is sustained.
Give uterotonics to keep the uterus contracted and prevent re-inversion: oxytocin 20 U in 500 mL IV fluid at 10 drops/min; if the uterus doesn't contract on oxytocin, ergometrine 0.2 mg or prostaglandins.
Prophylactic antibiotics: ampicillin 2 g IV + metronidazole 500 mg IV, or cefazolin 1 g IV + metronidazole 500 mg IV.
Watch for postpartum haemorrhage.
Debrief and document.

Remark: MRP = manual removal of placenta; SC = subcutaneous.

Surgery, if all else fails

Abdominal approach

Huntington procedure: Allis or Babcock clamps placed in the dimple of the inverted uterus (on the round ligaments), with gentle upward traction to pull the fundus up.
Haultain procedure: a vertical incision on the posterior uterine surface cuts the constriction ring, and the fundus is pulled up.

Vaginal approach

Spinelli procedure: incise the constricting cervical ring anteriorly.
Cascarides procedure: incise the constricting cervical ring posteriorly.

Consider a uterine compression suture after successful replacement.

Uterine rupture

Uterine rupture: disruption of the uterine muscle including the serosa.
Uterine dehiscence: disruption of the uterine muscle with the serosa intact.

Clinical features

Abnormal fetal heart rate changes.
Severe abdominal pain, and scar tenderness.
Shoulder tip pain, chest pain or haematuria.
Signs of shock or breathlessness.
Cessation of contractions.
Blood-stained liquor or vaginal bleeding.
Loss of the presenting part, or a high presenting part.

Managing rupture

Call for help: Red Alert.
Start resuscitation and activate the massive transfusion protocol.
Arrange an immediate laparotomy, aiming for delivery within 30 minutes under GA.
Continuous fetal heart monitoring if the baby is alive.
A midline skin incision is preferred, for better access and extension.
Assess the extent of the trauma and minimise bleeding.

Whether to repair or do a hysterectomy depends on the mother's stability, the volume of blood loss, signs of DIC, the response to resuscitation, the extent of the tear, the blood products and resources available, and her desire for future childbearing.

Remark: GA = general anaesthesia; DIC = disseminated intravascular coagulation.

Sources

Obstetric Life Saving Skills (OLSS) lecture: Uterine Inversion (including uterine rupture). Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, 2026.
Sarawak Advanced Life Support in Obstetrics (SALSO) Course Manual. 2022 (severity and Johnson manoeuvre figures, as reproduced in the lecture).