NCLEX Review Guide: Uterine Inversion

Understanding Uterine Inversion

• Uterine inversion is a rare but life-threatening obstetric emergency where the uterus turns inside out, with the fundus prolapsing through the cervix into the vagina or beyond the introitus.
• This complication occurs in approximately 1 in 2,000 to 1 in 23,000 deliveries and can result in severe hemorrhage and shock if not promptly managed.

Predisposing Factors

• Excessive cord traction during third stage of labor is the most common iatrogenic cause.
• Fundal pressure applied before complete cervical dilation or when uterus is relaxed increases risk significantly.
• Uterine atony, retained placenta, and abnormally adherent placenta (placenta accreta) predispose to inversion.
• Rapid labor, multiparity, and use of uterine relaxants (magnesium sulfate, halothane) are additional risk factors.

Signs and Symptoms

• Sudden severe lower abdominal pain followed by profuse vaginal bleeding and signs of shock.
• Inability to palpate uterine fundus abdominally, with a visible mass protruding from the vagina in complete inversion.
• Rapid onset of hemorrhagic shock with hypotension, tachycardia, and altered mental status.
• Patient may experience severe pelvic pressure and an urge to bear down.

Emergency Interventions

1. Do not attempt to remove placenta if still attached - this can worsen bleeding and complicate replacement.
2. Immediately call for emergency assistance and prepare for manual replacement of the uterus.
3. Establish large-bore IV access and begin fluid resuscitation while preparing for blood transfusion.
4. Administer IV tocolytics (terbutaline, magnesium sulfate) to relax the uterus and facilitate replacement.
5. Attempt manual replacement using Johnson maneuver - push the fundus back through the cervix with steady pressure.
6. Once replaced, immediately administer uterotonic agents (oxytocin, methylergonovine) to maintain uterine contraction.

Priority Nursing Interventions

• Continuously monitor vital signs, focusing on blood pressure, pulse, and oxygen saturation for signs of shock.
• Assess and document blood loss by weighing pads and monitoring hemoglobin/hematocrit levels.
• Maintain strict intake and output monitoring and assess for signs of fluid overload during resuscitation.
• Provide emotional support and explain procedures to patient and family during this frightening emergency.
• Monitor uterine tone and position after replacement to ensure it remains contracted and in proper position.

Preventive Measures

• Avoid excessive cord traction and never apply fundal pressure before complete cervical dilation.
• Use controlled cord traction technique during third stage of labor, allowing natural placental separation.
• Recognize high-risk patients (multiparity, previous uterine surgery, abnormal placentation) and prepare accordingly.
• Ensure adequate uterine contraction before attempting any manual maneuvers during delivery.