A nurse is caring for a client who has just experienced a complete uterine inversion immediately after delivery. What is the most critical nursing intervention that should be performed first?

Manual replacement (Johnson maneuver) is the priority to restore uterine anatomy and control bleeding. Other options (detaching placenta, oxytocin, Trendelenburg) are secondary or contraindicated until uterus is replaced.

Understanding the Emergency
The scenario describes a complete uterine inversion, a rare but life-threatening obstetric emergency where the uterine fundus collapses into the endometrial cavity and protrudes through the cervix and vagina. The immediate clinical clues are the non-palpable fundus abdominally, a bluish mass at the introitus, severe pain, and signs of hypovolemic shock (BP 80/50 mmHg, HR 120 bpm). The pathophysiology of shock in this condition is not solely due to blood loss; the stretching of the ovaries, fallopian tubes, and peritoneal nerves by the inverted fundus triggers a profound vagal response, leading to severe bradycardia and hypotension, which compounds hemorrhagic shock [1, 2].

Prioritizing the First Intervention
The most critical first action is to immediately attempt manual replacement of the uterus by applying steady, gentle upward pressure to the protruding fundus. The guiding principle in managing acute uterine inversion is that the uterus must be repositioned as quickly as possible. Delay in replacement allows the cervix to constrict, forming a tight ring around the inverted, engorged fundus, which makes subsequent reduction efforts far more difficult and increases the risk of uterine atony, necrosis, and uncontrollable hemorrhage [2, 3]. The Johnson maneuver, a standard manual technique, involves placing the palm of the hand on the fundus with fingertips at the cervicouterine junction and pushing the fundus upward through the cervix along the axis of the vagina, using the last part to emerge as the first part to be replaced ^[3].

Why Other Options Are Incorrect or Secondary
- Option 1 (Detaching the placenta first) is contraindicated as the initial step. The placenta is still attached to the inverted fundus, and forcibly removing it before reduction can tear the delicate endometrial surface, dramatically increasing hemorrhage. The placenta should only be manually removed after the uterus has been successfully repositioned to minimize blood loss [1, 2].
- Option 3 (Administering oxytocin) is dangerous while the uterus is inverted. Oxytocin stimulates uterine contractions, which would tighten the cervical ring around the trapped fundus, making manual reduction mechanically impossible and exacerbating tissue ischemia. Uterotonic agents are only administered after the uterus is fully reverted to promote contraction and prevent recurrence [2, 3].
- Option 4 (Trendelenburg position and IV fluids) is a critical supportive measure for managing hypovolemic shock but is not the first priority. While fluid resuscitation and calling for help should be initiated simultaneously by other team members, the nurse’s immediate, hands-on priority is to relieve the vagal stimulation and mechanical obstruction by initiating uterine replacement. The patient’s hemodynamic status will not stabilize until the inversion is corrected [1, 2].

The urgency of manual replacement is paramount; the literature emphasizes that successful, prompt repositioning is the definitive treatment that directly addresses the cause of shock and hemorrhage, and every minute of delay increases the likelihood of requiring surgical intervention such as a hysterectomy [2, 3].