| |
UTERINE INVERSION
| 1 |
Start
an IV infusion. |
| 2 |
Give
appropriate analgesia and sedation, or if necessary,
use general anaesthesia. |
| 3 |
Thoroughly
cleanse the inverted uterus using antiseptic solution. |
| 4 |
Apply
compression to the inverted uterus with a moist, warm
sterile towel
until ready for the procedure. |
Manual correction
| 1 |
Wearing
sterile gloves, grasp the uterus and push it through
the cervix towards the umbilicus to its normal position,
using the other hand to support the uterus (Figure
12.22).
If the placenta is still attached, perform manual removal
after correction. |
|
| 2 |
If
correction is not achieved, proceed to hydrostatic correction.
It is important that the part of the uterus that came
out last (the part closest to the cervix) goes in first. |
Hydrostatic correction
| 1 |
Place
the woman in deep head-down position (head about 0.5
metres below the level of the perineum). |
| 2 |
Prepare
a high-level disinfected douche system with large nozzle
and long tubing (2 metres) and a warm water reservoir
(3 to 5 L). This can also be done using warmed normal
saline and an ordinary IV administration set. |
| 3 |
Identify
the posterior fornix. This is easily done in partial
inversion when the inverted uterus is still in the vagina.
In other cases, the posterior fornix is recognized by
where the rugose vagina becomes the smooth vagina. |
| 4 |
Place
the nozzle of the douche in the posterior fornix. |
| 5 |
At
the same time, with the other hand hold the labia sealed
over the nozzle and use the forearm to support the nozzle. |
| 6 |
Ask
an assistant to start the douche with full pressure (raise
the water reservoir to at least 2 metres). Water will
distend the posterior fornix of the vagina gradually so
that it stretches. This causes the circumference of
the orifice to increase, relieves cervical constriction and results in correction of
the inversion. |
Manual
correction under general anaesthesia
If hydrostatic correction is not successful, try manual repositioning
under general anaesthesia. Halothane is recommended because
it relaxes the uterus.
| 1 |
Grasp
the inverted uterus and push it through the cervix in
the direction of the umbilicus to its normal anatomic
position. |
| 2 |
If
the placenta is still attached, perform a manual removal
after correction.
|
Combined
abdominal-vaginal correction
Abdominal-vaginal correction under general anaesthesia may be required if the
above measures fail.
| 1 |
Make
a midline vertical incision below the umbilicus to the
pubic hair, through the skin and to the level of the fascia. |
| 2 |
Open
the abdomen:
| • |
Make
a 2–3 cm vertical incision in the fascia. |
| • |
Hold
the fascial edge with forceps and lengthen the
incision up and down using scissors |
| • |
Use
fingers or scissors to separate the rectus muscles
(abdominal wall muscles) |
| • |
Use
fingers or scissors to make an opening in the peritoneum
near the
umbilicus. Use scissors to lengthen the incision up and down. Carefully, to prevent
bladder injury, use scissors to separate layers and open the lower part of the
peritoneum |
| • |
Place
a bladder retractor over the pubic bone and place
self-retaining abdominal retractors. |
|
| 3 |
Dilate
the constricting cervical ring digitally. |
| 4 |
Place
a tenaculum through the cervical ring and grasp the inverted
fundus. |
| 5 |
Apply
gentle continuous traction to the fundus while an assistant
attempts
manual correction vaginally. |
| 6 |
If
traction fails, incise the constricting cervical ring
posteriorly (where the incision is least likely to injure
the bladder or uterine vessels) and repeat digital dilatation,
tenaculum and traction steps. |
| 7 |
If
correction is successful, close the abdomen:
| • |
Make
sure there is no bleeding; use a sponge to remove
any clots inside the abdomen |
| • |
Close
the fascia with continuous 0 chromic non absorbable
(or polyglycolic) suture |
| • |
If
there are signs of infection, pack the subcutaneous
tissue with gauze and place loose 0 non absorbable
(or polyglycolic) sutures; close the skin with a
delayed closure after the infection has cleared |
| • |
If
there are no signs of infection, close the skin
with vertical mattress sutures of 3-0 nylon (or
silk) and apply a sterile dressing. |
|
Post-procedure care
| 1 |
Once
the inversion is corrected, infuse oxytocin 20 units
in 500 ml IV fluids (normal saline or Ringer’s lactate)
at 10 drops per minute:
| • |
If
haemorrhage is suspected, increase the infusion
rate to 60 drops per minute |
| • |
If
the uterus does not contract after oxytocin, give
ergometrine 0.2 mg or prostaglandins IV. |
|
| 2 |
Give
a single dose of prophylactic antibiotics after correcting
the inverted uterus. If there are signs of infection
or the woman currently has fever, give a combination of
antibiotics until she is fever-free for 48 hours. Give
appropriate analgesic drugs. |
|
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