Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Emergency Obstectric Care
Hypertension in Pregnancy
Hypertension
Assessment and management
Delivery
Postpartum care
Chronic hypertension
Complications
Management of Slow Progress of Labour
General principles
Slow progress of labour
Progress of labour
Operative procedures
Bleeding in Pregnancy and Childbirth
Bleeding
Diagnosis and initial management
Specific management
Procedures
Aftercare and follow-up
Procedures
 


> MANUAL VACUUM ASPIRATION
> DILATATION AND CURETTAGE
> CULDOCENTESIS
> COLPOTOMY
> SALPINGECTOMY FOR ECTOPIC PREGNANCY
> REPAIR OF RUPTURED UTERUS
> MANUAL REPAIR OR PLACENTA
> REPAIR OF CERVICAL TEARS
> REPAIR OF VAGINAL AND PERINEAL TEARS
>

UTERINE INVERSION

> UTERINE AND UTERO-OVARIAN ARTERY LIGATION
> POSTPARTUM HYSTERECTOMY


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.
Figure 12.22
Figure 12.22

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.
  

> MANUAL VACUUM ASPIRATION
> DILATATION AND CURETTAGE
> CULDOCENTESIS
> COLPOTOMY
> SALPINGECTOMY FOR ECTOPIC PREGNANCY
> REPAIR OF RUPTURED UTERUS
> MANUAL REPAIR OR PLACENTA
> REPAIR OF CERVICAL TEARS
> REPAIR OF VAGINAL AND PERINEAL TEARS
>

UTERINE INVERSION

> UTERINE AND UTERO-OVARIAN ARTERY LIGATION
> POSTPARTUM HYSTERECTOMY



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