What is the next step in managing a 24-year-old primigravida (G1P1) with hypotension, pallor, and minimal vaginal bleeding, who has just delivered her first baby and placenta, with no prior cesarean section, and is found to have an inverted uterus on examination?

Immediate Manual Replacement of the Uterus

Replace the uterus as soon as possible (option c) – this is the definitive first-line treatment for acute uterine inversion and must be performed immediately before the cervical ring contracts, which would make reduction significantly more difficult or impossible. 1, 2

Why Immediate Manual Replacement is Critical

• Time is tissue: The cervical ring rapidly contracts after uterine inversion occurs, creating a constricting band that makes manual reduction progressively more difficult with each passing minute 1
• Hypotension with minimal bleeding is pathognomonic: This patient's presentation of severe hypotension and pallor despite little vaginal bleeding is classic for uterine inversion – the shock is neurogenic/vasovagal from traction on the uterine ligaments and peritoneum, not purely hypovolemic 1, 2
• The longer you wait, the more edematous the inverted fundus becomes, further complicating reduction 1

Immediate Management Algorithm

Step 1: Call for help and prepare for manual replacement

• Do NOT remove the placenta if still attached – this reduces bleeding during the reduction attempt 1, 2
• Administer IV fluids for hemodynamic support 3
• Consider tocolytics (terbutaline, nitroglycerin, or general anesthesia) to relax the cervical ring if initial attempts fail 1, 2

Step 2: Manual replacement technique

• Place your fist/palm against the inverted fundus and apply steady upward pressure through the vagina, pushing the fundus back through the cervical ring 1, 2
• An assistant should apply counter-pressure on the abdomen if needed 1
• If the placenta is still attached, leave it in place during reduction – it actually helps tamponade bleeding 1, 2

Step 3: If manual replacement fails

• Proceed immediately to laparotomy with opposing pressures: one hand pushing the fundus up through the vagina while another hand pulls the cervical ring upward through the abdominal cavity 1
• Surgical incision of the cervical ring (Haultain procedure) may be necessary but should be avoided if possible 1

Why the Other Options Are Wrong

Option a (Methergine): Absolutely contraindicated at this moment – uterotonics will cause the cervical ring to contract further, making manual reduction impossible 4. Uterotonics are only given AFTER successful uterine replacement to prevent recurrence 2

Option b (Fetal pillow): This device is used for intrapartum management of obstructed labor or to elevate the fetal head during cesarean section – it has no role in uterine inversion management

Option d (B-Lynch suture): This compression suture is used for refractory uterine atony AFTER other measures have failed, not for uterine inversion 4. You cannot place a B-Lynch suture on an inverted uterus – the anatomy must be restored first

Common Pitfalls to Avoid

• Do not give uterotonics before reduction – this is the most dangerous error, as it will lock the uterus in the inverted position 4, 2
• Do not manually remove the placenta before attempting reduction – if still attached, leave it in place as it reduces bleeding 1, 2
• Do not delay for imaging or extensive workup – uterine inversion is a clinical diagnosis requiring immediate manual intervention 3, 1
• Do not underestimate the urgency – this is a true obstetric emergency that can rapidly progress to cardiovascular collapse despite minimal visible bleeding 1, 2

Post-Reduction Management

• After successful replacement, NOW administer uterotonics (oxytocin first-line, then methylergonovine if no hypertension) to maintain uterine tone and prevent reinversion 3, 4
• Manually remove the placenta if still attached 2
• Administer tranexamic acid 1 g IV over 10 minutes if significant bleeding occurs 3
• Monitor closely for at least 24 hours for recurrence and hemodynamic stability 3