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 begins to contract within minutes of uterine inversion, creating a constricting band that makes manual reduction progressively more difficult 1
• Hypotension with minimal bleeding is pathognomonic: This patient's presentation of shock with little vaginal bleeding is classic for uterine inversion – the hypotension results from vagal stimulation and the inverted uterus itself, not primarily from blood loss 1, 2
• Early intervention has the best prognosis: The best outcomes occur when diagnosis and manual reduction are performed immediately, before cervical ring contraction and before the need for laparotomy 1

Manual Replacement Technique

• Apply steady upward pressure on the inverted fundus through the vagina, pushing it back through the cervical ring 1, 2
• Use the palm of your hand to push the fundus upward toward the umbilicus 1
• If the placenta is still attached, do not remove it before attempting reduction – leave it in place during the initial replacement attempt, as removing it may worsen bleeding 2
• Perform this under adequate analgesia or general anesthesia if time permits 2

Why the Other Options Are Wrong

Option A (Methergine) is Contraindicated

• Never give uterotonics before reducing the inversion – methergine and other uterotonics will cause the cervical ring to contract further, making manual reduction impossible 2
• Uterotonics should only be administered after successful uterine replacement to prevent recurrence 2
• The FDA label for methergine indicates use for postpartum atony and hemorrhage 3, but this does not apply when the uterus is inverted

Option B (Fetal Pillow) is Not Standard

• A fetal pillow is not mentioned in standard management algorithms for uterine inversion
• This may refer to hydrostatic reduction techniques, which are second-line interventions if manual reduction fails

Option D (B-Lynch Suture) is Premature

• B-Lynch sutures are compression sutures used for uterine atony refractory to medical management 4
• This patient needs the uterus replaced first – surgical interventions come only after failed manual reduction attempts 1

If Manual Reduction Fails

• Proceed to laparotomy with combined abdominal and vaginal approach: apply opposing pressures on the cervical ring from above (through the abdomen) and on the uterine fundus from below (through the vagina) 1
• Surgical incision of the cervical ring (Haultain procedure) may be necessary if the above fails 1
• Hysterectomy is the last resort if all reduction attempts fail 4

Common Pitfall to Avoid

Do not give uterotonics before reducing the inversion – this is the most critical error that will convert a manageable emergency into a surgical one by causing irreversible cervical ring contraction 2