I. Pathophysiology

  1. Serious complication of Vaginal Delivery

II. Epidemiology

  1. Incidence: 1 per 25,000 deliveries
  2. More commonly affects multiparous patients
  3. Iatrogenic cause most often

III. Signs

  1. Placenta appears at introitus attached to mass
  2. Shock
    1. Bradycardia associated with vagal response
  3. Excessive Hemorrhage

IV. Grading

  1. First Degree: Incomplete inversion
  2. Third Degree: Complete inversion to perineum

V. Management

  1. Treat shock and blood loss
    1. Immediate Intravenous Access
    2. Intravenous Fluid replacement
  2. Call for Consultation
    1. Obstetrics
    2. Anesthesia (consider Halothane)
  3. Give uterine relaxants (Tocolytics)
    1. Terbutaline 0.25 mg SC
    2. Nitroglycerin
      1. Intravenous: 50 to 200 mcg IV
      2. Sublingual (200 mcg per spray): 2 sprays sublingual
  4. Immediate Manual Replacement (Johnson Maneuver)
    1. Replace Uterus in non-inverted position
      1. Replace last part out first (last out, first in)
    2. Administer Terbutaline or Nitroglycerin as above
    3. Consider General Anesthesia
    4. Repeat trial of Manual Replacement
    5. Surgical Replacement
  5. Post-Replacement Uterine Hemorrhage Management Options
    1. Pitocin IV 40 u/L at 100-250 cc/h
    2. Hemabate 0.25mg IM Myometrium q15 minutes (max: 2 mg)
    3. Methergine 0.2 mg IM or PO q6-8h
  6. Consider exploratory laparotomy if needed

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