INVERSION OF THE UTERUS.pptx

It is a life threatening obstetrics emergency occurs when the uterus turns partially or completely inside out.

1. INVERSION OF THE UTERUS PRESENTED BY Mrs.Simarjeet Kaur Associate Professor Obstetrics and Gynaecological Nursing M.M.College of Nursing Mullana

2. DEFINITION It is an extremely rare but a life threatening complication in third stage in which the uterus is turned out partially or completely.

3. Inversion of Uterus

4. Type of Inversion Incomplete inversion describes an inverted fundus that lies within the endometrial cavity without extending beyond the external os. Complete inversion describes an inverted fundus that extends beyond the external os

5. A prolapsed inversion is one in which the inverted uterine fundus extends beyond the vaginal introitus . A total inversion , usually nonpuerperal and tumor related, results in inversion of the uterus and vaginal wall as well.

6. INCIDENCE The incidence is about 1 in 20,000 deliveries. The obstetric inversion is always an acute one and usually complete.

7. CLASSIFICATION Based on the degree of inversion First degree — There is dimpling of the fundus which still remains above the level of internal os.

8. Second degree — The fundus passes through the cervix but lies inside the vagina.

9. Third degree ( complete ) — The endometrium with or without the attached placenta is visible outside the vulva. The cervix and part of the vagina may also be involved in the process . It may occur before or after separation of placenta.

10. Third degree ( complete)

11. Based on the time of onset : Acute - occurs immediately after delivery and before the cervix constricts Sub - acute - once cervix constricts Chronic - noted >4/52 after delivery, or non-puerperal  

12. ETIOLOGY : Principle behind its occurrence: Cervix must be dilated. Uterine fundus must be relaxed.Many cases of acute uterine inversion results from mismanagement of third stage of labour in women who already are at risk.

13. ETIOLOGY(cont....) Spontaneous (40%) : This is brought about by localised atony on the placental site over the fundus associated with sharp rise of intra abdominal pressure as in coughing, sneezing or bearing down effort. Fundal attachments of the placenta (75%), short cord and placenta accreta are often associated.

14. ETIOLOGY(cont....) Iatrogenic : This is due to the mismanagement of third stage of labour. Pulling the cord when the uterus is atonic specially when combined with fundal pressure Fundal pressure while the uterus is relaxed Faulty technique in manual removal

15. Risk Factors uterine over enlargement, prolonged labour, fetal macrosomia, uterne formations, short umbilical cord, tocolysis Strong fundal pressure

16. Risk Factors.... Rapid emptying of uterus Fundal implantation of the placenta Previous uterine inversion manual removal of placenta more common in women with collagen disease like Ehler Danlos Syndrome.

17. Risk Factors.... Vaginal birth after previous caeserean section Protracted labour Certain drugs such as magnesium sulphate Tumors- submucuos myomas Cervical incompetence

18. Risk Factors.... Abnormal adherence of the placenta(e.g placenta accreata) Uterine anomalies(e.g unicornuate uterus) Congenital or acquired weakness of the myometrium Chronic endometritis

19. SIGNS AND SYMPTOMS Symptoms Pain in the lower abdomen Sensation of vaginal fullness: with a desire to bear down after delivery of the placenta Vaginal bleeding: unless the placenta is not separated

20. Signs General examination ; Shock: out of proportion to blood loss. More neurogenic due to traction on the peritoneum & press On the tubes , ovaries, & maybe, the intestine. Parasympathetic effect of traction on the ligaments supporting the uterus & maybe associated with bradycardia.

21. Abdominal examination Cupping of the fundus-1st &2nd degree Absence of the uterus-3rd degree Vaginal examination : Soft purple(dark bluish-red) mass in the vagina or vulva

22. DANGERS : Shock is extremely profound mainly of neurogenic origin due to — tension oo the nerves due to stretching of the infundibulo-pelvic ligament pressure on the ovaries as they are dragged with the fundus through the cervical ring and peritoneal irritation.

23. Dangers.... hemorrhage , specially after detachment of placenta Pulmonary embolism If left uncared lead to — (a) infection (b) uterine slough c) a chronic one.    

24. INVESTIGATIONS :  Diagnosis is usually based on clinical symptoms and signs. If not clinically very obvious, imaging is useful if patient is clinically stable to undergo such evaluation; USG & MRI

25. CONT... USG : Transverse image - a hypoechoic mass in the vagina with a central hypoechoic H-shaped cavity. Longitudinal - U-shaped depressed longitudinal groove from the uterine fundus to the centre of the inverted part MRI- Findings are more conspicuous

26. PREVENTION : Do not employ any method to expel the placenta out when the uterus is relaxed. Pulling the cord simultaneous with fundal pressure avoided. Manual removal should be done .

27. PROGNOSIS As it is commonly met in unfavourable surroundings, the prognosis is extremely gloomy. Death may be occur suddenly due to shoc, hemorrhage or embolism. Even if the patient survives, infection, sloughing of the uterus and chronic inversion with ill health may occur.  

28. MANAGEMENT : Call for extra help Before the shock develops urgent manual replacement is necessary

29. Before the shock develops.... Principal steps : (1) To replace that part first which is inverted last with the placenta attached to the uterus become contracted by steady firm pressure exerted by the fingers. (2) To apply counter support by the other hand placed on the abdomen.

30. Before the shock develops....

31. Before the shock develops.... (3) After replacement, the hand should remain inside the uterus until the uterus becomes contracted by parenteral oxytocin or PGF 2α.

32. Before the shock develops.... (4) The placenta is to be removed manually only after the uterus becomes contracted. The placenta may however be removed prior to replacement — (a) to reduce the bulk which facilitates replacement or (b) if partially separated to minimise the blood loss

33. Before the shock develops.... (5) Usual treatment of shock including blood transfusion should be arranged simultaneously.

34. After the shock develops Principal steps : (1) The treatment of shock should be instituted with an urgent dextrose saline drip and blood transfusion (2) To push the uterus inside the vagina if possible and pack the vagina with antiseptic roller guaze.

35. After the shock develops.... (3) Foot end of the bed is raised (4) Replacement of the uterus either manually or hydrostatic method ( O’Sullivan's ) under general anaesthesia is to be done along with resuscitative measures. Hydrostatic method is quite effective and less shock producing.

36. Hydrostatic method : The inverted uterus is replaced into the vagina. Warm sterile fluid (up to 5 litres) is gradually instilled in to the vagina through a douche nozzle. The vaginal orifice is blocked by operator's palms supplemented by labial apposition around the palm by an assistant.

37. Hydrostatic method .... Alternatively a silicon cup (Vacuum extraction cup) is placed into the vagina. The douch can be placed at a height of about 3 feet above the uterus. The water distends the vagina and the consequent intravaginal pressure leads to replacement of the uterus.

38. Subacute stage : (1) To improve the general condition by blood transfusion (2) Antibiotics are given to control sepsis (3) Reposition of the uterus either manually or by hydrostatic method may be tried (4) If fails,reposition may be done by Huntington procedure and abdominal operation ( Haultain's operation).

39. Huntington procedure Locate the cup of the uterus formed by the inversion Dilate the constricting cervical ring digitally Place clamps in the cup of the inversion below the cervical ring and gentle upward traction is applied Repeated clamping and traction continue until the inversion is corrected.

40. Haultaim’s procedure Incision is made in the posterior portion of the inversion ring, to increase the size of the ring and allow repositioning of the uterus Further steps as in huntington procedure  

41. NURSING CARE

42. NURSING CARE.... "Massage the uterus while supporting the lower uterine segment. Express clots. Insert an indwelling catheter to empty the bladder and allow accurate measure of output. Place the woman in supine position. Avoid Trendelenburg position which may interfere with respiratory and cardiac function.

43. NURSING CARE.... Maintain IV access and start a second IV with large-bore catheter capable of carrying whole blood. Draw blood (per protocol or orders) for hemoglobin and hematocrit, type and crossmatch, platelets, prothrombin time, activated partial thromboplastin time (aPTT), fibrinogen, fibrin degradation products, and fibrin split products.

44. NURSING CARE.... Administer IV fluids, volume expanders, and blood as directed. Administer prescribed drugs, such as oxytocin, prostaglandins, or methylergonovine maleate. Apply a pulse oximeter to determine the oxygen saturation; administer oxygen by snug face mask at 8 to 10 L/min or as directed by the physician or facility protocol.

45. NURSING CARE.... Anticipate further medical interventions (uterine packing, ligation or embolization of uterine, ovarian, or hypogastric arteries, or hysterectomy if other measures fail to control bleeding.

46. NURSING CARE.... In addition, the nurse will: Monitor the condition of the woman, and communicate with the health care provider. Provide explanations and emotional support for the woman and her family. Obtain signed consents for specific surgical procedures or blood transfusions."  

47. assessment and physical examination Ask if the patient has perineal pain. Although some discomfort is expected after a vaginal delivery, severe pain or pressure is uncommon and often indicates a hematoma.

48. Cont..... Observe the amount and characteristics of blood loss; sometimes there is a pooling of blood and the passage of large clots. Usually, complete saturation of one perineal pad within 15 minutes or saturation of two or more pads in 1 hour suggests hemorrhage.

49. Cont..... Palpate the fundus, noting if it is firm or boggy, if it is midline or deviated laterally, and if it is above or below the umbilicus. Normally, after delivery, the fundus is firm, midline, and at the level of the umbilicus.

50. Cont..... A fundus above the umbilicus and deviated laterally may indicate a full bladder. A boggy uterus is indicative of uterine atony and, if it is not corrected, results in a PPH. If the fundus is firm, midline, and at or below the umbilicus and if there is steady, bright red bleeding, further assessment for trauma is necessary.

51. Cont..... If a hematoma is suspected, the patient is placed in lithotomy position, and the vagina and perineal area are carefully inspected. A bulging and discoloration of the skin is noted if a hematoma is present. Assess the patient’s vital signs.

52. Cont..... A temperature above 100.4°F may indicate uterine infection, which decreases the myometrium’s ability to contract and makes the patient more susceptible to PPH. Note any foul vaginal odor that may accompany the fever with infection.

53. Cont..... Elevated heart rate, delayed capillary refill, decreased blood pressure, and increased respiratory rate may be noted if PPH is occurring. Assess the patient’s color and skin temperature; pallor and cool, clammy skin also indicate hypovolemic shock.

54. Cont..... Assess the anxiety level of the patient; the patient going into hypovolemic shock is highly anxious and then may lose consciousness. The significant others experience a high level of anxiety as well and need a great deal of support.

55. Nursing care plan primary nursing diagnosis: Fluid volume deficit related to blood loss.

56. Intervention The goal of treatment is to correct the cause and replace the fluid loss. Patients should have nothing by mouth until hemostasis is established. Expedient diagnosis and treatment of the cause reduce the likelihood of a blood transfusion.

57. Intervention.... Treatment for uterine atony involves performing frequent fundal massage, sometimes bimanual massage (by the medical clinician only), and pharmacologic therapy.

58. Intervention.... Fluid replacement with normal saline solution, lactated Ringer’s injection, volume expanders, or whole blood may be necessary. Multiple venous access sites, 100% oxygen, and a Foley catheter are often needed. If uterine atony is not corrected quickly, a lifesaving hysterectomy is indicated.

59. Intervention.... Monitor the hematocrit and hemoglobin to determine the success of fluid replacement and the patient’s intake and output. If an infection is the cause of the atony, the physician prescribes antibiotics. PPH caused by trauma requires surgical repair with aseptic technique.

60. Intervention.... Hematomas may absorb on their own; however, if they are large, an incision, evacuation of clots, and ligation of the bleeding vessel are necessary. Administer analgesics for perineal pain. If retained fragments are suspected at the time of delivery, the uterine cavity should be explored.

61. Intervention.... Monitor for hypertension if oxytocics and prostaglandins are used. Encourage the patient to void; a full bladder interferes with contractions and normal uterine involution. If the patient is unable to void on her own, a straight catheterization is necessary.

62. Intervention.... Monitor vaginal bleeding; the lochia is usually dark red and should not saturate more than one perineal pad every 2 to 3 hours. Notify the physician if the bleeding is steady and bright red in the presence of a normal firm fundus; this usually indicates a laceration. Ice packs and sitz baths may relieve perineal discomfort.

63. Intervention.... The patient is usually on complete bedrest. Rooming in with the infant may be difficult; provide for safe care for the infant while it is in the mother’s room. Assist the patient and significant others as much as possible with newborn care to facilitate quality time between the mother and her newborn.

64. Intervention.... Assist the patient with ambulation the first few times out of bed; syncope is common after a large blood loss. Ensure adequate rest periods.

65. discharge and home health care guidelines Teach the patient how to check her own fundus and do a fundal massage; this is especially important for patients at risk who are discharged early from the hospital.

66. cont,..... Advise the patient to contact the physician for the following: a boggy uterus that does not become firm with massage, excessive bright red or dark red bleeding, many large clots, fever above 100.4°F, persistent or severe perineal pain or pressure.

67. Cont.... If iron supplements are provided, teach the patient to take the drug with orange juice and expect some constipation and a dark-colored stools. If oxytocics are ordered, emphasize the importance of taking them around the clock as prescribed.

68. Cont.... If antibiotics are ordered, teach the patient to finish the prescription, even though the symptoms may have ceased.

69. THANK YOU...