Management ^{1, 2, 5}

>  Call for assistance – both senior obstetric and anaesthetic assistance

>  Immediately try to correct the inversion

>  With sterile gloves on, grasp the uterus and push it through the cervix towards the umbilicus to its normal position, using the other hand to support the uterus

>  Keep the hand in the uterus until firm contraction of the uterus is felt

Simultaneous maternal resuscitation:

>  Withhold Syntocinon^® until after successful correction of inversion

>  Do not attempt to remove the placenta from an inverted uterus (danger of massive haemorrhage)

>  Administer oxygen via face mask

>  Ensure the head of the bed is flat.  (The woman may remain with her legs bent or in lithotomy)

>  Commence monitoring immediately, including automated blood pressure recording, pulse, respirations, SpO₂ 

>  Assess for clinical signs of shock e.g. cool, clammy, pale, rapid pulse, decreased blood pressure

>  Insert intravenous access x 2 using 16 gauge cannulas

>  Group and cross match at least 4 units of blood, complete blood picture

>  Resuscitate with appropriate intravenous fluid, e.g. sodium chloride 0.9 %, Hartmann’s solution (crystalloids) or Gelafusine^® (gelatin – based colloid).  When using crystalloid, the ratio of resuscitative intravenous fluid required to blood lost is 3:1 

>  To resuscitate more quickly, administer intravenous fluids using a pressure infusion device

>  Insert indwelling catheter without hindering resuscitation

>  If the uterus is successfully returned to its normal position  then the placenta can be manually removed in theatre under anaesthesia 

>  Following removal of the placenta, administer 10 IU of Syntocinon^® intravenously followed by an oxytocic infusion (Syntocinon^® 40 IU in 1000 mL Hartmann’s solution or sodium chloride 0.9 % at 250 mL / hour over 4 hours)

>  If the above measures are unsuccessful then employ O’Sullivan’s hydrostatic technique. Failure to reduce a uterine inversion may be the result of contraction of the cervix once the uterus has prolapsed through it. This leaves insufficient room for the prolapsed uterus to be inverted back through the cervix

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