Intrapartum Complications: Uterine Intervention

A.DESCRIPTION. The uterus turns completely or partially inside out; it occurs immediately following delivery of the placenta or in the immediate postpartum period.

B. ETIOLOGY
1. Forced inversion is caused by excessive pulling of the cord or vigorous manual expression of the placenta or clots from an atonic uterus.
2. Spontaneous inversion is due to increased abdominal pressure from bearing down, coughing, or sudden abdominal muscle contraction.
Predisposing factors include straining after delivery of the placenta, vigorous kneading of the fundus to expel the placenta, manual separation, and extraction of the placenta, rapid delivery with multiple gestation, or rapid release of excessive amniotic fluid.

C.PATHOPHYSIOLOGY
1. The inverted uterus is unable to restore normal position or contract appropriately.
2. The woman is placed at increased risk for bleeding and infection.

D. ASSESSMENT FINDINGS. Clinical manifestations include:
1. Excruciating pelvic pain with a sensation of extreme fullness extending into the vagina.
2. Extrusion of the inner uterine lining into the vagina or extending past the vaginal introitus.
3. Vaginal bleeding and signs of hypovolemia.

E. NURSING MANAGEMENT. Promptly identify & assist with the resolution of uterine inversion.
1. Recognize signs of impending inversion, and immediately notify the physician and call for assistance.
2. Immediate manual replacement of the uterus at the time of inversion will prevent cervical entrapment of the uterus; if reinversion is not performed immediately, rapid and extreme blood loss ma occur, resulting in hypovolemic shock.
3. Take steps to prevent or limit hypovolemic shock.
a. Insert a large gauge intravenous catheter for fluid replacement.
b. Measure and record maternal vital signs every 5 to 15 minutes to established a baseline and document change.
c. Open an established intravenous line for optimal fluid replacement.
d. A fibrinogen level should be drawn to determine the risk of blood clot formation.
e. Prepare for anesthesia as needed.
f. Prepare to administer a cardiopulmonary resuscitation, if required.
4. If manual reinversion is not successful, prepare the client and family for possible general anesthesia and surgery.


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