Warning: Do NOT read this if you are currently pregnant or have a pregnant partner. My recommendation for my pregnant patients is to say that their doctor forbids them to listen to any horrific delivery stories until after the baby arrives.

Uterine inversion is a feared complication after delivering a baby. Who fears it? Me, all of the other doctors and nurses I know, and anyone else who has gone through obstetric training.

I've never seen one. As a family practice physician, I did obstetrics for twenty years, with about 350 deliveries. I am darn happy I didn't see one.

In a uterine inversion, the uterus comes out through the cervix, into the vagina and even can stick out of the vulva. (If you feel faint, stick your head between your knees.) Just as the name implies, it is inside out. This happens very rarely but it happens after a baby is born. The baby was attached to the placenta by an umbilical cord, right? The umbilical cord went to the placenta. The placenta is a mixture of baby's and mother's tissues and a solid wall of blood vessels, meant to get oxygen and food from mother to baby, and wastes from baby to mother. That wall was attached to the inside of the uterus. The uterus is much larger than usual because it has been holding a baby, and it either still has the placenta attached or has just released it. Anyhow, if it is sticking out of the cervix inverted, it bleeds like stink.

I am looking at websites which say blithe things like "An iv will be started and you will be given medications for pain and to relax the uterus so that the doctor can reposition it." What I was taught was "GET IT BACK IN RIGHT BEFORE SHE DIES." The technique I was taught was "IMMEDIATELY put your fist against the uterus and push it all the way back in." At the same time, one yells at the nurse who calls for 5 other nurses, iv, cross match blood, alert the operating room, have the crash cart standing by. One website mentions surgery if needed, another says 85% survival.

Gabbe's Obstetrics: Normal and Problem Pregnancies does not have the edge of panic that I absorbed from my medical faculty: "Treatment of uterine inversion should include fluid therapy for the mother and restoration of the uterus to its normal position. The latter is best accomplished using the technique illustrated in Figure 17-22 and should be attempted immediately upon recognition of the inversion." (Third edition, p 525). Yes, I did pick up on that immediately.

Why do uterine inversions happen? The placenta can stick. The placenta can do more than stick, it can actually grow in to the wall of the uterus (placenta accreta) and through the wall of the uterus (placenta percreta) but those are luckily very rare. After the baby delivers, I was taught to "actively manage" the umbilical cord. That is, pay attention. When the placenta separates from the wall of the uterus, the uterus will rise a little in the abdomen, there is a little increase in bleeding and the cord "lengthens". It slides out a little. Only placentas, just like people, don't always do what the book says. A clamp is on the cord and I check every so often to see if the placenta is ready to be encouraged gently to come out -- without that uterus following it. Pull but not too hard, right? Just right. And don't wait too long, because once the uterus and placenta separate, the uterus can keep bleeding and fill up with blood....and it's still in that stretchy state.

Sometimes the uterus inverts without the placenta sticking and it just happens. After the placenta is out. My partner did see one and said that there is a horrible moment of "What is THAT?" and then realization and then he PUT IT BACK and then he went in the hall until his heart rate came back down from 200. The patient, distracted by the delightful new baby, was in surprised pain for a moment, but was fine.

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