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Check for Uterine Inversions.

ASHEVILLE, N.C. -- A complete uterine inversion is easy to recognize, but a partial inversion can initially go unnoticed, Dr. Sharon T. Phelan said at the annual Southern Obstetric and Gynecologic Seminar.

Be on the lookout for the only clues that may alert you to a partial inversion: excessive bleeding and a smaller than expected uterus for gestational age at delivery, advised Dr. Phelan of the University of Alabama, Birmingham. For example, instead of the larger uterus typically found in a woman who has just given birth to a term infant, it may feel like a 14- to 16-week-size uterus.

When uterine inversion is detected, attempt replacement right away before the cervix has a chance to close. Instinct says to try to push an inverted uterus back into place from the fundus, but that won't work. "Remember, last out, first in," she said.

Locate the cervix, then ease the uterus slowly back into place, starting with the lower part of the uterine segment and working your way to the fundus.

If the uterus cannot be replaced easily and immediately, call for both nursing and anesthesia help.

"You'll want a second nurse to start a large bore IV," Dr. Phelan said.

Often, 18-gauge intravenous needles are used in uncomplicated deliveries for the mother's comfort, but an emergent situation like uterine inversion calls for the capability to provide fluid resuscitation in case the mother goes into shock. A 16-gauge needle is sufficient. An anesthesiologist can be a great help by starting intravenous access as well as managing fluid replacement as needed and providing general anesthesia for those rare cases when it becomes necessary

At this point, relax the uterus by administering magnesium sulfate. If preloaded bags of magnesium sulfate aren't available for intravenous piggyback, very slowly administering 2-4 g IV using a 23- to 25-gauge needle will prevent too rapid of a bolus. Nitroglycerin can also be used to relax the uterus if preferred.

Once relaxed, uterus replacement can again be attempted. If the placenta hasn't been delivered, it typically can be left until the uterus is replaced, which will decrease blood loss.

The mother should be kept in the delivery or recovery room to assess her for reinversion and to evaluate blood loss and adequateness of fluid replacement for 2-4 hours or longer if she is unstable.
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Author:Worcester, Sharon
Publication:OB GYN News
Geographic Code:1USA
Date:Oct 15, 1999
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