The incidence of uterine inversion ranges from 1 in 2000 to 1 in 20,000 vaginal deliveries (Coad, 2017; Ogah, 2011; Rana, 2009; Witteveen, 2013). Our experiences at Parkland Hospital comport with the higher 1 :2000 incidence. his is despite our policy of discouraging placental delivery by cord traction alone, and before certainty of its separation. It is unknown if active management o/third-stage labor with cord traction applied ostensiblyater signs of placental separation raises the likelihood of uterine inversion (Deneux-Tharaux, 2013; Gulmezoglu, 2012; Prick, 2013).
Immediate recognition of uterine inversion improves the chances of a quick resolution and good outcome (Furukawa, 20 15b). If initially unrecognized, continued hemorrhage likely
FIGURE 41-6 Progressive degrees of uterine inversion.
FIGURE 41 -9 Surgical anatomy of a completely inverted uterus viewed from above at laparotomy.
In some cases, the uterus will again invert almost immediately after repositioning. With this problem, uterine compression sutures can be used to prevent another inversion (Matsubara, 2009; Mondal, 2012). Occasionally, chronic puerperal uterine inversion may become apparent weeks after delivery.
Childbirth is invariably associated with trauma to the birth canal, which includes the uterus and cervix, vagina, and perineum. Injuries sustained during labor and delivery range from minor mucosal tears to lacerations that create life-threatening hemorrhage or hematomas.
According to the American College of Obstetricians and Gynecologists (2016b), up to 80 percent of women sustain some type of laceration at vaginal delivery. hese may lie proximally or distally along the lower genital tract.
First, small tears of the anterior vaginal wall near the urethra are relatively common. hey are often supericial with little to no bleeding, but they occasionally require sutures for hemostasis. Those large enough to require extensive repair are typically associated with short-term voiding diiculty, and an indwelling bladder catheter will obviate this.
Deeper perineal lacerations are usually accompanied by varying degrees of injury to the outer third of the vaginal vault. Some extend to involve the anal sphincter or varying depths of the vaginal walls. Repair of these perineal lacerations is detailed in Chapter 27 (p. 531).
Lacerations involving the middle or upper third of the vaginal vault usually are comorbid with injuries of the perineum or cervix. hese sometimes are missed unless inspection is thorough. Those that extend upward usually are longitudinal. They may follow spontaneous delivery but frequently result from injries sustained during operative vaginal delivery. Most niicant hemorrhage, which is controlled by suture repair. For this, efective analgesia or anesthesia, clear visualization, capable assistance, and suicient resuscitation of hypovolemia are man datory.
search for evidence of retroperitoneal hemorrhage or of perito neal perforation with hemorrhage. Also, intrauterine explora tion is considered to exclude uterine tears or rupture (Conrad, 2015). If peritoneal perforation or uterine rupture is strongly suspected, laparotomy is considered (Rai, 2010). As discussed later (p. 793), imaging and potential embolization may be suit able for large retroperitoneal hematomas.