43 Once the uterus is reverted, uterotonic agents should be given to promote uterine tone and to prevent recurrence. The uterus is returned to position by lifting it up through the pelvis and into the abdomen ( Figure 3C 29). The Johnson method of reduction begins with grasping the protruding fundus Figure 3A 29) with the palm of the hand and fingers directed toward the posterior fornix ( Figure 3B 29). 42 Every attempt should be made to replace the uterus quickly. The placenta often is still attached, and it should be left in place until after reduction. Vasovagal effects producing vital sign changes disproportionate to the amount of bleeding may be an additional clue. 10 The inverted uterus usually appears as a bluish-gray mass protruding from the vagina. 42 Fundal implantation of the placenta may lead to inversion the roles of fundal pressure and undue cord traction are uncertain. 10 Active management of the third stage of labor may reduce the incidence of uterine inversion. Uterine inversion is rare, occurring in 0.05 percent of deliveries. Early recognition, systematic evaluation and treatment, and prompt fluid resuscitation minimize the potentially serious outcomes associated with postpartum hemorrhage. Coagulopathies require clotting factor replacement for the identified deficiency. Traumatic causes include lacerations, uterine rupture, and uterine inversion.
Rarely, an invasive placenta causes postpartum hemorrhage and may require surgical management.
#RETAINED PLACENTAL FRAGMENTS MANUAL#
Retained placenta is a less common cause and requires examination of the placenta, exploration of the uterine cavity, and manual removal of retained tissue. Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins, and ergot alkaloids. Although risk factors and preventive strategies are clearly documented, not all cases are expected or avoidable. Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal morbidity in developed countries.
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