KIMS COLLEGE OF NURSING

LESSON PLAN
ON
Retroversion & inversion of uterus
Prepared By
Mrs. Gopika Krishnan. G
Lecturer
KIMS COLLEGE OF NURSING

Name of the teacher: - Mrs. Gopika Krishnan. G date: -

Subject- Obstetrics and gynaecological nursing time: -
Unit: - 5 (Mechanical disturbance and injuries to female genital tract) duration: -

Topic: - Retroversion and Inversion of uterus venue: - IV Year B.Sc. classroom

Method of teaching: - Lecture cum discussion Group: - 4th year B.Sc. Nursing

Av aids: - Slides showing with the help of LCD, White board, OHP. Number of students: -

Previous knowledge: - Students may have knowledge from textbooks and medias.

Central objective: - At the end of the class students will be able to gain adequate knowledge regarding retroversion and inversion of uterus
and apply this knowledge in clinical setting with a positive attitude.
Specific objective: - Students will be able to,

 describe about retroversion of uterus

 explain about inversion of uterus
 Teacher’s /
time Specific Content Learner’s Av Aids Evaluation
objectives activity

1 hr Describe about RETROVERSION Teacher explains LCD What are the

retroversion of about content and degrees of
uterus Definition students actively retroversion of
Retroversion of the uterus occurs when a woman’s uterus listens. the uterus?
tilts backward rather than forward. It is commonly called a tipped
uterus

Incidence
• 15 -20 Percent of normal women.

Degrees of uterine retroversion

• First degree: fundus is vertical and pointing towards the
sacral promontory
• Second degree: fundus lies in the sacral hollow but not
below the internal OS.
• Third degree: fundus lies below the internal OS.
Causes
• Developmental- due to the developmental defect, there is a
lack of muscle tone.
• Acquired:
• Puerperal: the stretched ligaments caused by child birth
fail to keep the uterus in its position
• Prolapse: caused by traction following cystocele
• Tumor: fibroid produces heaviness of the uterus and
hence it falls behind
• Pelvic adhesions: either inflammatory, operative or due
to pelvic endometriosis pull the uterus posteriorly.
Clinical presentations
Mobile: Symptoms
• Quite common
• Asymptomatic
• Chronic premenstrual pelvic pain (varicosities of broad
ligament)
• Back ache
• Dyspareunia (direct thrust of penis against the
retroflexed uterus or prolapsed ovaries ----- pouch of
Douglas
• Infertility (external os is away from the seminal pool at
the post. Fornix)
Mobile: signs
• Bimanual examination:
• The cervix is directed upwards and forwards
• The body of the uterus is felt through post.
Fornix.
• Speculum examination reveals
• Cervix comes in view much easily and the
 external os points forward
• Rectal examination: helps to confirm diagnosis

• Fixed: symptoms
• Associated with pelvic pathology
• Menstrual abnormalities (menorrhagia)
• Congestive dysmenorrhea, chronic pelvic
pain/dyspareunia
Diagnosis
• Attempt to replace it by moving cervix backwards
• Pessary test.

Prevention
• Empty the bladder regularly
• Increase tone of pelvic muscles by regular exercise
• To encourage lying in prone position for ½ - 1 hour once or
twice daily between 2- 4 weeks postpartum
Corrective treatment
• Pessary:
• Acts as stretching the uterosacral ligaments so as to pull
cervix backwards
• Hodge smith pessary is commonly pessary.
• Surgical treatment:
• Ventrosuspension of the uterus by replicating the round
ligaments
Explain about
inversion of INVERSION OF THE UTERUS
1hr uterus Teacher explains What are the
Definition about content and types of inversion
It is an extremely rare but a life – threatening complication in students actively LCD of uterus?
third stage in which the uterus is turned inside out partially or listens.
completely.
Incidence
1 in 20,000 deliveries
Types
Classified in two categories
• Incomplete inversion: In this type the uterine fundus is
inverted but not herniated through the cervix
• Complete: In this type the uterine fundus herniates
completely through the cervix and is found lying in the
vagina or seen out at the vulva
On the basis of duration of onset
• Acute: within 24 hours of delivery
• Subacute: 24 hours to 4 weeks of delivery
• Chronic: Beyond 4 weeks postpartum
Degrees/varieties
The extent of uterine inversion has also been described in
three degrees as follows:
• First degree (incomplete): there is dimpling of the fundus
and still remains above the level of internal os
• Second degree (complete): the fundus passes through the
cervix but lies inside the vagina
• Third degree (prolapsed): the endometrium with or without
the attached placenta is visible outside the vulva.
Etiology
• Spontaneous
• Iatrogenic
Spontaneous (40%):
• This is brought about by localised atony on the placental site
over the fundus associated with sharp rise of intra-abdominal
pressure as in coughing, sneezing, or bearing down efforts
• Fundal attachment of the placenta, short cord and placenta
accrete, weakness of the uterine wall at the placental site are
often associated.
Iatrogenic or induced (60%):
• In majority of cases of inversion, there is some
mismanagement of the third stage of labour.
• Pulling the cord: when the uterus is atonic
• Fundal pressure: while the uterus is relaxed
• Faulty technique in manual removal.
Risk factors
• Uterine over enlargement
• Prolonged labour
• Fetal macrosomia
• Uterine malformation
• Morbid adherent placenta
• Short umbilical cord
• Tocolysis and manual removal of placenta
• More common in women with collagen disease like ehler
Danlos syndrome.
Clinical features
Acute inversion:
• First degree: asymptomatic
• Second degree/third degree
• A purple coloured mass appearing along with the
placenta, the patient complaints of excruciating pain and
sudden collapse are the characteristics feature of acute
uterine inversion. The symptoms include
• Acute pain in abdomen
• Sensation of vaginal fullness with bearing down
sensation after delivery of the baby
• PPH
• Appearance of a vaginal mass outside the vulva
Sub-acute inversion:
• Pain in the lower abdomen
• Sensation of vaginal fullness with a desire to bear down
 even after delivery of placenta
• Vaginal bleeding (unless placenta is not separated)
• Minimal symptoms and the condition is discovered later
when the patient develops blood stained offensive vaginal
discharge due to infection.
Chronic inversion:
• These cases present with prolonged vaginal spotting, low
backache and offensive vaginal discharge.
• These cases of incomplete inversion can be quite deceptive
and may pass unnoticed until a few days later when the
uterine inversion progressively becomes complete and is
recognized.
Diagnosis
 History: Symptoms: acute lower abdominal pain with
bearing down sensation
• Physical examination:
Signs: varying degrees of shock is a constant feature.
 Abdominal examination- a cupping or dimpling of the
fundal surface
 Bimanual examination not only helps to confirm the
diagnosis but also to identify the degrees.
 Sonography
Management
• Call for extra help
• Before shock develops urgent manual replacement even
without anaesthesia
Principal steps:
1. To replace the part first, which is inverted last with the
placenta attached to the uterus by steady firm pressure
exerted by the fingers.
2. To apply counter support by the other hand placed on the
abdomen
 3. After replacement, the hand should remain inside the
uterus until the uterus becomes contracted by parenteral
oxytocin or PGF2∞
4. The placenta is to be removed manually only after the
uterus becomes contracted. The placenta may however
be removed prior to replacement
5. The placenta is to be removed manually only after the
uterus becomes contracted. The placenta may however
be removed prior to replacement
a) to reduce the bulk which facilitates replacement
b) if partially separated to minimize the blood loss
6. Usual treatment of shock, including blood transfusion
should be arranged simultaneously.
After shock develops:
Principal steps:
1. The treatment of shock should be instituted with an urgent
normal saline infusion and blood transfusion
2. The inverted fundus lies on the palm of the hand with the
fingers placed near the uterocervical junction. When the
pressure is exerted on the fundus, it gradually returns into
the vagina. The vagina is packed with antiseptic roller gauze.
3. Foot end of the bed is raised.
4. Replacement of the uterus using hydrostatic method (O
Sullivan’s) under general anaesthesia is to be done along
with resuscitative measures. Hydrostatic method is effective
and less shock producing
Treatment in subacute stage:
1. To improve general condition by blood transfusion
2. Antibiotics are given to control sepsis
3. Reposition of the uterus either manually or by hydrostatic
method may be tried
4. If fails, reposition may be done by abdominal operations
 (Haultians operation)
5. For surgical operation details refer Holland & Brews Manual
of obstetrics, 4th edition … page no. 410
Dangers/complications
• Shock – mainly due to the compression of ovary, tension on
nerves as a result of pull on infudibulo pelvic ligaments and
peritoneal irritation
• Haemorrhage (especially after detachment of placenta)
• Pulmonary embolism
• If left uncared--- infection, uterine sloughing, chronic
inversion.
Prevention
• Do not employ any method to expel the placenta out when
the uterus is relaxed
• Pulling the cord simultaneously with fundal pressure should
be avoided
• Manual removal should be done in a manner as it should be.
• Do not attempt delivering unseparated placenta.
Prognosis
 The prognosis is extremely gloomy
 Even if patient survives, infection, sloughing of the uterus
and chronic inversion with ill health may occur.
Conclusion
Retroversion and inversion of uterus are the rare condition even
though it should be identified and corrected immediately.
RECAPITULATION
 What is retroversion of uterus?
 What are the degrees of retroversion of uterus?
 What are the causes of retroversion of uterus?
 What are the clinical manifestations of retroversion of uterus?
 What is inversion of uterus?
 What are the causes of inversion of uterus?
 What are the clinical manifestations of inversion of uterus?

REFERENCE
 Hiralal Konar, D.C Dutta’s textbook of gynecology, 7th edition, Jaypee publication, Newdelhi.

 Diane. M. Fraser, Margret . A. Cooper, Myle’s textbook for midwives, 15th edition, Elsvier publication.

 Annamma Jacob, Comprehensive text book of midwifery, Jaypee brothers, New Delhi.

 Saritha Shamsunder, Manual of Gynaecology,1st edition, CBS Publishers, Bangalore.