⚡ Uterine Inversion
IN REVIEWPENDING CLINICAL VERIFICATIONTIME-CRITICAL PROTOCOL
1 RECOGNIZE
- After birth: fundus absent/dimpled abdominally or a uterine mass in the vagina/introitus, with pain, bleeding and shock that may be disproportionate to measured loss.
2 CALL FOR HELP
- Senior obstetrician, anaesthetist, theatre and blood bank urgently; resuscitation and replacement must proceed together.
3 IMMEDIATE ACTION
- Treat shock/haemorrhage with IV access, blood/fluid support and warming; avoid further cord traction. Stop uterotonics temporarily while attempting replacement.
- If the placenta is still attached, do NOT remove it before reducing the inversion.
- A skilled operator promptly replaces the uterus by sustained pressure toward the umbilicus through the cervical ring, with abdominal counter-support. Do not delay the first attempt for elaborate investigations.
- Anaesthesia may be needed for relaxation and repeat attempts; failed manual reduction requires urgent senior operative management.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Oxytocin — treatment of atonic PPHMSFchecked
Dose5–10 IU slowly IV, then 20 IU in 1 L isotonic crystalloid over 2 hours (MSF regimen)
RouteSlow IV loading + IV infusion
FrequencyLoading followed immediately by infusion
DurationInitial infusion over 2 h; reassess continuously and prescribe further treatment according to response
PreparationWith 10 IU/mL stock, 20 IU = 2 mL added to 1 L sodium chloride 0.9% or Ringer lactate. Pump 500 mL/hour = 10 IU/hour. Include this litre in total resuscitation fluid
Max doseMSF maximum total oxytocin 60 IU; avoid rapid boluses and excessive fluid
- Indication: Atonic bleeding after delivery; treatment continues alongside the PPH bundle
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
- Fluid balance, sodium if prolonged/high-volume treatment; cardiac disease needs a separately prescribed concentrated infusion
Contraindications: Rapid IV injection can cause hypotension/tachycardia · Monitor fluid overload, especially pre-eclampsia or cardiac disease
Tranexamic acid — PPHWHO · Supersedes 2012 TXA recommendation; now folded into Consolidated PPH 2025 Recs 27/29checked
Dose1 g IV over 10 min; repeat 1 g if bleeding continues after 30 min OR restarts within 24 h
RouteIV only
FrequencyOne initial dose; at most one additional 1 g dose under those criteria
DurationAcute PPH treatment, maximum 2 doses in this regimen
Preparation100 mg/mL: 1 g = 10 mL. Give no faster than 1 mL/min, or dilute in compatible sodium chloride 0.9% and infuse over 10 min. Clearly label IV ONLY; never intrathecal
Max dose2 g total. The 24 h repeat rule does NOT permit a first dose after the 3 h window
- Indication: PPH of any cause; first dose as soon as possible and WITHIN 3 h of birth
- Renal / hepatic: Renal clearance: assess renal function and seek dose advice with impairment; do not repeatedly dose without review
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
Contraindications: Clear contraindication to antifibrinolysis, such as a known thromboembolic event during pregnancy; renal dysfunction needs dose review
4 INVESTIGATIONS (never delaying treatment)
- CBC, crossmatch, coagulation/fibrinogen and perfusion tests in parallel; do not delay anatomical correction.
5 DEFINITIVE MANAGEMENT
- After successful reduction, hold/support the uterus until tone returns; then resume/start the prescribed oxytocin regimen and manage residual PPH.
- Remove retained tissue only after reduction when appropriate, explore gently, and prescribe indicated prophylactic antibiotics for intrauterine manipulation.
- If reduction fails, proceed to theatre for the appropriate surgical reduction; continuing haemorrhage may require additional source control.
6 ESCALATION
- Failure to reduce or continuing shock: immediate theatre/major-haemorrhage rescue and ICU support.
7 POST-EVENT CARE
- Monitor recurrence, bleeding, uterine tone, urine output and coagulopathy.
- Document the reduction/placental sequence and explain recurrence/future-birth planning.
Admission & discharge after the acute event
Care setting: Emergency admission; major bleeding may need theatre/critical care
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit and treat ongoing heavy bleeding, abnormal haemodynamics, suspected retained tissue/infection or coagulopathy. Transfer to theatre/critical care according to bleeding and organ-support requirements.
When clinic, day care or home care may be suitable
- Active PPH, shock or suspected secondary PPH with systemic illness is not suitable for routine outpatient management.
Before going home
- The inversion has been reduced, uterine position/tone is satisfactory and the obstetric team has excluded recurrent inversion or continuing haemorrhage.
- The bleeding source is controlled; uterine/perineal/wound assessment is satisfactory and there is no recurrent concerning loss.
- Haemodynamics, consciousness, urine output, oral intake, mobility and pain control support home care. Review anaemia symptoms, Hb trend and any coagulopathy/organ injury; there is no single Hb value that alone certifies safe discharge.
Discharge medicines and treatment changes
- Prescribe iron replacement when iron deficiency/anaemia is present, using a documented formulation, dose and response plan; assess whether IV treatment or transfusion is needed before discharge.
- Uterotonics and TXA used for the acute event are not automatically continued at home. Reassess VTE prophylaxis after bleeding risk has fallen.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
Only for diagnosed postpartum iron-deficiency anaemia after bleeding is controlled.
Oral iron and folic acid — postpartum anaemia treatmentWHO / FIGO / ICM · 2025 consolidated recommendations, supportive care tablesummary checked
Dose120 mg ELEMENTAL iron plus 400 micrograms folic acid per day
RouteOral
FrequencyDaily; tailor administration for tolerance without accidentally changing the prescribed total
DurationWHO postpartum anaemia treatment: until Hb normalises. Then document any continuing preventive/repletion course and review; the preventive 6–12-week recommendation is a different indication.
PreparationUse the product’s ELEMENTAL iron content, not salt weight: two tablets each containing 60 mg elemental iron provide 120 mg. Check the combined-tablet folate separately. Separate iron from calcium by several hours and levothyroxine by 4–5 hours.
Max dose120 mg/day elemental iron in this WHO treatment schedule; do not add duplicate antenatal/OTC iron or overlap oral and IV courses without an explicit plan.
- Indication: Diagnosed postpartum iron-deficiency anaemia after haemorrhage is controlled and outpatient oral treatment is suitable
- The WHO 2025 supportive-care recommendation supplies the postpartum dose/endpoint. Preparation and response monitoring reuse the checked oral-iron reference; breastfeeding is compatible with indicated maternal supplementation.
Monitoring
- Arrange Hb response review after 2–4 weeks, tolerance and adherence; investigate non-response or ongoing bleeding and reassess the replacement route.
- Review the cause of anaemia and any coexisting B12/folate deficiency or haemoglobinopathy.
Contraindications: Iron overload or anaemia without iron deficiency; oral iron alone is inadequate for unstable bleeding or cardiovascular compromise.
Tests, pending results and their reviewer
- Record quantified loss, procedures, transfusion and latest relevant CBC/coagulation/renal results; assign a reviewer/date for outstanding investigations.
Home care and counselling
- Explain the cause and treatment, expected lochia, worsening-bleeding warnings, fatigue/feeding support and the future-birth haemorrhage plan. Offer a debrief and emotional support.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before leaving | Book anaemia/Hb response review and communicate any organ-injury or transfusion follow-up to the responsible team. |
Early postnatal contacts and 6-week review | Review bleeding, recovery, mental health and the future-pregnancy plan; review sooner for symptoms or major anaemia. |
Return urgently
- Sudden/heavy or increasing bleeding, fainting, breathlessness, fever, offensive discharge or worsening abdominal pain require immediate assessment.
Open the complete discharge checklist →
Sources for this plan:
Sources
MSFcheckedMSFcheckedMSFcheckedWHO · Supersedes 2012 TXA recommendation; now folded into Consolidated PPH 2025 Recs 27/29checkedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedWHOsummary checkedWHO / FIGO / ICM · 2025 consolidated recommendations, supportive care tablesummary checkedRCOG · Current public recovery informationcheckedNICE · CG50, recommendationschecked