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Summary Table

Feature	Detail
Risk Factors	Fundal placental implantation, excessive umbilical cord traction, fundal pressure during third stage of labor, short umbilical cord, uterine atony, placenta accreta spectrum, connective tissue disorders (Marfan, Ehlers-Danlos), prolonged labor, use of uterotonic agents before placental separation
Etiology	The uterine fundus collapses inward through the cervix, turning the uterus partially or completely inside out, most commonly caused by mismanagement of the third stage of labor
Patient Presentation	Sudden postpartum hemorrhage immediately after delivery, severe lower abdominal pain, signs of hemodynamic instability disproportionate to visible blood loss
Classic Physical Exam	A smooth, round mass protruding from the cervix or vagina; inability to palpate the uterine fundus abdominally; the "dimpling sign" on abdominal exam where the fundus should be
Key Diagnostic Results	Clinical diagnosis based on physical examination; ultrasound may show a "target sign" or fundal indentation if the inversion is incomplete and not visually obvious
Management	Immediate manual repositioning (Johnson maneuver), uterine relaxation with terbutaline or general anesthesia (halothane/sevoflurane), IV fluid resuscitation, surgical correction (Huntington or Haultain procedure) if manual reduction fails
Keywords	"Unable to palpate fundus," "mass at introitus after delivery," "cord traction," "hemorrhage with shock out of proportion to blood loss," "smooth round mass in vagina postpartum"

1. Pathophysiology

Uterine inversion occurs when the uterine fundus folds inward and descends through the endometrial cavity toward or beyond the cervix. Think of it as a sock being turned inside out. The process begins when the fundus, weakened by the placental implantation site, is pulled or pushed downward. This happens most often during the third stage of labor when excessive traction is applied to the umbilical cord before the placenta has fully separated, or when fundal pressure (Crede maneuver) is applied to a relaxed, atonic uterus.

The reason patients develop shock that appears disproportionate to the visible blood loss is twofold. First, the inversion itself causes significant hemorrhage because the placental bed is now exposed and the uterus cannot contract effectively around the bleeding vessels when it is inverted. Second, and critically for exam purposes, traction on the peritoneal structures and the round and broad ligaments triggers a parasympathetic (vasovagal) response, producing neurogenic shock with bradycardia and hypotension. This combination of hemorrhagic and neurogenic mechanisms explains why a patient may appear far more unstable than the amount of visible bleeding would suggest.

The fundal placental implantation is the single most important predisposing anatomical factor. When the placenta attaches at the fundus, the thinnest part of the myometrium at the implantation site becomes the weakest point, making it susceptible to inversion under traction or pressure forces. Additionally, conditions in the placenta accreta spectrum (accreta, increta, percreta) create abnormally adherent placentation that, when traction is applied, pulls the entire fundal wall downward rather than allowing the placenta to shear off cleanly.

2. Classification and Clinical Manifestation

By Degree of Inversion

Degree	Anatomical Description	Clinical Finding
First degree (Incomplete)	Fundus inverts but does not descend beyond the cervical os	Fundal dimpling felt abdominally; mass palpable within the uterine cavity on vaginal exam; fundus not visible externally
Second degree (Complete)	Fundus protrudes through the cervix into the vagina	Smooth, round, bleeding mass visible or palpable in the vaginal canal; fundus absent on abdominal palpation
Third degree (Prolapsed)	Entire uterus protrudes beyond the introitus	The inverted uterus is visible outside the vulva, often with the placenta still attached
Fourth degree (Total)	Uterus and vaginal walls are both inverted	Vaginal walls are pulled along with the inverted uterus; rare and most severe form

Classification by Timing

Timing	Definition	Notes
Acute	Within 24 hours of delivery	Most common; best prognosis if recognized immediately
Subacute	24 hours to 4 weeks postpartum	Cervical ring begins to constrict, making reduction more difficult
Chronic	Beyond 4 weeks postpartum	Very rare; may present as persistent vaginal bleeding or a prolapsing mass; often requires surgical correction

The clinical manifestation follows a recognizable triad: postpartum hemorrhage, severe pelvic pain, and a palpable or visible fundal mass with absence of the fundal contour on abdominal exam. In acute inversion, the patient often presents with sudden cardiovascular collapse immediately after cord traction or placental delivery, and this rapid hemodynamic deterioration is the key distinguishing feature from simple uterine atony.

3. Diagnostic Workup

Test	Role	Key Findings
Bimanual and abdominal examination	Best initial test and often the only test needed	Smooth, globular mass in or protruding from the vagina; "crater" or dimple where the fundus should be on abdominal palpation
Pelvic ultrasound	Adjunctive when clinical exam is equivocal (incomplete inversion)	"Target sign" or "bull's-eye" appearance on transverse view; a hyperechoic fundal depression or an "H-shaped" uterine cavity on longitudinal view
MRI pelvis	Reserved for chronic inversion or nonpuerperal cases	Clearly delineates the degree of inversion and relationship to surrounding structures; rarely needed acutely
Complete blood count, coagulation panel, type and crossmatch	Supportive workup for hemorrhage management	Dropping hemoglobin/hematocrit; possible coagulopathy if prolonged hemorrhage triggers DIC

Uterine inversion is a clinical diagnosis. The best initial test is a thorough physical examination, which in most acute cases is both the first and the only diagnostic step needed. The classic finding on vaginal examination is a smooth, round, dark red or bluish mass in the vaginal canal, often with the placenta still attached. Simultaneously, abdominal palpation reveals the absence of the normal fundal contour, replaced by a cup-shaped depression or dimple at the expected fundal location.

The scenario where imaging becomes relevant is in incomplete (first-degree) inversion, where the fundus has not descended through the cervix and the clinical picture may be mistaken for a retained placenta, uterine atony, or cervical fibroid. In this setting, bedside ultrasound showing the characteristic "target sign" on transverse view (the inverted endometrium surrounded by myometrium) or indentation of the fundal contour on longitudinal view can confirm the diagnosis.

An important exam point: do not delay treatment to obtain imaging studies. If the clinical picture is consistent with uterine inversion (postpartum hemorrhage, absent fundus, visible or palpable mass), proceed directly to manual repositioning. Imaging is a tool for unclear cases, not a prerequisite for intervention.

4. Management and Treatment

Phase	Intervention	Details
Immediate resuscitation	IV access, crystalloid bolus, blood products	Two large-bore IVs; type and crossmatch; transfuse PRBCs if hemodynamically unstable; activate massive transfusion protocol if needed
Stop uterotonic agents	Discontinue oxytocin	Oxytocin causes cervical ring constriction around the inverted fundus, making reduction harder
Uterine relaxation	Terbutaline, nitroglycerin, or halogenated general anesthesia	Terbutaline 0.25 mg IV/SC; nitroglycerin 50-200 mcg IV; or sevoflurane/halothane if in OR; relaxes the myometrium and cervical ring to allow repositioning
Manual repositioning (Johnson maneuver)	First-line definitive treatment	Place hand in the vagina, push the fundus upward through the cervix back to its normal anatomical position; apply steady, continuous pressure rather than intermittent force
Do not remove the placenta before reduction	Critical management principle	Removing the placenta before repositioning worsens hemorrhage; reduce first, then remove the placenta
Post-reduction uterotonic therapy	Oxytocin infusion, methylergonovine, carboprost	After successful reduction: oxytocin 20-40 units in 1 L normal saline IV; methylergonovine 0.2 mg IM (avoid in hypertension); carboprost (15-methyl PGF2-alpha) 0.25 mg IM every 15-90 minutes, max 8 doses (avoid in asthma)
Surgical correction	Huntington procedure (abdominal) or Haultain procedure (abdominal with posterior uterine incision)	Reserved for cases where manual reduction fails; Huntington involves progressive upward traction on the round ligaments laparoscopically or via laparotomy; Haultain adds a posterior myometrial incision to release the constriction ring
Hydrostatic method (O'Sullivan technique)	Alternative to manual reduction	Infuse warm saline into the vagina with the introitus sealed (by hand or balloon); hydrostatic pressure gradually pushes the fundus back into position; used when manual repositioning is unsuccessful

The next best step when you recognize uterine inversion is simultaneous resuscitation and manual reduction. Do not wait for the patient to be fully stabilized before attempting the Johnson maneuver, because the longer the uterus remains inverted, the more edematous and congested it becomes, and the harder reduction will be.

Discontinue oxytocin immediately. This is a commonly tested point. While oxytocin is the standard treatment for postpartum hemorrhage from uterine atony, in uterine inversion it is harmful because it causes the cervical ring to contract around the inverted fundus, trapping the uterus in its inverted position.

Administer a tocolytic agent to relax the uterus before or during the reduction attempt. Terbutaline 0.25 mg subcutaneously or intravenously is the most commonly cited agent. If the patient is already in the operating room, halogenated anesthetic agents (sevoflurane) provide excellent uterine relaxation. Nitroglycerin 50-200 mcg IV is another rapid-onset option.

Do not detach the placenta before attempting reduction. If the placenta is still attached to the inverted fundus, leave it in place. Premature placental removal exposes the raw placental bed to open hemorrhage without the ability of the uterus to contract and achieve hemostasis. Reduce first, then manage the placenta.

Once the uterus is successfully repositioned, immediately restart uterotonics (oxytocin infusion) to maintain uterine tone and prevent recurrence. The operator should keep a hand in the uterine cavity briefly to maintain the fundal position until the uterus firms up with oxytocin.

If manual reduction fails after adequate tocolysis and multiple attempts, proceed to surgical correction. The Huntington procedure (gradual upward traction on the round ligaments via laparotomy) is the standard first-line surgical approach. If the cervical constriction ring prevents reduction even with traction, the Haultain procedure adds a posterior longitudinal incision through the constriction ring to release it before repositioning the fundus.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Uterine atony	Both present with postpartum hemorrhage; both involve a "boggy" uterus	In atony, the fundus is palpable abdominally (soft and enlarged but present); in inversion, the fundus is absent on abdominal exam and a mass is found in or beyond the vagina
Retained placenta	Both cause postpartum hemorrhage with tissue visible at the cervix	Retained placenta presents as irregular tissue fragments at the os; uterine inversion presents as a smooth, round mass, and the fundus cannot be palpated abdominally
Cervical or vaginal laceration	Both cause postpartum hemorrhage	Lacerations cause bright red bleeding with a firm, contracted, normally positioned uterus; uterine inversion features absent fundus and a protruding mass
Uterine rupture	Both cause sudden hemodynamic collapse with pain	Rupture is associated with prior uterine scar (previous cesarean), loss of fetal station, and abnormal fetal heart tracing during labor; the uterus is palpable (though tender) and there is no vaginal mass
Prolapsed fibroid	A mass is visible or palpable in the vaginal canal	A prolapsed pedunculated fibroid is firm, well-circumscribed, and does not involve absence of the fundal contour; it is typically not associated with recent delivery or acute hemorrhage

6. Traps and High-Yield Pearls

The single most common way students lose points on uterine inversion questions is by treating it like uterine atony. Both present with postpartum hemorrhage, and the reflexive answer for postpartum hemorrhage is uterine massage and oxytocin. However, giving oxytocin in the setting of uterine inversion worsens the condition by tightening the cervical ring. The vignette will contain the critical clue: the fundus is not palpable on abdominal exam, and there is a mass in or beyond the vagina. If the question mentions "unable to palpate the fundus" or "smooth round mass at the introitus," that is the signal to switch from the atony algorithm to the inversion algorithm.

Another frequently tested concept is the correct sequence of management. Students often want to remove the placenta first or obtain imaging before acting. The correct sequence is: recognize the inversion clinically, stop oxytocin, give a tocolytic, perform the Johnson maneuver with the placenta still in situ, and only after successful reduction remove the placenta and restart uterotonics. Questions that test "next best step" are looking for you to choose manual repositioning, not ultrasound, not placental removal, and not oxytocin.

The disproportionate shock is another pearl that test-writers exploit. If a vignette describes a patient with cardiovascular collapse after delivery but the visible blood loss seems modest, consider uterine inversion and its neurogenic (vasovagal) component contributing to the hemodynamic picture. This "shock out of proportion to blood loss" is a classic exam phrasing designed to point you toward this diagnosis.

Finally, remember the role of terbutaline versus oxytocin in this context. In almost every other postpartum hemorrhage scenario, oxytocin is the answer. Uterine inversion is the notable exception where a tocolytic (terbutaline, nitroglycerin, or halogenated anesthetics) is the correct pharmacologic choice for facilitating treatment.

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