[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Uterine inversion [Conditions](https://durgical.com/en/conditions/) · [Obstetrics and gynecology](https://durgical.com/en/conditions/) # Uterine inversion After birth the uterus turns inside out and comes down into the vagina. It causes heavy bleeding and shock and must be put back right away. Updated 2026-11-01 ## Structures involved Tap one to see what it is and open it in 3D. - [Fundus of uterus](https://durgical.com/en/anatomy/fundus-of-uterus/) - [Cervix](https://durgical.com/en/anatomy/cervix-of-uterus/) - [Vagina](https://durgical.com/en/anatomy/vagina/) - [Body of uterus](https://durgical.com/en/anatomy/body-of-uterus/) - [Myometrium](https://durgical.com/en/anatomy/myometrium/) - [Endometrium](https://durgical.com/en/anatomy/endometrium/) - [Uterine artery](https://durgical.com/en/anatomy/uterine-artery/) ## Why it happens - [Shock: types, stages and the organs it damages](https://durgical.com/en/general-pathology/shock-types-stages-and-the-organs-it-damages/) ## What it is An obstetric emergency in which the uterine fundus collapses into the uterine cavity and may pass through the cervix into the vagina or beyond the introitus. Most cases occur in the third stage of labour, during delivery of the placenta. ## Who gets it Rare: estimates range from about 1 in 2,000 to 1 in 50,000 deliveries. It is more likely where the third stage of labour is managed with excessive cord traction or fundal pressure, a training issue relevant to births attended outside hospitals in parts of Latin America. ## Causes - Excessive traction on the umbilical cord before the placenta has separated (most common cause) - Excessive fundal pressure to expel the placenta - Uterine atony with a relaxed fundus - Abnormally adherent placenta (placenta accreta) at the fundus - Rarely, outside pregnancy: a large submucous fibroid or tumour pulling the fundus down ## Risk factors - Mismanaged third stage of labour - Fundal implantation of the placenta - Placenta accreta - Short umbilical cord - Uterine atony or use of uterine relaxants - Rapid labour and connective tissue disorders ## Pathophysiology If the fundus is relaxed and is pulled or pushed while the placenta is still attached, it can indent and then fold down through the uterine cavity and cervix. The cervix may contract around the inverted body, trapping it and congesting it. Bleeding comes from the placental bed and the atonic uterus; traction on the pelvic ligaments and [peritoneum](https://durgical.com/en/anatomy/peritoneum/) also triggers vagal reflexes, so shock may be out of proportion to visible blood loss. ## Classification - By degree: incomplete (fundus within the cavity), complete (fundus through the cervix), prolapsed (fundus beyond the introitus), total (uterus and vagina inverted) - By timing: acute (within 24 hours of delivery), subacute (24 hours to 4 weeks), chronic (more than 4 weeks) ## Symptoms and signs - Sudden heavy postpartum bleeding - Severe lower abdominal pain - Shock, sometimes with bradycardia from vagal stimulation - A smooth, red mass in the vagina or outside the introitus, sometimes with the placenta still attached - Fundus not palpable, or a cup-shaped dent at the top, on abdominal examination ## Red flags - Postpartum haemorrhage with a fundus that cannot be felt abdominally - Shock that seems greater than the visible blood loss - A mass at the introitus after cord traction ## Diagnosis **Clinical** Clinical diagnosis: haemorrhage and shock after delivery, an absent or indented fundus on abdominal palpation, and a mass in the [vagina](https://durgical.com/en/anatomy/vagina/) or at the introitus. Do not wait for tests. **Tests** Complete blood count, coagulation studies, blood group and cross-match, to guide transfusion; they do not make the diagnosis. **Imaging** Usually not needed. Ultrasound or MRI may help in doubtful, subacute or chronic cases (showing the inverted fundus in the vagina). ## Differential diagnosis - Uterine atony - Retained placenta - Prolapsed submucous fibroid or polyp - Uterine prolapse - Genital tract laceration - Uterine rupture ## Goal of treatment Replace the uterus immediately, before the cervix contracts, while treating shock, and then keep the uterus contracted to prevent reinversion and further bleeding. ## Treatment **Acute** Call for help (obstetrician and anaesthetist), stop any uterotonic infusion, insert two large-bore IV lines, give fluids and blood products. **Procedure** Immediate manual replacement: the hand pushes the fundus back up through the [cervix](https://durgical.com/en/anatomy/cervix-of-uterus/) along the [axis](https://durgical.com/en/anatomy/axis/) of the [pelvis](https://durgical.com/en/anatomy/region/pelvis/) (Johnson manoeuvre). If the placenta is still attached it is usually left in place until the uterus has been replaced. **Medical** Uterine relaxants (for example a beta-agonist tocolytic, nitroglycerin or general anaesthesia) if the cervical ring prevents replacement; once the uterus is back, uterotonics such as oxytocin to keep it contracted. **Surgical** If manual replacement fails: laparotomy with surgical correction (Huntington or Haultain procedures); hysterectomy if bleeding cannot be controlled. **Follow-up** Close monitoring of vital signs, uterine tone, bleeding and urine output; analgesia and prophylactic antibiotics are commonly used after manual procedures. ## Complications - Massive haemorrhage and hypovolaemic shock - Maternal death - Reinversion - Endometritis and infection - Necrosis of the trapped uterus in delayed cases - Hysterectomy ## Prognosis Good when recognised and reduced promptly; mortality rises steeply with delay. The risk may recur in a later delivery, so the third stage should be managed carefully next time. ## Prevention - Active management of the third stage of labour done correctly: controlled cord traction only with the uterus contracted and with counter-pressure above the pubis (guarding the uterus), and no excessive fundal pressure ## Test yourself Think of the answer, then tap the question to see it. ## What is the most common cause of acute uterine inversion? Excessive umbilical cord traction (or fundal pressure) before the placenta has separated, especially with a fundal placenta and a relaxed uterus. ## What abdominal finding suggests inversion in a woman bleeding after birth? The fundus cannot be palpated, or there is a cup-shaped depression where it should be. ## Should the attached placenta be removed before replacing the uterus? Generally no: the uterus is replaced first, then the placenta is removed, to limit bleeding. ## When are uterotonics given in uterine inversion? Only after the uterus has been replaced; before that, relaxants may be needed and uterotonics are stopped. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/uterine-inversion/) ## Related conditions - [Postpartum haemorrhage](https://durgical.com/en/conditions/postpartum-haemorrhage/) - [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/) - [Uterine fibroids (leiomyomas)](https://durgical.com/en/conditions/uterine-fibroids/) - [Placenta accreta spectrum](https://durgical.com/en/conditions/placenta-accreta-spectrum/) - [Uterine rupture](https://durgical.com/en/conditions/uterine-rupture/) Educational information, not medical advice. For any symptom, see a health professional. Sources: [Uterine Inversion](https://www.merckmanuals.com/professional/gynecology-and-obstetrics/intrapartum-complications/uterine-inversion) (Merck Manual Professional Edition, 2024). 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