How to pull the cervix out. Postpartum uterine inversion. Pathological changes in the cervix after childbirth

Uterine inversion ( eversion of the uterus) is serious, but rare complication childbirth, in which the uterus is literally turned inside out after the baby is born. When this happens, the top of the uterus (the bottom) passes through the cervix, and sometimes even fully extends outside the vagina. This happens in about 1 case in 3000 women in labor.

Usually after the baby is born, the placenta is caused to separate from the wall of the uterus. This happens within 5 to 10 minutes after giving birth, although it may take a little longer for some women. After the doctor notices that you have contractions again, he will ask you to push slightly to expel the placenta from the uterus. He can gently pull on the umbilical cord to quickly remove the placenta from the vagina.

If a woman does not have abnormal postpartum hemorrhage, the doctor usually waits for the placenta (“placenta birth”) to occur on its own. If the placenta does not separate from the uterus within 30 minutes, or if you start bleeding, the doctor will perform a manual removal of the placenta, during which he gets through the vagina to the uterus and separates the placenta from its wall.

But sometimes the placenta does not separate normally, and trying to remove it can lead to uterine inversion. In addition, inversion of the uterus can occur without medical intervention.

Inversion of the uterus can cause serious problems, including life-threatening bleeding and shock, especially if the inversion is not detected in time and its immediate treatment is not started.

Uterine inversion treatment

Your doctor will try to return the uterus to its normal position by pushing it back into place through the cervix.

If you have not received medication for pain relief, you will be given anesthesia and drugs to relax the uterus immediately. These medications are needed to relieve pain and to relax the muscles of the uterus so that the doctor can successfully turn it back. Sometimes it is not possible to do it manually - in such cases, open abdominal surgery is required.

Once your uterus is back in place, the medication to relax the uterus will be stopped. The woman will then be given a continuous injection of oxytocin, which will strengthen your uterus and help keep it in place, as well as prevent bleeding.

Your health care provider will closely monitor your condition. They will check your uterus regularly to make sure it stays in place and to monitor your overall health and vaginal bleeding. You will be prescribed antibiotics to prevent it. If necessary, you can get a blood transfusion.

For some time you will suffer from dizziness, so for some time (at the discretion of the doctor) you will have to stay in bed.

When you are discharged home, you will need to take good care of yourself. Eat nutritious foods, drink plenty of fluids, and follow all your healthcare provider's recommendations. You will also need to take iron supplements to prevent anemia from developing.

If you decide to have a baby again, then you should know that if you had a uterine inversion in previous births, then in the next birth it will most likely also be. Therefore, check with your doctor: perhaps to prevent eversion of the uterus, you should go for a caesarean section.

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Inversion of the uterus is a serious and life-threatening obstetric complication that occurs in one case in 400 thousand births. Inversion of the uterus is called the depression of the fundus of the uterus from the side of the abdomen and chest inward, until the entire uterus is everted through the cervix by the mucous membrane outward. In this case, the uterus descends into the vagina, and a deep funnel is formed inside the abdominal cavity, which is lined with a serous layer. The fallopian tubes, uterine ligaments and ovaries are drawn into it.

The main cause of eversion is relaxation in all parts of the uterus, loss of tone and elasticity of the muscle layer. In this state of the uterus, even increased pressure inside the abdominal cavity during pushing, coughing or sneezing can lead to its eversion.

Usually predisposes to eversion the attachment of the placenta at the bottom of the uterus, the formation of fibroids in the submucosal layer of the uterus and in the region of its bottom, which prevents it from maintaining a normal anatomical structure.

Types of eversion

There are complete and incomplete or partial types of inversion of the uterus. When complete, vaginal inversion can also occur. The uterus can be inverted quickly or sharply, and also gradually - chronic eversion. Most often, acute eversion of the uterus occurs, most of them occur in the early postpartum period, and the remainder in the first days after childbirth.

For a reason, one can also distinguish artificial (or violent) eversion and natural. With forced eversion occurs when stretching the umbilical cord or using obstetric techniques when the uterus is not in good shape. Natural - the occurrence without any actions of doctors.

Manifestations

Acute eversion of the uterus manifests itself sharply, severe pain in the lower abdomen occurs, a condition close to shock develops, and severe bleeding appears. Bleeding can precede eversion due to a violation of uterine contraction (atony) and then continues after the eversion itself has occurred.

With a complete eversion, the body and cervix with the vagina can be inverted, or the vagina is not affected. With eversion with the vagina, the uterus and the placenta in it is outside the genital gap or in it. In cases without a vagina, the uterus is identified in the mirrors inside the vagina. When probing the abdomen, in all cases, the uterus is absent in the womb zone.

If this is an incomplete inversion of the uterus, then the woman's condition is not so quickly and not so severely disturbed, although pain also occurs, accompanied by bleeding of varying degrees of intensity. In order to diagnose with other complications, a manual examination is carried out on a chair, with which the doctor will note that the uterus is too low for the postpartum period. In addition, a funnel-shaped depression appears on the uterus itself.

Treatment

If a woman is not given urgent help, she may die from blood loss and shock, or severe sepsis may develop. The eversion itself cannot be corrected without the help of doctors. Therefore, immediate reduction is carried out in a state of general anesthesia with preliminary manual separation of the placenta from the endometrium.

In addition, postoperative close monitoring of the woman and uterine contraction is necessary. The faster the operation is performed, the higher the chance of maintaining a woman's further reproductive capacity. If a complication is noticed late, more than a day has passed, it is necessary to remove the uterus, since its parts are subject to necrosis.

Prevention

Carrying out childbirth in maternity hospitals, careful observation during the field of childbirth. If there are problems with the separation of the placenta, the use of manual techniques, avoiding stretching the umbilical cord.

Its frequency ranges from 1: 2000 births to 1: 50,000 births, which largely depends on the accepted standards of management of the third stage of labor. Acute eversion of the uterus occurs within 24 hours after delivery; subacute - from 24 hours to 4 weeks: the diagnosis of chronic eversion of the uterus is made after 4 weeks. or in a non-pregnant woman. Cases of subacute and chronic inversion of the uterus require surgical treatment.

Types of eversion of the cervix during labor

Incomplete eversion occurs when the fundus of the uterus is turned inside out, like the toe of a stocking, but does not pass through the cervix.

A complete inversion occurs when the fundus of the uterus passes completely through the cervix and is located in the vagina or (less often) outside the genital slit.

Inversion of the uterus is sometimes subdivided into degrees:

1st degree - incomplete eversion;
2nd degree - complete eversion in the vagina;
3rd degree - complete eversion beyond the genital gap.

Causes of eversion of the cervix during labor

The uterus turns out only in a relaxed state, if it has not contracted, which is an important predisposing factor along with the attachment of the placenta in the area of the uterine fundus. Additional factors are as follows.

Improper management of the third stage of labor, namely, putting pressure on the fundus and / or pulling on the umbilical cord until the placenta is separated and the uterus is contracted. Inversion of the uterus with this provision of benefits is observed in most cases, despite the apparent surprise for the obstetrician. Munro Kerr (1908), evaluating cases of acute eversion of the uterus in order to establish the cause, wrote: “When studying them, it becomes obvious that in most cases the accident is the result of pressure from above or stretching from below ... Looking through all these cases, I was not at all surprised that the main reason was cord traction. "
The absolute shortness of the umbilical cord or its relative shortening as a result of entanglement around the fetus in combination with traction of the umbilical cord at birth.
A sharp increase in intra-abdominal pressure with coughing or vomiting. This can happen when, when the uterus is relaxed and the placenta is attached in the area of the fundus, they exert a strong effect on the fundus of the uterus, causing a sharp increase in intra-abdominal pressure.
Pathological attachment of the placenta in the fundus of the uterus.
Manual separation of the placenta. The part of the placenta can remain attached to the wall of the uterus, therefore, when traction of the placenta by the umbilical cord, traction of the fundus of the uterus also occurs. This is possible if, during a cesarean section, manual removal of the placenta is performed before the uterine contraction.
Pathology connective tissue eg Marfan syndrome.

Symptoms and signs of cervical inversion during labor

The diagnosis is clear and obvious with the appearance of a bulky bleeding mass, with or without an attached placenta, in the genital fissure. This is the most obvious clinical manifestation, however, it is very rare.

Other signs and symptoms are:

severe persistent pain in hypogastrium in the third stage of labor;
shock, the severity of which at first does not correspond to the apparent blood loss. The development of shock is due to the displacement of the vortex and round ligaments of the uterus, ovaries and the corresponding innervating fibers, which contributes to the appearance of a vasovagal reflex (pallor of the patient, sweat, bradycardia, deep hypotension, in rare cases, cardiac arrest is possible);
with complete eversion, the uterus is not palpable through the anterior abdominal wall, the fundus of the uterus is outside the genital slit or in the vagina. In the case of incomplete inversion of the uterus, the location of the fundus may seem normal, and only in thin women can the funnel-shaped depression of partial inversion be palpated.

Management tactics for eversion of the cervix during labor

Inversion of the uterus can occur if the myometrium and cervix are relaxed. A quick diagnosis of “hypotonic state of the myometrium and cervix allows for reduction. Therefore, in the event of eversion of the uterus, a manual reduction should be attempted immediately. However, usually within 1-2 minutes, the cervix and the lower uterine segment contract, and this contraction, combined with the large mass of the uterus, edema and contraction of the fundus, makes reduction without anesthesia very difficult, painful and, as a rule, impossible. With a failed first attempt to straighten the uterus, the procedure may be as follows:

call assistants (anesthesiologist, nurse, obstetrician);
prepare for the development of bleeding and hypovolemia, which in most cases follow shock, despite its initially neurogenic nature. It is necessary to install two large-diameter intravenous catheters, quickly infuse 1-2 liters of crystalloids, combine 4 doses of donor erythrocyte mass and place a Foley catheter in bladder:
inject small doses of morphine intravenously if pain is the dominant symptom;
choose the type of anesthesia depending on the availability of equipment and the conclusion of the anesthesiologist. An epidural that has already been administered will provide adequate pain relief. In the rare event that the patient is stable, there is no bleeding, and her vital signs are normal, some anesthesiologists prefer to perform spinal anesthesia. However, in most patients, the presence of cardiovascular insufficiency and a state of shock make regional anesthesia unacceptable. Thus, more often the choice falls on anesthesia using fluorinated hydrocarbons (sevoflurane, isoflurane) to ensure relaxation of the uterus. In the past, halothane was successfully used for this purpose, which was replaced due to such rare side effects, as a violation of myocardial contractility, the development of arrhythmias and hepatotoxicity;
carry out tocolysis if the anesthesia has not provided sufficient relaxation of the uterus or in the case of regional anesthesia;
perform manual reduction of the uterus as soon as anesthesia is carried out and tocolytics are administered. If the afterbirth is completely attached to the bottom, there is no need to separate it, because this will increase blood loss. If the afterbirth is partially attached, you should separate it.

“The success of your actions will depend mainly on their speed: the uterus must be set urgently; but if you hesitate or make excessive efforts, it will be impossible to accomplish this "

The bottom of the uterus (with or without placenta) is grasped with the palm of the hand, and with the fingers it is necessary to feel the area of transition of the uterus into the cervix. The entire uterus is lifted and brought above the level of the navel. Additional force must be applied with your fingertips to evenly and consistently press and push the walls of the uterus through the cervix. For full reduction, it is necessary to apply pressure for 3-5 minutes. When the fundus of the uterus is adjusted, you need to hold your hand in the uterine cavity until the oxytocin is quickly injected to contract the uterus. Feeling that the uterus has contracted, you should slowly withdraw your hand.

With a quick manual adjustment, there is a better chance of reaching the goal. With appropriate anesthesia and tocolysis within 2 hours of diagnosis, manipulation is usually effective.

In the case of a delayed start of treatment and / or in case of unsuccessful manual reduction, the technique of hydrostatic reduction according to O "Sullivan should be used. Before starting this procedure, it is necessary to make sure that there are no ruptures of the soft genital tract (if ruptures are found, they should be sutured). The principle of manipulation is to introduce a large volume of liquid (3-5 l) in upper part vagina and "inflating" in this way the fornices to stretch the cervical canal, which allows the reduction of the uterus. Use containers with 1 L warm saline solution, which is injected under pressure. The intravenous system is passed into the posterior fornix of the vagina with one hand, which simultaneously covers the bottom of the uterus. With the other hand, close the genital slit, covering the wrist to prevent fluid from pouring out. The cannula can be attached to the silicone cup of the vacuum extractor installed in the area of the genital crevice to ensure better tightness. In the event of unsuccessful manual adjustment, the Sullivan O technique can be extremely effective.
In rare cases, with large delayed manipulations, reduction with or without hydrostatic techniques may be ineffective. In this situation, surgical reduction is the treatment of choice. It consists in performing a laparotomy and Huntington's operation, in which an Allis forceps or the like is used to capture the myometrium directly inside the funnel-shaped depression of the inverted uterus. Before applying the Allis clamp, it is necessary to stretch the contraction ring with the fingers or jaws of the clamp. Systematically and sequentially, using a clamp on both sides, the fundus of the uterus is released from the funnel until it is completely reduced.
Sometimes the cervix is so compressed that the attempt to perform the Huntington operation is unsuccessful, and its implementation leads only to stretching the myometrium and damage to the uterus. In this case, Holtein's operation should be performed. The posterior part of the contraction ring is incised and the uterus is reduced using the Allis forceps, as in the Huntington operation. The incision is sutured immediately after reduction.
Any method of reduction requires subsequent administration of oxytocin to maintain uterine contraction for 8–12 hours. After the initial intravenous administration of oxytocin, long-acting prostaglandins such as 15-methyl PGF 2α or misoprostol can be used.
Within 24-48 hours, it is necessary to administer broad-spectrum antibiotics. with these manipulations, a large surface of the uterus is traumatized and the bacterial flora of the vagina is affected.

In acute eversion of the uterus and the absence of anesthetic equipment, reduction is performed using a combination of intravenous narcotic analgesics, inhalation anesthesia and a combination of pudendal and paracervical blockade, as far as possible and feasible. If manual reduction fails, the hydrostatic O "Sullivan technique should be used.

Acute eversion of the uterus is a clear threat to the life of the mother, especially in the absence of equipment for anesthesia and reduction of the uterus. Careful and adequate management of the third stage of labor can completely prevent the development of this complication.

Inversion of the uterus - displacement of the uterus, in which the uterus is partially or completely inverted by the mucous membrane outward. As a rule, eversion of the uterus is associated with improper management of labor. This pathology poses a danger to a woman's life and requires the immediate start of treatment.

Causes of occurrence

Uterine inversion can occur for a variety of reasons:

atony of the uterus with an increase in intra-abdominal pressure;
rough execution by the doctor of Krede-Lazarevich's reception (pressure with hands on the uterus to stimulate the separation of the placenta);
stretching the umbilical cord with the placenta not separated;
the presence of neoplasms of the uterus (for example, a polyp or myomatous node).

Unfavorable risk factors for eversion of the uterus can be:

bottom attachment of the placenta;
the presence of a large submucosal myomatous node in the area of the fundus of the uterus.

Symptoms of uterine inversion

The main symptoms of eversion of the uterus can be:

Diagnostics

At the first stage, a medical history is collected, complaints are analyzed and an obstetric and gynecological history is analyzed. The doctor gets acquainted with the information regarding the transferred gynecological diseases, surgical interventions, pregnancies, childbirth (their characteristics and outcomes).

With an objective study, the pregnant woman is examined, measured arterial pressure, the pulse is measured, the abdomen and uterus are palpated. With an external obstetric examination, the doctor determines the shape and size of the uterus with his hands, as well as muscle tension. During the examination, a bimanual examination and examination of the cervix are carried out using special instruments.

Classification

Eversion of the uterus can occur spontaneously or as a result of medical intervention. Spontaneous eversion of the uterus is associated with relaxation of the uterine muscles and an increase in intrauterine pressure. As for the forcible eversion of the uterus, it can occur when stretching the umbilical cord with the placenta not yet separated, as well as when the Crede-Lazarevich reception is rudely performed.

Inversion of the uterus is complete and incomplete. With incomplete eversion of the uterus, the fundus of the uterus does not go beyond the internal os of the uterus. With a complete eversion, the uterus is located in the vagina with the mucous membrane outward.

Due to the occurrence of eversion of the uterus, it can be postpartum and oncogenetic. Postpartum inversion of the uterus occurs in the postpartum period, and oncogenetic is associated with neoplasms of the uterus. The latter type of eversion of the uterus is extremely rare.

Depending on the time of occurrence, the eversion of the uterus is acute (occurs immediately after childbirth) and chronic, which develops slowly, within a few days after childbirth.

Patient actions

Treatment of this disease is carried out by an obstetrician-gynecologist.

Treatment of uterine inversion

Treatment of eversion of the uterus is carried out by manual reduction of the uterus. In some cases, manual separation of the placenta from the walls of the uterus is necessary.

Medical treatment for eversion of the uterus consists in the use of cholinomimetics (prevent spasm), antiseptic drugs (prevent the spread of infections) and aqueous colloidal solutions.

Surgical treatment is performed in the form of colpohysterotomy surgery. The doctor makes an incision in the back wall of the vagina and uterus, after which the uterus is adjusted, and the defect in the vagina and uterus is sutured.

Complications

With eversion of the uterus, the following complications may develop:

infectious complications (endometritis, peritonitis, sepsis);
necrosis of the uterus;
disseminated intravascular coagulation syndrome;
hemorrhagic shock;
death of the mother.

Prevention of eversion of the uterus

The main preventive measures for eversion of the uterus are:

competent planning of pregnancy and preparation of a woman for it, timely registration of a pregnant woman;
regular visits to the obstetrician-gynecologist;
adherence to the principles of rational balanced nutrition;
good rest and sleep;
taking vitamin and mineral complexes;
giving up bad habits (smoking and drinking alcoholic beverages);
elimination of stress and excessive physical exertion.

The prolapse or prolapse of the genitals is a violation of the normal position of the uterus and the walls of the vagina, which is manifested by their displacement to the vaginal opening or prolapse outside of it. Approximately every eleventh woman undergoes surgery due to prolapse or prolapse of the internal genital organs, so it is recommended to know why such a pathology occurs and how it can be prevented.

Grade 1 is characterized by a slight loss of tone in the pelvic muscles and retaining ligaments. The musculature that holds the uterus in a normal physiological position weakens and begins to poorly support the organs. The vaginal opening does not close completely. Its walls are falling. Patients do not observe pronounced symptoms. The diagnosis at this stage can only be made after a two-handed gynecological examination, examination in mirrors and ultrasound examination of the pelvic organs.
Grade 2 - The pelvic muscles continue to weaken. The uterus, vaginal walls are lowered down. In addition to them, other organs are also involved in the process. The bladder and rectum are most commonly affected. Women at this stage feel the presence of a foreign body in the vagina. When walking and changing body position, this sensation is aggravated. There are aching periodic or persistent pain in the lower abdomen, in the region of the sacrum or lower back. Difficulty urinating and defecating is possible. Sometimes, on the contrary, patients have urinary and fecal incontinence. Cystitis and pyelonephritis often join due to a violation of the outflow of urine. There is discomfort during intercourse.
3 degree. At this stage, the prolapse of the uterus reaches such a state in which its cervix is already in the lower third of the vagina, but does not look out of it. A woman can independently feel the neck with her fingers. The blood supply to the genitals is disrupted, the outflow of venous blood and lymph is hampered. The pelvic organs and female genital organs become edematous, swollen, and acquire a bluish color. Perhaps the addition of infection, the formation of pressure sores on the uterus. Sexual intercourse becomes impossible due to the uterus, which fills the vagina. When walking and physical activity the woman experiences difficulties and bursting pains in the vagina and lower abdomen.
4 degree. This stage is called incomplete or partial prolapse of the uterus. The cervix protrudes from the opening of the vagina. The body and the fundus of the uterus are still inside the vagina. When a sick woman strains or lifts a weight, the protruding part of the uterus comes out even more in the form of a red rounded formation. The uterus can become infected, suppurate, necrotic. The diagnosis at this stage of the disease is made even without examination in the mirrors.
The 5th degree is placed when the body and the fundus of the uterus fell out. In this case, the vagina may be inverted together with the uterus, or it may not remain inverted. This condition is considered urgent and requires urgent surgical treatment in a hospital setting.