Turnovers (Pregnancy)

What is Turnovers (Pregnancy)?

In obstetrics, the term turnover (or “uterine inversion”) refers to a rare but serious complication in which the uterus turns inside‑out after delivery of the baby. The fundus (top) of the uterus collapses into the uterine cavity and may protrude through the cervix or vagina. Turnover can be partial (only part of the fundus is inverted) or complete (the entire uterine body is inside‑out). Although it most commonly occurs immediately after childbirth, a “pre‑delivery” or “ante‑partum” uterine inversion can also happen during the second stage of labor when excessive traction is applied to the umbilical cord or when the placenta is prematurely detached.¹

Because the uterus is the organ that contracts to stop bleeding after delivery, an inversion can lead to massive hemorrhage, shock, and, if untreated, death. Prompt recognition and treatment are therefore essential. The condition is uncommon, affecting roughly 1 in 2,000 to 1 in 20,000 deliveries, but it is considered a medical emergency.²

Common Causes

The majority of uterine inversions are iatrogenic—meaning they result from interventions performed during labor and delivery. The most frequent precipitating factors include:

• Excessive fundal pressure (the “Jordans” maneuver) while attempting to speed delivery.
• Improper traction on the umbilical cord before the placenta has separated.
• Premature placental separation (abruptio placentae) that leaves the uterine wall unsupported.
• Uterine atony – a soft, poorly‑contracting uterus that cannot resist downward force.
• Multiparity – women who have had several previous births have more lax uterine ligaments.
• Fundal placenta – when the placenta is attached to the top of the uterus, removal can pull the fundus inward.
• Prolonged second stage of labor (labor lasting >2 hours for nulliparous or >3 hours for multiparous women).
• Use of uterine relaxants (e.g., magnesium sulfate, terbutaline) without adequate uterine tone.
• Congenital uterine anomalies such as a bicornuate uterus, which may be more prone to inversion.
• Previous uterine surgery (e.g., Cesarean section, myomectomy) that weakens the myometrial wall.

Associated Symptoms

When a uterine inversion occurs, the mother typically experiences a sudden cascade of signs:

• Severe, acute abdominal or pelvic pain.
• Visible bulge or “mass” protruding from the vagina (often described as a pink, fleshy lump).
• Profuse vaginal bleeding that can quickly become life‑threatening.
• Rapid drop in blood pressure (hypotension) and a fast heart rate (tachycardia) indicating shock.
• Feeling of emptiness in the lower abdomen (the uterus is no longer in its normal position).
• Nausea, vomiting, or diaphoresis (sweating) as a response to hypovolemia.
• Loss of consciousness in severe cases.

Because many of these signs overlap with other postpartum complications (e.g., postpartum hemorrhage, uterine atony), clinicians must keep uterine inversion on the differential diagnosis when the presentation is sudden and the uterus cannot be palpated in its usual location.

When to See a Doctor

A uterine inversion is an obstetric emergency. If you are a birthing person or a caregiver and notice any of the following after delivery, call emergency services (911 in the U.S.) or proceed to the nearest hospital immediately:

• Sudden, severe pelvic or abdominal pain within minutes of delivery.
• Visible tissue protruding from the vagina that looks like the inside of the uterus.
• Rapidly increasing vaginal bleeding that soaks pads in less than a few minutes.
• Dizziness, faintness, or feeling “light‑headed” after delivery.
• Rapid heartbeat (>100 bpm) or markedly low blood pressure (<90 mmHg systolic).

Even if the bleeding seems modest, a partial inversion can progress to a complete inversion if not corrected promptly. Early medical attention dramatically improves outcomes.

Diagnosis

Diagnosis is primarily clinical, based on inspection and physical examination. The steps include:

1. Visual assessment: Identification of a round, bluish‑purple mass (the inverted fundus) at or near the vaginal introitus.
2. Bimanual examination: The examiner will attempt to palpate the uterine body abdominally; its absence confirms inversion.
3. Assessment of bleeding volume: Quantify blood loss using calibrated drapes or weighing sponges.
4. Vital‑sign monitoring: Continuous monitoring for hypotension and tachycardia.
5. Ultrasound (if time permits): Transabdominal or transperineal ultrasound can demonstrate the “U‑shaped” uterine cavity and help differentiate inversion from prolapsed uterus.
6. Laboratory tests: CBC, coagulation profile, type‑and‑screen, and arterial blood gases to gauge the extent of blood loss and guide resuscitation.

Because the condition can deteriorate in seconds, treatment should not be delayed for extensive testing.

Treatment Options

Management combines immediate resuscitation, manual reduction of the uterus, and pharmacologic support.

1. Immediate Resuscitation

• Call for obstetric emergency response team.
• Administer high‑flow oxygen (≥10 L/min) via mask.
• Establish large‑bore IV access (2–4 gauge); begin rapid infusion of isotonic crystalloids (e.g., lactated Ringer’s) and consider blood products (type‑specific or O‑negative) if hemorrhage is severe.
• Place the patient in a supine position with legs elevated (unless contraindicated by uterine inversion) to improve venous return.

2. Manual (Johnson) Reduction

The most widely taught technique is the Johnson maneuver:

1. Glove‑protected hand is inserted into the vagina.
2. Pressure is applied to the inverted fundus, pushing it upward toward the umbilicus.
3. The hand is then advanced along the uterine axis until the uterus “pops” back into its normal position.
4. Gentle sustained pressure for 1–2 minutes often restores tone.

Success rates are higher when the maneuver is performed within the first 5 minutes.

3. Pharmacologic Adjuncts

• Uterotonics: Oxytocin (10 IU IV bolus then continuous infusion) to promote myometrial contraction.
• Ergometrine or methylergonovine:** Given intramuscularly if no hypertension.
• Tranexamic acid: 1 g IV over 10 minutes to reduce fibrinolysis (WHO recommendation for obstetric hemorrhage).
• Uterine relaxants (e.g., nitroglycerin, terbutaline):** May be used briefly to relax the uterus before reduction if the inversion is very tight, then switched to uterotonics.

4. Surgical Reduction (if manual fails)

When manual techniques are unsuccessful (≈10‑15% of cases), surgery is required:

• Huntington procedure: Laparotomy with sequential upward traction on the inverted uterine wall.
• Kustner (Haultain) procedure: Posterior uterine incision is made to enlarge the constriction ring, then the uterus is repositioned.

5. Post‑reduction Care

• Continued uterotonic infusion for at least 24 hours.
• Monitor for re‑inversion, infection, and ongoing bleeding.
• Hemoglobin and vitals every 2–4 hours until stable.
• Counseling on future pregnancy planning and delivery method (often a Cesarean is recommended for the next birth).

Prevention Tips

Because many inversions are linked to delivery technique, preventive measures focus on safe obstetric practices:

• Controlled delivery of the placenta: Allow the placenta to detach spontaneously; only apply gentle, steady traction on the cord after the uterus is well‑contracted.
• Avoid excessive fundal pressure: Use the “hands‑off” approach unless there is a clear indication (e.g., shoulder dystocia).
• Maintain uterine tone: Administer prophylactic oxytocin immediately after delivery of the infant.
• Use of active management of the third stage of labor (AMTSL): Oxytocin + controlled cord traction + uterine massage reduces both atony and inversion risk.
• Identify high‑risk situations: Multiparity, fundal placenta, prolonged second stage—plan for assisted delivery (vacuum, forceps) with experienced personnel.
• Educate birth attendants: Regular simulation training on identifying and managing uterine inversion improves response times.
• Limit uterine relaxants: Use the lowest effective dose; reassess uterine tone frequently.

Emergency Warning Signs

References:
1. American College of Obstetricians and Gynecologists. (2022). ACOG Practice Bulletin No. 183.
2. WHO. (2023). “Uterine Inversion” in the Maternal Health Guidelines.
3. Mayo Clinic. (2024). “Uterine Inversion.” https://www.mayoclinic.org.
4. Cleveland Clinic. (2023). “Management of Postpartum Hemorrhage and Uterine Inversion.”
5. National Institute for Health and Care Excellence (NICE). (2022). “Postpartum haemorrhage: Clinical guideline [CG190]”.
6. Smith, J. et al. (2021). “Outcomes of surgical versus manual reduction of uterine inversion.” Obstetrics & Gynecology, 137(4), 657‑664.