Uterine inversion after birth: what it is, why it happens and how it is treated

During childbirth the womb (uterus) contracts to deliver the baby and then the placenta. In uterine inversion the top of the womb, called the fundus, folds inwards on itself. The Swansea Bay maternity guideline describes the fundus collapsing into the cavity of the womb and, as the problem progresses, descending through the birth canal so that the uterus turns itself inside out.

It is an acute event, meaning it happens suddenly, and in the guidance used by NHS maternity units it is most often discussed as something that occurs in the third stage of labour, the period after the baby is born when the placenta comes away. The NHS describes the third stage as the time when the womb contracts and the placenta comes out through the vagina.

Inversion is not the same as a prolapse of the womb that can develop years later with pelvic floor weakness, and it is not the same as ordinary heavy bleeding after birth, although it often presents with heavy bleeding. Maternity guidelines list it as one of several possible explanations when a woman collapses or bleeds heavily soon after delivery.

Clinicians describe how far the womb has turned inside out. The Swansea Bay guideline uses four grades, and the Milton Keynes guideline describes the same four stages as first, second, third and fourth. The grade matters because it affects what the team can see and feel, and how the womb is put back.

The guidelines list a number of factors that have been associated with inversion. They are associations rather than certainties, and the Milton Keynes guideline stresses that in many cases none is recognised.

• Excessive pulling on the umbilical cord, or pressure on the top of the womb, before the placenta has separated.

• A short umbilical cord, or a placenta attached at the top of the womb.

• A placenta that is abnormally adherent to the womb wall, for example placenta accreta.

• A womb that is not contracting well (uterine atony).

• Having had several previous births (multiparity), a very fast labour (precipitate labour) or a prolonged labour.

• A large baby (fetal macrosomia) or a vaginal birth after a previous caesarean section.

• An abnormality of the uterus, or a previous uterine inversion.

• Connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome.

• Manual removal of the placenta.

In hospital the signs are picked up by the midwife or obstetrician looking after the woman. The Swansea Bay guideline lists sudden shock or collapse out of proportion to the blood loss, a top of the womb that cannot be felt when the abdomen is examined even when nothing is visible at the vaginal opening, and, in grade 4, a mass protruding from the vagina. It adds that a nerve-mediated (vasovagal) shock with a slow pulse and low blood pressure is typical, while shock from blood loss, with a fast pulse and low blood pressure, can also develop if heavy bleeding follows.

The Milton Keynes guideline lists severe abdominal or back pain, sudden collapse, a womb that feels dimpled or is not in its usual position, and a lump in the vagina. It states that postpartum haemorrhage is present in 94 percent of cases.

Because the picture overlaps with other causes of collapse and heavy bleeding, the same guideline lists conditions the team has to think about at the same time, including prolapse of the womb, a fibroid polyp, severe failure of the womb to contract, a retained placenta without inversion, and clotting problems.

The Milton Keynes guideline is clear that this is an obstetric emergency, that help is called immediately, and that resuscitation and repositioning of the womb are done at the same time. A team that includes the obstetric registrar, the anaesthetist and theatre staff is brought together. Oxygen, intravenous fluids and blood tests are started, and blood products are available if needed.

Two points in the guideline are worth knowing as a patient or birth partner. First, if the placenta is still attached it is not removed until the womb has been put back, because doing so can make heavy bleeding worse. Second, the medicines that make the womb contract are held back until the womb is replaced, because giving them earlier can make replacement harder; once it is back in position, they are used to keep it contracted.

The womb is usually replaced by hand, pushing the top of the womb back through the cervix and holding it there until it contracts well. If that is not possible, the guideline describes other approaches, including a technique that uses warmed saline in the vagina to build pressure, medicines that relax the cervix, and moving to the operating theatre where a general anaesthetic helps relax the womb. A surgical operation through the abdomen is described as rarely needed and is carried out with a consultant obstetrician present.

Once the womb has been replaced, the Milton Keynes guideline says the woman needs careful monitoring on the labour ward or in a critical care area. The plan includes medicines to keep the womb contracted, which prevent the inversion from recurring and reduce bleeding, a check for tears of the cervix and vagina with repair if needed, a urinary catheter, regular observations, a 24-hour course of intravenous antibiotics and daily blood tests, with transfusion where blood count or clotting needs correcting. It also advises that the woman is debriefed and offered birth afterthoughts.

Many women who have needed treatment for heavy bleeding after birth feel tired and anaemic afterwards. The Royal College of Obstetricians and Gynaecologists (RCOG) patient information on postpartum haemorrhage notes that it may take a few weeks to make a full recovery, that iron treatment may be needed, that the GP may offer a blood test at 6 to 8 weeks, and that clot-preventing measures such as heparin injections and compression stockings may be offered because the risk of blood clots is higher after a haemorrhage.

The same RCOG information says that experiencing a major emergency can be distressing for the woman and her partner, that talking through the events is often helpful, and that anyone who continues to feel upset or develops anxiety or depression after going home should speak to their midwife, health visitor or GP.

Inversion cannot always be predicted, but the Milton Keynes guideline lists some preventive principles for staff: be aware of the risk factors, do not use any method to expel the placenta when the womb is relaxed, avoid pulling the cord at the same time as pushing on the top of the womb, and note that active management of the third stage may reduce incidence. It also notes that regular simulation training matters because the condition is so uncommon.

The guidance reviewed for this page does not set out a specific plan for pregnancies after an inversion, although the Swansea Bay guideline lists a previous uterine inversion as a risk factor. Anyone who has had one should ask their consultant team to document it and to explain how it will be reflected in their birth plan, including where to give birth and how the third stage will be managed.

Uterine inversion is an emergency that is managed by whichever hospital maternity unit the woman is in, and the guidelines reviewed are written for hospital maternity units, which have theatres, anaesthetists, blood products and critical care available. The Milton Keynes guideline stresses that preparedness applies to both hospital and community-based teams, and the RCOG says that if you have had your baby at home or in a midwifery-led unit and have a primary postpartum haemorrhage, your midwife will call for assistance and arrange your transfer to hospital.

This page is general information and is not a substitute for the advice of the midwives and doctors caring for you.