Immediately after placental delivery in a term vaginal birth, a complete, crater-like mass protrudes through the introitus. The mother complains of severe lower abdominal pain and shows signs of shock disproportionate to visible blood loss. What is the first step in management?

• A Administration of oxytocin infusion before any manipulation
• B Immediate manual replacement of the uterus through the vagina ✓
• C Hydrostatic replacement using warm saline instilled into the vagina
• D Removal of the placenta before replacing the uterus

Explanation

This is acute complete uterine inversion. Prompt manual replacement (Johnson manoeuvre), pushing the fundus through the cervix toward the umbilicus, is the first step and should be done before removing the placenta if it is attached, since removal increases bleeding and shock. Oxytocin is withheld until the uterus is replaced because it contracts the constricting cervical ring, and hydrostatic methods are for failed manual replacement.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.