Obstetric Trauma

The expulsion of the placenta was probably intended by Nature to occur as a result of gravitational forces, with the mother in the same squatting position that is often adopted for defecation. When the third stage is conducted in the dorsal position, however, help may be necessary for placental expulsion. Accordingly, the inappropriate management of the third stage of labor is often implicated in the etiology of acute uterine inversion. Indeed, Crede’s method of placental delivery with uncontrolled cord traction, referred to in most textbooks of midwifery and older textbooks of obstetrics, may indeed increase the risk of acute uterine inversion. The firmly contracted uterus is used as a piston to push the placenta out, in the same manner that a piston is used to push fluid out of the barrel of a syringe. Pressure is applied with the palm of the hand in the axis of the pelvic inlet, in a downward and backward direction with the aim of forcing the placenta out through the lower genital tract. Unfortunately, application of Crede’s maneuver when the uterus is not contracted may well facilitate acute inversion. On the other hand, the Brandt Andrews maneuver, also mentioned in standard textbooks of midwifery and obstetrics, a modification of Aristotle’s method of delivering the placenta by cord traction, recommends applying tension, but not traction, to the umbilical cord with one hand, whilst the other hand is placed on the abdomen gently moving the uterus upwards and backwards. Today, controlled cord traction is standard practice for the third stage of labor. Other etiological factors include forcibly attempting to expel the placenta by using fundal pressure when the uterus is atonic, and traction on the umbilical cord in a fundally placed placenta when the uterus is relaxed. It may also be brought about by a local atony, more particularly of the fundal placental site together with active contractions of the rest of the uterus. Other etiological factors include macrosomia, polyhydramnios, multiple pregnancy, primiparity and oxytocin administration5. In other instances, however, the inversion occurs spontaneously from sudden increased abdominal pressure as a result of coughing, sneezing or straining. Chronic inversion may result from an acute inversion left unrecognized or from a sub-mucous fibroid which has prolapsed through the cervix. A placental polyp resulting from a retained cotyledon of the placenta may present in the same fashion.