Displacement of the uterus

NUR 235
Gynecology Nursing Course
 Objectives
At the end of the lecture the student will be able
to:
1- State the normal and abnormal positions of
uterus.
2- Discuss causes, symptoms and complications of
Retro-vertion Retro-flexion (RVF).
3- Outlines management of RVF.
4- Discuss different degrees, causes, symptoms and
management of uterine prolapse.
5- Discuss different degrees, causes, symptoms and
management of uterine inverstion
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 Normal position of the uterus
 The uterus has central position in the pelvic cavity.
The internal os is at the level of the ischial spine.

The long axis of the uterus is bent forward on the long axis
of the vagina, against the urinary bladder. This
position is referred to as anteversion of the uterus.

The long axis of the body of the uterus is bent forward at

the level of the internal os with the long axis of the cervix.
This position is termed anteflexion of the uterus

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 The
uterus assumes an anteverted position in 50%
women, a retroverted position in 25% women, and a
midposed position in the remaining 25% of women.

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  Retroversion & Retroflexion

Retroversion: The uterus and cervical axis oriented

toward the sacrum

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 ”Retroversion & Retroflexion cont

Retroflexion: The uterus oriented toward the sacrum, with the

anterior portion of uterus convex

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 Causes of Retroversion Retroflexion
(RVF)
A. Acquired during L&D;
1. Bearing down
2. Forceps delivery
3. breach extraction before fully dilatation.

B. During puerperium ;
4. No kegle’s ex
5. No sim’s position
6. heavy uterus; fibroid , subinvolution
7. Lax ligament ; pregnancy
8. Adhesion ; inflammation

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 Symptoms of Retroversion Retroflexion
(RVF)

1. Low backache
2. Dysmenorrheal
3. Dysparunia
4. Dyschasia
5. Mid cyclic pain
6. Menstrual disturbance ;polymenorrhea
7. Leucorrhea

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Complications of Retroversion Retroflexion
(RVF)
1. Kinking of the uterine vessels:
Congestion of uterus (dysmenorrhea, menorrhagia) &
abortion.
2. Congestion of the ovary
polymenorrhra , anovulation ,mid cyclic pain.
3. Infertility
anovulation, cervix away from seminal pool.
4. Uterine prolapse.
5. Prolapse of tube & ovaries.

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Management of Retroversion Retroflexion
(RVF)
Prophylactic

1. During labor: avoid bearing down, breach extraction

before full dilatation of the cervix.

2. During puerperium: sleeping in semi’s position, empty

of bladder, Hodge pessary.

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  Prolapsed Uterus

Definition
The downward displacement of the vagina and uterus.

 The uterus (or womb) is normally held in place inside

the pelvis with various muscles, tissue, and ligaments.
Because of childbirth or difficult labor and delivery,
in some women these muscles weaken.

 Also, as a woman ages and with a natural loss of the

hormone estrogen, her uterus can drop into the vaginal
canal, causing the condition known as a prolapsed
uterus.
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 Degrees of Uterine Prolapse

a. First degree: external os lies behind ischial

spine but inside the introitus.

b. Second degree: external os lies outside the

introitus but the fundus is inside the introitus

c. Third degree: the fundus lies outside the

introitus (procedentia ) .

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Degrees of Uterine Prolapse

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 Degrees of Vaginal Prolapse
Cystocele: Occur when the posterior bladder wall protrudes downward through the
anterior vaginal wall.
This may lead to urinary frequency, urgency, retention, and incontinence (loss of
urine).

Enterocele: occurs when the small intestine bulges through the posterior vaginal wall
(especially common when straining). Standing leads to a pulling sensation and
backache that is relieved when you lie down.

Rectocele: occurs when the rectum sags and pushes against or into the posterior
vaginal wall. This makes bowel movements difficult, to the point that you may need to
push on the inside of your vagina to empty your bowel.

• Hernia of Dougl’s pouch:

• The pouch of Douglas is between uterus and rectum.
• Occur when a loop of intestine bulges into upper part of post vaginal wall.
• Occur with multiparity, old age or pelvic surgery (may lead to pelvic weakening or
defect of the pelvic floor resulting in herniation of bowel through the Pouch of
Douglas).
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Degrees of Vaginal Prolapse

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Degrees of Vaginal Prolapse

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 Causes of Uterine Prolapse
A. Congenital prolapse ---at birth
B. Acquired
 During Labor:
1. Bearing down, or Forceps delivery
2. Breach extraction before fully dilatation
3. Large head without episiotomy
4. Traction on cord
5. Prolonged labor
 During puerperium :
1. No kegle’s ex
2. No sim’s position
C. heavy uterus: fibroid, tumors, pregnancy & sub involution.
D. Menopausal atrophy: decrease of estrogen
E. increased intra-abdominal pressure: in the abdomen such as
chronic cough, constipation, or ascitis. 17
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 Symptoms of Prolapsed Uterus
1. A feeling of fullness or pressure in your pelvis (you
may describe it as a feeling of sitting on a small ball).
2. Low back pain.
3. Feeling that something is coming out of your vagina.
4. Painful sexual intercourse and sometimes sterility.
5. Difficulty with urination or moving your bowels.
6. Frequency of urination and the patient feels difficulty
in total emptying of the bladder. burning sensation due
to infection.

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Prevention of Uterine Prolapse
1. Good antenatal care in pregnancy,
2. Proper management during delivery,
a. Empty of bladder &rectum
b. Avoid bearing down

3. Good postnatal care

c. With proper rest, correct diet and appropriate
exercise so as to strengthen the pelvic musculature.
d. Sleeping in semi’s position empty of bladder ,
Hodge pessary ,avoid early ambulation.

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 3.Uterine Inversion
Uterine Inversion: is the turning inside out of
the uterus.

Itis a rare but serious condition that occur

during third stage of labor.

Itoccurs when the placenta fail to detach from

the uterus as it exit, pull on the inside surface
and turns the organ inside out.

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 Uterine Inversion Degrees
1. First-degree inversion: the inverted wall
extends to but not through the cervix.

2. Second-degree inversion: the inverted wall

protrudes through the cervix but remains
within the vagina.

3. Third-degree inversion: the inverted fundus

extends outside the vagina.

4. Fourth degree or total inversion: both the

vagina and uterus are inverted.
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 Possible Causes of Uterine Inversion

1. Excessive cord traction or a short umbilical

cord.
2. Credé (fundal) pressure
3. Placenta accreta or increta or percreta.
4. Fundal implantation of the placenta
5. Chronic endometritis
6. Fetal macrosomia.
7. Trials of vaginal birth following cesarean
delivery.
8. Myometrial weakness
9. Precipitate labor.
10. Drugs, including magnesium sulfate
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 Signs and Symptoms of Uterine Inversion

1. Postpartum hemorrhage.
2. Sudden appearance of a vaginal mass.
3. Varying degrees of cardiovascular collapse-all
usually occurring in the immediate puerperium.
4. In other cases, the sudden and disconcerting
protrusion of a large, dark red, polypoid mass
through the vagina either accompanying or
following the placenta is noted.

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Management of Uterine Inversion
Following uterine inversion, prompt
treatment of hemorrhage and shock is
vital in limiting maternal morbidity and
the risk of mortality.
Hypotension and hypovolemia require
aggressive fluid resuscitation. The general
principles of treatment follow the (STAR)
protocol.

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