1. Displacement of the uterus
Dr ; sahar anwar rizk

2. The uterus has central position in the pelvic
The ternal os is at the level of the ischial spine
It is ante verted & ante flexed
Anteverted ;angle between axis of the cervic and vertical axis of female .
Ante flexed ;angle between
Axis of the uterine body and
Axis of the cervix

3. Retroversion of the uterus ;
it mean that the axis of the cervix become
behind the vertical axis of femal body .
Retoflexion;
axis of the uterine body become behind the ais
of female body .

4. Second ;the fundus is below the promontory
DEGREE
First ;axis of the cervix is behind the vertical axis of female but the fundus is above the promontory .
Second ;the fundus is below the promontory
but still above the external os .
Third ; the fundus is
below the external os

5. Causes of RVF ;
Acquired during L&D;
1-Bearing down
2- Forceps delivery
3-breach extraction before fully dilatation
During puerperium ;
No kegle’s ex
No sim’s position
heavy uterus; fibroid , subinvolution
Lax ligament ; pregnancy
Adhesion ; inflammation

6. symptoms Pain Low backache Dysmenorrheal Dysparunia Dyschasia
Mid cyclic pain
Menstrual disturbance ;polymenorrhea
Leucorrhea

7. Signs Cervix is displaced Fundus in dougl’s pouch
Absent of the uterus interiorly
4. Acute anterior angulation of the vagina
5. The cervix positioned well behind the pubic symphysis
6. A soft, smooth, nontender mass filling the cul-de-sac

8. investigation PV Examination -----fied or mobile uterus
Hystrography---- position of the uterus
Double pessary test

9. complication Kinking of the uterine vessels----------
congestion of utters-- dysmenorrhea ,abortion menorrhagia
Congestion of the ovary
polymenorrhra , anovulation ,mid cyclic pain
Infertility
anovulation, cervix away from seminal pool
Uterine prolapse
Prolapse of tube & ovaries

10. Management Prophylactic
During labor ,avoid bearing down , breach extraction before full dilatation of the cervix
During puerperium , sleeping in semi’s position empty of bladder , Hodge pessary

11. Management
Possible therapies for retroversion or incarceration include the following:
Bladder drainage by indwelling catheter
Patient positioning exercises (eg, intermittent knee-chest or all-fours positioning, sleeping prone)
Manipulation of the uterus into its usual anatomic position, with or without tocolysis or anesthesia
Colonoscopic manipulation of the uterine fundus under anesthesia
Surgical exploration and replacement (almost never indicated)
Specialized and rarely attempted techniques of replacement (eg, employment of a mercury-filled Voorhees bag in the vagina, amniocentesis with manipulation)

12. Prolapse of the Uterus
Prolapse of the uterus refers to the downward displacement of the vagina and uterus. The word prolapse is derived from the latin procidere which means with effect to fall.
The uterus is held in position by adequate ligaments Besides, it has the support of the muscular structures of vagina and all other local tissues and muscles. Due to the laxity of support by muscles, tissue and ligaments, the uterus sags downwards.

13. Types of uterine prolapse;
True uterine prolapse
False uterine prolapse
DEGREE
First degree ;external os lies behind ischial spine but inside the introitus
Second degree ; external os lies outeside the introitus but the fundus is inside the introitus
Third degree,fundus lies outside the introitus (procedentia )

14. Vaginal prolapse
Cystocoele ; bulge of bladder into anterior vaginal wall
Urethrocoele ; bulge of post wall of urethra into vaginal wall
Rectocoele ; bulge of anterior wall of rectum into post vaginal wall
Prolapse of post vaginal wall; bulge of lower posterior vaginal wall of into lumen of vagina
Hernia of Dougl’s pouch ; bulge of loop of intestine into upper part of post vaginal wall
Vault prolapse ; bulge of the scare of TAH

15. causes Congenital Congenital prolapse ---at birth
Virginal prolapse -----before marriage
Acquired
Labor 1-Bearing down
2- Forceps delivery
3-breach extraction before fully dilatation
4- large head without episiotomy
5-traction on cord
6-prolonged labour, an interference in the delivery by inexpert people,

16. During puerperium ;
No kegle’s ex
No sim’s position
lack of exercise and bodily weakness
lack of proper rest and diet in post natal periods, repeated deliveries and manual work.
heavy uterus; fibroid , sub involution
Lax ligament ; pregnancy
Menopausal atrophy ----decrease of estrogen

17. Increase in intra abdominal pressure;
Abdominal mass
Ascitis
Chronic cough
Chronic constipation
Heavy uterus
tumors of the uterus,
Pregnancy
Subinvolution

18. symptoms
She feels a sense of fullness in the region of the bladder and rectum.
dragging discomfort in the lower abdomen, low backache, heavy menses and milk vaginal discharge
. increase in the frequency of urination and the patient feels difficulty in total emptying of the bladder. burning sensation due to infection. sexual

19. The woman may experience difficulty in passing stools and complete evacuation of bowels.
These symptoms become more pronounced before and during menstruation.
The condition may also result in difficulty in normal sexual intercourse and sometimes sterility.

20. Complications Cystocoele ; Cystitis Pyelonephrinits
Kinking of the tube
Uterine prolapse
Keratinisation of the
Decubital ulcer

21. prevention
good antenatal care in pregnancy,
proper management and timely intervention during delivery,
Empty of bladder &rectum
Avoid bearing down
Avoid piston technique in placental delivery
good postnatal care
with proper rest, correct diet and appropriate exercise so as to strengthen the pelvic musculature.
sleeping in semi’s position empty of bladder , Hodge pessary ,avoid early ambulation

22. Uterine inversion
Uterine inversion may occur immediately postpartum or, much less frequently, during the puerperium.
Inversions are usually described as acute (<30 d after delivery) or chronic (>30 d after delivery).

23. Degree
In first-degree inversion, the inverted wall extends to but not through the cervix.
In second-degree inversion, the inverted wall protrudes through the cervix but remains within the vagina.
In third-degree inversion, the inverted fundus extends outside the vagina. In fourth degree or total inversion, both the vagina and uterus are inverted.

24. Possible etiology
Reported associations for uterine inversion include the following:
Idiopathic
Excessive cord traction or a short umbilical cord
Credé (fundal) pressure
Placenta accreta or increta or percreta
Fundal implantation of the placenta
Chronic endometritis
Fetal macrosomia
Trials of vaginal birth following cesarean delivery
Myometrial weakness
Precipitate labor
drugs, including magnesium sulfate

25. S&S The classic observations include postpartum hemorrhage,
the sudden appearance of a vaginal mass, and
varying degrees of cardiovascular collapse—all usually occurring in the immediate puerperium.
The postpartum hemorrhage is usually the most striking of the symptoms and initially commands the attention of the clinician.
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. The characteristic appearance of the inverted uterus either retained within the vagina or protruding externally is both surprising and startling and usually immediately establishes the correct diagnosis

26. Management
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

27. Shock
Initiate fluid resuscitation with 2 large-bore intravenous lines. Promptly administer 1 or more liters of an isotonic salt solution such as lactated Ringer parenterally.
Submit specimens to the laboratory for possible transfusion and for determination of baseline values of hemoglobin (Hgb), hematocrit (Hct), and coagulation factors.
Insert a Foley catheter.
Immediately summon an anesthesiologist.
Treat aggressively
Order appropriate surgical equipment and assistants to ready the operating room for a possible laparotomy.
Administer tocolytics to promote uterine relaxation. These may include nitroglycerin , or magnesium sulfate at 4-6 g IV over 20 minutes.

28. Attempt prompt uterine replacement
Attempt prompt uterine replacement. First, proceed with a trial of simple manual replacement. If this is unsuccessful, promptly perform a laparotomy for a surgical replacement At laparotomy, general anesthesia employing a uterine relaxing agent is best,

29. It is important that the part of the uterus that came out last (the part closest to the cervix) goes in first. 
Figure P-52
Manual replacement of the inverted uterus

30. Repair
Suture birth canal lacerations and any surgical incisions in cervix or vagina.
Perform uterine massage (after replacement).
Administer uterotonics. These may include methyl ergonovine maleate (Methergine 0.2

31. Surgical techniques
If 2 or more attempts at manual replacement are unsuccessful, surgery is indicated. An abdominal approach for uterine replacement is favored. A vaginal technique has also been described but has few adherents.
In the vaginal procedure, the bladder is dissected from the cervix, and the anterior lip of the cervix and the anterior wall of the uterus are incised to the extent necessary to permit replacement.

32. POST-PROCEDURE CARE
Once the inversion is corrected, infuse oxytocin 20 units in 500 mL IV fluids (normal saline or Ringer’s lactate) at 10 drops per minute:
- If haemorrhage is suspected, increase the infusion rate to 60 drops per minute;
- If the uterus does not contract after oxytocin, give ergometrine 0.2 mg or prostaglandins (Table S-8).
Give a single dose of prophylactic antibiotics after correcting the inverted uterus:
- ampicillin 2 g IV PLUS metronidazole 500 mg IV;
- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.