A junior doctor applies cord traction immediately after the baby is born, before any sign of placental separation and while the uterus is relaxed. The fundus suddenly descends and the patient collapses. What is the single most likely complication?

Answer: B. Acute uterine inversion

Acute uterine inversion

Controlled cord traction must only be applied after signs of placental separation and with the uterus contracted, while guarding the uterus suprapubically.

Mechanism of inversion

• Pulling the cord before separation while the uterus is relaxed can drag the fundus through the cervix.
• This produces acute uterine inversion (partial or complete), often with profound shock (partly neurogenic) out of proportion to blood loss.

Recognition and response

• The fundus is no longer palpable abdominally, or a mass is felt at or beyond the cervix.
• Immediate management is prompt replacement of the uterus, resuscitation, and uterotonics only after replacement.

This is why the sequence in active management is uterotonic, await separation, then controlled cord traction with the uterus guarded.