Fundal Pressure During Labor

Fundal pressure is a simple obstetric technique that doctors, midwives, and nurses frequently utilize during the second phase of labor. The “fundal pressure” technique is performed by manually pushing or applying constant downward pressure with the hands at the top of the woman’s uterus. Although fundal pressure is commonly used in delivery rooms it is a controversial method. There has never been any reliable evidence to show that the technique actually works. Moreover, that the use of fundal pressure in certain situations can actually cause complications and injury to the baby.

The application of manual pressure to speed up vaginal childbirth is a technique that has been around since the 19^th century. The technique was first described in medical texts in the 1870s. It has remained an accepted obstetric practice and is currently used in some fashion in approximately 80% of all vaginal deliveries.

The underlying concept of fundal pressure is simple. The doctor or another delivery room attendant applies pressure to the uppermost part of the mother’s uterus during the second labor stage. The pressure is typically applied by simply pushing and holding down on the mother’s abdomen with 2 hands. Sometimes an inflatable belt is used to maintain the fundal pressure. The belief is that applying gentle fundal pressure accelerates the second stage of labor by helping the mother “bear down” and move the baby into the birth canal for the final stage of delivery.

None of these studies have been able to establish any clear benefit to the use of fundal pressure. Specifically, several studies found no difference in the duration of the second labor stage for deliveries in which fundal pressure was used vs. those in which fundal pressure was not used. Currently the general consensus is that we simply don’t know if fundal pressure actually helps speed up delivery or not.

Research has conclusively linked the use of uterine fundal pressure to at least 3 major delivery complications:

• Perineal Lacerations : a perineal laceration occurs when the skin and soft tissue between the mother’s vagina and anus is torn apart during childbirth. Perineal lacerations come in several degrees of severity. Most are superficial tears that heal on their own with no treatment. The more severe perineal lacerations can be very serious and cause long term consequences for the mother. The use of fundal pressure significantly increases the risk of the more severe (3^rd and 4^th degree) perineal lacerations.
• Uterine Rupture : uterine rupture is when the wall of the uterus actually tears apart at some point during labor and delivery. This is one of the most dangerous complications that can occur during childbirth. Once the uterine wall tears the baby is under very immediate threat of oxygen deprivation and an emergency C-section must be performed immediately. The application of fundal pressure has been linked to an increased rate of uterine rupture.
• Uterine Inversion : acute uterine inversion is a very rare delivery complication that occurs when the mother’s uterus gets turned inside out (partially or completely) after the baby comes out. Uterine inversion can cause maternal death from internal bleeding and shock. Some researchers have linked fundal pressure to an increased risk of this rare complication.

Fundal Pressure and Shoulder Dystocia

Shoulder dystocia is a potentially serious delivery complication which occurs when the baby’s shoulder (or shoulders) becomes stuck behind the mother’s pelvic bone, preventing the baby from entering the birth canal. When shoulder dystocia occurs the baby is left dangerously stuck with its head in the birth canal. Doctors must quickly dislodge the shoulder and deliver the baby to avoid oxygen deprivation.

The application of fundal pressure is sometimes used in combination with other obstetric techniques in response to shoulder dystocia. This can be problematic, however, because the additional downward force from fundal pressure can push the baby’s shoulder even harder against the mother’s pelvis. This type of force can fracture the baby’s clavicle bone or damage the network of nerves at the base of the neck called the brachial plexus. Injuries to the brachial plexus cause a permanent birth injury called Erb’s palsy.

Fundal Pressure – Studies & Research

Asti, Parvin, et al. “The Outcomes of Delivery by Fundal Pressure Maneuver in the Second Stage of Labor.” Interdisciplinary Journal of Acute Care 1.1 (2020): 18-22. (This study looked at whether fundal pressure during the second stage of labor yielded maternal and neonatal complications. The researchers found that fundal pressure maneuvers increased maternal and neonatal complication rates. They concluded that healthcare providers should consider patient circumstances before applying fundal pressure maneuvers.)

Hofmeyr, G. Justus, et al. “Fundal pressure during the second stage of labour.” Cochrane Database of Systematic Reviews 3 (2017). (This study looked at whether fundal pressure facilitated spontaneous vaginal births and prevented prolonged the second stage of labor. It also sought to determine potential adverse effects. The researchers found that there was “insufficient evidence to draw conclusions” on fundal pressure’s benefits and drawbacks. They concluded that additional research should be conducted to determine whether fundal pressure harms babies.)

Pinar, Semra, and Zekiye Karaçam. “Applying fundal pressure in the second stage of labour and its impact on mother and infant health.” Health Care for Women International 39.1 (2018): 110-125. (This study examined the Kristeller maneuver’s (KM) prevalence and impact on maternal health. The researchers found that the technique did not negatively impact maternal satisfaction or maternal and infant health.)

Takmaz, Taha, et al. “The usual suspect: cross-sectional study of fundal pressure at second stage of delivery and the association with pelvic floor damage.” International Urogynecology Journal (2020): 1-8. (This study looked at the association between the Kristeller maneuver and pelvic floor damage in primiparous women. Researchers found that KMs were associated with anterior vaginal wall prolapses and levator ani injuries.)

Youssef, A., et al. “Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion.” Ultrasound in Obstetrics & Gynecology 53.1 (2019): 95-100. (This study looked at the association between the Kristeller maneuver (KM) and levator ani muscle (LAM) injuries. The researchers found that LAM injuries were more prevalent in women who underwent a KM compared to women who did not. They concluded that healthcare providers should consider this association when considering KMs.)