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Volume 60, Number 9

OBSTETRICAL AND GYNECOLOGICAL SURVEY


Copyright 2005
by Lippincott Williams & Wilkins

CME REVIEWARTICLE

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CHIEF EDITORS NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA category 1 credit hours can be earned in 2005. Instructions for how CME credits can be earned appear on
the last page of the Table of Contents.

The Role of Uterine Fundal Pressure in


the Management of the Second Stage
of Labor: A Reappraisal
Zaher O. Merhi, MD,* and Awoniyi O. Awonuga, MB, BS
*PGY3 Resident, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New
York; and Attending Physician, Department of Obstetrics and Gynecology, Maimonides Medical Center,
Brooklyn, New York
Among the maneuvers that are used in the second stage of labor, uterine fundal pressure is one
of the most controversial. The prevalence of its use is unknown. We reviewed the existing literature
to assess whether there is justification for the use of fundal pressure in the contemporary management of the second stage of labor. Only one randomized, controlled study and a few prospective studies, review articles, and case reports have been published. No confirmed benefit of the
procedure has been documented and a few adverse events have been reported in association with
its use. Alternative management strategies in the second stage of labor exist and should be
considered whenever possible. In conclusion, the role of fundal pressure is understudied and
remains controversial in the management of the second stage of labor. We believe that caution
should be exercised using this maneuver until it is proven to be safe and effective.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader should be able to recall that there is
a scarcity of literature related to the efficacy and safety of using fundal pressure during the second stage
of labor, state that there is no confirmed benefit of the procedure and there may be some adverse
maternal/fetal effects, and explain that there are alternative strategies for management of the second
stage of labor.

Over the last generation, a variety of clinical options used in the management of the second stage of
labor have undergone reappraisal. Several of these
such as mid and high forceps, Duhrssen incisions,
and total breech extraction are rarely if ever used any
longer. Among the remaining maneuvers that are
occasionally used in the second stage of labor, uterine fundal pressure is one of the most controversial.
The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to
this educational activity.
Wolters Kluwer Health has identified and resolved all faculty
conflicts of interest regarding this educational activity.
Reprint requests to: Zaher O. Merhi, MD, Maimonides Medical
Center, 967 48th Street, Brooklyn, NY 11219. E-mail: zom00@
hotmail.com.

Its use dates back to antiquity when no alternatives


existed for mothers who needed help in the second
stage of labor (1). In more recent times, the ready
availability of forceps/vacuum and the demonstrated
safety of cesarean operation have made the use of
fundal pressure less common in the management of
the second stage of labor. However, some obstetricians continue to apply uterine fundal pressure to aid
delivery in the terminal phase of the second stage of
labor.
The purpose of this article is to review the literature with a view to ascertaining whether the use of
fundal pressure should have a role in the contemporary management of the second stage of labor. We
performed a literature review for which we used

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search engines, including PubMed, the Cochrane Database, and MEDLINE using the terms fundal pressure and second stage of labor. For the purpose of
this article, we did not include the use of uterine
fundal pressure to aid in the artificial rupture of
membranes or in the placement of an internal fetal
scalp electrode when the presenting part is high in the
pelvis. In addition, it is not our purpose to address its
use during cesarean section or during transvaginal
sonogram for cervical length evaluation.
Our literature review revealed that relatively limited data exist on the subject of the safety and/or
efficacy of fundal pressure. Also, the American College of Obstetricians and Gynecologists (ACOG) and
the Royal College of Obstetricians and Gynecologists (RCOG) have not expressed opinions on this
subject that would help to guide their members in
understanding the proper role of the technique; and
there are no publications that document the prevalence of the use of fundal pressure in the second stage
of labor because documentation of such technique is
often missing from medical records. Indeed, the only
randomized trial that addressed this issue used an
inflatable obstetric belt in nulliparous women with an
epidural to increase intraabdominal pressure during
bearing down efforts in the second stage of labor (2).
In that study, 500 nulliparous women with vertex
singleton pregnancies at term were randomized in the
second stage of labor into either a belt group or a
control group. Measurement of the intrauterine pressure was not performed. One hundred eleven of the
260 women in the belt group (42.7%) had vaginal
deliveries versus 94 of the 240 women in the control
group (39.2%). There was no significant difference
in the length of the second stage, fetal outcomes, or
operative delivery rates between groups. Although
the authors were unable to demonstrate a clinically
significant decrease in operative delivery rates, the
use of an inflatable belt is not, a priori, a reasonable
surrogate for fundal pressure as used in the clinical
setting.
Buhimschi et al (3), in a prospective study of 40
women, found that fundal pressure during expulsion
under controlled conditions significantly increased
intrauterine pressure in some but not all women.
Forty women with vertex singleton pregnancies in
active labor had intrauterine pressure measured by a
sensor tip catheter during the performance of fundal
pressure (applied at a 3040 angle to the spine in the
direction of the pelvis through a semiinflated disposable cuff with a constant pressure between 80 and 90
mm Hg) with or without a Valsalva maneuver. The

fundal pressure and the Valsalva were applied either


concomitantly or independently. It was found that
fundal pressure together with the Valsalva maneuver
applied during the uterine contraction increased the
intrauterine pressure by 86% over baseline versus
only a 28% increase over baseline when fundal pressure was applied alone during contraction. However,
this finding of increased intrauterine pressure was not
correlated with delivery outcome or adverse neonatal
outcomes.
Although these studies did not demonstrate risk
associated with the use of fundal pressure, it is well
known that the mechanical forces (ie, pushing in the
second stage) of labor can increase intracranial pressure and that sufficient pressure can cause fetal heart
rate changes. A study by OBrien et al (4) showed
that both the level and the duration of increased
intracranial pressure influenced the fetal heart rate
and cerebral blood flow in the goat model. Similarly,
it has been shown that in humans, once the pressure
outside and inside the skull exceeds 50 mm Hg, there
is a dramatic decrease in heart rate (5). With severe
increases in head compression such as that which
might be seen after application of fundal pressure,
cerebral perfusion decreases and brain edema may
supervene, resulting in even greater increase in intracranial pressure (5). Thereafter, what initially may
have been a simple reflex (vagal) bradycardia may
become prolonged as a result of increased intracranial pressure and fetal hypoxia. It is therefore plausible, as some authors have speculated, (6), that an
increase in intrauterine pressure and a concomitant
increase in fetal intracranial pressure caused by mechanical forces of labor, whether spontaneous (ie,
uterine tetany) or iatrogenic (ie, by fundal pressure or
forceps), can cause a decrease in cerebral blood flow
that might be related to a subsequent increase in
cerebral handicap in infants. However, that possibility remains speculative.
Other studies have suggested that the use of fundal
pressure can also cause harm. Cosner (7), in a study
of 34 deliveries, reported a longer second stage of
labor and a higher incidence of third- and fourthdegree perineal lacerations in women who had fundal
pressure compared with those who delivered spontaneously. However, that study may have been biased
by confounding because it was not randomized, ie,
the reason for the poor outcome in the fundal pressure group may have been related to a greater proportion of patients with dystocia being in that group.
An additional issue to be considered is uterine
rupture. Pan et al (8) reported a case of uterine

Role of Uterine Fundal Pressure Y CME Review Article

rupture in a primigravid woman with an unscarred


uterus after the application of fundal pressure. A
prospective study in Niger consisting of 63 patients with uterine rupture, among whom half had
a uterine scar, revealed that fundal pressure, along
with forceps and oxytocin use, was an iatrogenic
factor associated with uterine rupture (9). However, in that study, there was no control group so it
is unknown whether fundal pressure was an independent factor in causing uterine rupture. Simpson
and Knox (10), in a review, reported a variety of
morbid outcomes, both maternal (abdominal bruising
and pain, uterine inversion, hypotension, respiratory
distress, liver rupture, and fractured ribs) and fetal
(neurologic and orthopedic, nonreassuring fetal heart
tracing secondary to head compression, fetal hypoxemia and asphyxia, and intracranial hemorrhages),
that have occurred in association with fundal
pressure.
In certain circumstances, the risks associated with
fundal pressure may be even greater. For example,
Gross et al (11) strongly discouraged the use of
fundal pressure in instances of fetal macrosomia and
shoulder dystocia because it could exacerbate the
entrapment of the anterior shoulder of the baby and
consequently increase the risk of orthopedic and neurologic injuries, particularly the risk of stretching the
brachial plexus. In their study that involved 24 cases
of shoulder dystocia, fundal pressure was associated
with orthopedic and neurologic complications in
77% (ie, in 18 of the 24 cases). Finally, the effect of
fundal pressure performed in the second stage of
labor on the outcome of the third stage of labor has
not been fully assessed. One of the rarer, but potentially more serious, complications in the third stage
of labor is uterine inversion. Several authors have
noted an increase in incidence of this complication
when fundal pressure had been applied in the second
stage of labor (12).
The possible association of fundal pressure with all
the complications noted here suggests the need to
consider alternative management strategies in the
second stage of labor. One alternative would be to
allow more time for passive descent in the absence of
nonreassuring fetal status, especially in situations in
which epidural analgesia has been used. Because
published data have demonstrated that epidural anesthesia may prolong the second stage of labor, it
would be reasonable to consider the use of analgesic
rather than anesthetic doses of epidural as a potential
alternative to fundal pressure (10). The role of episiotomy is controversial. Although it might help in
the primigravida with a rigid perineum, it has been

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shown to be associated with an increase in morbidity.


For instance, in a prospective cohort study of women
who were followed for 3 months after vaginal delivery, the incidence of dyspareunia and perineal pain
was significantly higher (7.9%) among 254 primiparous women who had mediolateral episiotomy than
it was among 265 women with no episiotomy but
with first- or second-degree lacerations (3.4% P
.026) (13). In that same study, the case group had
also lower pelvic floor muscle strength measured by
digital testing and vaginal manometry. Additionally,
a systematic review revealed that outcomes of routine episiotomy do not support maternal benefits (no
benefit for prevention of fecal and urinary incontinence or pelvic floor relaxation) (14). Indeed, in that
review, routine episiotomy increased the severity of
perineal lacerations, produced more perineal pain,
and caused more discomfort with intercourse in the
period after pregnancy. The provider can also encourage more effective pushing in cases of maternal
exhaustion, although supporting evidence for the efficacy of that approach is sparse. Lastly, forceps or a
vacuum may be used, particularly when fetal status
dictates immediate delivery. Forceps and a vacuum
also can be used in cases of maternal exhaustion.
Unfortunately, there are no studies comparing fundal
pressure with these alternatives.
It is possible that some physicians who want to
avoid performing operative vaginal deliveries may at
times use fundal pressure instead. That choice may
relate to clinicians concerns that instrumental vaginal deliveries may be associated with an increase in
both maternal and neonatal risks. Additionally, there
could be concern about the potential litigation that
may be associated with the use of instrumental delivery. However, given the absence of data demonstrating the safety of fundal pressure, in addition to
data in review articles and case reports (limited as
they may be), suggesting that both the mother and the
baby can potentially sustain damage with the application of uterine fundal pressure, there is no guarantee its use will protect the obstetrician from lawsuit.
A related question is whether the use of fundal pressure should be discussed with patients before it is
applied. Given case reports of adverse events associated with its use and the lack of guidance from
academic organizations, it may be appropriate to
inform patients in the same manner that one would
discuss other interventions in the setting of labor. A
countervailing argument might be that fundal pressure is a simple maneuver that patients would overwhelmingly accept. However, researchers in parts of

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the world where other options are not readily available have reported that mothers in some focus groups
describe fundal pressure as a harmful traditional
practice (15).
Perhaps as a reflection of the controversial nature
of fundal pressure, obstetricians often do not document their performance of this procedure. In 1990, a
nationwide study revealed that physicians in 62 of 74
hospitals used fundal pressure during the second
stage of labor (16). Of those who used fundal pressure, only 11% documented it in the patients chart.
Again, fear of litigation may have contributed to the
failure of physicians to document. This fear involves
nurses as well as doctors, the former group having
had lawsuits brought against them as well. For instance, in a case in which fundal pressure was applied
and the baby had complications, including seizures,
hemiparesis, and cerebral palsy, a suit was brought
against the nurse who applied the fundal pressure,
although she had been instructed to do so by a
physician (17). Although the case against the defendants was not sustained (there was insufficient proof
of a correlation between the fundal pressure exerted
by the nurse and the permanent brain damage to the
newborn), providers apprehensions persist. Additionally, there are now several web sites on the
Internet on this subject where patients can obtain
information. They contain pictures of injured babies,
detailed graphics and videos that seem to suggest that
excessive fundal pressure can cause harm to babies at
delivery (10). Therefore, in the current litigious climate, physicians may be concerned that even if fundal pressure does not increase biologic risks, its use
in cases with adverse outcomes would be perceived
as causative, not coincidental.
In the absence of definitive data that can provide
guidance regarding the safety and role of fundal pressure, it is reasonable to consider whether its use should
be discouraged. Currently, although the extant literature
does not demonstrate any benefits and hints at potentially serious risks, surveys suggest that it is still commonly used. If its use is going to continue in the
absence of reassuring studies, it seems appropriate to
suggest that clinicians follow a few modest guidelines.
First, the provider should consider alternatives before applying fundal pressure. If there is no urgency
attendant on the delivery, allowing more time for
spontaneous descent will often suffice. Second, some
lessons can be drawn from experiences with operative vaginal deliveries. The second stage of labor can
be divided into the descent and expulsive phases. Just
as instrumental deliveries should only be performed
when the head has reached the pelvic outlet, uterine

fundal pressure to affect delivery before that stage


should be avoided. Third, those involved should be
trained. Most delivery room nurses and residents
learn fundal pressure application at the bedside
when, under great stress, they are initially called on
to apply it. If fundal pressure is to continue as a
second-stage option, it is essential that formal instructions in its use be given to nurses, medical
students, and junior residents (the groups often called
on to apply it). It has been advised by some authors
that fundal pressure be applied with a steady, gentle
pressure with one open hand on the fundus of the
uterus at a 30 to 40 angle to the maternal spine in
the direction of the cervix. Application should be
applied concomitantly with contractions and during
active bearing-down effort. During this time, contractions of the parturients abdominal muscle can act
as a counterpressure that may act to prevent damage
to the uterus and other maternal organs (10). The
same authors have warned that it is very important to
avoid perpendicular force to the spine when fundal
pressure is applied because it can cause compression
of maternal vena cava and hypotension. However,
even if providers rigorously adhere to these suggestions, the lack of evidence demonstrating their safety
should give obstetricians pause.
Finally, if the provider decides that there is still
a role for this technique, it is incumbent on them to
document its use in the delivery note, including the
indication, number, and duration of applications
and maternalfetal response. In that way, it will be
possible to perform analyses in the future that may
help to delineate the risks and benefits of this
maneuver.
In conclusion, the role of fundal pressure is understudied and, not coincidentally, remains controversial
in management of the second stage of labor. Uncertainty about its role can contribute to disagreements
between nurses and doctors about the appropriateness of its use. Alternatives to fundal pressure exist
and should be used when possible. Fundal pressure is
rarely documented in medical records and almost
never in some hospitals because of medicolegal concerns. That failure contributes to the difficulty that
exists in quantifying any risk that fundal pressure
may pose for the mother and the baby. Methods
described in the literature for the performance have
not been validated in any trial. With almost no evidence of efficacy and until appropriate research
proves it is safe, fundal pressure should be used with
caution, if at all, in clinical practice.

Role of Uterine Fundal Pressure Y CME Review Article

Acknowledgment
The authors thank Dr. Howard Minkoff for his
helpful comments on an earlier version of the manuscript.
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