Controversy

The use of fundal pressure during cases of shoulder dystocia, or even during normal deliveries was not uncommon 30 years ago. It made so much intuitive sense to help mom push if her own efforts were not progressing. Often fundal pressure was employed routinely for forceps deliveries. After seeing a few babies manage to get born this way, it was hard for practioners to let go of the feeling that this perfectly sensible measure was helpful.

Eventually evidence came out that fundal pressure during a shoulder dystocia was not actually useful, and contrary to popular belief, harmful. For older physicians it must have been an uncomfortable change of ritual. Some of us nurses had a difficult time putting babies to sleep on their backs after years of putting them down on their stomachs. As with the adoption of "time outs" to prevent wrong site surgery, some physicians were slower to adapt the new change in practice than nurses. Change can be good, SIDS has decreased in the United States since the "back to sleep" campaign, and wrong site surgery has too. Nurses of the fashion forward variety were soon scandalized by physicians who continued to call for "Fundal Pressure" in the light of evidence based research.

The pendullum began to swing away from "Fundal Pressure" so violently that the very phrase sounded ominous to nurses. There may still be some knee jerk reactions from nurses who have decided that all fundal pressure is a bad thing after being innoculated against it by other nurses. Of course nurses talk. The way we usually innocualte eachother against things we think are bad: with horror stories. This is where critical thinking really comes in handy. Who is to say the patient who came in after smoking crack for 2 days would not have abrupted her placenta without the fundal pressure exerted during her delivery?

Appropriate use of Fundal Pressure.

The amount of pressure varies according to the intended purpose. For delivery of a baby's head when the body is stuck, it is generally very hard. Generally, now only employed during a difficult Cesearian birth. The hand should be on the fundus at a 30-40 degree angle to the maternal spine in the direction of the pelvis. Direct downward pressure could cause serious maternal hypotention.

This from a 2006 article, The Effect of Fundal Pressure at Cesarean Section on Maternal Hemodynamics by Kim, T Y.; Ryu, D H.:

Applying pressure on the uterine fundus to hasten passage of the fetus through the hysterotomy during cesarean delivery is generally viewed as harmless, in part because pressure usually is directed caudally for only a brief time.

Fundal pressure under vaginal birth circumstances has been associated with uterine rupture, abruption, and cross perfusion of maternal/fetal blood.

A fundal pressure request from a physician is entirely reasonable under many circumstances. Some practioners use fundal pressure during rupture of membrances to apply the fetal head down against the cervix, in an effort to prevent cord prolapse. A very posterior cervix that is difficult to reach during an internal exam can be facilitated with a hand on the fundus to stabalize a ballotable baby. Of course bimanual exams may be done after delivery to compress the uterus during heavy postpartum bleeding. After vaginal twin delivery of baby "A", "B" may need some exterior guidence, (usually under ultrasound) into a more favorable presentation for delivery. During an amniocentisis or other invasive procedure hands on the uterus may help stabalize the baby's lie.

In the case of vaginal deliveries, both suprapubic pressure and fundal pressure are associated with some degree of maternal/infant injuries or neuropathies, but those associated with fundal pressure are much less benign, and much less defensible in court. If parents perceive that caregivers are conflicted about using it, the legal risks are compounded. This is one reason some L&D units have instituted 'Dystocia Drills', to improve 'team' performance. Everybody has to be on the same page.

Shoulder dystocia is associated most famously with brachial plexus injury and clavicle fracture, in the newborn. For the mother, fourth degree episiotomies, symphisis pubis separation, or coccyx fracture may complicate recovery.

Generally accepted risks are not lawsuit worthy unless negligence can be proven. Getting the rest of the baby's body out in a timely manner, alive, is considered the prudent course of action, as long as care providers have taken the best course of action available to them at the time.

From the Iowa Statewide Perinatal paper, Progeny (pdf):

Fundal pressure should be avoided if shoulder dystocia is identified. If given in this circumstance, the shoulder will be further impacted and increase chances of injury to the baby. In one study, there was a 77 percent injury rate when fundal pressure was used as the only maneuver to relieve shoulder dystocia. Correct procedure is suprapubic pressure directed away from the pubic bone to the left or right side using the palm of your hand and McRobert's Maneuver (hyperflexion of thighs). Other maneuvers are Woods (rotation maneuver), Gaskin (hands and knees position), and Zanvanelli (returning the head to the vagina).