I would dearly love to hear responses and opinions regarding the use of
fundal pressure during the second stage of labour.
To define what I mean by fundal pressure: It is pressure applied to the
fundus of the uterus by the open palm of the hand in second stage of
labour, in order to assist the delivery of the infant. Some of the
versions I have seen require that the women is lying flat so that the
angle of the pelvis is correct.
Fundal pressure appears to be acceptable or common in certain countries.
Have seen its use in Indonesia. Women have reported to me that it was
used on them in previous births in Germany and Japan.
A review of the literature revealed the following: There appears to be
very little research done on either neonatal or maternal outcomes
relating to the use of fundal pressure. In the USA 2 studies found gross
under-reporting in the women's notes regarding the fact that fundal
pressure had been applied. There appeared to be a fairly high incidence
of use. This was by both obstetricians, nurses and midwives. It appears
to be a fairly common phenomena in certain birth settings there.
A pilot study by Costner (journal of nurse-midwifery) revealed no
adverse neonatal or maternal outcomes, in fact apgar scores in the two
groups were similar. What she did find was that the fundal pressure
group had a mean length of second stage of labour twice that of the
control group. Reasons cited for the use of fundal pressure in this
study were, foetal distress, maternal exhaustion and prolonged labour.
A Swedish study warned of the danger of embolism (pulmonary ?). If I
remember correctly that actually documented cases where this had
occurred.
Adverse outcomes extrapolated regarding the use of fundal pressure
include: uterine inversion and haemorrhage. Increase in perineal trauma.
Neonatal outcomes: concerns have been expressed regarding neonatal
adrenal damage and haemorrhage, liver damage, impacted shoulders with
the use of this manoeuvre.
This procedure has been justified a less harmful alternative to vacuum
extraction by one obstetrician that I have personally discussed it with.
I have also witnessed one case where the head appeared to asynclitic
this baby needed resuscitation and developed what appeared to be a TTN
on day 3. I also think I have seen more jaundice in the babies that have
had this procedure used on them - not able to substantiate it. Maternal:
one or two of the mothers complained of a sore diaphragm for a few days
afterwards. Equally some of the women did not seem to be distressed by
the use of this procedure on them and did not complain of any
pain/discomfort.
Elizabeth Davis in her book "Hearts and Hands" advocates for the use of
fundal pressure if the second stage is prolonged.
This is obviously a very controversial procedure and I have to admit
bias after seeing it in action. I would dearly love to debate this one
and would be happy to hear opinions from lots of folk. My impression is
that in certain countries this would just not be considered acceptable
practice and could even lead to disciplinary action.
Comments please.
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