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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.
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.
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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
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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
Acknowledgment
The authors thank Dr. Howard Minkoff for his
helpful comments on an earlier version of the manuscript.
REFERENCES
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1280.
3. Buhimschi CS, Buhimschi IA, Malinow AM, et al. The effect of
fundal pressure manoeuvre on intrauterine pressure in the
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Am J Obstet Gynecol 1970;106:407411.
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