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

The Role of Uterine Fundal Pressure inthe Management of the Second Stage

of Labor: A ReappraisalZaher O. Merhi, MD,* and Awoniyi O. Awonuga, MB, BS†

*PGY3 Resident, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NewYork; 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 oneof the most controversial. The prevalence of its use is unknown. We reviewed the existing literatureto assess whether there is justification for the use of fundal pressure in the contemporary man-agement of the second stage of labor. Only one randomized, controlled study and a few prospec-tive studies, review articles, and case reports have been published. No confirmed benefit of theprocedure has been documented and a few adverse events have been reported in association withits use. Alternative management strategies in the second stage of labor exist and should beconsidered whenever possible. In conclusion, the role of fundal pressure is understudied andremains controversial in the management of the second stage of labor. We believe that cautionshould be exercised using this maneuver until it is proven to be safe and effective.

Target Audience: Obstetricians & Gynecologists, Family PhysiciansLearning 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 stageof labor, state that there is no confirmed benefit of the procedure and there may be some adversematernal/fetal effects, and explain that there are alternative strategies for management of the secondstage of labor.

Over the last generation, a variety of clinical op-tions used in the management of the second stage oflabor have undergone reappraisal. Several of thesesuch as mid and high forceps, Duhrssen incisions,and total breech extraction are rarely if ever used anylonger. Among the remaining maneuvers that areoccasionally used in the second stage of labor, uter-ine fundal pressure is one of the most controversial.

Its use dates back to antiquity when no alternativesexisted for mothers who needed help in the secondstage of labor (1). In more recent times, the readyavailability of forceps/vacuum and the demonstratedsafety of cesarean operation have made the use offundal pressure less common in the management ofthe second stage of labor. However, some obstetri-cians continue to apply uterine fundal pressure to aiddelivery in the terminal phase of the second stage oflabor.

The purpose of this article is to review the litera-ture with a view to ascertaining whether the use offundal pressure should have a role in the contempo-rary management of the second stage of labor. Weperformed a literature review for which we used

The authors have disclosed that they have no financial relation-ships with or interests in any commercial companies pertaining tothis educational activity.

Wolters Kluwer Health has identified and resolved all facultyconflicts of interest regarding this educational activity.

Reprint requests to: Zaher O. Merhi, MD, Maimonides MedicalCenter, 967 48th Street, Brooklyn, NY 11219. E-mail: zom00@hotmail.com.

CME REVIEWARTICLEVolume 60, Number 9OBSTETRICAL AND GYNECOLOGICAL SURVEY

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search engines, including PubMed, the Cochrane Da-tabase, and MEDLINE using the terms “fundal pres-sure” and “second stage of labor.” For the purpose ofthis article, we did not include the use of uterinefundal pressure to aid in the artificial rupture ofmembranes or in the placement of an internal fetalscalp electrode when the presenting part is high in thepelvis. In addition, it is not our purpose to address itsuse during cesarean section or during transvaginalsonogram for cervical length evaluation.

Our literature review revealed that relatively lim-ited data exist on the subject of the safety and/orefficacy of fundal pressure. Also, the American Col-lege of Obstetricians and Gynecologists (ACOG) andthe Royal College of Obstetricians and Gynecolo-gists (RCOG) have not expressed opinions on thissubject that would help to guide their members inunderstanding the proper role of the technique; andthere are no publications that document the preva-lence of the use of fundal pressure in the second stageof labor because documentation of such technique isoften missing from medical records. Indeed, the onlyrandomized trial that addressed this issue used aninflatable obstetric belt in nulliparous women with anepidural to increase intraabdominal pressure duringbearing down efforts in the second stage of labor (2).In that study, 500 nulliparous women with vertexsingleton pregnancies at term were randomized in thesecond stage of labor into either a belt group or acontrol group. Measurement of the intrauterine pres-sure was not performed. One hundred eleven of the260 women in the belt group (42.7%) had vaginaldeliveries versus 94 of the 240 women in the controlgroup (39.2%). There was no significant differencein the length of the second stage, fetal outcomes, oroperative delivery rates between groups. Althoughthe authors were unable to demonstrate a clinicallysignificant decrease in operative delivery rates, theuse of an inflatable belt is not, a priori, a reasonablesurrogate for fundal pressure as used in the clinicalsetting.

Buhimschi et al (3), in a prospective study of 40women, found that fundal pressure during expulsionunder controlled conditions significantly increasedintrauterine pressure in some but not all women.Forty women with vertex singleton pregnancies inactive labor had intrauterine pressure measured by asensor tip catheter during the performance of fundalpressure (applied at a 30–40° angle to the spine in thedirection of the pelvis through a semiinflated dispos-able cuff with a constant pressure between 80 and 90mm Hg) with or without a Valsalva maneuver. The

fundal pressure and the Valsalva were applied eitherconcomitantly or independently. It was found thatfundal pressure together with the Valsalva maneuverapplied during the uterine contraction increased theintrauterine pressure by 86% over baseline versusonly a 28% increase over baseline when fundal pres-sure was applied alone during contraction. However,this finding of increased intrauterine pressure was notcorrelated with delivery outcome or adverse neonataloutcomes.

Although these studies did not demonstrate riskassociated with the use of fundal pressure, it is wellknown that the mechanical forces (ie, pushing in thesecond stage) of labor can increase intracranial pres-sure and that sufficient pressure can cause fetal heartrate changes. A study by O’Brien et al (4) showedthat both the level and the duration of increasedintracranial pressure influenced the fetal heart rateand cerebral blood flow in the goat model. Similarly,it has been shown that in humans, once the pressureoutside and inside the skull exceeds 50 mm Hg, thereis a dramatic decrease in heart rate (5). With severeincreases in head compression such as that whichmight be seen after application of fundal pressure,cerebral perfusion decreases and brain edema maysupervene, resulting in even greater increase in intra-cranial pressure (5). Thereafter, what initially mayhave been a simple reflex (vagal) bradycardia maybecome prolonged as a result of increased intracra-nial pressure and fetal hypoxia. It is therefore plau-sible, as some authors have speculated, (6), that anincrease in intrauterine pressure and a concomitantincrease in fetal intracranial pressure caused by me-chanical forces of labor, whether spontaneous (ie,uterine tetany) or iatrogenic (ie, by fundal pressure orforceps), can cause a decrease in cerebral blood flowthat might be related to a subsequent increase incerebral handicap in infants. However, that possibil-ity remains speculative.

Other studies have suggested that the use of fundalpressure can also cause harm. Cosner (7), in a studyof 34 deliveries, reported a longer second stage oflabor and a higher incidence of third- and fourth-degree perineal lacerations in women who had fundalpressure compared with those who delivered sponta-neously. However, that study may have been biasedby confounding because it was not randomized, ie,the reason for the poor outcome in the fundal pres-sure group may have been related to a greater pro-portion of patients with dystocia being in that group.

An additional issue to be considered is uterinerupture. Pan et al (8) reported a case of uterine

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rupture in a primigravid woman with an unscarreduterus after the application of fundal pressure. Aprospective study in Niger consisting of 63 pa-tients with uterine rupture, among whom half hada uterine scar, revealed that fundal pressure, alongwith forceps and oxytocin use, was an iatrogenicfactor associated with uterine rupture (9). How-ever, in that study, there was no control group so itis unknown whether fundal pressure was an inde-pendent factor in causing uterine rupture. Simpsonand Knox (10), in a review, reported a variety ofmorbid outcomes, both maternal (abdominal bruisingand pain, uterine inversion, hypotension, respiratorydistress, liver rupture, and fractured ribs) and fetal(neurologic and orthopedic, nonreassuring fetal hearttracing secondary to head compression, fetal hypox-emia and asphyxia, and intracranial hemorrhages),that have occurred in association with fundalpressure.

In certain circumstances, the risks associated withfundal pressure may be even greater. For example,Gross et al (11) strongly discouraged the use offundal pressure in instances of fetal macrosomia andshoulder dystocia because it could exacerbate theentrapment of the anterior shoulder of the baby andconsequently increase the risk of orthopedic and neu-rologic injuries, particularly the risk of stretching thebrachial plexus. In their study that involved 24 casesof shoulder dystocia, fundal pressure was associatedwith orthopedic and neurologic complications in77% (ie, in 18 of the 24 cases). Finally, the effect offundal pressure performed in the second stage oflabor on the outcome of the third stage of labor hasnot been fully assessed. One of the rarer, but poten-tially more serious, complications in the third stageof labor is uterine inversion. Several authors havenoted an increase in incidence of this complicationwhen fundal pressure had been applied in the secondstage of labor (12).

The possible association of fundal pressure with allthe complications noted here suggests the need toconsider alternative management strategies in thesecond stage of labor. One alternative would be toallow more time for passive descent in the absence ofnonreassuring fetal status, especially in situations inwhich epidural analgesia has been used. Becausepublished data have demonstrated that epidural an-esthesia may prolong the second stage of labor, itwould be reasonable to consider the use of analgesicrather than anesthetic doses of epidural as a potentialalternative to fundal pressure (10). The role of epi-siotomy is controversial. Although it might help inthe primigravida with a rigid perineum, it has been

shown to be associated with an increase in morbidity.For instance, in a prospective cohort study of womenwho were followed for 3 months after vaginal deliv-ery, the incidence of dyspareunia and perineal painwas significantly higher (7.9%) among 254 primip-arous women who had mediolateral episiotomy thanit was among 265 women with no episiotomy butwith first- or second-degree lacerations (3.4% P �.026) (13). In that same study, the case group hadalso lower pelvic floor muscle strength measured bydigital testing and vaginal manometry. Additionally,a systematic review revealed that outcomes of rou-tine episiotomy do not support maternal benefits (nobenefit for prevention of fecal and urinary inconti-nence or pelvic floor relaxation) (14). Indeed, in thatreview, routine episiotomy increased the severity ofperineal lacerations, produced more perineal pain,and caused more discomfort with intercourse in theperiod after pregnancy. The provider can also en-courage more effective pushing in cases of maternalexhaustion, although supporting evidence for the ef-ficacy of that approach is sparse. Lastly, forceps or avacuum may be used, particularly when fetal statusdictates immediate delivery. Forceps and a vacuumalso can be used in cases of maternal exhaustion.Unfortunately, there are no studies comparing fundalpressure with these alternatives.

It is possible that some physicians who want toavoid performing operative vaginal deliveries may attimes use fundal pressure instead. That choice mayrelate to clinicians’ concerns that instrumental vagi-nal deliveries may be associated with an increase inboth maternal and neonatal risks. Additionally, therecould be concern about the potential litigation thatmay be associated with the use of instrumental de-livery. However, given the absence of data demon-strating the safety of fundal pressure, in addition todata in review articles and case reports (limited asthey may be), suggesting that both the mother and thebaby can potentially sustain damage with the appli-cation of uterine fundal pressure, there is no guaran-tee its use will protect the obstetrician from lawsuit.A related question is whether the use of fundal pres-sure should be discussed with patients before it isapplied. Given case reports of adverse events asso-ciated with its use and the lack of guidance fromacademic organizations, it may be appropriate toinform patients in the same manner that one woulddiscuss other interventions in the setting of labor. Acountervailing argument might be that fundal pres-sure is a simple maneuver that patients would over-whelmingly accept. However, researchers in parts of

Role of Uterine Fundal Pressure Y CME Review Article 601

the world where other options are not readily avail-able have reported that mothers in some focus groupsdescribe fundal pressure as a harmful traditionalpractice (15).

Perhaps as a reflection of the controversial natureof fundal pressure, obstetricians often do not docu-ment their performance of this procedure. In 1990, anationwide study revealed that physicians in 62 of 74hospitals used fundal pressure during the secondstage of labor (16). Of those who used fundal pres-sure, only 11% documented it in the patient’s chart.Again, fear of litigation may have contributed to thefailure of physicians to document. This fear involvesnurses as well as doctors, the former group havinghad lawsuits brought against them as well. For in-stance, in a case in which fundal pressure was appliedand the baby had complications, including seizures,hemiparesis, and cerebral palsy, a suit was broughtagainst the nurse who applied the fundal pressure,although she had been instructed to do so by aphysician (17). Although the case against the defen-dants was not sustained (there was insufficient proofof a correlation between the fundal pressure exertedby the nurse and the permanent brain damage to thenewborn), providers’ apprehensions persist. Addi-tionally, there are now several web sites on theInternet on this subject where patients can obtaininformation. They contain pictures of injured babies,detailed graphics and videos that seem to suggest thatexcessive fundal pressure can cause harm to babies atdelivery (10). Therefore, in the current litigious cli-mate, physicians may be concerned that even if fun-dal pressure does not increase biologic risks, its usein cases with adverse outcomes would be perceivedas causative, not coincidental.

In the absence of definitive data that can provideguidance regarding the safety and role of fundal pres-sure, it is reasonable to consider whether its use shouldbe discouraged. Currently, although the extant literaturedoes not demonstrate any benefits and hints at poten-tially serious risks, surveys suggest that it is still com-monly used. If its use is going to continue in theabsence of reassuring studies, it seems appropriate tosuggest that clinicians follow a few modest guidelines.

First, the provider should consider alternatives be-fore applying fundal pressure. If there is no urgencyattendant on the delivery, allowing more time forspontaneous descent will often suffice. Second, somelessons can be drawn from experiences with opera-tive vaginal deliveries. The second stage of labor canbe divided into the descent and expulsive phases. Justas instrumental deliveries should only be performedwhen the head has reached the pelvic outlet, uterine

fundal pressure to affect delivery before that stageshould be avoided. Third, those involved should betrained. Most delivery room nurses and residentslearn fundal pressure application at the bedsidewhen, under great stress, they are initially called onto apply it. If fundal pressure is to continue as asecond-stage option, it is essential that formal in-structions in its use be given to nurses, medicalstudents, and junior residents (the groups often calledon to apply it). It has been advised by some authorsthat fundal pressure be applied with a steady, gentlepressure with one open hand on the fundus of theuterus at a 30° to 40° angle to the maternal spine inthe direction of the cervix. Application should beapplied concomitantly with contractions and duringactive bearing-down effort. During this time, con-tractions of the parturient’s abdominal muscle can actas a counterpressure that may act to prevent damageto the uterus and other maternal organs (10). Thesame authors have warned that it is very important toavoid perpendicular force to the spine when fundalpressure is applied because it can cause compressionof maternal vena cava and hypotension. However,even if providers rigorously adhere to these sugges-tions, the lack of evidence demonstrating their safetyshould give obstetricians pause.

Finally, if the provider decides that there is stilla role for this technique, it is incumbent on them todocument its use in the delivery note, including theindication, number, and duration of applicationsand maternal–fetal response. In that way, it will bepossible to perform analyses in the future that mayhelp to delineate the risks and benefits of thismaneuver.

In conclusion, the role of fundal pressure is under-studied and, not coincidentally, remains controversialin management of the second stage of labor. Uncer-tainty about its role can contribute to disagreementsbetween nurses and doctors about the appropriate-ness of its use. Alternatives to fundal pressure existand should be used when possible. Fundal pressure israrely documented in medical records and almostnever in some hospitals because of medicolegal con-cerns. That failure contributes to the difficulty thatexists in quantifying any risk that fundal pressuremay pose for the mother and the baby. Methodsdescribed in the literature for the performance havenot been validated in any trial. With almost no evi-dence of efficacy and until appropriate researchproves it is safe, fundal pressure should be used withcaution, if at all, in clinical practice.

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Acknowledgment

The authors thank Dr. Howard Minkoff for hishelpful comments on an earlier version of the manu-script.

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