When Push Comes to Shove

According to Listening to Mothers II, a survey of U.S. women giving birth in 2005, 17% of women having vaginal birth reported a “health professional pressing down on her belly to help push the baby out” (Declercq 2006, p. 35). This is called fundal pressure, and 17% is fairly common, so I decided to look at its safety and effectiveness in the chapter I’m working on now for the new edition of Obstetric Myths Versus Research Realities. Here’s what I found out:

Fundal pressure can harm mothers. Three studies concluded that fundal pressure increased likelihood of anal sphincter injury. A small study comparing 34 women who had fundal pressure with 34 similar women who didn’t found that fundal pressure was a disaster for the anal sphincter when combined with midline episiotomy. Ten of 16 women—a whopping 63%—who had fundal pressure and episiotomy had an anal sphincter tear compared with only 1 woman of the 16—6%—who had episiotomy and no fundal pressure. A larger study of 845 women reported that fundal pressure increased the risk of anal sphincter injury 4.6-fold after adjusting for correlating factors. Rates in the overall population were 6% while rates with no fundal pressure were 3%, and rates with fundal pressure were 21%. A very large study of 238,500 women having spontaneous vaginal birth and 46,300 women having instrumental vaginal delivery found much smaller differences, but the addition of fundal pressure increased risk of anal sphincter injury with spontaneous birth (2.1% vs. 1.7%) and forceps delivery (5.2% vs. 4.7%), although, not, oddly enough, with vacuum extraction. Finally, a study looked at factors associated with painful intercourse 12 to 18 months after delivery. Investigators excluded women who had had anal sphincter tears. Even so, fundal pressure popped up as a problem. Among women experiencing painful intercourse, 35% had had fundal pressure compared with 13% of women not experiencing painful intercourse.

But we’re not done. Fundal pressure can harm babies too. A study of 13,700 vacuum extractions reported more brachial plexus injuries (a cluster of nerves serving the shoulder and arm) in babies when fundal pressure was used—2% versus 1%. Study authors theorized that fundal pressure may jam (the word they used was “impact”) the baby’s shoulder behind the pubic bone. So much for safety.

Still, every intervention has potential harms. The question is: “Does fundal pressure do sufficient good to counterbalance those harms?” Despite its fairly common use, until this year, we had no evidence that it did. Now we do, and it doesn’t. In a randomized controlled trial (women assigned by chance to one form of treatment or the other), investigators allocated healthy women with full-term, head-down babies and no epidural analgesia or oxytocin (Pitocin or “Pit”) infusion to have fundal pressure or not when they reached full dilation and felt an urge to push. (RCTs produce the strongest evidence because random assignment eliminates many sources of bias.) Second-stage duration rates were similar in the group overall as well as among first-time mothers and among women with prior births. Ominously, umbilical cord oxygen levels at birth were lower in the fundal pressure group and carbon dioxide levels were higher. All newborns were in good condition at birth, but these were healthy pregnancies, and the same might not be true for babies already having some difficulty. So much for efficacy.

I could speculate on why the practice has persisted and continues to persist in the absence of any evidence to support it—in fact, I will in the book—but the take-home pay here is if progress is slow in second stage, women would be much better off trying an upright position, or better yet, preventing the slow progress by staying off her back in the first place and choosing a provider who practices patience rather than imposing time limits on second stage. Most women can get upright even with an epidural and confined to bed. Modern epidurals can relieve pain while still leaving sufficient feeling and muscle strength in the legs, for example, to rest on hands and knees between contractions and push back onto heels during contractions, or to kneel upright using a stack of pillows or a stability ball (A.K.A. “birth ball”) for support, or to sit between contractions and use the help of labor companions or a squatting bar to pull into a squat during contractions. Women with weak contractions would also be better off using breast stimulation or having I.V. oxytocin to bring strength up to par before resorting to more aggressive means of getting the baby born. And if push does come to pull, instrumental vaginal delivery isn’t entirely harmless, but at least it’s effective. Fundal pressure is neither. The wise woman whose care provider wants to press on the top of her belly either alone or in conjunction with instrumental delivery, will, in the words of a famous campaign, “just say, ‘No.’”’

Click on the extended post to see the references.

Reference List

Api, O., Balcin, M. E., Ugurel, V., Api, M., Turan, C., & Unal, O. (2009). The effect of uterine fundal pressure on the duration of the second stage of labor: A randomized controlled trial. Acta Obstet Gynecol Scand, 88(3), 320-324.

Cosner, K. R. (1996). Use of fundal pressure during second-stage labor. A pilot study. J Nurse Midwifery, 41(4), 334-337.

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers ii:  Report of the second national u.S. Survey of women’s childbearing experiences. New York: Childbirth Connection.

de Leeuw, J. W., Struijk, P. C., Vierhout, M. E., & Wallenburg, H. C. (2001). Risk factors for third degree perineal ruptures during delivery. BJOG, 108(4), 383-387.

Ejegard, H., Ryding, E. L., & Sjogren, B. (2008). Sexuality after delivery with episiotomy: A long-term follow-up. Gynecol Obstet Invest, 66(1), 1-7.

Mollberg, M., Hagberg, H., Bager, B., Lilja, H., & Ladfors, L. (2005). Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction. Obstet Gynecol, 106(5 Pt 1), 913-918.

Zetterstrom, J., Lopez, A., Anzen, B., Norman, M., Holmstrom, B., & Mellgren, A. (1999). Anal sphincter tears at vaginal delivery: Risk factors and clinical outcome of primary repair. Obstet Gynecol, 94(1), 21-28.

Do No Harm, Research for Advocacy , , , ,

  1. | #1

    Yikes! I didn’t realize it had that much potential for harm!

    The World Health Organization also lists fundal pressure in the category “6.3 Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue”. (I discuss these “safe motherhood” guidelines in a 4-part series on my blog; these Category C practices are in this post which also includes a link to the WHO document.

  2. avatar
    | #2

    While i agree that Fundal pressure may have some negative effects,it can also hasten baby delivery in case of delayed second stage to prevent asphyxia.However,it should be applied cautiously with moderate effort when the woman is unable to push the baby out while the head has crowned.More research is required

  3. | #3

    Could you clarify? Once the head has crowned, it has passed through the pelvis. All fundal pressure would do is up the chances of splitting her perineum by the extra pressure and causing a anal sphincter tear. The only reason that a woman would be unable to birth the baby at that point is that the shoulders are hanging up, in which case the last thing you would want to do is apply fundal pressure, as my blog post discusses, because it makes matters worse. And if the baby is in distress at this point, telling the woman in an urgent voice that the baby needs to come out NOW!and why that is the case can galvanize the efforts of even an exhausted woman. Medical model thinkers tend to think that solving problems means taking actions on a passive patient, but the woman’s efforts can often solve or contribute to solving the problem.

  4. avatar
    | #4

    Dear Readers,

    Our son is born with severel bleeding, one subdural hemorrhage and intraventricular hemorrhage and a cephalic hematoma.

    During the childbirth (labour) the nurses have applied fundal pressure (many times) at the time that the head of the child was standing high into the birth canal (hodge 3 -)

    The doctors in Holland are sure that the bleeding is a consequence due to the fundal pressure, but there is not evidence on paper (literature) that confirms our suspicion.

    I have read in several American newspapers that there is a connection between fundal pressure and head bleeding.

    I would like to have a medical document in which there is a correlation between expression and brain haemorrhage (the so-called causality).

    Is it possible to send me some (med)literature?

    I hope that you can help me, I would be very happy.

    Many thanks and I hope to hear from you soon!

    Kind regards,

  5. | #5

    I wish I could help, but none of the studies I have report an association between intracranial hemorrhage and fundal pressure. This does not mean, however, that fundal pressure did not play a role in the injury to your baby. What gets published depends on what research questions are asked and, in the case of rare events, whether studies are big enough to detect differences between populations having or not having the intervention or whether the event is reported as a case history or case series.

  6. avatar
    Prof C Nikodem
    | #6

    Dear Henci

    Please provide me with with the article or the authors names of what you referred to “In a randomized controlled trial (women assigned by chance to one form of treatment or the other), investigators allocated healthy women with full-term, head-down babies and no epidural analgesia or oxytocin (Pitocin or “Pit”) infusion to have fundal pressure or not when they reached full dilation and felt an urge to push.”
    I can assure you that at the present moment there is NO PUBLISHED BEST evidence or systematic review that support or decline the use of fundal pressure. I also wish to share with you that WHO and others are embarking on RCT’s to establish the effect of fundal pressure, because
    there is currently no best evidence available but
    The first one is an RCT that compare gentle assisted pushing in the upright posture (GAP) or upright posture alone compared with routine practice to reduce prolonged second stage of labour (The Department of Reproductive Health and Research at the World Health Organization [RHRUWHO], 2014: 4). The second study is a randomised control trial that evaluate the adoption of an upright posture compared to the application of uterine fundal pressure of women in a routine semi-supine position to reduce postpartum haemorrhage during the third and fourth stage of labour (Aku, Nikodem, Tyler & Singata-Madliki, 2014: 2).

  1. | #1

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