The usual suspect: cross-sectional study of fundal pressure at second stage of delivery and the association with pelvic floor damage

"First do no harm": Fundal pressure during labor-How safe is it?

OBJECTIVE

Fundal pressure (FP), a controversial obstetric maneuver due to its potential benefits and risks, lacks robust evidence concerning its effects. This study aimed to evaluate the maternal and neonatal outcomes associated with the application of FP during the second stage of labor.

METHODS

Following our departmental protocol, FP is applied by obstetricians trained under the supervision of the head of the labor ward. Its implementation requires patient consent and documentation. This case-control study encompassed vaginal deliveries (VDs) involving FP (FP group) during the second stage of labor. The control group included subsequent deliveries matched 1:1 for gestational age, parity, and mode of delivery (vacuum extraction [VE] or VD). Maternal and neonatal outcomes were compared between the groups. Composite adverse outcomes included the presence of at least one of the following: grade 3-4 perineal tear, shoulder dystocia, postpartum hemorrhage, postpartum hospitalization exceeding 4 days, or postpartum use of analgesics exceeding five doses.

RESULTS

Among 12 048 deliveries during the 3-year study period, 325 (2.7%) involved FP. There were no significant differences in maternal age, body mass index, or gestational age between the FP (n = 325) and control groups (n = 325). However, the FP group exhibited higher rates of labor induction (41.5% vs. 19.3%, P < 0.0001), oxytocin augmentation (52% vs. 23.6%, P < 0.0001), and prolonged duration of the second stage of labor (1.88 ± 1.2 vs. 1.57 ± 1.3 h, P = 0.003). There were no significant differences in the rate of postpartum hemorrhage, composite adverse maternal outcomes, or early neonatal outcomes between the groups.

CONCLUSION

Fundal pressure, when administered by trained obstetricians, was not associated with adverse obstetric, maternal, or neonatal outcomes.

The condemned fundal pressure maneuver: time to reconsider?

Due to a concern of severe adverse neonatal and maternal complications, fundal pressure (FP) maneuver has been discouraged by several national obstetric guidelines as well as the World Health Organization. In this manuscript, we argue that previously published evidence pointing to unfavorable effects of FP might not be relevant to the common practice. Our main concern is that the inherent limitations of published studies undermining the association of FP with various obstetric complications, in conjunction with fear of medical-legal implications, might lead to an absolute avoidance of this procedure, with a potential subsequent increase in vacuum-assisted and cesarean deliveries. We suggest establishing standardized guidelines for FP application, intend to prevent application of uncontrollable and aggressive pressure, assist the obstetricians in case of legal claims, and yet to preserve the use of gentle and respectful FP application to benefit the delivery.

Risk of obstetric anal sphincter injury with fundal pressure in second stage of labor: Transperineal ultrasound study

AIMS

Clinical management of the second stage of labor and effectiveness of preventive measures for severe perineal tears are controversial. The aim of this study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on obstetric anal sphincter injury (OASI), among primiparous women using three-dimensional (3D) transperineal ultrasonography.

METHODS

A total of 73 women who had their first vaginal birth were included in the study, the fundal pressure group included women where the fundal pressure maneuver was applied (n = 37); and the control group included women who delivered spontaneously without fundal pressure (n = 36). Tomographic ultrasound imaging with 3D transperineal assessment was performed within 48 h of delivery, internal anal sphincter (IAS) and external anal sphincter (EAS) defect were determined.

RESULTS

Five (13.5%) women in the fundal pressure group, seven (20%) women in the control group had complete EAS defect (p = 0.4). Complete IAS defect was observed in one (2.7%) woman in the fundal pressure group and two (5.7%) women in the control group (p = 0.5). A Half-moon sign was observed in one woman in both groups (p = 0.9). The rate of other signs was similar in both groups. Multivariate regression models revealed that none of age, fetal birth weight, episiotomy, length of the second stage of labor, fundal pressure application status, and number were independent predictors of complete IAS or EAS defect.

CONCLUSION

Fundal pressure with mediolateral episiotomy during the second stage of delivery does not increase the rate of OASI detected with ultrasonography.