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Volkert A, Bach L, Hagenbeck C, Kössendrup J, Oberröhrmann C, Okumu MR, Scholten N. Obstetric interventions' effects on the birthing experience. BMC Pregnancy Childbirth 2024; 24:508. [PMID: 39068395 PMCID: PMC11283698 DOI: 10.1186/s12884-024-06626-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 06/07/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND The birth experience plays a pivotal role in the mother´s mental well-being and has a crucial effect on the mother-child bond. Unanticipated medical interventions, including fundal pressure, episiotomy, assisted vaginal delivery (AVD), or unplanned cesarean section (CS) during labor, may adversely affect the birth experience. The objective of this study is to identify factors contributing to the diminished evaluation of the birth experience after assessing the prevalence of unplanned obstetrical interventions in Germany. METHODS For this cross-sectional analysis, 4000 mothers whose children were born 8 or 12 months before were asked about their birth experience via a paper-based questionnaire. Overall 1102 mothers participated in the study, representing a response rate of 27.6%. The revised Childbirth Experience Questionnaire (CEQ2) was used to measure the childbirth experience. In addition to descriptive and bivariate analyses using the Wilcoxon rank-sum test and Kruskal-Wallis-test, we calculated multivariate linear regression models for each dimension of the CEQ2. RESULTS In general, the participants evaluated their childbirth experience favorably, assigning an average rating of 3.09 on a scale ranging from 1 to 4. Women who experienced fundal pressure, an AVD, or an unplanned CS rated their birth experience significantly worse compared to women who gave birth without interventions. Unplanned CSs received the lowest ratings for "personal capability" and "perceived safety," and an AVD resulted in lower scores for "professional support" and "participation." However, the interventions we studied did not account for much of the variation in how the childbirth experience plays out for different individuals. CONCLUSION Obstetric interventions have a significant effect on different dimensions of the birth experience. If a high level of birth satisfaction is to be achieved, it is important to know which dimension of satisfaction is affected by the intervention so that explicit measures, like fostering communication, participation or safety can be taken to promote improvement. GERMAN CLINICAL TRIAL REGISTER DRKS00029214, retrospectively registered (Registration Date 22.06.2023).
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Affiliation(s)
- Anna Volkert
- Chair of Health Services Research, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Lisa Bach
- Chair of Health Services Research, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Carsten Hagenbeck
- Department of Gynecology and Obstetrics, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Kössendrup
- Chair of Health Services Research, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Charlotte Oberröhrmann
- Chair of Health Services Research, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mi-Ran Okumu
- Chair of Health Services Research, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nadine Scholten
- Chair of Health Services Research, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Health Communication and Health Services Research, Department for Psychosomatic Medicine and Psychotherapy, Faculty of Medicine, University Hospital Bonn, Bonn, Germany
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Kanninen T, Bellussi F, Berghella V. Fundal pressure to shorten the second stage of labor: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 275:70-83. [PMID: 35753230 DOI: 10.1016/j.ejogrb.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Systematically review the evidence on fundal pressure to expedite vaginal delivery. STUDY DESIGN Literature search in electronic databases. Randomized controlled trials of fundal pressure to expedite delivery were included in this systematic review and meta-analysis. The primary outcome was the length of the second stage. RESULTS We identified 10 randomized controlled trials. Fundal pressure was associated with a shorter length of the second stage of labor (mean difference (MD) -20.33 min, 95% confidence intervals (CI) -28.55, -12.11). Sub-group analysis with only manual pressure or a belt confirmed the association. There was no significant difference in the rate of vaginal delivery (relative risk (RR) 1.00, 95%, CI 0.98, 1.02), one and five minute Apgar scores (MD 0.10, 95%, confidence intervals -0.05, 0.24; and MD 0.02, 95%, CI -0.12, 0.15), neonatal trauma (RR 0.33, 95%, CI 0.01, 7.90), vaginal/perineal laceration (RR 0.83, 95%, CI 0.57, 1.22), cervical laceration (RR 1.30, 95%, CI 0.21, 8.02), episiotomy (RR 1.08, 95%, CI 0.96, 1.21), cesarean section rate (RR 0.72; 95%, CI 0.34, 1.51), operative vaginal deliveries (RR 0.79; 95%, CI 0.55, 1.13) and neonatal intensive care admissions (RR 0.33, 95%, CI 0.01, 7.90). However, patients receiving fundal pressure had a lower umbilical cord arterial pH (MD -0.03, 95%, CI -0.04, -0.01), and a 3.5 non-significantly higher incidence of Apgar scores < 7 at 5 min (4.9% vs 0.7%, RR 3.48, 95%, CI 0.57, 21.32). CONCLUSIONS Fundal pressure in the second stage is associated with a 20-minute decrease in the length of labor and a small decrease in neonatal umbilical artery pH.
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Affiliation(s)
- Tomi Kanninen
- Department of Obstetrics and Gynecology, Richmond University Medical Center, New York, NY, USA
| | - Federica Bellussi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
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Akpınar G, Kanbur A. Effect of uterine fundal pressure applied in the second stage of labor on birth outcomes and neonatal oxygen saturation. J Obstet Gynaecol Res 2022; 48:1165-1174. [PMID: 35231953 DOI: 10.1111/jog.15204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/20/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
AIM To examine the effect of fundal pressure applied in the second stage of labor on birth outcomes and neonatal O2 saturation. METHODS The study is of a descriptive and comparative type. Research data were collected in the obstetrics clinic of a Maternity Hospital between August 15, 2019 and February 15, 2020. The study sample consisted of 160 pregnant women who met the research criteria (80 pregnant women who received fundal pressure, 80 pregnant women who did not receive fundal pressure). RESULTS The duration of the second and third stages of labor was found to be shorter in the nonfundal pressure group (t = -3.422, p = 0.001; t = 2.195, p = 0.030). When the groups were compared, the formation of perineal trauma and second-degree laceration, episiotomy requirement, elongation of the episiotomy incision and cervical laceration rate were found to be significantly higher in the fundal pressure group χ2 = 10.794 p = 0.001; χ2 = 8.403 p = 0.004; χ2 = 10.014, p = 0.002; χ2 = 16.579 p = 0.000; χ2 = 16.276 p = 0.000). The 1st and 5th min Apgar scores of the newborns were lower in the fundal pressure group (t = -6.377, p = 0.000; t = -3.581, p = 0.001). The 1st, 5th, 10th, and 15th min oxygen saturation of the newborns were determined to be significantly lower in the fundal pressure group (t = -4.753, p = 0.000; t = -2.427, p = 0.016; t = -2.604, p = 0.010; t = -2.492, p = 0.014). CONCLUSION According to the study results, it was determined that the uterine fundal pressure has a negative effect on birth outcomes and neonatal oxygen saturation. Adverse effects of fundal pressure application should be revealed in different aspects.
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Affiliation(s)
- Gamze Akpınar
- Department of Midwifery, Graduate School of Health Science, Atatürk University, Erzurum, Turkey
| | - Ayla Kanbur
- Department of Midwifery, Faculty of Health Science, Atatürk University, Erzurum, Turkey
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Pinar S, Karaçam Z. Applying fundal pressure in the second stage of labour and its impact on mother and infant health. Health Care Women Int 2017; 39:110-125. [DOI: 10.1080/07399332.2017.1376332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Semra Pinar
- Midwife, Department of Health Sciences, Faculty of Science, University of York, Heslington, UK
| | - Zekiye Karaçam
- Adnan Menderes University Faculty of Health Sciences, Division of Midwifery, Aydın, Turkey
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Abstract
BACKGROUND Fundal pressure during the second stage of labour (also known as the 'Kristeller manoeuvre') involves application of manual pressure to the uppermost part of the uterus directed towards the birth canal, in an attempt to assist spontaneous vaginal birth and avoid prolonged second stage or the need for operative birth. Fundal pressure has also been applied using an inflatable belt. Fundal pressure is widely used, however methods of its use vary widely. Despite strongly held opinions in favour of and against the use of fundal pressure, there is limited evidence regarding its maternal and neonatal benefits and harms. There is a need for objective evaluation of the effectiveness and safety of fundal pressure in the second stage of labour. OBJECTIVES To determine if fundal pressure is effective in achieving spontaneous vaginal birth, and preventing prolonged second stage or the need for operative birth, and to explore maternal and neonatal adverse effects related to fundal pressure. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (30 November 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of fundal pressure (manual or by inflatable belt) versus no fundal pressure in women in the second stage of labour with singleton cephalic presentation. DATA COLLECTION AND ANALYSIS Two or more review authors independently assessed potential studies for inclusion and quality. We extracted data using a pre-designed form. We entered data into Review Manager 5 software and checked for accuracy. MAIN RESULTS Nine trials are included in this updated review. Five trials (3057 women) compared manual fundal pressure versus no fundal pressure. Four trials (891 women) compared fundal pressure by means of an inflatable belt versus no fundal pressure. It was not possible to blind women and staff to this intervention. We assessed two trials as being at high risk of attrition bias and another at high risk of reporting bias. All other trials were low or unclear for other risk of bias domains. Most of the trials had design limitations. Heterogeneity was high for the majority of outcomes. Manual fundal pressure versus no fundal pressureManual fundal pressure was not associated with changes in: spontaneous vaginal birth within a specified time (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.71 to 1.28; 120 women; 1 trial; very low-quality evidence), instrumental births (RR 3.28, 95% CI 0.14 to 79.65; 197 women; 1 trial), caesarean births (RR 1.10, 95% CI 0.07 to 17.27; 197 women; 1 trial), operative birth (average RR 0.66, 95% CI 0.12 to 3.55; 317 women; 2 studies; I² = 43%; Tau² = 0.71; very low-quality evidence), duration of second stage (mean difference (MD) -0.80 minutes, 95% CI -3.66 to 2.06 minutes; 194 women; 1 study; very low-quality evidence), low arterial cord pH in newborn babies (RR 1.07, 95% CI 0.72 to 1.58; 297 women; 2 trials; very low-quality evidence), or Apgar scores less than seven at five minutes (average RR 4.48, 95% CI 0.28 to 71.45; 2759 infants; 4 trials; I² = 89%; Tau² = 3.55; very low-quality evidence). More women who received manual fundal pressure had cervical tears than in the control group (RR 4.90, 95% CI 1.09 to 21.98; 295 women; 1 trial). No neonatal deaths occurred in either of the two studies reporting this outcome (very low-quality evidence). No trial reported the outcome severe maternal morbidity or death. Fundal pressure by inflatable belt versus no fundal pressureFundal pressure by inflatable belt did not reduce the number of women havinginstrumental births (average RR 0.73, 95% CI 0.52 to 1.02; 891 women; 4 trials; I² = 52%; Tau² = 0.05) or operative births (average RR 0.62, 95% CI 0.38 to 1.01; 891 women; 4 trials; I² = 78%; Tau² = 0.14; very low-quality evidence). Heterogeneity was high for both outcomes. Duration of second stage was reported in two trials, which both showed that inflatable belts shortened duration of labour in nulliparous women (average MD -50.80 minutes, 95% CI -94.85 to -6.74 minutes; 253 women; 2 trials; I² = 97%; Tau² = 975.94; very low-quality evidence). No data on this outcome were available for multiparous women. The inflatable belt did not make any difference to rates of caesarean births (average RR 0.56, 95% CI 0.14 to 2.26; 891 women; 4 trials; I² = 70%; Tau² = 0.98), low arterial cord pH in newborn babies (RR 0.47, 95% CI 0.09 to 2.55; 461 infants; 1 trial; low-quality evidence), or Apgar scores less than seven at five minutes (RR 4.62, 95% CI 0.22 to 95.68; 500 infants; 1 trial; very low-quality evidence). Third degree perineal tears were increased in the inflatable belt group (RR 15.69, 95% CI 2.10 to 117.02; 500 women; 1 trial). Spontaneous vaginal birth within a specified time, neonatal death, andsevere maternal morbidity or death were not reported in any trial. AUTHORS' CONCLUSIONS There is insufficient evidence to draw conclusions on the beneficial or harmful effects of fundal pressure, either manually or by inflatable belt. Fundal pressure by an inflatable belt during the second stage of labour may shorten duration of second stage for nulliparous women, and lower rates of operative birth. However, existing studies are small and their generalizability is uncertain. There is insufficient evidence regarding safety for the baby. There is no evidence on the use of fundal pressure in specific clinical settings such as inability of the mother to bear down due to exhaustion or unconsciousness. There is currently insufficient evidence for the routine use of fundal pressure by any method on women in the second stage of labour. Because of current widespread use of the procedure and the potential for use in settings where other methods of assisted birth are not available, further good quality trials are needed. Further evaluation in other groups of women (such as multiparous women) will also be required. Future research should describe in detail how fundal pressure was applied and consider safety of the unborn baby, perineal outcomes, longer-term maternal and infant outcomes and maternal satisfaction.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Joshua P Vogel
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and ResearchAvenue Appia 20GenevaSwitzerlandCH‐1211
| | - Anna Cuthbert
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Mandisa Singata
- University of the Witwatersrand/University of Fort Hare/East London Hospital complexEffective Care Research UnitEast LondonSouth Africa
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Hofmeyr GJ, Singata M, Lawrie T, Vogel JP, Landoulsi S, Seuc AH, Gülmezoglu AM. A multicentre randomized controlled trial of gentle assisted pushing in the upright posture (GAP) or upright posture alone compared with routine practice to reduce prolonged second stage of labour (the Gentle Assisted Pushing study): study protocol. Reprod Health 2015; 12:114. [PMID: 26669766 PMCID: PMC4681100 DOI: 10.1186/s12978-015-0105-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/04/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fundal pressure (pushing on the upper part of the uterus in the direction of the birth canal) is often performed in routine practice, however the benefit and indications for its use are unclear and vigorous pressure is potentially harmful. There is some evidence that it may be applied routinely or to expedite delivery in some situations (e.g. fetal distress or maternal exhaustion), particularly in settings where other methods of achieving delivery (forceps, vacuum) are not available. Gentle assisted pushing (GAP) is an innovative method of applying gentle but steady pressure to the uterine fundus with the woman in an upright posture. This trial aims to evaluate the use of GAP in an upright posture, or upright posture alone, on reducing the mean time of delivery and the associated maternal and neonatal complications in women not having delivered following 15-30 min in the second stage of labour. METHODS/DESIGN We will conduct a multicentre, randomized, unblinded, controlled trial with three parallel arms (1:1:1). 1,145 women will be randomized at three hospitals in South Africa. Women will be eligible for inclusion if they are ≥18 years old, nulliparous, gestational age ≥ 35 weeks, have a singleton pregnancy in cephalic presentation and vaginal delivery anticipated. Women with chronic medical conditions or obstetric complications are not eligible. If eligible women are undelivered following 15-30 min in the second stage of labour, they will be randomly assigned to: 1) GAP in the upright posture, 2) upright posture only and 3) routine practice (recumbent/supine posture). The primary outcome is the mean time from randomization to complete delivery. Secondary outcomes include operative delivery, adverse neonatal outcomes, maternal adverse events and discomfort. DISCUSSION This trial will establish whether upright posture and/or a controlled method of applying fundal pressure (GAP) can improve labour outcomes for women and their babies. If fundal pressure is found to have a measurable beneficial effect, this gentle approach can be promoted as a replacement for the uncontrolled methods currently in use. If it is not found to be useful, fundal pressure can be discouraged.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology at East London Hospital Complex (ELHC), Effective Care Research Unit (ECRU), and Eastern Cape Department of Health, University of the Witwatersrand, University of Fort Hare, East London, South Africa.
| | - Mandisa Singata
- Department of Obstetrics and Gynaecology at East London Hospital Complex (ELHC), Effective Care Research Unit (ECRU), and Eastern Cape Department of Health, University of the Witwatersrand, University of Fort Hare, East London, South Africa.
| | - Theresa Lawrie
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - Joshua P Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - Sihem Landoulsi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - Armando H Seuc
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - A Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
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Bode-Jänisch S, Bültmann E, Hartmann H, Schroeder G, Zajaczek JEW, Debertin AS. Serious head injury in young children: birth trauma versus non-accidental head injury. Forensic Sci Int 2011; 214:e34-8. [PMID: 21868179 DOI: 10.1016/j.forsciint.2011.07.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 07/11/2011] [Accepted: 07/21/2011] [Indexed: 11/18/2022]
Abstract
Birth injury of the skull and central nervous system can be a complication of a difficult delivery, especially following forceps or vacuum-assisted delivery. Birth trauma of the head can also mimic the appearance of a non-accidental head injury and is therefore an important differential diagnosis. We report on two young infants with serious head injuries. The difficult differential diagnosis birth trauma versus non-accidental head injury is discussed and the necessity for cooperation between clinicians, forensic doctors and specialized neuroradiologists is emphasized.
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Affiliation(s)
- S Bode-Jänisch
- Hannover Medical School, Institute of Legal Medicine, Hannover, Germany
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Abstract
BACKGROUND Fundal pressure during the second stage of labour involves application of manual pressure to the uppermost part of the uterus directed towards the birth canal in an attempt to assist spontaneous vaginal delivery and avoid prolonged second stage or the need for operative delivery. Fundal pressure has also been applied using an inflatable girdle. A survey in the United States found that 84% of the respondents used fundal pressure in their obstetric centres.There is little evidence to demonstrate that the use of fundal pressure is effective to improve maternal and/or neonatal outcomes. Several anecdotal reports suggest that fundal pressure is associated with maternal and neonatal complications: for example, uterine rupture, neonatal fractures and brain damage. There is a need for objective evaluation of the effectiveness and safety of fundal pressure in the second stage of labour. OBJECTIVES To determine the benefits and adverse effects of fundal pressure in the second stage of labour. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008). SELECTION CRITERIA Randomised and quasi-randomised controlled trials of fundal pressure versus no fundal pressure in women in the second stage of labour with singleton cephalic presentation. DATA COLLECTION AND ANALYSIS Three review authors independently assessed for inclusion all the potential studies. We extracted the data using a pre-designed form. We entered data into Review Manager software and checked for accuracy. MAIN RESULTS We excluded two of three identified trials from the analyses for methodological reasons. This left no studies on manual fundal pressure. We included one study (500 women) of fundal pressure by means of an inflatable belt versus no fundal pressure to reduce operative delivery rates. The methodological quality of the included study was good.Use of the inflatable belt did not change the rate of operative deliveries (RR 0.94, 95% CI 0.80 to 1.11). Fetal outcomes in terms of five-minute Apgar scores below seven (RR 4.62, 95% CI 0.22 to 95.68), low arterial cord pH (RR 0.47, 95% CI 0.09 to 2.55) and admission to the neonatal unit (RR 1.48, 95% CI 0.49 to 4.45) were also not different between the groups. There was no severe neonatal or maternal mortality or morbidity. There was an increase in intact perineum (RR 1.73, 95% CI 1.07 to 2.77), as well as anal sphincter tears (RR 15.69, 95% CI 2.10 to 117.02) in the belt group. There were no data on long-term outcomes. AUTHORS' CONCLUSIONS There is no evidence available to conclude on beneficial or harmful effects of manual fundal pressure. Good quality randomised controlled trials are needed to study the effect of manual fundal pressure. Fundal pressure by an insufflatable belt during the second stage of labour does not appear to increase the rate of spontaneous vaginal births in women with epidural analgesia. There is insufficient evidence regarding safety for the baby. The effects on the maternal perineum are inconclusive.
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Affiliation(s)
- Evelyn C Verheijen
- Women's Health Care, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton, UK, BL4 0JR
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