fundal pressure

rdhdnrs · Aug 4, 2004

Well said, Jan. If a doc ever asks me to do something I know is wrong, I don't do it...period. The doc is not going to get up in court and defend you. But more importantly, if you do a procedure that you know you shouldn't that is not being a patient advocate. And isn't that what nursing is, patient advocacy?

JenTheRN · Aug 4, 2004

Ok, I'm glad that I read this thread. I'm a new nurse, and have been working OB since I graduated about a year ago. One of our docs asks for fundal pressure from time to time. I actually performed it a few days ago. I had no idea this was not a standard practice, and that it held so many risks. I will talk to my supervisor when I work next and explain what is happening. I don't know if the rest of our nurses know this either. Our OB dept has recently undergone a major overhaul, and most of our nurses are new to OB.

Thanks again for this thread!!!

LizzyL&DRN · Aug 5, 2004

We have a doc who will use fundal pressure on occasion for ineffective pushing. He puts both forearms on the fundus and applies extreme pressure to force the baby down through the canal. He was actually my doctor when I had my son(before I was a nurse). I can tell you that it was very painful, and his purpose was to lower the baby enough to apply a vacuum. I consequently had a 4th degree laceration from that delivery. I'm pregnant again now, and not going to that doctor.

JenTheRN · Aug 5, 2004

Wow...this is scary stuff. Anyone have a link to an article that I could show my manager?

SmilingBluEyes · Aug 5, 2004

Here is one for you that discusses ways to properly relieve dystocia:

Boschert

MAUI, HAWAII -- The different maneuvers to deliver a baby with shoulder dystocia fall into three categories: the good, the not bad, and the downright ugly.

Leading off the ugly category is traction with fundal pressure, which increased the neonatal death rate to 16% in one study, increased the rate of complications to 77% in another study, and increased complications by 28-fold compared with no fundal pressure in a third study, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

"Fundal pressure absolutely should not be used," he said.

To avoid litigation if a baby with shoulder dystocia has a bad outcome, train delivery room nurses to document suprapubic pressure if it is performed, but first to be sure that suprapubic pressure was actually used. "I frequently see situations where the nurse writes fundal pressure, and the doctor emphatically denies that fundal pressure was used," said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Instead, address shoulder dystocia by trying the McRoberts maneuver, suprapubic pressure, and early attempts to deliver the posterior arm, he advised. Exaggerated flexion of the mother's legs in the McRoberts maneuver will not change the diameter of the pelvis, but it decreases the angle of inclination and may allow the blocked shoulder to dislodge. Don't be too exuberant with this maneuver, though, he cautioned. Prolonged or overly forceful flexion of the patient's hips can damage maternal femoral nerves, ligaments, or other body parts.

A recent case report from Georgetown University in Washington suggested that physicians should make earlier attempts to deliver the posterior arm of a baby with shoulder dystocia.

Also called the Barnum maneuver, delivery of the posterior arm allowed the fetal trunk to follow easily after initial attempts at the McRoberts maneuver with traction had failed. A geometric analysis concluded that using posterior arm delivery reduces the shoulder obstruction by more than a factor of two relative to the McRoberts maneuver (Obstet. Gynecol. 101[5, pt. 2]: 1068-72, 2003).

The maneuver usually is not considered a first- or second-line strategy in algorithms of managing shoulder dystocia. "A lot of people leave it until late in the process before they start going for the posterior arm. At that point they may have damaged the maternal anatomy. They may have pushed or pulled the baby into a position where they can't get the posterior arm," Dr. Belfort commented at the meeting, sponsored by Boston University and the Center for Human Genetics.

Another maneuver to avoid is the Woods screw maneuver--applying pressure on the anterior portion of the posterior shoulder plus fundal pressure. Aside from the dangers of fundal pressure, the pressure on the anterior part of the shoulder can abduct the shoulder girdle, making it bigger and more difficult to get out.

Instead, Dr. Belfort uses the Rubin maneuver if the McRoberts maneuver, suprapubic pressure, and attempts to deliver the posterior arm have failed to deliver the baby. The Rubin maneuver involves transabdominal rocking of the fetal shoulders and translady partsl adduction of the most accessible shoulder (not necessarily the posterior one, as in the Woods maneuver) by pressing on the posterior aspect to collapse the shoulders inward.

If you're still stuck, try delivering the baby with the mother on her hands and knees, as recommended in some publications for nurse midwives. "I have done this once, and it worked for me," he said.

If all these maneuvers have failed but the baby's head is out and you have someone to help you, consider attempting an abdominal rescue as you're preparing the patient for surgical delivery. Open the abdomen and press behind the symphysis to get the shoulder out and allow a lady partsl delivery. If that doesn't work, open the uterus as well to push the shoulder out, even if you have to break the clavicle and humerus.

Final options include C-section delivery, symphysiotomy, or the Zavanelli maneuver, which has been known to rupture cervical vertebrae and cause major intracranial damage.

DATA WATCH

Rate of Complications of Labor and/or Delivery, 2002

Per 1,000 Live Births

Meconium, Moderate/Heavy 50.1

Fetal Distress 38.6

Breech/Malpresentation 38.1

Dysfunctional Labor 28.6

Premature Rupture of Membranes 23.1

Cephalopelvic Disproportion 15.8

Note: Based on all 4.02 million live births in 2002.

Source: Centers for Disease Control and Prevention

Note: Table made from bar graph.

BY SHERRY BOSCHERT

San Francisco Bureau

SmilingBluEyes · Aug 5, 2004

May 2004 Legal Case Study

Excessive Traction by Obstetrician and Nursing Staff Produce Brachial Plexus Injury to Infant -Confidential Pretrial Mediation Settlement in Arizona.

The plaintiff parents alleged that the defendant obstetrician, Dr. Richard Moos, fell below the standard of care when he used excessive traction of the plaintiff daughter's head and neck after shoulder dystocia was encountered during her delivery. The parents also alleged the defendant hospital's nursing staff fell below the standard of care when it negligently applied fundal pressure at Dr. Moos' direction. The defendants denied falling below the standard of care.

Dr. Moos testified during his first deposition that he instructed the hospital's nursing staff to apply fundal pressure when the shoulder dystocia occurred. However, during a subsequent deposition, Dr. Moos testified he had not ordered the use of fundal pressure and he had been confused and mis-spoke at the time of his first deposition. The hospital denied its nursing staff used fundal pressure. The infant sustained a severe and permanent brachial plexus injury of her left arm.

This matter settled for a confidential amount after two settlement conferences, according to The Trial Reporter of Central and Northern Arizona. Plaintiffs' Experts: Harlan R. Giles, M.D., obstetric~/fetal medicine, Pittsburgh, PA. Salah M. Shenaz, M.D., plastic surgery, Houston, TX. Defendant's Experts: Hugh Stephen Miller, M.D., obstetrics/gynecology/neonatal-perinatal medicine, Tucson, AZ. Theodore J. Tarby, M.D., pediatric neurology, Phoenix, AZ. Bolkovatz v. Scottsdale Healthcare Corporation and Scottsdale Healthcare Hospitals dba Scottsdale Healthcare Shea, and Moos, M.D., Maricopa County (AZ) Superior Court, Case No. CY 2002-0 11307 and CY 2002-0 11307, consolidated.

With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298-6288. From:

http://www.nso.com/case/com_print.php?id=99&area=$dbareaofhealth

My note: Yes, true, It's unclear whether fundal pressure was used or not for sure, but NOW you will see how quickly a physician will "back you up" in the face of legal trouble, don't you???

Dawn27 · Aug 5, 2004

Hi I am a Midwife from the UK

I am new to the forums but read this threadand decided to make it my first post.

Fundal pressure should never be carried out as a means to speed delivery, as others have indicated it can have very disastorous consequences.

In cases of shoulder dystocia fundal pressure compounds the problem it doesn't help although supra pubic pressure in the direction of the lie can be of benefit if the shoulder is stuck behind the pelvic brim.

profjanmc · Aug 5, 2004

Boy, I really thought this was an obsolete issue. I am surprised with all the studies that there are doctors out there still doing it for delivery!!!! That's why we all need to go to conferences, and read our journals!

L&D_RN_OH · Aug 7, 2004

I've never heard a doc request fundal pressure during a routine delivery.

Only once did we use it. The pt "seized", collapsed, FHR dropped to 70's. Pt went from 1-10. Pt alternated between being lucid, combative,and unresponsive. She was barely able to push, FHR down to 60's. We used fundal pressure for a forcep assisted delivery. The entire delivery was only minutes long, though it felt like forever to get that baby out. Minutes after delivery, while some of us tried to stabilize baby, Mom coded. She died from an amniotic fluid embolism. The baby spent some time in NICU, but later went home with Dad.

I think in that case, running to the OR would have cost us Mom and baby.

LizzyL&DRN · Aug 8, 2004

That sounds so scary!!! We lost a mom not too long ago from an amniotic fluid embolism. Those are the worst. :crying2:

profjanmc · Aug 10, 2004

An incrediblly rare too, hopefully you will never see another one in your career. It is so sad when everything seems to be going great and out of the blue-wham! - an amniotic fluid embolism-

Sad to hear about that, you feel so helpless....

BETSRN · Aug 15, 2004

Never give fundal pressure. If there is a problem, your name is all over that chart and you'll be in court with that doc.