fundal pressure

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I have been a labor nurse for 12 years at the same hospital. Although not used often, fundal pressure has been something used in our institution for emergent cases. Recently our new manager sent out a general email that was very threatening to everyone that we would lose our job and be every penny we own if we do it. She also gave us a scripted response to share with the doctors that ask for fundal pressure. I see fundal pressure being used very often on c sections as well, although that issue is being ignored. I have read many articles about fundal pressure and it's very "wishy washy." I know that fundal pressure is not appropriate for shoulder dystocia, but how about at other times, say when the patient is crowning, heart tones are down and there is now maternal effort with pushing because her epidural level is so dense she can't move her legs? Thanks

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

our doctors do not do AROM when a baby is that high. I would do what fergus suggested in another thread:

ask the doctor (innocently) about the implications of AROM'ing at such a high station....e.g., are you worried the cord may prolapse, etc.

Still, if they ask, you have to refuse to do fundal pressure, even in this case. Just ask about the risks of what they are doing. For some, it may cause them to stop and think twice.

Anecdotally, I saw a very clear cord prolapse after a high-station AROM by dr. The cord washed out the introitus with the fluid. Well, It was not pretty, having to sit there holding the head up off the cord, the ENTIRE time til they did her csection.........what an unnecessary emergency. That dr does not do AROM unless the head is engaged now. At least he learned something.

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No one has mentioned this, but what about when you have a doc doing an AROM on a patient with a -3 station?

I applied light fundal pressure at AROM per the doc for a 2nd twin who was at a -3 during a lady partsl delivery of twins. Not the first time I've been asked and done it for AROM of baby B either.

Jen

L&D RN

I have done this for a perinatologist in a Level III hospital when it was a question of "section her later for failure to go into labor" (a medically indicated induction) or risk prolapse with a high station AROM to imporve the chances of the induction taking. This in a facility used to crash sections where the "decision to incision" time was less than 5 min. In this situation, the perinatologist would use a spinal needle to "needle" the membranes rather than a hook to tear them. This allows a slow leak that is less likely to wash the cord out in front of the head than the gush that goes with a regular AROM. Of course, sometimes the membranes will pop when they're needled and the cord will prolapse. That's why it was only done infrequently and after the patient was fully informed of the risks and benefits by the perinatologist.

I've been around a long time and used to give fundal pressure in the "old days" when it was still acceptable. Having done both, I can tell you that there is a very big difference between fundal pressure and "holding the baby in place" for a high AROM.

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I have done this for a perinatologist in a Level III hospital when it was a question of "section her later for failure to go into labor" (a medically indicated induction) or risk prolapse with a high station AROM to imporve the chances of the induction taking. This in a facility used to crash sections where the "decision to incision" time was less than 5 min. In this situation, the perinatologist would use a spinal needle to "needle" the membranes rather than a hook to tear them. This allows a slow leak that is less likely to wash the cord out in front of the head than the gush that goes with a regular AROM. Of course, sometimes the membranes will pop when they're needled and the cord will prolapse. That's why it was only done infrequently and after the patient was fully informed of the risks and benefits by the perinatologist.

I've been around a long time and used to give fundal pressure in the "old days" when it was still acceptable. Having done both, I can tell you that there is a very big difference between fundal pressure and "holding the baby in place" for a high AROM.

Hello, NurseNora,

So your physician electively selects these women who he/she "thinks" will fail induction? Or, the phsician weighs the risks/benefits of AROM with high presentation? Why? Maternal/fetal indications? Just wondering.

I am associated with hi risk OB at two institutions and my physicians would never consider this action. At least we have not run across a situation where this was deemed prudent........

Again, just wondering ........

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Specializes in L&D.
Hello, NurseNora,

So your physician electively selects these women who he/she "thinks" will fail induction? Or, the phsician weighs the risks/benefits of AROM with high presentation? Why? Maternal/fetal indications? Just wondering.

I am associated with hi risk OB at two institutions and my physicians would never consider this action. At least we have not run across a situation where this was deemed prudent........

Again, just wondering ........

They were being induced for medical reasons, that's why they were seeing the perinatologist and being induced with an unfavorable cervix.

Before doing a high station AROM, they had usually had 2-3 days of failed induction. For someone with a very unripe cervix who just had to be delivered ASAP, we'd give some sort of prostaglandin in the evening, sleep her, then pit in the morning. If there was no cervical change after 8 hours, we'd stop the pit, feed the mother, sometimes use more prostaglandin, let her sleep, then pit again.

Induction is more sucessful with ruptured membranes. After a couple of days of getting nowhere, it was one of the things that could be tried to get the baby delivered lady partslly, when the baby needed to be delivered soon.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
They were being induced for medical reasons, that's why they were seeing the perinatologist and being induced with an unfavorable cervix.

Before doing a high station AROM, they had usually had 2-3 days of failed induction. For someone with a very unripe cervix who just had to be delivered ASAP, we'd give some sort of prostaglandin in the evening, sleep her, then pit in the morning. If there was no cervical change after 8 hours, we'd stop the pit, feed the mother, sometimes use more prostaglandin, let her sleep, then pit again.

Induction is more sucessful with ruptured membranes. After a couple of days of getting nowhere, it was one of the things that could be tried to get the baby delivered lady partslly, when the baby needed to be delivered soon.

Hi, Nurse Nora,

Thank you for your reply.

I still do not understand, if these women need to be delivered "soon", why not perform a C-section instead of risk cord prolapse with a high AROM? Especially if they fail the induction and need to be re-induced. Unless proceeding to C-section after the first induction failure is too risky (medically wise) and warrants another try.

Still.....high AROM and prolapse cord.

How often do you see this?

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I have also been taught that fundal pressure is contraindicated and I have only been asked to apply pressure during AROM and during a twin delivery to keep B from flipping. I believe there is a definite difference between that and applying enough pressure to push the kid out.

How do you guys say NO! when asked in the heat of the moment?

By the way, in my perinatal nursing AWHONN book there IS mention of fundal pressure for the Woods maneuver for shoulder dystocia....I was surprised when I first read it as I have never heard that in practice. It is the 2001 edition, pg 325.

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Specializes in L&D.
Hi, Nurse Nora,

Thank you for your reply.

I still do not understand, if these women need to be delivered "soon", why not perform a C-section instead of risk cord prolapse with a high AROM? Especially if they fail the induction and need to be re-induced. Unless proceeding to C-section after the first induction failure is too risky (medically wise) and warrants another try.

Still.....high AROM and prolapse cord.

How often do you see this?

Some physicians are more willing than others to work with a patient's desire for a lady partsl delivery over a Cesarean delivery. It was done with full disclosure to the patient of the risks/benefits and of the options available. They didn't do if for all their patients that were not responding to induction attempts. I can't explain their thought processes as to who they were willing to do it for and who got an immediate C/S. Medicine (as well as nursing) is an art as well as a science. The best doctors I've worked with have good "instincts" as well as good scientific knowledge.

Don't remember ever seeing a prolapse in this situation, although I have seen patients walk into the hospital with a cord between their legs after a spontaneous rupture at home. Nothing is without some risk.

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