fundal pressure - page 3

Is fundal pressure ever an appropriate nursing intervention? we are having a little debate over this, some are saying that it is never to be used . what do you think? do you use it?... Read More

  1. by   LizzyL&DRN
    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.
  2. by   JenTheRN
    Wow...this is scary stuff. Anyone have a link to an article that I could show my manager?
  3. by   SmilingBluEyes
    Here is one for you that discusses ways to properly relieve dystocia:


    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 transvaginal 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 vaginal 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.


    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.

    San Francisco Bureau

    COPYRIGHT 2004 International Medical News Group
    COPYRIGHT 2004 Gale Group
    Last edit by SmilingBluEyes on Aug 4, '04
  4. by   SmilingBluEyes
    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:$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???
    Last edit by SmilingBluEyes on Aug 4, '04
  5. by   Dawn27
    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.
  6. by   profjanmc
    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!
  7. by   L&D_RN_OH
    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.
  8. by   LizzyL&DRN
    That sounds so scary!!! We lost a mom not too long ago from an amniotic fluid embolism. Those are the worst.
  9. by   profjanmc
    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....
  10. by   BETSRN
    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.
  11. by   BETSRN
    Lizzy L&D. Someone needs to investigate that doc who uses the fundal pressure. Your description is very scary! I would make sure you talk to your hospital's risk manager ASAP! Please.
  12. by   AlaskaKat
    Once when I was a student (1996), I went to the Philippines with a transcultural nursing course. We did mainly L&D, with some NICU as well. At one of the very first deliveries I went to, the labor nurse actually jumped up onto the bed next to the mom's shoulder, facing her belly and applied fundal pressure with the force of her whole body for a long time, throughout the entire second stage. My eyes musta popped out of my head because afterwards she asked me if I was OK and explained to me that first time moms "never know how to push". Yikes! I asked my instructor about it after all was said and done and she told me to never never do that, and that their practice at that particular hospital was modeled after the standard of care in the US about 20 years ago. Scarey stuff...I didn't know anyone was still doing it here. Never once has it come up for me in practice.
  13. by   BETSRN
    Quote from mark_LD_RN
    i do the fake manuever it seems to make them happy!
    I think I would say that "faking it" could be misconstrued by the patient/family in court. Even if you fake it and there is a problematic outcome, you could NOT defend yourself in court, stating that you "faked it." It would seem to me better to question the doc at the time and tell him that it is NOT standard of care. You are the patient advocate. better you have to endure the wrath (he'll get over it) of the doc than be involved in a lawsuit. Any lawyer worth his salt is going to be able to bring in every study that shows fundal pressure to be contraindicated and then you're screwed. You could never prove that you were faking it.

    Document your refusal everywhere you need to.