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doi:10.1111/jog.12284
J. Obstet. Gynaecol. Res. Vol. 40, No. 4: 946–953, April 2014
Fundal pressure during the second stage of labor in a tertiary obstetric center: A prospective analysis Fady M. Shawky Moiety1,2 and Amal Z. Azzam2 1
Department of Obstetrics and Gynecology, Shatby University Hospital, and 2Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Abstract Aim: To ascertain whether uterine fundal pressure should have a role in the management of the second stage of labor and to determine its prevalence, benefits and adverse maternal–fetal outcomes. Methods: This was a prospective observational study set in a tertiary teaching and research obstetric hospital. A total of 8097 women in labor between 37 and 42 gestational weeks with a singleton cephalic presentation were enrolled. Subjects were subdivided into two groups: fundal pressure group (n = 1974 women) and control group (n = 6123 women). The primary outcome measure was the duration of the second stage. The secondary outcome measures were maternal outcomes (immediate or delayed) and neonatal outcomes. Results: The prevalence of fundal pressure in our center was 24.38%. Fundal pressure maneuver significantly shortened the duration of the second stage among primiparous women, increased the risk of severe perineal laceration and admission to neonatal intensive care unit in comparison to the non-fundal group. Delayed maternal outcomes showed significant increase in dyspareunia and de novo stress urinary incontinence in the fundal pressure group. Conclusion: Although fundal pressure maneuver shortens the duration of the second stage of labor among primiparous women, it should not be used except when indicated, and under strict guidelines owing to its adverse maternal and fetal outcomes. Key words: fundal pressure, labor, outcome.
Introduction Fundal pressure involves the application of manual pressure on the uppermost part of the uterus directed towards the birth canal in an attempt to shorten the second stage of labor.1 However, the role of fundal pressure in the management of the second stage of labor is understudied and remains controversial.2 The performance of fundal pressure differs widely between countries. It is frequently applied in conditions where instrumental deliveries are not readily available.3 In some Western countries, mainly English-
speaking, it is considered an obsolete maneuver due to intense medicolegal aspects and adverse outcomes.4,5 While in developing countries, the procedure appears to be routine practice during vaginal delivery.6,7 The clinical indications of fundal pressure are fetal distress, failure to progress in the second stage of labor and/or maternal exhaustion or medical conditions when prolonged pushing is contraindicated such as maternal heart disease.8 Relatively scarce data exists on the safety and/or efficacy of fundal pressure as well as publications on the prevalence of the use of fundal pressure in the
Received: May 18 2013. Accepted: August 20 2013. Reprint request to: Prof Fady M. Shawky Moiety, Department of Obstetrics and Gynecology, Shatby University Hospital, Shatby, Alexandria 21526, Egypt. Email: [email protected] Conflict of interest: There has been no conflict of interest of any kind with the authors of this work.
946
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Fundal pressure during labor
second stage of labor due to lack of documentation of such technique in medical records.2 Several previous reports suggested that the use of fundal pressure was associated with adverse maternal and fetal outcomes such as pain and discomfort from excessive pressure on the mother’s abdomen, uterine rupture,9 maternal anal sphincter tears,10 amniotic fluid embolism,11 fetal fractures, brain damage1 and neonatal brachial plexus injuries.3 However, such information may not be published for medicolegal reasons. Another concern may be the increased blood transfusion between the mother and her unborn baby which may be important with rhesus factor or when the mother has hepatitis B, HIV or other viral diseases.12 The aim of this work was to ascertain whether the fundal pressure maneuver should have a role in the contemporary management of the second stage of labor and to determine its prevalence, benefits and adverse effects on both maternal and fetal outcomes during the study duration which lasted 1 year.
Methods The present study was carried out on 8097 women admitted to the labor ward at a tertiary teaching and research obstetric center (with estimated annual deliveries of ∼24 000 cases based on the local hospital statistics). All the study subjects were admitted for vaginal delivery. The study was conducted over a period of 1 year from March 2010 to March 2011. Pregnancy between 37 and 42 weeks was an inclusion criterion. Informed consent was obtained from all women and the study was formally approved by the ethics committee of the Faculty of Medicine, Alexandria University. Other inclusion criteria included full-term pregnancy, spontaneous labor and singleton cephalic presentations. The exclusion criteria were non-vertex presentation, grand multiparity, uterine anomalies, placental abnormality, previous uterine scar, suspected fetal macrosomia, fetal heart rate abnormalities, cesarean section or instrumental delivery. None of the patients received epidural analgesia and all women were alert and responsive during the course of the study. When parturients were admitted to obstetric ward and met the inclusion criteria, the local hospital guidelines were followed by the professional team conducting all deliveries. The researchers just observed the course of labor without any interference. The women were allocated into two unequal groups: group I (fundal pressure group) including those to
whom the fundal pressure maneuver was applied (n = 1974) and group II (control group) including those who delivered spontaneously without fundal pressure (n = 6123). Oxytocin was used for induction or augmentation during the first stage of labor. With the onset of the second stage of labor (defined as the time in minutes between the cervix being fully dilated, identified by digital examination, together with the spontaneous urge to push and expulsion of the fetus)1 the oxytocin infusion was stopped. Uterine fundal pressure was then applied manually by obstetricians with one of the following modes: forearm and elbow, fist of one hand, palm of one hand or combined. The obstetrician pressed on the uppermost part of the uterus at a 30–45° angle to the maternal spine in the direction of the pelvis concomitant with each uterine contraction until delivery of the fetal head. This maneuver was performed with careful maternal observation and fetal heart rate monitoring under the supervision of skilled obstetricians. The primary outcome measure was the duration of the second stage of labor. Because the two groups were not homogenous in terms of parity, we compared the mean duration of the second stage of labor separately in the primiparous and multiparous women and when both subgroups (primiparous and multiparous) were added together. The secondary outcome measures were maternal outcomes either immediately (perineal lacerations, uterine rupture or shoulder dystocia) or delayed (at 6 months to 1 year follow-up, including dyspareunia or de novo stress urinary incontinence) and fetal outcomes (Apgar score after 5 min and neonatal admission to intensive care unit [NICU]). Statistical analysis of the data was done using SPSS version 18.0 statistical package. Values were expressed as mean ± standard deviation or percentage. Comparison of the variables between the study and control groups were performed by Student’s t-test and Pearson χ2-test. A 5% level of significance was chosen.
Results Among a total of 8563 women delivered during the study period from March 2010 to March 2011, 8097 women were studied and subjected to statistical analysis. Of those, 3114 cases (38.46%) were primiparous and 4983 cases (61.54%) were multiparous. The prevalence of uterine fundal pressure maneuver in vaginal delivery in our tertiary center was 24.38%.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
947
F. M. S. Moiety and A. Z. Azzam
Table 1 Patient characteristics in groups I (receiving fundal pressure) and II (not fundal pressure)
Age (years) Range Mean ± SD Primiparous Multiparous Gestational age at delivery (weeks) Range Mean ± SD
Group I, n = 1974 (24.38%)
Group II, n = 6123 (75.62%)
P-value
20–35 25.75 ± 4.53 1792 (90.8%) 182 (9.2%)
21–38 27.02 ± 5.49 1322 (21.6%) 4801 (78.4%)
0.001*
38–42 39.46 ± 1.51
37–42 39.33 ± 1.68
0.0001* 0.062
*Significant at P < 0.05. SD, standard deviation.
50 % 44.7%
40 %
30 %
29.3%
20 % 14.3% 11.7%
10 %
0%
Fetal distress (n= 578)
Failure to progress Maternal exhaustion in 2nd stage (n = 282) (n = 883)
Maternal medical condition (n = 231)
Figure 1 Distribution of subjects according to indications for fundal pressure.
The patient characteristics of both groups are shown in Table 1. Women in the fundal pressure group were significantly younger than those in the control group (P < 0.01). Also, the distribution of women according to indications of fundal pressure is shown in Figure 1. Modes of fundal pressure used were forearm and elbow in 34%, fist of one hand in 13.4%, palm of one hand in 11.8% or combined in 40.8% of cases. The remaining 466 cases were excluded because of cesarean delivery (171 cases) due to failure to progress in the second stage of labor (of which 97 cases were in group I and 74 cases were in group II) and forceps delivery (295 cases) due to fetal distress (of which 52 cases were in group I and 243 cases were in group II). The mean duration of the second stage of labor is shown in Table 2. There was a significant shortening in the mean duration of the second stage among primiparous women in group I compared to those in group II (21.64 ± 5.53 vs 24.32 ± 5.1, P < 0.5). However,
948
insignificant changes between both groups were seen among multiparous women and among both subgroups (primiparous and multiparous) when added together (P > 0.05). The secondary outcome measures included the maternal outcomes and the neonatal outcomes. As regards the immediate maternal outcomes, the fundal pressure maneuver in group I increased the risk of severe perineal lacerations significantly in relation to group II (10.9% vs 7.2%, P < 0.01). However, insignificant changes were found between both groups in terms of uterine rupture and shoulder dystocia (P > 0.05, Table 3a). The delayed maternal outcomes were only done on 805 women in group I and 1615 women in group II due to contact failure during the follow-up period of 6–12 months. A significant increase in dyspareunia (15.3% vs 6.3%, P < 0.01) and de novo stress urinary incontinence (8.1% vs 4.5%, P < 0.01) in group I in comparison to group II was detected (Table 3a). The maternal outcomes were also correlated to the method used in fundal pressure (Table 3b). When maternal outcomes were discussed in terms of parity in group I, severe perineal lacerations, shoulder dystocia and dyspareunia were significantly increased among primiparous women (P < 0.05). However, uterine rupture and de novo urinary incontinence were significantly increased among multiparous women (P < 0.05). Maternal outcomes are shown in Tables 4 and 5. As regards neonatal outcomes, there was a significant increase in the admission to NICU in group I in comparison to group II (5.2% vs 1.6%, P < 0.001). However, insignificant changes (P > 0.05) were detected in both groups in 5-min Apgar score of less than 7 (Table 6). With respect to parity, neonatal
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Fundal pressure during labor
Table 2 Mean duration of second stage of labor (primary outcome measures)
Duration of second stage of labor (min) Range Mean ± SD Duration of second stage in primiparous women (min) Range Mean ± SD Duration of second stage in multiparous women (min) Range Mean ± SD
P-value
Group I
Group II
n = 1974 9.06–35.74 20.83 ± 5.91 n = 1792
n = 6123 10.32–37.66 21.5 ± 5.00 n = 1322
18.5–35.74 21.64 ± 5.53 n = 182
20.3–37.66 24.32 ± 5.10 n = 4801
0.013*
9.06–18.33 14.81 ± 2.58
10.32–20.0 15.03 ± 2.89
0.062
0.077
*Significant at P < 0.05. SD, standard deviation.
Table 3a Maternal outcomes
Severe perineal lacerations Uterine rupture Shoulder dystocia
Immediate Group I Group II (n = 1974) (n = 6123)
P-value
Delayed (6–12-month follow-up) Group I Group II (n = 805) (n = 1615)
216 (10.9%)
439 (7.2%)
0.001*
Dyspareunia
29 (1.5%)
37 (0.6%)
0.07
Stress urinary incontinence
17 (0.86%)
22 (0.36%)
0.107
P-value
123 (15.3%)
101 (6.3%)
0.001*
65 (8.1%)
72 (4.5%)
0.001*
*Significant at P < 0.05.
Table 3b Maternal outcomes in relation to the method of fundal pressure Group I (n = 1974) Severe perineal lacerations
216 (10.9%) Forearm/elbow 75 34.7%
One fist 38 17.5%
One palm 3 1.3%
Combined 100 46.2%
Uterine rupture
29 (1.5%) Forearm/elbow 9 31.0%
One fist 7 24.1%
One palm 1 3.4%
Combined 12 41.3%
17 (0.86%) Forearm/elbow 12 70.5%
One fist 1 5.8%
One palm 0 0
Combined 4 23.5%
Shoulder dystocia
outcomes were significantly increased among primiparous women in comparison to multiparous women in group I (P < 0.01, Table 7).
Discussion Although the use of fundal pressure dates back to long ago, the safety of cesarean operations recently has made this maneuver less common in the management of the second stage of labor. However, some obstetri-
cians still use fundal pressure to shorten the second stage of labor as a traditionally used practice in their local areas.5,8 A dilemma exists about the use of fundal pressure. Those who advocate this maneuver blame epidural analgesia for blunting the women’s urge to push13 and/or maternal exhaustion creating an inability to push effectively.1 While those against its routine use found no reason to induce any unnecessary risks to the mother or fetus. An inability to resolve this dilemma is
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
949
F. M. S. Moiety and A. Z. Azzam
Table 4 Immediate maternal outcomes in primiparous versus multiparous women Primiparous, n = 3114 Group I, Group II, n = 1792 n = 1322 No. % No. % Severe perineal lacerations Uterine rupture Shoulder dystocia
204 24 16
11.4 1.3 0.89
92 12 7
Multiparous, n = 4983 Group I, Group II, n = 182 n = 4801 No. % No. %
P1
6.96 0.9 0.53
0.01* 0.265 0.241
12 5 1
6.6 2.7 0.55
347 25 15
7.2 0.5 0.31
P3 P2
0.745 0.01* 0.579
0.01* 0.01* 0.01*
*Significant at P ≤ 0.05. P1: relation between groups I and II in primiparous women. P2: relation between groups I and II in multiparous women. P3: relation between primiparous and multiparous women in group I.
Table 5 Delayed maternal outcomes in primiparous versus multiparous women
Dyspareunia De novo urinary incontinence
Primiparous, n = 1301 Group I, Group II, P1 n = 469 n = 832 No. % No. %
Multiparous, n = 1119 Group I, Group II, n = 336 n = 783 No. % No. %
100 24
23 41
21.3 5.1
55 38
6.6 4.6
0.001* 0.654
6.8 12.2
46 34
5.9 4.3
P3 P2
0.536 0.01*
0.001* 0.002*
*Significant at P ≤ 0.05. P1: relation between groups I and II in primiparous women. P2: relation between groups I and II in multiparous women. P3: relation between primiparous and multiparous women in group I.
Table 6 Fetal outcomes
5-min Apgar score
doi:10.1111/jog.12284
J. Obstet. Gynaecol. Res. Vol. 40, No. 4: 946–953, April 2014
Fundal pressure during the second stage of labor in a tertiary obstetric center: A prospective analysis Fady M. Shawky Moiety1,2 and Amal Z. Azzam2 1
Department of Obstetrics and Gynecology, Shatby University Hospital, and 2Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Abstract Aim: To ascertain whether uterine fundal pressure should have a role in the management of the second stage of labor and to determine its prevalence, benefits and adverse maternal–fetal outcomes. Methods: This was a prospective observational study set in a tertiary teaching and research obstetric hospital. A total of 8097 women in labor between 37 and 42 gestational weeks with a singleton cephalic presentation were enrolled. Subjects were subdivided into two groups: fundal pressure group (n = 1974 women) and control group (n = 6123 women). The primary outcome measure was the duration of the second stage. The secondary outcome measures were maternal outcomes (immediate or delayed) and neonatal outcomes. Results: The prevalence of fundal pressure in our center was 24.38%. Fundal pressure maneuver significantly shortened the duration of the second stage among primiparous women, increased the risk of severe perineal laceration and admission to neonatal intensive care unit in comparison to the non-fundal group. Delayed maternal outcomes showed significant increase in dyspareunia and de novo stress urinary incontinence in the fundal pressure group. Conclusion: Although fundal pressure maneuver shortens the duration of the second stage of labor among primiparous women, it should not be used except when indicated, and under strict guidelines owing to its adverse maternal and fetal outcomes. Key words: fundal pressure, labor, outcome.
Introduction Fundal pressure involves the application of manual pressure on the uppermost part of the uterus directed towards the birth canal in an attempt to shorten the second stage of labor.1 However, the role of fundal pressure in the management of the second stage of labor is understudied and remains controversial.2 The performance of fundal pressure differs widely between countries. It is frequently applied in conditions where instrumental deliveries are not readily available.3 In some Western countries, mainly English-
speaking, it is considered an obsolete maneuver due to intense medicolegal aspects and adverse outcomes.4,5 While in developing countries, the procedure appears to be routine practice during vaginal delivery.6,7 The clinical indications of fundal pressure are fetal distress, failure to progress in the second stage of labor and/or maternal exhaustion or medical conditions when prolonged pushing is contraindicated such as maternal heart disease.8 Relatively scarce data exists on the safety and/or efficacy of fundal pressure as well as publications on the prevalence of the use of fundal pressure in the
Received: May 18 2013. Accepted: August 20 2013. Reprint request to: Prof Fady M. Shawky Moiety, Department of Obstetrics and Gynecology, Shatby University Hospital, Shatby, Alexandria 21526, Egypt. Email: [email protected] Conflict of interest: There has been no conflict of interest of any kind with the authors of this work.
946
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Fundal pressure during labor
second stage of labor due to lack of documentation of such technique in medical records.2 Several previous reports suggested that the use of fundal pressure was associated with adverse maternal and fetal outcomes such as pain and discomfort from excessive pressure on the mother’s abdomen, uterine rupture,9 maternal anal sphincter tears,10 amniotic fluid embolism,11 fetal fractures, brain damage1 and neonatal brachial plexus injuries.3 However, such information may not be published for medicolegal reasons. Another concern may be the increased blood transfusion between the mother and her unborn baby which may be important with rhesus factor or when the mother has hepatitis B, HIV or other viral diseases.12 The aim of this work was to ascertain whether the fundal pressure maneuver should have a role in the contemporary management of the second stage of labor and to determine its prevalence, benefits and adverse effects on both maternal and fetal outcomes during the study duration which lasted 1 year.
Methods The present study was carried out on 8097 women admitted to the labor ward at a tertiary teaching and research obstetric center (with estimated annual deliveries of ∼24 000 cases based on the local hospital statistics). All the study subjects were admitted for vaginal delivery. The study was conducted over a period of 1 year from March 2010 to March 2011. Pregnancy between 37 and 42 weeks was an inclusion criterion. Informed consent was obtained from all women and the study was formally approved by the ethics committee of the Faculty of Medicine, Alexandria University. Other inclusion criteria included full-term pregnancy, spontaneous labor and singleton cephalic presentations. The exclusion criteria were non-vertex presentation, grand multiparity, uterine anomalies, placental abnormality, previous uterine scar, suspected fetal macrosomia, fetal heart rate abnormalities, cesarean section or instrumental delivery. None of the patients received epidural analgesia and all women were alert and responsive during the course of the study. When parturients were admitted to obstetric ward and met the inclusion criteria, the local hospital guidelines were followed by the professional team conducting all deliveries. The researchers just observed the course of labor without any interference. The women were allocated into two unequal groups: group I (fundal pressure group) including those to
whom the fundal pressure maneuver was applied (n = 1974) and group II (control group) including those who delivered spontaneously without fundal pressure (n = 6123). Oxytocin was used for induction or augmentation during the first stage of labor. With the onset of the second stage of labor (defined as the time in minutes between the cervix being fully dilated, identified by digital examination, together with the spontaneous urge to push and expulsion of the fetus)1 the oxytocin infusion was stopped. Uterine fundal pressure was then applied manually by obstetricians with one of the following modes: forearm and elbow, fist of one hand, palm of one hand or combined. The obstetrician pressed on the uppermost part of the uterus at a 30–45° angle to the maternal spine in the direction of the pelvis concomitant with each uterine contraction until delivery of the fetal head. This maneuver was performed with careful maternal observation and fetal heart rate monitoring under the supervision of skilled obstetricians. The primary outcome measure was the duration of the second stage of labor. Because the two groups were not homogenous in terms of parity, we compared the mean duration of the second stage of labor separately in the primiparous and multiparous women and when both subgroups (primiparous and multiparous) were added together. The secondary outcome measures were maternal outcomes either immediately (perineal lacerations, uterine rupture or shoulder dystocia) or delayed (at 6 months to 1 year follow-up, including dyspareunia or de novo stress urinary incontinence) and fetal outcomes (Apgar score after 5 min and neonatal admission to intensive care unit [NICU]). Statistical analysis of the data was done using SPSS version 18.0 statistical package. Values were expressed as mean ± standard deviation or percentage. Comparison of the variables between the study and control groups were performed by Student’s t-test and Pearson χ2-test. A 5% level of significance was chosen.
Results Among a total of 8563 women delivered during the study period from March 2010 to March 2011, 8097 women were studied and subjected to statistical analysis. Of those, 3114 cases (38.46%) were primiparous and 4983 cases (61.54%) were multiparous. The prevalence of uterine fundal pressure maneuver in vaginal delivery in our tertiary center was 24.38%.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
947
F. M. S. Moiety and A. Z. Azzam
Table 1 Patient characteristics in groups I (receiving fundal pressure) and II (not fundal pressure)
Age (years) Range Mean ± SD Primiparous Multiparous Gestational age at delivery (weeks) Range Mean ± SD
Group I, n = 1974 (24.38%)
Group II, n = 6123 (75.62%)
P-value
20–35 25.75 ± 4.53 1792 (90.8%) 182 (9.2%)
21–38 27.02 ± 5.49 1322 (21.6%) 4801 (78.4%)
0.001*
38–42 39.46 ± 1.51
37–42 39.33 ± 1.68
0.0001* 0.062
*Significant at P < 0.05. SD, standard deviation.
50 % 44.7%
40 %
30 %
29.3%
20 % 14.3% 11.7%
10 %
0%
Fetal distress (n= 578)
Failure to progress Maternal exhaustion in 2nd stage (n = 282) (n = 883)
Maternal medical condition (n = 231)
Figure 1 Distribution of subjects according to indications for fundal pressure.
The patient characteristics of both groups are shown in Table 1. Women in the fundal pressure group were significantly younger than those in the control group (P < 0.01). Also, the distribution of women according to indications of fundal pressure is shown in Figure 1. Modes of fundal pressure used were forearm and elbow in 34%, fist of one hand in 13.4%, palm of one hand in 11.8% or combined in 40.8% of cases. The remaining 466 cases were excluded because of cesarean delivery (171 cases) due to failure to progress in the second stage of labor (of which 97 cases were in group I and 74 cases were in group II) and forceps delivery (295 cases) due to fetal distress (of which 52 cases were in group I and 243 cases were in group II). The mean duration of the second stage of labor is shown in Table 2. There was a significant shortening in the mean duration of the second stage among primiparous women in group I compared to those in group II (21.64 ± 5.53 vs 24.32 ± 5.1, P < 0.5). However,
948
insignificant changes between both groups were seen among multiparous women and among both subgroups (primiparous and multiparous) when added together (P > 0.05). The secondary outcome measures included the maternal outcomes and the neonatal outcomes. As regards the immediate maternal outcomes, the fundal pressure maneuver in group I increased the risk of severe perineal lacerations significantly in relation to group II (10.9% vs 7.2%, P < 0.01). However, insignificant changes were found between both groups in terms of uterine rupture and shoulder dystocia (P > 0.05, Table 3a). The delayed maternal outcomes were only done on 805 women in group I and 1615 women in group II due to contact failure during the follow-up period of 6–12 months. A significant increase in dyspareunia (15.3% vs 6.3%, P < 0.01) and de novo stress urinary incontinence (8.1% vs 4.5%, P < 0.01) in group I in comparison to group II was detected (Table 3a). The maternal outcomes were also correlated to the method used in fundal pressure (Table 3b). When maternal outcomes were discussed in terms of parity in group I, severe perineal lacerations, shoulder dystocia and dyspareunia were significantly increased among primiparous women (P < 0.05). However, uterine rupture and de novo urinary incontinence were significantly increased among multiparous women (P < 0.05). Maternal outcomes are shown in Tables 4 and 5. As regards neonatal outcomes, there was a significant increase in the admission to NICU in group I in comparison to group II (5.2% vs 1.6%, P < 0.001). However, insignificant changes (P > 0.05) were detected in both groups in 5-min Apgar score of less than 7 (Table 6). With respect to parity, neonatal
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Fundal pressure during labor
Table 2 Mean duration of second stage of labor (primary outcome measures)
Duration of second stage of labor (min) Range Mean ± SD Duration of second stage in primiparous women (min) Range Mean ± SD Duration of second stage in multiparous women (min) Range Mean ± SD
P-value
Group I
Group II
n = 1974 9.06–35.74 20.83 ± 5.91 n = 1792
n = 6123 10.32–37.66 21.5 ± 5.00 n = 1322
18.5–35.74 21.64 ± 5.53 n = 182
20.3–37.66 24.32 ± 5.10 n = 4801
0.013*
9.06–18.33 14.81 ± 2.58
10.32–20.0 15.03 ± 2.89
0.062
0.077
*Significant at P < 0.05. SD, standard deviation.
Table 3a Maternal outcomes
Severe perineal lacerations Uterine rupture Shoulder dystocia
Immediate Group I Group II (n = 1974) (n = 6123)
P-value
Delayed (6–12-month follow-up) Group I Group II (n = 805) (n = 1615)
216 (10.9%)
439 (7.2%)
0.001*
Dyspareunia
29 (1.5%)
37 (0.6%)
0.07
Stress urinary incontinence
17 (0.86%)
22 (0.36%)
0.107
P-value
123 (15.3%)
101 (6.3%)
0.001*
65 (8.1%)
72 (4.5%)
0.001*
*Significant at P < 0.05.
Table 3b Maternal outcomes in relation to the method of fundal pressure Group I (n = 1974) Severe perineal lacerations
216 (10.9%) Forearm/elbow 75 34.7%
One fist 38 17.5%
One palm 3 1.3%
Combined 100 46.2%
Uterine rupture
29 (1.5%) Forearm/elbow 9 31.0%
One fist 7 24.1%
One palm 1 3.4%
Combined 12 41.3%
17 (0.86%) Forearm/elbow 12 70.5%
One fist 1 5.8%
One palm 0 0
Combined 4 23.5%
Shoulder dystocia
outcomes were significantly increased among primiparous women in comparison to multiparous women in group I (P < 0.01, Table 7).
Discussion Although the use of fundal pressure dates back to long ago, the safety of cesarean operations recently has made this maneuver less common in the management of the second stage of labor. However, some obstetri-
cians still use fundal pressure to shorten the second stage of labor as a traditionally used practice in their local areas.5,8 A dilemma exists about the use of fundal pressure. Those who advocate this maneuver blame epidural analgesia for blunting the women’s urge to push13 and/or maternal exhaustion creating an inability to push effectively.1 While those against its routine use found no reason to induce any unnecessary risks to the mother or fetus. An inability to resolve this dilemma is
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
949
F. M. S. Moiety and A. Z. Azzam
Table 4 Immediate maternal outcomes in primiparous versus multiparous women Primiparous, n = 3114 Group I, Group II, n = 1792 n = 1322 No. % No. % Severe perineal lacerations Uterine rupture Shoulder dystocia
204 24 16
11.4 1.3 0.89
92 12 7
Multiparous, n = 4983 Group I, Group II, n = 182 n = 4801 No. % No. %
P1
6.96 0.9 0.53
0.01* 0.265 0.241
12 5 1
6.6 2.7 0.55
347 25 15
7.2 0.5 0.31
P3 P2
0.745 0.01* 0.579
0.01* 0.01* 0.01*
*Significant at P ≤ 0.05. P1: relation between groups I and II in primiparous women. P2: relation between groups I and II in multiparous women. P3: relation between primiparous and multiparous women in group I.
Table 5 Delayed maternal outcomes in primiparous versus multiparous women
Dyspareunia De novo urinary incontinence
Primiparous, n = 1301 Group I, Group II, P1 n = 469 n = 832 No. % No. %
Multiparous, n = 1119 Group I, Group II, n = 336 n = 783 No. % No. %
100 24
23 41
21.3 5.1
55 38
6.6 4.6
0.001* 0.654
6.8 12.2
46 34
5.9 4.3
P3 P2
0.536 0.01*
0.001* 0.002*
*Significant at P ≤ 0.05. P1: relation between groups I and II in primiparous women. P2: relation between groups I and II in multiparous women. P3: relation between primiparous and multiparous women in group I.
Table 6 Fetal outcomes
5-min Apgar score
