Delayed diagnosis of an atypical rupture of an unscarred uterus due to assisted fundal pressure: a case report

Kristeller maneuvers or fundal pressure and maternal/neonatal morbidity: obstetric and judicial literature review

AIM

A significant amount of data concerning maternal-fetal damage arising from the exertion of Kristeller maneuvers (KMs) or fundal pressure (FP) go unreleased due to medicolegal implications.

MATERIALS AND METHODS

For this reason, the paper gathers information as to the real magnitude of litigation related to FP-induced damages and injuries. The authors have undertaken a research in order to include general search engines (PubMed-Medline, Cochrane, Embase, Google, GyneWeb) and legal databases (De Jure, Italian database of jurisprudence daily update; Westlaw, Thomson Reuters, American ruling database and Bailii, UK Court Ruling Database).

RESULTS

Results confirm said phenomenon to be more wide ranging than it appears through official channels. Several courts of law, both in the United States of America (USA) and in European Union (EU) Member States as well, have ruled against the use of the maneuver itself, assuming a stance conducive to a presumption of guilt against those doctors and healthcare providers who resorted to KMs or FP during deliveries. Given how rife FP is in mainstream obstetric practice, it is as if there were a wide gap between obstetric real-life and what official jurisprudence and healthcare institutions-sanctioned official practices are.

CONCLUSION

The authors think that it would be desirable to draft specifically targeted guidelines or recommendations on maneuvers during vaginal delivery, in which to point out exactly what kinds of maneuvering techniques are to be absolutely banned and what maneuvers are to be allowed, and under what conditions their application can be considered appropriate.

Selective uterine fundal pressure maneuver during the second stage of the first twin delivery at near term

OBJECTIVE

We examined the perinatal outcomes of twin deliveries following selective uterine fundal pressure maneuver (UFPM) during the second stage of the first twin delivery.

METHODS

At our institute, if non-reassuring fetal heart rate and/or maternal exhaustion were observed during the second stage of the first twin, selective UFPM was performed following making sure of the position of the first twin's buttocks by ultrasonography. We reviewed the obstetric records of all cases of trial of vaginal delivery of twins between 2002 and 2012.

RESULTS

A total of 64 cases were evaluated for the statistical analyses. Of these, selective UFPM for the first twin was performed in 15 cases (24%). Although the cases requiring selective UFPM for the first twin was associated with an increased postpartum hemorrhage, there were no significant differences in neonatal outcomes between the two groups.

CONCLUSION

There was no evidence that the selective UFPM is unsafe for both mother and two babies during the second stage of the first twin delivery.

Fundal pressure during the second stage of labor in a tertiary obstetric center: a prospective analysis

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.

Intestinal adhesion due to previous uterine surgery as a risk factor for delayed diagnosis of uterine rupture: a case report

Introduction

Uterine rupture is a life-threatening condition both to mothers and fetuses. Its early diagnosis and treatment may save their lives. Previous myomectomy is a high risk factor for uterine rupture. Intestinal adhesion due to previous myomectomy may also prevent early diagnosis of uterine rupture.

Case presentation

A 38-year-old primiparous non-laboring Japanese woman with a history of myomectomy was admitted in her 34^th week due to lower abdominal pain. Although the pain was slight and her vital signs were stable, computed tomography revealed massive fluid collection in her abdominal cavity, which led us to perform a laparotomy. Uterine rupture had occurred at the site of the previous myomectomy; however, the small intestine was adhered tightly to the rupture, thus masking it. The baby was delivered through a low uterine segment transverse incision. The ruptured uterine wall was reconstructed.

Conclusion

Intestinal adhesion due to a prior myomectomy occluded a uterine rupture, possibly masking its symptoms and signs, which may have prevented early diagnosis.

Shortening the second stage of labor?

OBJECTIVE

To evaluate the benefits and risks of using uterine fundal pressure in shortening the second stage of labor and on the obstetrical outcome.

MATERIAL AND METHODS

A pilot study comprising 209 primigravidae between 37 and 40 gestational weeks with singleton fetus in cephalic presentation admitted to the delivery suite were considered and were randomly allocated into two groups: I (n=101) and II (n=108), with or without manual fundal pressure, respectively, during the second stage of labor. Main observation measures considered were: duration of the second stage of labor was the primary outcome measure and the secondary outcome measures were severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death.

RESULTS

There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures. Significant adverse findings having no mention in the earlier literature, were noticed which were: one case each of retained placenta and uterine prolapse besides increased evidence of maternal exhaustion and perineal injuries (including one case of complete perineal tear) in the group where fundal pressure was exercised.

CONCLUSION

Application of uterine fundal pressure in a delivering woman was not only ineffective in shortening the second stage of labor but added to the risks during parturition.