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Nakamura-Pereira M, Takemoto MLS, Bittencourt SDDA, Viellas EF, do Carmo CN, Schilithz AOC, Theme Filha MM, Leal MDC. Agreement between maternal self-report of birth-related information and medical records in Brazil: A comparison study between public, mixed, and private hospitals. Birth 2023; 50:789-797. [PMID: 37256263 DOI: 10.1111/birt.12731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/12/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND The study aims to assess agreement between data obtained from interviews with postpartum women and their health records about labor and birth characteristics, newborn care, and reasons for cesarean birth. METHODS The present study analyzes the Birth in Brazil study dataset, a nationwide hospital-based survey that included 23,894 postpartum women. Reliability was assessed using kappa coefficients and 95% confidence intervals. We also calculated the proportion of specific agreement: the observed proportion of positive agreement (Ppos) and the observed proportion of negative agreement (Pneg). RESULTS In terms of labor and birth characteristics, more significant discrepancies in prevalence were observed for fundal pressure (1.4%-42.6%), followed by amniotomy, and augmentation. All of these variables were reported more frequently by women. Reliability was nearly perfect only for mode of delivery (kappa 0.99-1.00, Ppos and Pneg >99.0%). Higher discrepancies in reasons for cesarean prevalence were observed for previous cesarean birth (CB) (3.9%-10.4%) and diabetes mellitus (0.5%-8.5%). Most kappa coefficients for CB reasons were moderate to substantial. Lower coefficients were seen for diabetes mellitus, induction failure, and prelabor rupture of membranes and Pneg was consistently higher than Ppos. DISCUSSION Our findings raise relevant questions about the quality of information shared with women during and after the process of care for labor and birth, as well as the information recorded in medical charts. Not having access to full information about their own health status at birth may impair women's health promotion behaviors or clear disclosure of risk factors in future interactions with the healthcare system.
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Affiliation(s)
- Marcos Nakamura-Pereira
- National Institute of Women, Children and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, FIOCRUZ/RJ, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | - Maria do Carmo Leal
- National School of Public Health-Oswaldo Cruz Foundation, FIOCRUZ/RJ, Rio de Janeiro, Brazil
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Sagi-Dain L, Maymon R. The condemned fundal pressure maneuver: time to reconsider? Arch Gynecol Obstet 2022; 306:1953-1957. [PMID: 35277748 DOI: 10.1007/s00404-022-06497-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/26/2022] [Indexed: 11/26/2022]
Abstract
Due to a concern of severe adverse neonatal and maternal complications, fundal pressure (FP) maneuver has been discouraged by several national obstetric guidelines as well as the World Health Organization. In this manuscript, we argue that previously published evidence pointing to unfavorable effects of FP might not be relevant to the common practice. Our main concern is that the inherent limitations of published studies undermining the association of FP with various obstetric complications, in conjunction with fear of medical-legal implications, might lead to an absolute avoidance of this procedure, with a potential subsequent increase in vacuum-assisted and cesarean deliveries. We suggest establishing standardized guidelines for FP application, intend to prevent application of uncontrollable and aggressive pressure, assist the obstetricians in case of legal claims, and yet to preserve the use of gentle and respectful FP application to benefit the delivery.
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Affiliation(s)
- Lena Sagi-Dain
- Genetics Institute, Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Ron Maymon
- Department of OB/GYN, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kamijo K, Shigemi D, Kaszynski RH, Nakajima M. Association between placental location and neonatal outcomes in manual fundal pressure-assisted vaginal deliveries: A retrospective single-center study in Japan. J Obstet Gynaecol Res 2022; 48:1691-1697. [PMID: 35534940 DOI: 10.1111/jog.15268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/08/2022] [Accepted: 04/06/2022] [Indexed: 11/30/2022]
Abstract
AIM Manual fundal pressure (MFP) is still used to assist vaginal deliveries during the second stage of labor in predominantly lower-middle income countries; however, there is insufficient evidence on the risk factors in MFP-assisted vaginal deliveries for adverse neonatal outcomes. The aim of the present study was to investigate the association between placental location and neonatal outcomes in MFP-assisted vaginal deliveries. METHODS The present study was a single-center retrospective cohort study in patients with all MFP-assisted vaginal singleton deliveries from January 2016 to December 2020. Placental location was divided into two categories: posterior-lateral and anterior-fundal. The primary outcome was a neonatal adverse composite including umbilical artery blood pH <7.2, Apgar score <7 at 5 min, neonatal intensive care unit admission and neonatal resuscitation. We used multivariable logistic regression models to investigate the association between placental location and neonatal outcomes. RESULTS We extracted 522 MFP-assisted deliveries among 5053 vaginal deliveries. The proportion of posterior-lateral and anterior-fundal placentation was 239 (45.8%) and 283 (54.2%), respectively. The crude prevalence of neonatal composite outcome in the anterior-fundal group was significantly higher than that in the posterior-lateral group (39.6% vs. 28.9%; p = 0.013). Multivariable logistic regression analysis found that the prevalence of neonatal adverse outcome in the anterior-fundal group was significantly higher compared with the posterior-lateral group (adjusted odds ratio, 1.52; 95% confidence interval, 1.04-2.23). CONCLUSION Anterior-fundal placentation was significantly associated with an increased risk of neonatal adverse outcomes compared to posterior-lateral placentation in MFP-assisted vaginal deliveries.
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Affiliation(s)
- Kyosuke Kamijo
- Department of Obstetrics and Gynecology, Iida Municipal Hospital, Iida, Japan.,Department of Obstetrics and Gynecology, Nagano Prefectural Kiso Hospital, Kiso-gun, Japan
| | - Daisuke Shigemi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Richard H Kaszynski
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Mikio Nakajima
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan.,Emergency Life-Saving Technique Academy of Tokyo, Foundation for Ambulance Service Development, Tokyo, Japan
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Akpınar G, Kanbur A. Effect of uterine fundal pressure applied in the second stage of labor on birth outcomes and neonatal oxygen saturation. J Obstet Gynaecol Res 2022; 48:1165-1174. [PMID: 35231953 DOI: 10.1111/jog.15204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/20/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
AIM To examine the effect of fundal pressure applied in the second stage of labor on birth outcomes and neonatal O2 saturation. METHODS The study is of a descriptive and comparative type. Research data were collected in the obstetrics clinic of a Maternity Hospital between August 15, 2019 and February 15, 2020. The study sample consisted of 160 pregnant women who met the research criteria (80 pregnant women who received fundal pressure, 80 pregnant women who did not receive fundal pressure). RESULTS The duration of the second and third stages of labor was found to be shorter in the nonfundal pressure group (t = -3.422, p = 0.001; t = 2.195, p = 0.030). When the groups were compared, the formation of perineal trauma and second-degree laceration, episiotomy requirement, elongation of the episiotomy incision and cervical laceration rate were found to be significantly higher in the fundal pressure group χ2 = 10.794 p = 0.001; χ2 = 8.403 p = 0.004; χ2 = 10.014, p = 0.002; χ2 = 16.579 p = 0.000; χ2 = 16.276 p = 0.000). The 1st and 5th min Apgar scores of the newborns were lower in the fundal pressure group (t = -6.377, p = 0.000; t = -3.581, p = 0.001). The 1st, 5th, 10th, and 15th min oxygen saturation of the newborns were determined to be significantly lower in the fundal pressure group (t = -4.753, p = 0.000; t = -2.427, p = 0.016; t = -2.604, p = 0.010; t = -2.492, p = 0.014). CONCLUSION According to the study results, it was determined that the uterine fundal pressure has a negative effect on birth outcomes and neonatal oxygen saturation. Adverse effects of fundal pressure application should be revealed in different aspects.
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Affiliation(s)
- Gamze Akpınar
- Department of Midwifery, Graduate School of Health Science, Atatürk University, Erzurum, Turkey
| | - Ayla Kanbur
- Department of Midwifery, Faculty of Health Science, Atatürk University, Erzurum, Turkey
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5
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Kamijo K, Shigemi D, Nakajima M, Kaszynski RH, Ohira S. Association between the number of pulls and adverse neonatal/maternal outcomes in vacuum-assisted delivery. J Perinat Med 2021; 49:583-589. [PMID: 33600672 DOI: 10.1515/jpm-2020-0433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/27/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine the association between the number of pulls during vacuum-assisted deliver and neonatal and maternal complications. METHODS This was a single-center observational study using a cohort of pregnancies who underwent vacuum-assisted delivery from 2013 to 2020. We excluded pregnancies transitioning to cesarean section after a failed attempt at vacuum-assisted delivery. The number of pulls to deliver the neonate was categorized into 1, 2, 3, and ≥4 pulls. We used logistic regression models to investigate the association between the number of pulls and neonatal intensive care unit (NICU) admission and maternal composite outcome (severe perineal laceration, cervical laceration, transfusion, and postpartum hemorrhage ≥500 mL). RESULTS We extracted 480 vacuum-assisted deliveries among 7,321 vaginal deliveries. The proportion of pregnancies receiving 1, 2, 3, or ≥4 pulls were 51.9, 28.3, 10.8, and 9.0%, respectively. The crude prevalence of NICU admission with 1, 2, 3, and ≥4 pulls were 10.8, 16.2, 15.4, and 27.9%, respectively. The prevalence of NICU admission, amount of postpartum hemorrhage, and postpartum hemorrhage ≥500 mL were significantly different between the four groups. Multivariable logistic regression analysis found the prevalence of NICU admission in the ≥4 pulls group was significantly higher compared with the 1 pull group (adjusted odds ratio, 3.3; 95% confidence interval, 1.4-7.8). In contrast, maternal complications were not significantly associated with the number of pulls. CONCLUSIONS Vacuum-assisted delivery with four or more pulls was significantly associated with an increased risk of NICU admission. However, the number of pulls was not associated with maternal complications.
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Affiliation(s)
- Kyosuke Kamijo
- Department of Obstetrics and Gynecology, Iida Municipal Hospital, Iida, Japan
| | - Daisuke Shigemi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Mikio Nakajima
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Richard H Kaszynski
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Ohira
- Department of Obstetrics and Gynecology, Iida Municipal Hospital, Iida, Japan
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Farrington E, Connolly M, Phung L, Wilson AN, Comrie-Thomson L, Bohren MA, Homer CSE, Vogel JP. The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis. Reprod Health 2021; 18:98. [PMID: 34006288 PMCID: PMC8132352 DOI: 10.1186/s12978-021-01148-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uterine fundal pressure involves a birth attendant pushing on the woman's uterine fundus to assist vaginal birth. It is used in some clinical settings, though guidelines recommend against it. This systematic review aimed to determine the prevalence of uterine fundal pressure during the second stage of labour for women giving birth vaginally at health facilities. METHODS The population of interest were women who experienced labour in a health facility and in whom vaginal birth was anticipated. The primary outcome was the use of fundal pressure during second stage of labour. MEDLINE, EMBASE, CINAHL and Global Index Medicus databases were searched for eligible studies published from 1 January 2000 onwards. Meta-analysis was conducted to determine a pooled prevalence, with subgroup analyses to explore heterogeneity. RESULTS Eighty data sets from 76 studies (n = 898,544 women) were included, reporting data from 22 countries. The prevalence of fundal pressure ranged from 0.6% to 69.2% between studies, with a pooled prevalence of 23.2% (95% CI 19.4-27.0, I2 = 99.97%). There were significant differences in prevalence between country income level (p < 0.001, prevalence highest in lower-middle income countries) and method of measuring use of fundal pressure (p = 0.001, prevalence highest in studies that measured fundal pressure based on women's self-report). CONCLUSIONS The use of uterine fundal pressure on women during vaginal birth in health facilities is widespread. Efforts to prevent this potentially unnecessary and harmful practice are needed.
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Affiliation(s)
- Elise Farrington
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia.
| | - Mairead Connolly
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Laura Phung
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Alyce N Wilson
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Liz Comrie-Thomson
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Meghan A Bohren
- Gender and Women's Health Unit, School of Population and Global Health, Centre for Health Equity, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Caroline S E Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- School of Population and Global Health, The University of Melbourne, Parkville, VIC, 2010, Australia
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7
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Papadakis K. Critical appraisal of the role of applying uterine fundal pressure in labour: First, do no harm. HYPERTENSION RESEARCH IN PREGNANCY 2019. [DOI: 10.14390/jsshp.hrp2019-007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Youssef A, Salsi G, Cataneo I, Pacella G, Azzarone C, Paganotto MC, Krsmanovic J, Montaguti E, Cariello L, Bellussi F, Rizzo N, Pilu G. Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:95-100. [PMID: 29749657 DOI: 10.1002/uog.19085] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/16/2018] [Accepted: 04/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury. METHODS This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion. RESULTS During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51)). CONCLUSION The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Salsi
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - I Cataneo
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Pacella
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - C Azzarone
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
- Department of Obstetrics and Gynecology, Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy
| | - M C Paganotto
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - J Krsmanovic
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
- Clinic for Gynecology and Obstetrics, University of Southampton, Kassel School of Medicine, Kassel, Germany
| | - E Montaguti
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - L Cariello
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - F Bellussi
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - N Rizzo
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Pilu
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Ekéus C, Wrangsell K, Penttinen S, Åberg K. Neonatal complications among 596 infants delivered by vacuum extraction (in relation to characteristics of the extraction). J Matern Fetal Neonatal Med 2017. [DOI: 10.1080/14767058.2017.1344631] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Cecilia Ekéus
- Department of Women’s and Children’s Health, Division of Reproductive Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Katarina Åberg
- Department of Women’s and Children’s Health, Division of Reproductive Health, Karolinska Institutet, Stockholm, Sweden
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Abstract
BACKGROUND Fundal pressure during the second stage of labour (also known as the 'Kristeller manoeuvre') involves application of manual pressure to the uppermost part of the uterus directed towards the birth canal, in an attempt to assist spontaneous vaginal birth and avoid prolonged second stage or the need for operative birth. Fundal pressure has also been applied using an inflatable belt. Fundal pressure is widely used, however methods of its use vary widely. Despite strongly held opinions in favour of and against the use of fundal pressure, there is limited evidence regarding its maternal and neonatal benefits and harms. There is a need for objective evaluation of the effectiveness and safety of fundal pressure in the second stage of labour. OBJECTIVES To determine if fundal pressure is effective in achieving spontaneous vaginal birth, and preventing prolonged second stage or the need for operative birth, and to explore maternal and neonatal adverse effects related to fundal pressure. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (30 November 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of fundal pressure (manual or by inflatable belt) versus no fundal pressure in women in the second stage of labour with singleton cephalic presentation. DATA COLLECTION AND ANALYSIS Two or more review authors independently assessed potential studies for inclusion and quality. We extracted data using a pre-designed form. We entered data into Review Manager 5 software and checked for accuracy. MAIN RESULTS Nine trials are included in this updated review. Five trials (3057 women) compared manual fundal pressure versus no fundal pressure. Four trials (891 women) compared fundal pressure by means of an inflatable belt versus no fundal pressure. It was not possible to blind women and staff to this intervention. We assessed two trials as being at high risk of attrition bias and another at high risk of reporting bias. All other trials were low or unclear for other risk of bias domains. Most of the trials had design limitations. Heterogeneity was high for the majority of outcomes. Manual fundal pressure versus no fundal pressureManual fundal pressure was not associated with changes in: spontaneous vaginal birth within a specified time (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.71 to 1.28; 120 women; 1 trial; very low-quality evidence), instrumental births (RR 3.28, 95% CI 0.14 to 79.65; 197 women; 1 trial), caesarean births (RR 1.10, 95% CI 0.07 to 17.27; 197 women; 1 trial), operative birth (average RR 0.66, 95% CI 0.12 to 3.55; 317 women; 2 studies; I² = 43%; Tau² = 0.71; very low-quality evidence), duration of second stage (mean difference (MD) -0.80 minutes, 95% CI -3.66 to 2.06 minutes; 194 women; 1 study; very low-quality evidence), low arterial cord pH in newborn babies (RR 1.07, 95% CI 0.72 to 1.58; 297 women; 2 trials; very low-quality evidence), or Apgar scores less than seven at five minutes (average RR 4.48, 95% CI 0.28 to 71.45; 2759 infants; 4 trials; I² = 89%; Tau² = 3.55; very low-quality evidence). More women who received manual fundal pressure had cervical tears than in the control group (RR 4.90, 95% CI 1.09 to 21.98; 295 women; 1 trial). No neonatal deaths occurred in either of the two studies reporting this outcome (very low-quality evidence). No trial reported the outcome severe maternal morbidity or death. Fundal pressure by inflatable belt versus no fundal pressureFundal pressure by inflatable belt did not reduce the number of women havinginstrumental births (average RR 0.73, 95% CI 0.52 to 1.02; 891 women; 4 trials; I² = 52%; Tau² = 0.05) or operative births (average RR 0.62, 95% CI 0.38 to 1.01; 891 women; 4 trials; I² = 78%; Tau² = 0.14; very low-quality evidence). Heterogeneity was high for both outcomes. Duration of second stage was reported in two trials, which both showed that inflatable belts shortened duration of labour in nulliparous women (average MD -50.80 minutes, 95% CI -94.85 to -6.74 minutes; 253 women; 2 trials; I² = 97%; Tau² = 975.94; very low-quality evidence). No data on this outcome were available for multiparous women. The inflatable belt did not make any difference to rates of caesarean births (average RR 0.56, 95% CI 0.14 to 2.26; 891 women; 4 trials; I² = 70%; Tau² = 0.98), low arterial cord pH in newborn babies (RR 0.47, 95% CI 0.09 to 2.55; 461 infants; 1 trial; low-quality evidence), or Apgar scores less than seven at five minutes (RR 4.62, 95% CI 0.22 to 95.68; 500 infants; 1 trial; very low-quality evidence). Third degree perineal tears were increased in the inflatable belt group (RR 15.69, 95% CI 2.10 to 117.02; 500 women; 1 trial). Spontaneous vaginal birth within a specified time, neonatal death, andsevere maternal morbidity or death were not reported in any trial. AUTHORS' CONCLUSIONS There is insufficient evidence to draw conclusions on the beneficial or harmful effects of fundal pressure, either manually or by inflatable belt. Fundal pressure by an inflatable belt during the second stage of labour may shorten duration of second stage for nulliparous women, and lower rates of operative birth. However, existing studies are small and their generalizability is uncertain. There is insufficient evidence regarding safety for the baby. There is no evidence on the use of fundal pressure in specific clinical settings such as inability of the mother to bear down due to exhaustion or unconsciousness. There is currently insufficient evidence for the routine use of fundal pressure by any method on women in the second stage of labour. Because of current widespread use of the procedure and the potential for use in settings where other methods of assisted birth are not available, further good quality trials are needed. Further evaluation in other groups of women (such as multiparous women) will also be required. Future research should describe in detail how fundal pressure was applied and consider safety of the unborn baby, perineal outcomes, longer-term maternal and infant outcomes and maternal satisfaction.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Joshua P Vogel
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and ResearchAvenue Appia 20GenevaSwitzerlandCH‐1211
| | - Anna Cuthbert
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Mandisa Singata
- University of the Witwatersrand/University of Fort Hare/East London Hospital complexEffective Care Research UnitEast LondonSouth Africa
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