What is the difference between fundal pressure and fundal support during delivery?

Fundal Pressure vs. Fundal Support During Delivery

Fundal pressure is a potentially harmful maneuver that applies direct downward force on the uterine fundus during delivery and should be avoided, while fundal support is a gentle guiding technique that stabilizes the uterus without applying significant pressure.

Key Differences

Fundal Pressure

• Definition: Manual pressure applied to the uppermost part of the uterus directed toward the birth canal
• Technique: Involves pressing on the uterine fundus with forearms, elbows, or palms at a 30° to 45° angle to the maternal spine 1
• Purpose: Attempt to assist vaginal delivery and avoid prolonged second stage or need for operative delivery 2
• Evidence: Lacks scientific evidence supporting its safety or efficacy 2
• Status: Discouraged or banned in many settings due to potential complications 3

Fundal Support

• Definition: Gentle stabilization of the uterus during delivery
• Technique: Involves minimal contact with the fundus to provide guidance rather than force
• Purpose: To stabilize the uterine position during delivery, particularly during cesarean sections
• Evidence: Considered acceptable when performed appropriately by experienced providers
• Status: Recognized as a potentially helpful maneuver when used appropriately

Risks and Complications

Fundal Pressure Complications

• Severe perineal lacerations (28.1% vs 4.8% in controls) 4
• Uterine rupture 1
• Postpartum urinary retention 1
• Rib fracture 1
• Postpartum dyspareunia 5
• De novo stress urinary incontinence 5
• Neonatal distress or trauma 1
• Increased risk of NICU admission 5

Fundal Support Considerations

• When performed correctly, minimal risk of complications
• Should be performed only by experienced providers
• Only minimal contact should be used during cesarean deliveries 6

Clinical Application

When Fundal Pressure Is Used (Despite Recommendations Against It)

• Prevalence remains high (24.38% in one study) despite lack of evidence 5
• More commonly used in:
  • Primiparity (76.9% vs 53.3% in controls) 4
  • Larger maternal weight gain during pregnancy 4
  • Longer duration of labor 4
• Often performed in secret or described euphemistically as "just a little help" 3

When Fundal Support Is Appropriate

• During cesarean delivery, only minimal fundal support should be used to assist delivery 6
• Should be performed by the most experienced surgeon available 6
• Particularly important in cases of impacted fetal head during cesarean delivery 6

Best Practices

1. Avoid fundal pressure during vaginal deliveries due to documented risks and lack of evidence supporting benefits
2. Use minimal fundal support during cesarean deliveries when necessary
3. Consider alternatives to fundal pressure for prolonged second stage:
   • Position changes
   • Directed pushing techniques
   • Instrumental delivery when indicated
   • Cesarean section when appropriate

Common Pitfalls and Caveats

1. Terminology confusion: Providers may use terms interchangeably or refer to fundal pressure with euphemisms
2. Unauthorized use: Despite being officially discouraged, fundal pressure continues to be practiced widely 3
3. Training gaps: Many providers learn fundal pressure techniques through informal channels rather than standard training 3
4. Patient consent issues: Women may plan to refuse fundal pressure but find it difficult when the procedure is presented as "help" 3
5. False sense of safety: Some providers believe they practice a "gentler" version of fundal pressure that is safer, despite lack of evidence 3

Fundal pressure should not be confused with the appropriate techniques for managing impacted fetal head during cesarean delivery, which may include reverse breech extraction or the Patwardhan method rather than direct fundal pressure 6.