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Uterine rupture after the uterine fundal pressure maneuver

Authors:
  • St. Marianna University Graduate School of Medicine

Abstract

To clarify the incidence of uterine fundal pressure at delivery and its effect on uterine rupture. A questionnaire was sent to 2518 institutions in Japan. We received a response from 1430. Of reporting institutions, 89.4% used fundal pressure in at least some of their deliveries. Among the 347,771 women who delivered vaginally in this study, 38,973 (11.2%) were delivered with the assistance of fundal pressure. There were six cases of uterine rupture associated with uterine fundal pressure, with one case resulting in maternal death secondary to amniotic fluid embolism. Since uterine fundal pressure may potentially cause serious injury to either the mother and/or neonates, the indications for application need to be clearly elucidated, and obstetric care providers also need comprehensive education and training.
J. Perinat. Med. 2014; aop
*Corresponding author: Dr. Junichi Hasegawa, Department of
Obstetrics and Gynecology, Showa University School of Medicine,
1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan,
Phone: + 81-3-3784-8551, Fax: + 81-3-3784-8355,
E-mail: hasejun@oak.dti.ne.jp
Akihiko Sekizawa: Department of Obstetrics and Gynecology,
Showa University School of Medicine, Tokyo, Japan
Isamu Ishiwata: Ishiwata Obstetrics and Gynecology Hospital,
Ibaraki, Japan
Tomoaki Ikeda: Department of Obstetrics and Gynecology, Mie
University School of Medicine, Mie, Japan
Katsuyuki Kinoshita: Seijo-Kinoshita Hospital, Tokyo, Japan
Group: Japan Association of Obstetricians and Gynecologists.
Junichi Hasegawa * , Akihiko Sekizawa , Isamu Ishiwata , Tomoaki Ikeda and
Katsuyuki Kinoshita
Uterine rupture after the uterine fundal pressure
maneuver
Abstract
Objective: To clarify the incidence of uterine fundal pres-
sure at delivery and its effect on uterine rupture.
Study design: A questionnaire was sent to 2518 institu-
tions in Japan. We received a response from 1430.
Results: Of reporting institutions, 89.4% used fundal
pressure in at least some of their deliveries. Among the
347,771 women who delivered vaginally in this study,
38,973 (11.2%) were delivered with the assistance of
fundal pressure. There were six cases of uterine rupture
associated with uterine fundal pressure, with one case
resulting in maternal death secondary to amniotic fluid
embolism.
Conclusion: Since uterine fundal pressure may potentially
cause serious injury to either the mother and/or neonates,
the indications for application need to be clearly eluci-
dated, and obstetric care providers also need comprehen-
sive education and training.
Keywords: Amniotic fluid embolism; maternal death;
postpartum bleeding; uterine fundal pressure; uterine
rupture.
DOI 10.1515/jpm-2014-0284
Received July 2 , 2014 . Accepted October 20 , 2014 .
Introduction
The uterine fundal pressure maneuver is usually applied
to assist the exclusive force and finish delivery quickly
when a non-reassuring fetal status, failure to progress or
maternal exhaustion occurs during the second stage of
labor. Several complications associated with this maneu-
ver have been reported, including pain and discomfort of
the maternal abdomen, maternal rib fracture, maternal
anal sphincter tears, amniotic fluid embolism, fetal frac-
tures and brain damage [1 4] .
It has been reported that the uterine fundal pressure
maneuver is likely to be performed in developing countries,
as instrumental delivery is often difficult [4, 5] . Despite the
fact that several complications have been reported to be
associated with the maneuver, we thought that, since it
was believed that the maneuver was a quick procedure
with limited complications, it might be performed instead
of instrumental delivery in Japan. However, the actual fre-
quency of the application of uterine fundal pressure and
its complications in Japan still remain unclear.
The objective of this study was to clarify the incidence
of uterine fundal pressure at delivery and its effect on
uterine rupture.
Methods
We conducted a population-based postal questionnaire study as an
investigation by the Japan Association of Obstetricians and Gynecol-
ogists (JAOG). A questionnaire regarding the total number of deliver-
ies, the procedure used for uterine fundal pressure to induce delivery
and the detailed clinical courses of cases of uterine rupture associ-
ated with uterine fundal pressure at each institution in 2012 was
sent to institutions that provide maternity services across Japan. The
questionnaire was accompanied by a cover letter outlining the aims
of the study and addressed by name to the director, chief obstetrician
or consultant in fetomaternal medicine. The answers to the question-
naires were therea er received via facsimile.
In order to accurately identify the frequency of complications
associated with the uterine fundal pressure maneuver, only fully
completed answers regarding the number of cases with complica-
tions, the number of deliveries and the number of cases involving
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2Hasegawa etal., Uterine rupture after the uterine fundal pressure maneuver
the use of the maneuver during the study period were included in
the present study. The frequencies and clinical courses of cases with
complications associated with the uterine fundal pressure maneuver
were analyzed.
This study was performed as an investigation of the JAOG and
was approved by its ethics board. Because this was a retrospective
analysis based on a questionnaire survey, patient information was
anonymized and de-identi ed prior to the institutions answering
the questions. Therefore, the con dentiality of the patients involved
was protected, and no personal data were required for the present
study.
Results
We sent the questionnaire to 2518 delivery institutions
and received responses from 1502 (59.4%) institutions,
which had a detailed database of information regard-
ing pregnancies and delivery courses. After excluding
incomplete answers, responses from 1430 institutions
were assessed (56.6% of all delivery institutions). Care
providers performed uterine fundal pressure at 1278
(90.4%) of institutions. A total of 432,516 deliveries at
these institutions were analyzed. Among these cases,
347,771 infants were delivered vaginally, and 38,973 were
delivered with the assistance of fundal pressure (11.2% of
vaginal deliveries).
Of the cases involving uterine fundal pressure, 188
cases of neonatal distress (Apgar score less than 7) were
reported. Fundal pressure was associated with 492 cases
of severe uterine, cervical, deep vaginal and/or perineal
laceration, one case of rib fracture, one case of bladder
injury, two cases of uterine inversion, and six cases of
uterine rupture.
Data for five cases with a uterine rupture were avail-
able for review and are shown in Table 1 . None of the
women had previous uterine surgery, but four women
received labor augmentation. In four of the cases, fundal
pressure was applied during instrumental delivery. One
case complicated with amniotic fluid embolism resulted
in maternal death. Fundal pressure at delivery was also
associated with poor neonatal outcomes. One neonate
had a fractured clavicle and a low Apgar score ( < 5), and/
or low umbilical pH ( < 7.00) were observed in four out of
the five of cases in our series. There was one case of cere-
bral palsy which occurred in a woman (case 1) who under-
went prostaglandin E
2 induction of labor. At 9cm dilated
tachysystole and bradycardia was noted, and a vacuum-
assisted delivery was performed with fundal pressure and
resulting uterine rupture. It is unclear if the cerebral palsy
was secondary to bradycardia, uterine rupture, or a com-
bination of factors.
Table 1 Cases of uterine rupture after uterine fundal pressure.
Case Age
(years)
Pregnancy
history
Previous
uterine
operation
Height
Weight Induction
of labor
Epidural
analgesia
Os Station
Gestational
age
Indication
fundal
pressure
Duration;
times of
procedure
Instru-
mental
delivery
Neonatal
weight
Apgar
/ min
Umbilical
artery pH
Neonatal
outcomes
Maternal
outcomes
Before
pregnancy
At
delivery
GPSA None  cm. kg. kgYes No  cm +  + NRFS  min;
six
VE  g / . Cerebral
palsy
Massive
bleeding;
hysterectomy
G None  cm. kg. kgNo No  cm +  + NRFS  min;
two
VE  g / n/a No
complication
Hysterectomy
GPSA None  cm. kg. kgYes No  cm +  + Weak
labor
 min;
three
VE, FD  g / . Neonatal
distress
Amniotic fluid
embolism;
maternal death
G None  cm. kg. kgYes No  cm +  + Weak
labor
 min;
four
No  g / n/a Neonatal
distress
Cesarean
section;
laceration suture
 GPSA None  cm . kg . kg Yes Yes  cm  +  NRFS  min;
three
VE  g / n/a Fracture of
the clavicle
Shock; maternal
transport
S A = spontaneous abortion, NRFS = non-reassuring fetal status, VE = vacuum extraction, FD = forceps delivery, CS = cesarean section, n/a = not applicable.
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Hasegawa etal., Uterine rupture after the uterine fundal pressure maneuver3
Discussion
An analysis of the questionnaire data revealed the inci-
dence of uterine rupture associated with the uterine
fundal pressure maneuver to be 1:6496. There have only
been case reports of uterine rupture associated with the
uterine fundal pressure maneuver [6 8] ; thus, the exact
incidence of uterine rupture after this maneuver still
remains unknown. To our knowledge, this is the first large
case series to demonstrate maternal and neonatal compli-
cations in association with uterine rupture after uterine
fundal pressure in Japan.
The association between previous uterine surgery and
uterine rupture is well known [9] . However, intrapartum
rupture of the unscarred uterus is an uncommon event.
Instrumental delivery is associated with uterine rupture
[1] , and the possibility of a strong association between
the application of uterine fundal pressure, as well as the
concomitant use of instrumental delivery, with uterine
rupture is supposed.
In our case series, a case with amniotic fluid embo-
lism associated with the uterine rupture resulting in
maternal death was reported. Although an amniotic
fluid embolism is extremely rare, with an incidence of
approximately 1 in 40,000 deliveries, the reported mor-
tality rate ranges from 20% to 60% [10] . Significant asso-
ciations with amniotic fluid embolism were observed for
the medical induction of labor, cesarean delivery, instru-
mental vaginal delivery, the application of fundal pres-
sure, and uterine/cervical trauma [11, 12] . In fact, 1.3%
(492/38,973) of our subjects who underwent the applica-
tion of fundal pressure experienced severe uterine, cer-
vical, vaginal, and/or perineal lacerations. With respect
to the prevention of an amniotic fluid embolism, the use
of the uterine fundal pressure maneuver should be cau-
tiously selected.
However, the use of questionnaire surveys in a large
population has some limitations and potential bias in
obtaining enough examples of such a rare occurrence.
Compared to western countries, there are many small
private hospitals that provide maternity services across
Japan. Care providers who work at such small hospitals
are generally unable to retrospectively obtain detailed
obstetric information and did not respond to this ques-
tionnaire survey. Therefore, although we believe that the
quality of the obtained answers was sufficient, this study
is limited by the small number of responses and subjects,
which might have been skewed by the incidence at larger,
and perhaps more academic, institutions.
In conclusion, it revealed that uterine fundal pres-
sure was applied frequently in Japan. Since uterine fundal
pressure maneuver may cause potential serious injury to
either mother and/or neonates, its indication of the use of
maneuver needs to be carefully determined.
Acknowledgments: We are grateful to all participants who
answered the present questionnaire survey and all indi-
viduals who helped to conduct the present study.
Disclosure of interests: The authors did not receive any
financial support for this study. None of the authors own
stock from any company associated with the content
of this manuscript or have any conflicts of interest to
declare.
Contribution to authorship: Hasegawa J., Sekizawa A.,
and Kinoshita K. designed the research. Hasegawa J., Seki-
zawa A., Ikeda T., Ishiwata I., and Kinoshita K. collected
the data. Hasegawa J. and Sekizawa A. analyzed and inter-
preted the data, and drafted the manuscript. Hasegawa J.
performed the statistical analyses.
Detail of ethics approval: This study was approved by the
ethics board of the Japan Association of Obstetricians and
Gynecologists. The present study was a retrospective anal-
ysis based on a questionnaire survey.
Funding: None.
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... 4) A large survey of 1,430 hospitals in Japan found evidence of practising fundal pressure in 89% of these and at least 11% of the deliveries. 5) In Spain, doctors employ fundal pressure up to 70% in protracted labour, and the procedure was applied in a minimum of 26% of births in 2010, despite clear advice against its use from the national guidelines. 6) Finally, in many developing societies, fundal pressure is done largely as a desperate measure since there is no alternative recourse to safe operative delivery. ...
... 11) In addition, there are reports on catastrophic results such as uterine rupture occurring in unscarred uterus and or even maternal deaths secondary to amniotic fluid embolism. 5,12) Neonatal consequences encompass, but not limited to shoulder dystocia, lower PO2 levels, acute acidosis and lower Apgar scores. 13,14) Fundal pressure has been unjustifiably used in management of shoulder dystocia with hazardous neonatal effects such as brachial plexus trauma. ...
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Aim: Fundal pressure during labour is a frequently used manoeuvre for expediting delivery in cases of fetal distress, dystocia and maternal exhaustion. It is often underreported and therefore challenging to accurately estimate its prevalence. It remains a highly controversial topic, having been abandoned in many countries due to its potentially harmful consequences. Still, some health care professionals consider it safe and effective in life-threatening obstetric emergencies. Our objective was to evaluate the evidence behind the merits and drawbacks of its implementation into clinical practice. Methods: This is a critical review based on utilising high-quality references on whether it is justifiable to insist on using fundal pressure in contemporary obstetrics. Results: Fundal pressure is understudied with significant variations worldwide. Reports documenting of any substantial benefit are sparse in the literature. Nevertheless, there is a clear association with various adverse outcomes. An increasing number of experts suggest that fundal pressure should be relinquished. Conclusions: Unless future randomised controlled trials change our views on traditional methods for shortening labour when needed, practitioners should be extra vigilant in avoiding dubious techniques, as deviation from national guidelines could jeopardise aspirations for optimal intrapartum care. In the time being, fundal pressure should be limited for research purposes only within well-designed studies.
... tabela 1). (Hasegawa et al., 2015). Uma alta frequência desta manobra foi encontrada mais recentemente em Espanha por Mena-Tudela et al. (2021), cujo estudo concluiu que há uma elevada prevalência do uso desta manobra e sem consentimento da mulher. ...
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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. 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. 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. 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.
Article
Amniotic fluid embolism (AFE) is a rare but serious cause of maternal mortality whose aetiology remains obscure. Previous population-based studies have reported associations with labour induction and caesarean delivery. We updated a previous analysis based on the US Nationwide Inpatient Sample from 1999 to 2008. We adapted a diagnostic validation algorithm to minimise false-positive diagnoses, along with statistical methods that account for the stratified random sampling design. Of the 8 571 209 deliveries recorded in the database, 276 met our case definition of AFE, of which 62 (22.9% of the 274 with known vital status) were fatal. Significant associations with AFE were observed for medical induction {adjusted odds ratio [aOR] = 1.7 [95% confidence interval (CI) 1.2, 2.5]}, caesarean delivery [aOR = 15.0; 95% CI 9.4, 23.9], instrumental vaginal delivery [aOR = 6.6; 95% CI 4.0, 11.1], and cervical/uterine trauma [aOR = 7.4; 95% CI 3.6, 14.9]. AFE was associated with increases in risk of stillbirth, hysterectomy, maternal death, and prolonged maternal length of delivery hospital stay. AFE remains an extremely serious obstetric complication with high risks of maternal and fetal mortality. The increased risks of AFE associated with labour induction and caesarean delivery have implications for elective use of these interventions.
Article
Owing to the lack of evidence supporting the use of uterine fundal pressure maneuver in vaginal delivery, the role of the maneuver is undetermined and remains controversial. The aim of this study was to identify the prone factor of the use of uterine fundal pressure maneuver and to evaluate its obstetrical outcomes. All vaginal delivery records between 1 January 2005 and 30 April 2006 were evaluated. Maternal and neonatal variables and obstetrical complications were analyzed for subjects underwent uterine fundal pressure maneuver. Six hundred sixty-one vaginal deliveries were evaluated. Fundal pressure maneuver was performed in 39 cases (5.9%, 95% CI 4.4-7.1). Primiparity (76.9 vs. 53.3%; odds ratio 2.92, 95% CI 1.36-6.25, P = 0.004), larger maternal body weight gain during pregnancy (11.16 +/- 0.4 kg vs. 10.05 +/- 0.16 kg, P = 0.013), and longer duration of labor (922.3 +/- 111.7 vs. 566.6 +/- 18.3 min, P = 0.003) were prone risk factors for the use of uterine fundal pressure maneuver at vaginal delivery. One case of shoulder dystocia following uterine fundal pressure maneuver was reported (2.5 vs. 0%). Episiotomy (76.9 vs. 44.9%, P < 0.001) and vacuum extraction (41.0 vs. 3.8%, P < 0.001) were frequently performed with uterine fundal pressure maneuver. Uterine fundal pressure maneuver increased the risk of severe perineal laceration (28.1 vs. 4.8%; odds ratio 2.71, 95% CI 1.03-7.15, P = 0.045). The risk of severe perineal laceration was synergistically increased with the concurrent use of uterine fundal pressure maneuver with vacuum extraction and episiotomy. Uterine fundal pressure maneuver during the second stage of labor increased the risk of severe perineal laceration. The use of the maneuver must be cautioned and careful attention must be paid to its application.
Article
To determine the effect of uterine fundal pressure on shortening the second stage of labor and on the fetal outcome. Randomized controlled trial. Teaching and research hospital. One hundred ninety-seven women between 37 and 42 gestational weeks with singleton cephalic presentation admitted to the delivery unit. Random allocation into groups with or without manual fundal pressure during the second stage of labor. The primary outcome measure was the duration of the second stage of labor. Secondary outcome measures were umbilical artery pH, HCO3-, base excess, pO2, pCO2 values and the rate of instrumental delivery, severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death. There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures except for mean pO2 which was lower and mean pCO2 which was higher in the fundal pressure group. Nevertheless, the values still remained within normal ranges and there were no neonates with an Apgar score <7 in either of the groups. Application of fundal pressure on a delivering woman was ineffective in shortening the second stage of labor.
Article
A critical review of animal and human data leads to a reassessment of traditional concepts of amniotic fluid embolism. Left ventricular failure, rather than pulmonary hypertension, is the major hemodynamic derangement consistently seen in humans. The detection of squamous cells in the pulmonary artery blood of pregnant women is not pathognomonic for amniotic fluid embolism.
Article
Amniotic fluid embolism is one of the least frequent complications of parturition, but the most dangerous of all. 38 cases of fatal amniotic fluid embolism were diagnosed in Sweden during the years 1951-1980, i.e. 1 case for every 83,000 live births. The proportion of amniotic fluid embolism in maternal mortality as a whole increased from 1.2 to 16.5% during this period. Predisposing factors identified were gemini/polydyramnios, abruptio placentae, hypertonic labor, rupture of the birth canal, macrosomia, and obstetrical interventions such as administration of oxytocin and fundal pressure. The main symptoms were cardiovascular shock with right heart strain, and hemorrhage with pathologic proteolysis. Four cases of presumed amniotic fluid embolism with survival of the patient were diagnosed during the years 1972-1980--a case fatality rate of 66% (4/12).
Article
The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.