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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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2Hasegawa etal., 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 9cm 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
GPSA 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
GPSA 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
GPSA 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 etal., Uterine rupture after the uterine fundal pressure maneuver3
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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The authors stated that there are no conflicts of interest regarding
the publication of this article.
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