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Meta-Analysis
. 2017 Mar 7;3(3):CD006067.
doi: 10.1002/14651858.CD006067.pub3.

Fundal pressure during the second stage of labour

G Justus Hofmeyr  1 , Joshua P Vogel  2 , Anna Cuthbert  3 , Mandisa Singata  4
Affiliations
Meta-Analysis

Fundal pressure during the second stage of labour

G Justus Hofmeyr et al. Cochrane Database Syst Rev. .

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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Conflict of interest statement

GJH is an author of one included (Novikova 2009) and one ongoing study (Hofmeyr 2015), but he has not participated in assessment of or data extraction from these studies.

JV is the research project manager on the ongoing Gentle Assisted Pushing Trial (Hofmeyr 2015). No other conflicts of interest to declare.

AC is a research assistant working in the editorial base of Cochrane Pregnancy and Childbirth. She is employed by the University of Liverpool to work as a research assistant in Cochrane Pregnancy and Childbirth (who receives infrastructure funding from the NIHR, UK). She has no other conflicts of interest to declare.

MS is an author of one included (Novikova 2009) and one ongoing study (Hofmeyr 2015), but she has not participated in assessment of or data extraction from these studies.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
1.1
1.1. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 1 No spontaneous vaginal birth within a specified time, as defined by the trial authors.
1.2
1.2. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 2 Instrumental birth.
1.3
1.3. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 3 Caesarean section.
1.4
1.4. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 4 Operative birth ‐ instrumental or caesarean.
1.5
1.5. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 5 Low arterial cord pH.
1.6
1.6. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 6 Apgar score less than 7 at 5 minutes.
1.7
1.7. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 7 Duration of active second stage.
1.8
1.8. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 8 Episiotomy.
1.9
1.9. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 9 Soft tissue damage ‐ perineal.
1.10
1.10. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 10 Soft tissue damage ‐ vaginal laceration.
1.11
1.11. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 11 Soft tissue damage ‐ cervical.
1.12
1.12. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 12 Postpartum haemorrhage.
1.13
1.13. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 13 Pain after enrolment as defined by trial authors.
1.14
1.14. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 14 Neonatal trauma ‐ fractures.
1.15
1.15. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 15 Neonatal trauma ‐ haematoma.
1.16
1.16. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 16 Admission to neonatal intensive care unit.
1.17
1.17. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 17 Neonatal death.
1.18
1.18. Analysis
Comparison 1 Manual fundal pressure versus no fundal pressure, Outcome 18 Sensitivity analysis: low arterial cord pH.
2.1
2.1. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 1 Instrumental birth.
2.2
2.2. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 2 Caesarean section.
2.3
2.3. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 3 Operative birth ‐ instrumental or caesarean section.
2.4
2.4. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 4 Low arterial cord pH.
2.5
2.5. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 5 Apgar score less than 7 after 5 minutes.
2.6
2.6. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 6 Duration of second stage.
2.7
2.7. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 7 Episiotomy.
2.8
2.8. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 8 Soft tissue damage ‐ perineal.
2.9
2.9. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 9 Soft tissue damage ‐ vaginal.
2.10
2.10. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 10 Soft tissue damage ‐ anal sphincter.
2.11
2.11. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 11 Soft tissue damage ‐ cervical/uterine.
2.12
2.12. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 12 Postpartum haemorrhage.
2.13
2.13. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 13 Neonatal trauma ‐ haematoma.
2.14
2.14. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 14 Admission to neonatal intensive care unit.
2.15
2.15. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 15 Sensitivity analysis: instrumental birth.
2.16
2.16. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 16 Sensitivity analysis: caesarean section.
2.17
2.17. Analysis
Comparison 2 Fundal pressure by inflatable belt versus no fundal pressure, Outcome 17 Sensitivity analysis: operative delivery ‐ instrumental or caesarean section.
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