WHO recommendation on fundal pressure to facilitate childbirth

Midwife performing a fundal pressure.

WHO recommendation on fundal pressure to facilitate childbirth

 

Recommendation

Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended.

(Not recommended)

 

Publication history

First published: February 2018

Updated: No update planned

Assessed as up-to-date: February 2018

 

Remarks

  • The GDG had serious concerns about the potential for harm to mother and baby with this procedure. 
  • The panel is aware of an ongoing trial, the Gentle Assisted Pushing (GAP) trial (1), which could help to provide important evidence on the effects of applying fundal pressure according to a specific protocol.

 

Background

Globally, approximately 140 million births occur every year (2). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (3,4). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (5,6). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (7). The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (8).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (9). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes 10).

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women’s innate childbirth capabilities, waste resources and reduce equity.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

 

Methods

These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development (11). Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (12) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) (13) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.

The GRADE evidence-to-decision (EtD) framework (14), an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at two technical consultations in May and September 2017. In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee (GRC) were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.

 

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following questions:

  • For women in the second stage of labour (P), does the application of fundal pressure (I), compared to no fundal pressure (C), improve birth outcomes (O)?

 

Evidence summary

The evidence was derived from a Cochrane systematic review that included nine trials involving 3948 women (15).

Five trials (3057 women) conducted in India, Iran, South Africa and Turkey (2 trials) evaluated manual fundal pressure in women with low-risk pregnancies compared with no fundal pressure. Four trials (891 women) conducted in Italy, Republic of Korea (2 trials) and the United Kingdom evaluated fundal pressure by means of an inflatable belt compared with no fundal pressure.

For the purposes of this recommendation, only the evidence on manual fundal pressure was considered, as the use of inflatable belt devices has not progressed beyond research settings. Manual fundal pressure was applied according to the Kristeller manoeuvre in four trials, and as “gentle assisted pushing” (see Additional considerations) in one small trial (120 women); two of these trials recruited primigravid women only. One trial limited the application of fundal pressure to three attempts. Most of the included trials had design limitations.

Comparison: Manual fundal pressure compared with no fundal pressure

Maternal outcomes

Mode of birth: Evidence on the relative effects on caesarean section and instrumental birth rates is of very low certainty.

Duration of the second stage of labour: Evidence on the duration of the second stage of labour is of very low certainty. Low-certainty evidence on the failure of women to give birth spontaneously within a time frame specified by the authors suggests that there may be little or no difference between manual fundal pressure and no fundal pressure (1 trial, 110 women, RR 0.96, 95% CI 0.71–1.28).

Mortality: This outcome was not assessed in the studies.

Morbidity: Low-certainty evidence suggests that fundal pressure compared with no fundal pressure may have little or no effect on PPH (1 trial, 110 women, RR 1.87, 95% CI 0.58–6.06). Evidence on the effect of fundal pressure on soft tissue damage (vagina, perineum or uterus) is very uncertain, mainly due to sparse data. Low-certainty evidence suggests that applying fundal pressure may make little or no difference to episiotomy rates compared with no fundal pressure (1 trial, 317 women, RR 1.18, 95% CI 0.92–1.50). The outcome “severe maternal morbidity or death” was not reported in any of the trials.

Birth experience: The trials did not report maternal satisfaction; however, low-certainty evidence suggests that women receiving manual fundal pressure may experience more pain after birth (assessed in terms of analgesic requirements) than those not receiving fundal pressure (1 trial, 209 women, RR 4.54, 95% CI 2.21–9.34).

Fetal and neonatal outcome

Birth trauma: Evidence on birth trauma, including fractures and haematomas, is of very low certainty due to sparse data (small sample, no events).

Perinatal hypoxia-ischaemia: Evidence on low arterial cord pH and Apgar score less than 7 at 5 minutes is of very low certainty.

Perinatal mortality: No neonatal deaths occurred in the comparison groups (2 trials, 2445 neonates), therefore evidence on neonatal death is of very low certainty.

Additional considerations Concerns relating to the practice of fundal pressure are due to the possibility that serious harm might arise in the mother or the baby from the application of excessive uncontrolled force (16, 17), including uterine and other organ rupture, and maternal and perinatal death; however, these occurrences might not often be reported in the literature. Fundal pressure in the included trials was applied with the birth attendants’ hands (i.e. not forearms or elbows); therefore, the evidence is not applicable to settings where other techniques of fundal pressure are applied. The review also included studies on inflatable belts. The resultant moderate-certainty evidence suggests that fundal pressure by an inflatable belt probably increases anal sphincter damage (third-degree tear) compared with no fundal pressure (1 trial, 500 women, RR 15.69, 95% CI 2.10–117.02).

Inflatable belt devices have not progressed beyond the research stage. A large multicentre trial is currently under way in South Africa to evaluate a new technique of fundal pressure, which is applied with the pregnant woman in an upright posture (1). The technique is called “gentle assisted pushing” whereby the health care professional applies “steady firm fundal pressure” with the palms of her hands, in the direction of the pelvis, taking care to use only the strength of her forearms and not to apply additional body weight. The health care professional is required to maintain the pressure for the full duration of each contraction or 30 seconds (whichever is shorter). The investigators hope that this trial, involving 1145 women, will establish whether or not a gentler form of fundal pressure can improve birth outcomes.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (18) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention may sometimes be necessary. Most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence) and fearful of some medical interventions, although in certain contexts and/or situations women welcome interventions to shorten labour or provide relief from pain (low confidence in the evidence). When interventions are introduced, women would like to receive relevant information from technically competent health care professionals who are sensitive to their needs (high confidence in the evidence). Findings also show that women desire to be in control of their birth process and would like to be involved in decision-making around the use of interventions (high confidence in the evidence).

Resources

There is no evidence on the costs or costeffectiveness of this practice.

Equity

No direct evidence of the impact of fundal pressure on equity was found. However, indirect evidence from a review of barriers and facilitators to facility-based birth indicates that unfamiliar and undesirable birth practices by health workers in facilities, such as unfamiliar birth positions, are an important barrier to the uptake of facility-based birth by disadvantaged women in LMICs (high confidence in the evidence) (9).

Additional considerations: WHO’s 2015 State of inequality report indicates that women who are poor, least educated and residing in rural areas have lower health intervention coverage and worse health outcomes than the more advantaged women (19). Based on the research evidence above, if disadvantaged women consider fundal pressure an unfamiliar and undesirable practice, the intervention might have a negative impact on equity by contributing to low use of health care facilities by disadvantaged women. However, in the absence of specific evidence on fundal pressure, the converse could also be true.

Findings from a study conducted in a rural population in India suggest that fundal pressure might be a desirable part of some traditional birth practices (20). In many settings where fundal pressure is used, women might not be given adequate information about the procedure and might not be asked for their consent. If non-consented, or applied indiscriminately and with excessive force, applying fundal pressure could be considered an abuse of a woman’s human rights.

Acceptability There is no specific evidence on receiving or applying fundal pressure in a qualitative systematic review on women’s and providers’ views and experiences of intrapartum care (21). However, general findings from this document suggest that women would rather avoid this type of procedure unless their baby is at risk (high confidence in the evidence). They would also like to be cared for by competent, skilled and sensitive health care professionals (high confidence in the evidence) and, even though they would prefer to have a quick labour (low confidence in the evidence), they would, where possible, like to remain in control of their labour and childbirth processes (high confidence in the evidence).

Additional considerations: As part of a recent global initiative looking at how women are treated during labour and childbirth, the authors of a qualitative study conducted in Guinea found that health care providers were using extreme force when pushing on the fundus (22). Women found this disturbing, painful and tantamount to physical abuse. In a study in rural India (20), the authors found that fundal pressure was being used routinely, often beginning in early labour, to the extent that the practice often left providers feeling exhausted. The authors did not discuss women’s experiences but noted that babies were sometimes injured as a consequence of the procedure.

Feasibility

There is no specific evidence on fundal pressure in a qualitative systematic review on women’s and health care professionals’ views and experiences of intrapartum care (21). However, findings from the review suggest that staff in certain contexts may lack the time, the training or the resources to use fundal pressure in a competent and sensitive manner (moderate confidence in the evidence).

Additional considerations: Use of uncontrolled fundal pressure application appears to be prevalent in a variety of settings (23, 24, 15 ,25–30), and it might not be feasible to ensure that health care professionals deliver fundal pressure in a consistent, standardized and controlled way. The birth attendant needs assistance from another health care professional to perform this procedure.

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=7E800B590A164DC7FC879E73B480D6FC?sequence=1

 

Implementation considerations

The successful introduction of evidence-based policies related to intrapartum care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.

The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.

An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.

Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

Health policy considerations 

  • A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
  • To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages. 
  • To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
  • To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

 

Organizational or health-system-level considerations 

  • Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.
  • Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible. 
  • Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools.
  • The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour). 
  • Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop. 
  • Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient. 
  • Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies. 
  • Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities. 
  • Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched. 
  • Successful implementation strategies should be documented and shared as examples of best practice for other implementers. User-level considerations 

 

Community-level sensitization activities should be undertaken to disseminate information about: 

  • respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities; 
  • facility-based practices that lead to improvements in women’s childbirth experience (e.g. RMC, labour and birth companionship, effective communication, choice of birth position, choice of pain relief method);
  • and unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy).

 

Research implications

The GDG did not identify any priority question related to this recommendation.

 

Related links

WHO recommendations on intrapartum care for a positive childbirth experience

(2018) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

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Citation: WHO Reproductive Health Library. WHO recommendation on fundal pressure to facilitate childbirth (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.