Re: Fundal Pressure
From: Joe (forcep@intercom.net)
Tue Feb 28 14:31:27 2006
There is no way to know that you will not have a palsy in any delivery.
If this occurs and you have used fundal pressure forget about going to
court. Joe C
Dr. Ainsworth wrote:
> I have always been taught that fundal pressure was contraindicated
> because of the risk of uterine rupture and shoulder impaction at the
> time of shoulder dystocia, i.e., I do not use it. When this policy came
> through our perinatal, I objected to it because of the above.
> Medical-legally, I don't feel it should be used. I have no problem with
> suprapubic pressure for stabilizing the head when rupturing membranes,
> applying the scalp electrode, assisting with rotation of the shoulders
> in a shoulder dystocia and use it in those circumstances. This policy
> came from "corporate headquarters" and one other OB wants to keep it as
> it is. Any comments would be appreciated.
>
> POLICY/PROCEDURE SUMMARY/INTENT (EXPECTED OUTCOME): 1) To describe the
> appropriate use and application of fundal pressure by the RN. Fundal
> pressure may be useful in the following clinical circumstances:
> a. To ease the fetal head against the cervix to prevent cord prolapse
> during artificial rupture of membranes (AROM).
> b. To stabilize the fetal head to facilitate placement of a scalp
> electrode.
> c. To expedite delivery when fetal heart tones (FHTs) are nonreassuring
> and fetal head is crowning.
> d. To assist with outlet forceps or vacuum delivery when the fetal head
> crowning and the mother’s pushing is ineffective.
>
> DEFINITION (S): 1) Fundal Pressure - The application of steady pressure
> on the fundus of the uterus.
>
> AFFECTED DEPARTMENTS/SERVICES (COLLABORATION): 1) Perinatal
>
> POLICY AND PROCEDURE: COMPLIANCE—KEY ELEMENTS
>
> I. POLICY
>
> A. Fundal pressure is to be performed by the RN upon the request of the
> physician in those situations where fundal pressure is appropriate and
> not contraindicated.
> B. Contraindications: Fundal pressure is contraindicated when there is
> a shoulder dystocia as it may lead to further impaction of the shoulder
> against the symphysis, or even catastrophic uterine rupture.
> C. Responsibility: Labor and Delivery Registered Nurses who can
> demonstrate knowledge of uterine anatomy and physiology and the forces
> of labor.
>
> II. PROCEDURE
>
> A. Apply gentle, steady pressure with one hand to the fundus at a
> 30-degree to 45-degree angle to the maternal spine in the direction of
> the pelvis.
> B. If a higher elevation is needed to achieve proper positioning and to
> maintain proper body mechanics, stand on a footstool.
> C. Avoid perpendicular (direct downward) pressure on the maternal
> spine, which may cause direct vena caval compression and maternal
> hypotension. Pressure should not be applied in a longitudinal
> direction.
>
> III. DOCUMENTATION
>
> A. Who ordered the fundal pressure.
> B. Who applied the fundal pressure.
> C. In what manner was fundal pressure applied (e.g., number of hands,
> steady vs. intermittent pressure, amount of pressure).
> D. How long was fundal pressure applied.
>
> APPLICABLE STANDARDS OR REGULATORY REQUIREMENTS: None
> REFERENCES: 1) T. Benedetti, “Dystocia: Causes, Consequences, Correct
> Response,” Contemporary OB/GYN, Vol. 36, Special Issue, Medical
> Economics Publishing, Montvale, NJ, Oct. 15, 1991, pp. 37-48. 2) V.
> Kline-Kaye and D. Miller-Slade, “The Use of Fundal Pressure During
> Second Stage Labor,” Journal of Obstetric, Gynecologic, and Neonatal
> Nursing, Lippincott, Hagerstown, MD, Vol. 19:6, Nov./Dec. 1990, pp.
> 511-517. 3) D.S. Penney and D.W. Perlis, “Shoulder Dystocia: When to
> Use Suprapubic or Fundal Pressure,” MCN, The American Journal of
> Maternal/Child Nursing, Vol. 7:1, 1992, pp. 34-36. 4) K.R. Simpson
> and P.A. Creehan, AWHONN’s Perinatal Nursing, Lippincott, Philadelphia,
> 1996, Chapter 8, pp.160-166. 5) C. Rommal, “Risk Management Issues in
> the Perinatal Setting,” Journal of Perinatal & Neonatal Nursing, Vol.
> 10:3, Aspen Publishers, Inc., Gaithersburg, MD, Nov./Dec. 1996, pp.
> 13-14.
>
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