Re: Fundal Pressure
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Tue Feb 28 12:07:45 2006
Maybe it would be best to have no policy at all, i.e. remain silent (I
learned that cool term from an attorney).
Garry
At Tue, 28 Feb 2006, 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.
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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