Re: Fundal Pressure
From: D. Ashley Hill (dahmd@cfl.rr.com)
Wed Mar 1 12:23:02 2006
I use fundal pressure at cesarean, because the "dystocia" keeping the
baby from delivering is the width of the incision, not the bony pubis.
It's a different mechanism of delivery. Thanks,
Ashley
At Wed, 1 Mar 2006, Efrain Ramirez wrote:
>
>Have no policy - BTW how do you get out the baby in a C/S?
>
>Ef
>
>.>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.
>
>--
>“ The greatest obstacle to knowledge is not ignorance,
>it is the illusion of knowledge.” Daniel J. Boorstin - Historian
>
--
D. Ashley Hill, MD
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
and Loch Haven Ob/Gyn Group
Orlando, Florida
