Fundal pressure during the second stage of labour for improving maternal and fetal outcomes

Fundal pressure involves using the hands (manual fundal pressure) to push on the upper part of the uterus and down toward the birth canal. It is used during the second stage of labour to shorten the labour and assist in vaginal birth, either as routine practice or because of complications such as fetal distress, failure to progress, maternal exhaustion, or medical conditions where prolonged pushing is contraindicated, for example if the mother has heart disease. Also an inflatable girdle has been used in research settings to provide fundal pressure.

Potential risks with its use include uterine rupture, anal sphincter damage, newborn fractures or brain damage, and increased blood transfusion between the mother and her unborn baby. This may be important with rhesus factor or when the mother has HIV, hepatitis B or other viral disease.

The review authors found no trials on the more widely used manual fundal pressure. There was only one controlled trial studying fundal pressure by inflatable belt. It involved 500 women who had epidural analgesia and were in the second stage of labour. The methodological quality of the trial was good. The number of women experiencing spontaneous vaginal births was similar with or without applying fundal pressure. The trial did not provide sufficient evidence to determine any safety issues of the manoeuvre for the baby, measured as low Apgar scores, low arterial fetal cord pH, or admission to the neonatal unit. Blinding was not possible with this intervention. It may have been perceived that the belt was 'doing the work' so that the women pushed less hard and the midwives encouraged them less enthusiastically. The number of women with an intact perineum increased with use of the belt but also anal sphincter tears increased, all but one associated with an instrumental delivery.

Authors' conclusions: 

There is no evidence available to conclude on beneficial or harmful effects of manual fundal pressure. Good quality randomised controlled trials are needed to study the effect of manual fundal pressure. Fundal pressure by an insufflatable belt during the second stage of labour does not appear to increase the rate of spontaneous vaginal births in women with epidural analgesia. There is insufficient evidence regarding safety for the baby. The effects on the maternal perineum are inconclusive.

Read the full abstract...

Fundal pressure during the second stage of labour involves application of manual pressure to the uppermost part of the uterus directed towards the birth canal in an attempt to assist spontaneous vaginal delivery and avoid prolonged second stage or the need for operative delivery. Fundal pressure has also been applied using an inflatable girdle. A survey in the United States found that 84% of the respondents used fundal pressure in their obstetric centres.There is little evidence to demonstrate that the use of fundal pressure is effective to improve maternal and/or neonatal outcomes. Several anecdotal reports suggest that fundal pressure is associated with maternal and neonatal complications: for example, uterine rupture, neonatal fractures and brain damage. There is a need for objective evaluation of the effectiveness and safety of fundal pressure in the second stage of labour.


To determine the benefits and adverse effects of fundal pressure in the second stage of labour.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008).

Selection criteria: 

Randomised and quasi-randomised controlled trials of fundal pressure versus no fundal pressure in women in the second stage of labour with singleton cephalic presentation.

Data collection and analysis: 

Three review authors independently assessed for inclusion all the potential studies. We extracted the data using a pre-designed form. We entered data into Review Manager software and checked for accuracy.

Main results: 

We excluded two of three identified trials from the analyses for methodological reasons. This left no studies on manual fundal pressure. We included one study (500 women) of fundal pressure by means of an inflatable belt versus no fundal pressure to reduce operative delivery rates. The methodological quality of the included study was good.

Use of the inflatable belt did not change the rate of operative deliveries (RR 0.94, 95% CI 0.80 to 1.11). Fetal outcomes in terms of five-minute Apgar scores below seven (RR 4.62, 95% CI 0.22 to 95.68), low arterial cord pH (RR 0.47, 95% CI 0.09 to 2.55) and admission to the neonatal unit (RR 1.48, 95% CI 0.49 to 4.45) were also not different between the groups. There was no severe neonatal or maternal mortality or morbidity. There was an increase in intact perineum (RR 1.73, 95% CI 1.07 to 2.77), as well as anal sphincter tears (RR 15.69, 95% CI 2.10 to 117.02) in the belt group. There were no data on long-term outcomes.