Wednesday, May 27, 2015

Obese Women Need Increased Access to Midwifery Care

Here is a study that looked at the pregnancy care of "obese" women with a BMI of 40 or more.

98% of these women saw a midwife only at the first screening appointment and never again, despite the fact that the majority of them did not develop complications.

And guess what, their cesarean rate was nearly 50%. This is far too high.

One of the most potent ways to lower the cesarean rate for women is to give them access to midwifery care. Yet this study shows that most higher-weight women are routinely being re-directed out of midwifery care.

This is not an isolated trend. If anything, maternity care is tilting towards an approach where women of size are not allowed to access midwives or low-intervention care.

We need to EXPAND midwifery care for healthy women of size, not restrict it.

In some areas, women of moderate obesity are able to access midwives and other low-intervention care choices, but Class III obese women (BMI of 40 or more) are often routinely given NO choice. In some areas, not even women of moderate obesity are being given access to low-intervention care.

Basing a decision like this simply on a number on a chart is short-sighted and probably results in many unnecessary cesareans. Instead, the decision should be made on a case-by-case basis, based not on the woman's size but on her health and particular circumstances.

If high BMI women have or develop complications, then sure, they should at least have an OB consult at some point, and can be co-managed by a midwife and OB if circumstances necessitate it. If their complications are significant enough, then care should be managed by a OB specialist or in a special bariatric center in some cases.

But women of size who do not experience complications do NOT need to be managed in a high-risk, high-intervention model of care, and they should not be routinely re-directed out of midwifery care. 

That includes Class III obese women (BMI 40+) ─ and Class IV obese women (BMI 50+) too. In fact, most probably would do better NOT being managed in a high-intervention model of care.

Size alone should NOT disqualify women of size from midwifery care, yet in the real world it often does. This needs to change.


Women Birth. 2013 Sep;26(3):179-84. doi: 10.1016/j.wombi.2013.05.001. Epub 2013 Jun 5. Pregnancy care and birth outcomes for women with moderate to super-extreme obesity. Slavin VJ1, Fenwick J, Gamble J. PMID: 23746783
PURPOSE: To describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity. BACKGROUND: Maternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40. METHOD: Women with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women. RESULTS: 153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1-16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n=150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n=74, 48.4%). CONCLUSION: Clinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.

Tuesday, May 19, 2015

Fundal Pressure: An Outdated Technique

Image from  

We blogged recently about common hospital birthing positions and "alternative" birthing positions used in many historical and traditional societies.

We discussed how traditional societies, both now and in the past, used different birthing positions than the ones usually seen in the hospital.

Typically their positions were more upright so as to use gravity to help move the baby down, although other positions were seen as well.

Today, though, let's talk about one practice found in both traditional societies and in modern hospital obstetrics that may actually be harmful ─ fundal pressure.

Fundal Pressure

As we have mentioned before, although ancient societies had a great deal of birth wisdom, ancient is not always better. Just because an ancient society used a particular position or technique does not necessarily make it a good idea.

One technique that is occasionally found in some ancient or tribal cultures that is not supported by research is Fundal Pressure (pushing down on the top of the mother's uterus to try to hurry up labor or force a baby out).

Sadly, this is one ancient practice that is still found in the modern obstetric world ─ but it shouldn't be. It is probably not helpful and is often harmful ─ especially when used during shoulder dystocia.

Managing a difficult labor in Siam by
pulling down for fundal pressure;
Englemann book*
Several cultures used the pressure of a birth helper's arm to press down on the woman's uterus during labor. Usually this was just added during a difficult birth as a last resort, since few other options existed and a cesarean was only done if the mother had already died or was dying. Most of the time, it was truly an option of last resort.

Using a sheet to exert fundal pressure during labor;
Drawing by G. Devy from Witkowski book*
However, sometimes it was used routinely during labor in certain cultures and times, as in the image above from California in about 1840. Although this downward squeeze was less forceful and more gradual than other fundal pressure techniques, it also holds some risks.

Although not common, fundal pressure was a technique seen in some ancient cultures. However, its use in modern settings is highly questionable.

Still Used in Many Hospitals

Fundal Pressure on a birthing mother
Photo credit: Lieve Blancquaert, WHO Reproductive Health Library
This ancient technique was brought into the hospital because in the mid-20th century, women birthed flat on their backs with feet elevated into stirrups (the "lithotomy" position). Usually the women were heavily drugged and had difficulty helping the baby to move down. Babies needed to be born as quickly as possible because of frequent fetal distress due to the drugs and the on-the-back position. As a result, hospitals tied women down, cut giant episiotomies to widen the vagina, and had nurses use fundal pressure to push while the doctor used forceps to pull the baby out as quickly as possible.

Despite the fact that such dangerous drugs are not used anymore, fundal pressure is a technique still seen in some hospitals. In the medical literature, it is often called the Kristeller Maneuver, after Samuel Kristeller, the doctor who wrote about its use.

Fundal pressure is when someone presses down on the top of the mother's uterus, on the area nearest her ribs at full term. Sometimes it's done with steady continuing downward pressure, as when an arm or a tightening abdominal binder is used, and sometimes it was a series of short, sharp, very forceful pushes on the top of the uterus during contractions (Kristeller's Maneuver**).

It is most often added during a slow labor, or when the mother is perceived as not being able to push very hard because she is tired or has an epidural. Care providers theorized it would increase intra-abdominal pressure, resulting in greater expulsive forces. In some areas of the world, it is added routinely during pushing to get the baby out faster.

Some hospitals have even been experimenting lately with routinely using an inflatable abdominal binder on women with epidurals, who may have difficulty moving the baby down through the pelvis because the muscles in that area are partially paralyzed from the epidural. [This is probably similar to the sheets used in the California picture in the last section, a slow squeeze downward.]

Fundal pressure used to be used routinely in U.S. hospitals, but its use has declined. However, some do still use it.

Listening to Mothers II, a 2006 survey of birthing women in the United States, found that 17% of mothers reported having fundal pressure applied during their births. If nearly 1 in 5 mothers are still experiencing fundal pressure that recently, then it is still a fairly common intervention that must be examined closely.

Some care providers utilize fundal pressure in the belief that it shortens labor, especially in the pushing stage. A Cochrane Review and the World Health Organization review have found few randomized controlled trials on its use and have concluded that there is not enough good evidence to evaluate this practice.

However, a randomized controlled trial published after the Cochrane review found no reduction in the duration of pushing. Even in studies that have found modest effects on the length of pushing, this was offset by a trade-off of risks, including an increase in perineal lacerations, anal sphincter tearsurinary problems afterwards for the mother, and increased admissions to the Neonatal Intensive Care Unit (NICU) for the baby.

Henci Goer has written a great review of the research examining fundal pressure in labor. She concluded that there are no real benefits, and that more mothers experienced anal sphincter tears and more babies experienced nerve damage injury when fundal pressure was used.

One review suggested that many more injuries from fundal pressure go unreported because the providers are afraid of being sued:
Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved.
There are a number of case reports of uterine rupture occurring in an unscarred uterus after fundal pressure during the pushing stage. In addition, there are isolated case reports of rib fractures/hemothorax and uterine prolapse after fundal pressure. There have also been fetal deaths and maternal deaths that have occurred which may have been associated with use of fundal pressure.

Obviously, there can be serious harms with the use of fundal pressure. Yet because of widespread fear around being sued, many of these harms are probably being under-reported, helping to keep this practice alive.

Fundal Pressure During Shoulder Dystocia

Image from
Fundal pressure during labor results in little benefit and is associated with some degree of harm. It is a practice that should be stopped.

However, fundal pressure when a baby's shoulders get stuck (shoulder dystocia) is CLEARLY harmful. It should have been abandoned long ago ─ yet it is still practiced in many institutions. Vacuum extraction/forceps plus fundal pressure seems to be a particularly dangerous combination.

Suprapubic Pressure for shoulder dystocia.
This is not the same as fundal pressure
Please note that suprapubic pressure is different from fundal pressure. Suprapubic pressure is a common and accepted maneuver for use with shoulder dystocia. It puts pressure on the mother's pubic symphysis joint ─ down low, not up high like fundal pressure. It is done to try to push the baby's top shoulder (which is stuck behind the pubic symphysis in a shoulder dystocia) under the bone. It accomplishes this by pushing the baby's impacted shoulder down and through, or by pushing the baby's shoulders towards each other, thereby reducing their width and helping them to move through.

Please note that we are also not talking about postpartum fundal massage. This is a technique sometimes done after the baby is delivered to try and help the uterus contract more efficiently and to help reduce significant postpartum bleeding.

Fundal pressure during labor, on the other hand, is pressing forcefully on the TOP of the mother's uterus (the "fundus," which is near the ribs at term), usually while pushing, to try and give more force to move the baby through the pelvis. Here is a picture of what fundal pressure in labor looks like.

Fundal pressure. The pushing is at the top of the uterus (fundus),
unlike suprapubic pressure, where the pushing is much lower,
on the mother's pubic symphysis pelvic joint
Fundal pressure is harmful in shoulder dystocia because the baby's shoulder is already trapped behind the pubic symphysis and pushing harder doesn't resolve the problem, but rather rams the baby harder into the mother's bones. 

Fundal pressure combined with the care provider pulling on the baby's head/neck area can damage the baby's nerves, resulting in Brachial Plexus Palsy (BPP). Although many cases of BPP resolve with time, some do not, leaving the baby permanently damaged.

Research shows that the risk for Brachial Plexus Palsy increases in the presence of fundal pressure. One review of obstetric maneuvers for shoulder dystocia states (my emphasis):
Excessive force must not be applied to the fetal head or neck and fundal pressure must be avoided. These activities are unlikely to free the impaction and may cause fetal and maternal injury.
Another review notes that BOTH the Royal College of Obstetricians and Gynaecologists (RCOG) from the U.K. and the American College of Obstetricians and Gynecologists (ACOG) from the U.S. recommend against fundal pressure for shoulder dystocia:
In any case fundal pressure should not be used for the treatment of SD because it could worsen the impaction, with subsequential risk of fetus or mother injury.
In fact, the most recent guidelines on managing shoulder dystocia from ACOG state outright (their emphasis): "CAUTION: NEVER USE FUNDAL PRESSURE." 

Similarly, RCOG's latest guidelines state, "Fundal pressure should not be used."

However, despite these recommendations and research that fundal pressure worsens outcomes, recent studies suggest that fundal pressure is still used too often when shoulder dystocia is encountered.

Fundal Pressure Around the World

Image from 
Unfortunately, fundal pressure is not a remnant of the past. It is still being used today.

Sometimes it is the slow steady downward pressure of an arm, as in the picture above, and sometimes an inflatable belt substitutes for the arm so the nurse doesn't have to be present all the time. And sometimes it is still the short, sharp downward pushes on the fundus (as Kristeller described), seen in the video below.

The good news is that use of fundal pressure has decreased in U.S. hospitals. In 1990, one nationwide survey of hospital nurses found that 84% of their hospitals used fundal pressure at times, but a study from 2005-6 in a Maryland hospital found a huge drop to a 5.9% rate of fundal pressure.

However, also remember that the Listening to Mothers II Survey in the same year reported that 17% of women had experienced fundal pressure during their labors. That's nearly 1 in 5 women.

Fundal pressure during labor is even more common in many non-U.S. hospitals. Hospitals in ItalyBulgariaBrazilTurkeyJapan, and India have published recent research on the use of fundal pressure, and I've read recent anecdotal reports on its use in Germany and Honduras.

Recent online discussion has suggested that it is most common in mid-Europe and Eastern Europe, as well as many Spanish-speaking countries. Korean hospitals seem to be pushing the inflatable abdominal binder as a way to use fundal pressure on women with epidurals. Italian hospitals have also investigated inflatable binders.

One hospital in Egypt reported recently that fundal pressure was used in 24% of the births there. A Brazilian study reported the use of fundal pressure in 37% of births.

A recent large study from Japan surveyed 1,430 hospitals and found that 89% of hospitals reported using fundal pressure in at least some of their births. Among the women who birthed vaginally, about 11% experienced fundal pressure. The survey documented six cases of uterine rupture and one maternal death due to complications from fundal pressure. Obviously, this practice can be associated with significant harms, yet the authors did not call for ending its use, only for clearer indications and better training on its use.

One recent study from Spain found that when pushing phases were "prolonged," doctors used fundal pressure nearly 70% of the time. The Ministry of Health and the Spanish Society of Ginecology and Obstetrics (SEGO) estimated that in 2010, the Kristeller Maneuver was used in at least 26% of births. As a result, there is a major campaign to stop the use of fundal pressure in Spanish hospitals at

The above youtube video graphically shows the Kristeller Maneuver in a classic lithotomy birth from 2007. Be warned, it's a very rough video to watch.

There are a number of other youtube videos that show similar scenes of fundal pressure, usually with the woman flat or nearly flat on her back. (Be aware that some of them are graphic and involve episiotomies.)

Every time I see one of these videos, I think how much simpler and safer it would be to simply get the woman into an upright position instead of using fundal pressure. 

From the ease of finding such videos, it seems clear that fundal pressure is a technique still used in many countries today, frequently in concert with on-the-back positioning and episiotomy. It is still an accepted practice in far too many countries.

It is time for this barbaric practice to STOP.

A Recent U.S. Fundal Pressure Story

Although less common in the U.S., fundal pressure is still sometimes used in U.S. hospitals too ─ even during shoulder dystocia when it CLEARLY contra-indicated.

In fact, a personal friend of mine had fundal pressure used on her ONE year ago this month when she experienced a shoulder dystocia in the hospital. It is in honor of that child's upcoming first birthday that I write this post.

I wasn't at the birth, but from the description of a nurse and midwife (who was acting as a doula) and the grandmother, the pulling force on the baby and the fundal pressure used on the mother was quite excessive.

I questioned them very closely about what exactly was done, and it seems clear that indeed it was fundal pressure and not suprapubic pressure that was done ─ and done very strongly. The traction on the baby was also VERY significant. Frankly, it's truly a miracle this baby did not sustain a BPP injury.

In the end, the baby's arm was broken and her ability to move was damaged for several months. The mother suffered significantly postpartum as well, with excessive bleeding, retained placental fragments, swelling, an infection, and urinary retention for more than a week. The mother needed a D&C eventually to get out all the placental fragments, and she had a long hard physical recovery.

With treatment (mostly Craniosacral Therapy, which is amazing for birth trauma), the baby is doing well now. Her broken arm has healed and she seems to have regained full use of it. They still have some concerns about her movement, but by and large she seems to have healed. She is lucky that she (apparently) didn't suffer more permanent damage, considering the amount of force that was used. The mother has also physically recovered, but was emotionally quite traumatized. Indeed, both the grandmother and the doula were left with significant emotional scars as well.

It's important to acknowledge that the mother had insulin-dependent Gestational Diabetes, a strong risk factor for shoulder dystocia, but the baby was average-sized and perfectly proportionate. The mother was also average-sized, athletic, and in very good shape, yet she still had a significant case of GD.

Because of her GD, it's possible this mother may truly have had a difficult shoulder dystocia no matter how the birth was managed, but it seems to me there is a good chance this highly traumatic birth could have been avoided if the mother had not been induced, kept in bed, kept on her back, and had fundal pressure and traction used in her birth. The doula (who is also nurse and midwife, remember) felt strongly that this birth had been badly managed.

And of course, the mother has been told that she HAS to have a cesarean for any subsequent children, which she is naturally happy to consider after the emotional and physical trauma of this birth. So the mother will likely endure the invasive trauma and all the risks of surgery in the future for a situation that might have been avoided (or at least better handled).

I am outraged by the subpar treatment this mother received, angry that her baby was endangered, and APPALLED that fundal pressure was used during a shoulder dystocia in this day and age, despite all the professional recommendations to the contrary.

Remember, this story happened only last year, and it was in the U.S. where fundal pressure is fairly uncommon now. Imagine how many stories similar to my friend's story must be happening in non-U.S. hospitals, where fundal pressure is far more common. This practice must stop.


Image from
Fundal pressure was done in tribal societies, but was done largely as a desperate, last-measure resort in a difficult and prolonged labor. Since they did not have recourse to a safe cesarean as an alternative during a difficult labor, fundal pressure became part of the folk tradition. Although a few cultures did use it as a regular part of their labor practices, it was mostly reserved for prolonged, obstructed labors.

While much wisdom can be gained from tribal and historic birthing practices, that doesn't mean that everything they did is appropriate anymore. We do have safer and more humane alternatives for some things nowadays; fundal pressure is not the only option anymore when faced with a long, hard labor.

Fundal pressure came into use in hospital settings in response to highly-drugged mothers in order to get the babies out as quickly as possible. The potential harm from fundal pressure was seen as less dangerous than the risk for fetal distress from drug exposure and hypoxia (low oxygenation).

However, birth conditions today are much different than they were in the mid-1900s. While many women are still exposed to drugs through epidurals today, the fetal exposure in epidurals is considerably lower than the IV drugs of the past, and the drugs used now are safer than the ones used previously. Labor does not have to be rushed in order to minimize the risk for fetal distress and hypoxia anymore.

There are simpler, safer and more humane alternatives to fundal pressure during labor. Research shows that these include:
If none of these techniques help, then a cesarean can be considered. Although cesareans are a significant surgery and should not be used without true need, they are far safer now than they used to be. Sometimes they can be the best choice in a long, hard, non-progressive labor. 

Similarly, even during the obstetric emergency of shoulder dystocia, there are FAR better alternatives than fundal pressure:
  • McRoberts plus Suprapubic Pressure - The first procedure usually recommended for shoulder dystocia is to flex the mother's knees back towards her shoulders (McRoberts maneuver), combined with suprapubic pressure. These two maneuvers together resolve about half of all shoulder dystocias without need for further maneuvers
  • Internal Rotational Maneuvers - There are a number of maneuvers that involve the care provider putting their hands inside the mother and helping the baby rotate its shoulders into an oblique (diagonal) presentation, which gives more room for the baby to get out. In addition, the posterior arm can be delivered, which reduces the width of the shoulders
  • Move the Mother's Position - Many midwives know that moving the mother is often even more effective than internal maneuvers. Although most doctors have not been trained in these maneuvers anymore, rolling the mother onto all fours (the Gaskin maneuver), moving her into an asymmetric position so that one hip is higher than the other, or raising the mother's pelvis and having her arch her back strongly (Walcher's Position) are all positional changes that can work for resolving shoulder dystocia. Many of these were recommended in old obstetric textbooks but have gone out of routine practice; it is time for these to be re-explored in modern obstetrics
To summarize, research suggests that there is no real benefit from fundal pressure during labor. Any possible benefits of a slightly shorter labor in a very few studies have been offset by more perineal damage, more babies in the Neonatal Intensive Care Unit (NICU), and more fetal nerve damage. Furthermore, sometimes fundal pressure can even result in catastrophic damage such as uterine ruptures, uterine prolapse, or even deaths.

Furthermore, fundal pressure during shoulder dystocia is a disaster waiting to happen. Every major organization recommends against its use during shoulder dystocia, yet my friend's horrendous story from only a year ago shows that it is STILL being used in response to shoulder dystocias, despite these recommendations. It is time for hospitals to make a concerted educational effort to eliminate its use.

There are other options that work just as well or better than fundal pressure, and with far less risk. Upright positions, fewer epidurals, delayed pushing, more mobility, more patience, and manual rotation are all options to help a labor that is slower than expected. If shoulder dystocia occurs, McRoberts position plus suprapubic pressure resolves most cases; other maneuvers usually resolve the rest. Fundal pressure in a shoulder dystocia only makes the problem worse and often damages the baby or mother.

Although the use of fundal pressure has decreased, more education is obviously needed, both against "routine" fundal pressure during pushing, and particularly against fundal pressure during shoulder dystocia.

With all we know about the risks of fundal pressure and its lack of any real benefit, it is appalling that fundal pressure is still being used during labor or shoulder dystocia in many hospitals around the world. It is clearly a procedure that is outdated and associated with far too many risks.

Unlike our ancestors, we have other options now. There is just no excuse for fundal pressure to still be in such common use in the world today.


Obstet Gynecol Surv. 2005 Sep;60(9):599-603. The role of uterine fundal pressure in the management of the second stage of labor: a reappraisal. Merhi ZO1, Awonuga AO. PMID: 16121114
Among the maneuvers that are used in the second stage of labor, uterine fundal pressure is one of the most controversial. The prevalence of its use is unknown. We reviewed the existing literature to assess whether there is justification for the use of fundal pressure in the contemporary management of the second stage of labor. Only one randomized, controlled study and a few prospective studies, review articles, and case reports have been published. No confirmed benefit of the procedure has been documented and a few adverse events have been reported in association with its use. Alternative management strategies in the second stage of labor exist and should be considered whenever possible. In conclusion, the role of fundal pressure is understudied and remains controversial in the management of the second stage of labor. We believe that caution should be exercised using this maneuver until it is proven to be safe and effective....
MCN Am J Matern Child Nurs. 2001 Mar-Apr;26(2):64-70; quiz 71. Fundal pressure during the second stage of labor. Simpson KR1, Knox GE. PMID: 11265438
The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.
J Obstet Gynaecol Res. 2014 Apr;40(4):946-53. doi: 10.1111/jog.12284. Epub 2014 Jan 15. Fundal pressure during the second stage of labor in a tertiary obstetric center: a prospective analysis. Moiety FM1, Azzam AZ. PMID: 24428496
...This was a prospective observational study set in a tertiary teaching and research obstetric hospital [in Egypt]. A total of 8097 women in labor between 37 and 42 gestational weeks with a singleton cephalic presentation were enrolled. Subjects were subdivided into two groups: fundal pressure group (n=1974 women) and control group (n=6123 women). The primary outcome measure was the duration of the second stage. The secondary outcome measures were maternal outcomes (immediate or delayed) and neonatal outcomes. RESULTS: The prevalence of fundal pressure in our center was 24.38%. Fundal pressure maneuver significantly shortened the duration of the second stage among primiparous women, increased the risk of severe perineal laceration and admission to neonatal intensive care unit in comparison to the non-fundal group. Delayed maternal outcomes showed significant increase in dyspareunia and de novo stress urinary incontinence in the fundal pressure group. CONCLUSION: Although fundal pressure maneuver shortens the duration of the second stage of labor among primiparous women, it should not be used except when indicated, and under strict guidelines owing to its adverse maternal and fetal outcomes.
J Turk Ger Gynecol Assoc. 2010 Jun 1;11(2):95-8. doi: 10.5152/jtgga.2010.07. eCollection 2010. Shortening the second stage of labor? Mahendru R1. PMID: 24591907
...A pilot study comprising 209 primigravidae between 37 and 40 gestational weeks with singleton fetus in cephalic presentation admitted to the delivery suite were considered and were randomly allocated into two groups: I (n=101) and II (n=108), with or without manual fundal pressure, respectively, during the second stage of labor...RESULTS: There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures. Significant adverse findings having no mention in the earlier literature, were noticed which were: one case each of retained placenta and uterine prolapse besides increased evidence of maternal exhaustion and perineal injuries (including one case of complete perineal tear) in the group where fundal pressure was exercised. CONCLUSION: Application of uterine fundal pressure in a delivering woman was not only ineffective in shortening the second stage of labor but added to the risks during parturition.
J Perinat Med. 2015 Mar;43(2):171-5. Intrapartum ultrasound prior to Kristeller maneuver: an observational study. Cuerva MJ, Tobias P, Espinosa JA, Bartha JL. PMID: 25032803
...In this prospective observational study, the station of the fetal head was measured using the angle of progression (intrapartum ultrasound) just prior to the intervention of the managing obstetrician in 52 women with prolonged second stage of labor. The managing obstetricians were blinded to the sonographic results. The decision of performing a Kristeller maneuver was taken by the obstetricians based on digital palpation and their experience...RESULTS: Kristeller maneuver was performed in 36/52 (69.2%) cases. There were no significant differences between the Kristellerand the non-Kristeller group regarding the angle of progression. There were no significant differences between both groups with respect to delivery mode, perineal tears, episiotomy, bleeding, Apgar score, and umbilical artery pH value. CONCLUSIONS: Our study failed to define any criteria followed by obstetricians when performing a Kristeller maneuver in cases of prolonged second stage of labor. There was no relation between the angle of progression and the decision to perform a Kristeller maneuver.
Acta Obstet Gynecol Scand. 2009;88(3):320-4. doi: 10.1080/00016340902730326. The effect of uterine fundal pressure on the duration of the second stage of labor: a randomized controlled trial. Api O1, Balcin ME, Ugurel V, Api M, Turan C, Unal O. PMID: 19172441
...One hundred ninety-seven women between 37 and 42 gestational weeks with singleton cephalic presentation admitted to the delivery unit. METHODS: Random allocation into groups with or without manual fundal pressure during the second stage of labor...CONCLUSION: Application of fundal pressure on a delivering woman was ineffective in shortening the second stage of labor.
Arch Gynecol Obstet. 2009 Nov;280(5):781-6. doi: 10.1007/s00404-009-1015-2. Epub 2009 Mar 5. Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration. Matsuo K1, Shiki Y, Yamasaki M, Shimoya K. PMID: 19263062
...All vaginal delivery records between 1 January 2005 and 30 April 2006 were evaluated...Six hundred sixty-one vaginal deliveries were evaluated. Fundal pressure maneuver was performed in 39 cases (5.9%, 95% CI 4.4-7.1)...One case of shoulder dystocia following uterine fundal pressure maneuver was reported (2.5 vs. 0%). Episiotomy (76.9 vs. 44.9%, P < 0.001) and vacuum extraction (41.0 vs. 3.8%, P < 0.001) were frequently performed with uterine fundal pressure maneuver. Uterine fundal pressure maneuver increased the risk of severe perineal laceration (28.1 vs. 4.8%; odds ratio 2.71, 95% CI 1.03-7.15, P = 0.045). The risk of severe perineal laceration was synergistically increased with the concurrent use of uterine fundal pressure maneuver with vacuum extraction and episiotomy. CONCLUSION: Uterine fundal pressure maneuver during the second stage of labor increased the risk of severe perineal laceration. The use of the maneuver must be cautioned and careful attention must be paid to its application.
J Perinat Med. 2014 Nov 8. pii: /j/jpme.ahead-of-print/jpm-2014-0284/jpm-2014-0284.xml. doi: 10.1515/jpm-2014-0284. [Epub ahead of print] Uterine rupture after the uterine fundal pressure maneuver. Hasegawa J, Sekizawa A, Ishiwata I, Ikeda T, Kinoshita K. PMID: 25389983
...A questionnaire was sent to 2518 institutions in Japan. We received a response from 1430. RESULTS: Of reporting institutions, 89.4% used fundal pressure in at least some of their deliveries. Among the 347,771 women who delivered vaginally in this study, 38,973 (11.2%) were delivered with the assistance of fundal pressure. There were six cases of uterine rupture associated with uterine fundal pressure, with one case resulting in maternal death secondary to amniotic fluid embolism....
Shoulder Dystocia Guidelines
*Historical birth illustrations were taken from the following resources. [Be aware that these books are products of their times and contain outdated attitudes and language]
  • The 1882 book, "Labor Among Primitive Peoples," by Dr. George Engelmann 
  • The illustrations by Georges Devy in "A History of Childbirth of All the People" by G. J. Witkowski (1887) [see the National Library of Medicine website]
**Ginekol Pol. 2008 Apr;79(4):297-300. [Kristeller's procedure--Expressio fetus, its genesis and contemporary application]. [Article in Polish] Waszyński E1. PMID: 18592869
The aim of the article is to introduce the original version of Kristeller's procedure - Expressio fetus. The author of the procedure, Samuel Kristeller, was bom in 1820 in Ksiaz Wielkopolski. He worked as a physician in Gniezno, then in Berlin. He is known as the creator of the described procedure - pushing out the foetus...In 1867, Kristeller published a study in which he described a procedure, of which he was the author, of pushing out the foetus (manual assistance), its technique, conditions and recommendations for its application. The main idea of the procedure meant strengthening uterine contractions during labour by massaging the uterus and pressing it many times shortly, towards the long axis of the birth canal. Nowadays this procedure has become warped in its form; there remains also the controversy whether or not to use external force directed on the uterine fundus during labour, due to the risk of intrauterine foetal anoxia and other complications.

Friday, May 8, 2015

A Midwife-Laborist Care Model Reduces Cesarean Rates

Here is brand-new research showing that a midwife-physician laborist care model resulted in lower cesarean rates than a private practice OB care model.

This could be one potent way to reduce stubbornly-high cesarean rates on a more widespread basis.

But first, let's start by discussing what a "laborist" is, since many readers may not be familiar with this model of care.

What is a "Laborist"?

More and more hospitals are beginning to implement "laborist" programs in their maternity wards. But what the heck is a "laborist"?

According to the American College of Obstetricians and Gynecologists:
The term laborist most commonly refers to an obstetrician–gynecologist who is employed by a hospital or physician group and whose primary role is to care for laboring patients and to manage obstetric emergencies.
Laborists are based on the "hospitalist" concept from other medical fields. A hospitalist is a physician that only works in the hospital and does not have care responsibilities elsewhere. Their focus is on hospitalized patients, not private patients.

A hospitalist might work up patients admitted to the hospital from the emergency room, get information from all the patient's doctors, order tests, look for potential cross-reactions between medications, and develop a plan of care for the patient's hospital stay, release, and after-care. The patient's main doctor collaborates with the hospitalist, but having a hospitalist assigned to a patient assures the patient of having a doctor immediately available if necessary, as well as someone who will coordinate care between various providers.

Basically, a laborist is a hospitalist in the OB-GYN field.

There are several different laborist models around so details can differ, but generally a laborist stays in the hospital and is in charge of consulting on patients in labor during his/her work shift. He/she would not be responsible for any other other duties or office hours, but instead manages whatever issues come up during that shift, including emergencies.

If a minor problem occurred, the woman's regular care provider and the laborist would consult on how to manage it. If there was an emergency that required immediate response, the laborist would handle it. If a c-section was needed, the laborist would do it (or would do it in conjunction with the woman's care provider). If a woman in labor came into the E.R. without an assigned physician from that hospital, the laborist would take the case. In addition, if the emergency room had an E.R. patient with a gynecological problem, the laborist would consult.

In the non-laborist model of care, a private OB group covers its own patients when they are in labor. This means that doctors must juggle covering office hours, meetings, and routine appointments with managing patients who are in labor. If there is an emergency, the doctor must drop everything to run over to the hospital and respond to the crisis. Regular patient appointments must often be rescheduled or covered by colleagues back at the office because of the unpredictable nature of labor.

Like hospitalists, the laborist care model is a rapidly expanding model of care. One survey showed that about 40% of the U.S. hospitals surveyed had moved to a laborist model, and this number is likely to increase over time.

That means it's time to have a more in-depth look at the pros and cons of laborist programs.

Advantages and Disadvantages of Laborists 

The biggest advantage of having a laborist is that an obstetric surgeon is always right at hand in the hospital, ready to intervene at a moment's notice if a true emergency occurred. 

This is HUGE in the field of obstetrics where sudden emergencies sometimes do occur. Most birthing women are surprised to learn that most hospitals don't have a doctor always on hand, ready to intervene. Thus there can be a critical delay while waiting for a physician to arrive from off-campus.

Private duty OBs juggle regular office hours with monitoring their patients in labor. They are usually on-call at a nearby office or home within a certain number of minutes, but that is not the same as being at the hospital 24/7. Having a laborist always on duty means that someone is always available right away on those rare occasions when immediate action is needed.

Another big advantage of laborist care is a more humane life-style for the care providers involved. In hospitals with laborist models, care providers have more off-duty time, more time with their families, and less need to juggle laboring patients with office hours. In a profession where stress contributes mightily to burn-out and substance abuse issues, a more sane schedule is a tremendous advantage for both care providers and the mothers they attend.

Laborists also offer business advantages. Hospitals with laborist programs have been able to reduce their malpractice premiums and do not have to hold as much money in reserve for possible liability claims. This means that even though laborists cost extra money in salaries, their overall effect often saves a hospital money.

One potential disadvantage of laborist care is less personal care. A woman might not be attended by her personal caregiver during labor. Many women feel strongly about having a personal relationship with a caregiver she knows and trusts, one who has a deep understanding of her medical history and birth preferences. A laborist model has the potential to decrease this. This is a real and substantial disadvantage.

However, the reality of hospital birth is that many caregivers already do not attend their own patients because they are part of large group practices. The mother gets whomever is on duty in the group on the day she goes into labor. Those caregivers who do promise to be there for a woman's labor often do so by inducing her when they are on duty, exposing the mother and baby to all the risks of induction and perhaps raising the risk for cesarean.

Additionally, most laborist models do allow the regular caregiver to attend a particular patient's birth if desired. It doesn't keep them from attending births, it just gives them more flexibility to balance other duties with births. And having a laborist working in conjunction with the regular caregiver might just ease some of the time constraints that caregivers feel and give the mother more opportunity to get the birth outcome she wants.

Possible Effect on Cesarean Rate

One VERY important potential advantage of having a laborist is hopefully lowering both the primary and repeat cesarean rate, while also increasing VBAC access. 

Because a private practice OB has dual duties with office hours and births, the constraints on their time may make them more quick to move to a cesarean. A laborist may have more patience to wait out a long labor because they don't have to rush off to other appointments, and they might be more willing to try alternatives (like mobility in labor, manual repositioning of the baby, etc.) when labor is "stuck." In this way, a laborist may help prevent primary cesareans, which in turn will help prevent many repeat cesareans in the future.

In addition, the current rules of many hospitals make it hard for many care providers to attend Vaginal Births After Cesarean (VBACs). Many hospitals demand that a doctor and anesthesiologist must be IN the hospital with a VBAC patient at all times, making it hard for caregivers to manage regular office hours and VBAC patients. This has resulted in many doctors refusing to attend VBAC mothers, forcing most of them into repeat cesareans.

Having a laborist on duty should boost the willingness of care providers to support VBAC patients.

This could be very important, since about one-third of U.S. hospitals have official VBAC bans, and many more have de facto VBAC bans. Many women are being forced into surgery they do not want or need by the "immediately available" VBAC criteria. Laborists can provide the 24/7 coverage needed to satisfy part of that criteria and may help bring VBAC back to many hospitals.

What Does the Research Say?

The theory has been that if laborists were added to hospitals, some lives would be saved, the quality of life of OBs would improve, and the cesarean rate would go down. But has the laborist model achieved this?

The research so far does seem to support this. In one study from Nevada, the cesarean rate dropped from 39% to 33% when a full-time laborist model was adopted ─ and this was during a period when the cesarean rate was rapidly increasing everywhere else.

[However, it's important to point out that even with the laborist model, the Nevada study still had a fairly high cesarean rate, over 30%, suggesting that there is still room for improvement.]

In 2013, three studies on laborist models were presented at a meeting of the Society of Maternal-Fetal Medicine. All three showed improvements with a laborist model of care, as summarized here:
Hospitals that employed laborists saw about a 15% decline in induction of labor and preterm deliveries after adjustment for other factors compared with centers that do not employ that OB equivalent of a hospitalist, Sindhu Srinivas, MD, of the University of Pennsylvania in Philadelphia, and colleagues reported.  
In a separate study, hospitals that provided 24-hour coverage through use of laborists or other means saw a similar reduction in cesarean delivery rates, with a more than twofold increase in attempted vaginal birth after a prior cesarean, said Yvonne Cheng, MD, PhD, of the University of California San Francisco and colleagues.
...In the third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues looked at a computer simulation comparing probabilistic scenarios for two events that require urgent delivery -- umbilical cord prolapse and major placental abruption -- at laborist and nonlaborist hospitals. In a theoretical cohort of 100,000 pregnant women, employment of laborists at hospitals with a volume of 1,000 deliveries a year would be expected to result in 83% fewer stillbirths, 17% fewer cases of major neurologic injury, and 13% fewer neonatal deaths.
So indeed, it does seem that a laborist model should save lives, lower the cesarean rate, and improve access to VBAC. Most OBs agree that it also brings a bit more sanity into their busy schedules and more time for family life.

All of this speaks strongly in favor of a laborist model of care. But what if that model of care could be improved on even further?

One hospital in California asked whether it could lower the cesarean rate even more by using both OBs and midwives in its laborist model.

Midwifery/Laborist Model of Care

Midwifery care has been shown numerous times to lower intervention rates and often c-section rates. Integrating midwives into a laborist care model might make for a particularly potent combination for reducing cesarean rates.

In this study from a community hospital in Marin, California, using both midwives and OBs as laborists helped lower the cesarean rate substantially compared to those handled in private OB practices.

In the study's private practice care model (also called an "out-of-hospital" model), a large practice of 18 OBs and 2 CNMs (Certified Nurse-Midwives) practiced together and handled 57% of the births during the 5-year study period.

In the collaborative midwife-laborist care model (also called an "in-hospital" model), a group of 20 CNMs and 25 OBs practiced together. They handled 42% of the births during the same study period. In this care model, both a midwife and an OB were on duty as laborists 24 hours a day. The care for most patients was midwife-led, with the OB laborist called in as the woman's risk factors and situation dictated.

In this study, women who were cared for in the private OB practice model had more cesareans than those under the care of midwife-laborist model, 31.6% vs. 17.3%

That's a HUGE difference. Even after adjusting for confounders, the women in private practice care had twice the risk for cesarean. They also had more inductions and more epidurals.

The midwife-laborist care model was effective for first-time mothers as well as multips. "NTSV" stands for Nulliparous, Term, Singleton, Vertex, and basically means first-time mothers, at full-term, with only one baby, and that baby is head-down. Many researchers feel these low-risk NTSV births are the best target for lowering overall cesarean rates because every primary cesarean prevented in NTSV mothers usually means that a repeat cesarean for a later birth is also prevented.

In this study, 29.8% of NTSV births in the private practice model ended in cesarean, whereas only 15.9% of NTSV births in the midwife-laborist care model ended in cesarean. That's a very important difference.

The difference was also clear in NTSV cesareans where medical judgment plays a critical part of when to move to a cesarean (such as interpreting abnormal fetal heart tracings or dealing with slower labors). In this situation, the private practice model had a 28.1% cesarean rate, versus a 15.6% cesarean rate in the midwife-laborist care model. The authors suggested that the difference may well have had to do with less competing demands for the care provider's time and as a result, more patience in labor.

The midwife-laborist care model was also helpful for mothers who had had a prior cesarean. 71.3% of women with prior cesareans had another cesarean in the private practice model, whereas 41.4% of women with prior cesareans seen in the collaborative care model had another cesarean.

This was probably both a reflection that midwives tend to be more supportive of offering VBACs, as well as the fact that 24-hour laborist care enabled more providers to meet the "immediately available" requirement without having to cancel regular office hours. So while the study did not have specific data on the "trial of labor" or success rates in each group, it's likely that midwife-laborist care model did significantly expand VBAC access at the hospital.

One item I'd particularly like studied in the future is whether a midwife-laborist care model could lower the cesarean rate in women of size. In the study, the authors did not have information on Body Mass Index and could not analyze for its effect. However, they pointed out that the midwife-laborist care model had far more Latina patients than the private OB care model. They noted that Latinas tend to have a higher prevalence of obesity than white women in the U.S. and that if that trend also held true in the study, the midwife-laborist care model "should" have had higher cesarean rates. <roll eyes> Yet the midwife-laborist care model actually had LOWER cesarean rates, despite a population that was probably heavier.

[Hmmmm. Maybe how an "obese" woman's labor is managed makes a big difference? Maybe differing expectations of normalcy make a difference? Maybe midwives should be handling more women of size? Sounds like this is a topic ripe to be studied in further detail, doesn't it?]

The authors concluded:
In this study, we observed a consistent pattern of a higher use of cesarean delivery among women cared for under a private model compared with women cared for under a midwife/laborist model...Based on our findings, the implementation of obstetrician-midwife laborist programs may also have a positive impact on reducing the rate of cesarean deliveries in the United States.
This is a study that deserves to be replicated to see if other hospitals can achieve similarly dramatic results. Heaven knows we need to reduce the amount of non-indicated cesareans we are doing in the U.S., and reducing that rate should help prevent some of the alarming downstream outcomes of a too-high cesarean rate, like placenta accreta, placenta previa, placental abruption, and cesarean scar pregnancies.

I'd also love to see researchers particularly focus on whether a midwife-laborist program can decrease the unacceptably high risk for cesarean among women of size, and thereby decrease their risks for downstream complications too.


These studies show that a full-time laborist care model can be part of a program to help reduce cesarean rates at the hospital level.

If having a laborist on duty at all times can help lower cesarean rates, make VBAC more accessible, save a few lives, and help make caregivers' lives more humane, then it's a win-win situation all around. Research shows that most women are satisfied with the care received under a laborist care model, despite some care providers' fears that they would not be.

Laborist care models seem like a winning innovation so far, but the California study shows that a midwife-laborist care model is worth looking at even more closely.

Note that the OB laborist program in Nevada reduced its cesarean rate from 39% to 33%, yet the midwife-laborist program in California reduced its cesarean rate from 31% to 17%.

This suggests that a midwife-laborist model of care is even more potent at reducing cesarean rates than an OB laborist model of care.

More research is needed to confirm these results, but this preliminary research is very promising. If hospitals are serious about lowering cesarean rates, then it's time they looked into a midwife-laborist model of care.


Am J Obstet Gynecol. 2015 Apr;212(4):491.e1-8. doi: 10.1016/j.ajog.2014.11.014. Epub 2014 Nov 13. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Nijagal MA1, Kuppermann M2, Nakagawa S3, Cheng Y4. PMID: 25446697
OBJECTIVE: The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESIGN: This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS: Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION: In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.
Am J Obstet Gynecol. 2013 Sep;209(3):251.e1-6. doi: 10.1016/j.ajog.2013.06.040. Epub 2013 Jul 29. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Iriye BK1, Huang WH, Condon J, Hancock L, Hancock JK, Ghamsary M, Garite TJ. PMID: 23904102
...In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. RESULTS: Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. CONCLUSION: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.
Other discussions of various "laborist" models: