Common Sense Prenatal Weight Gain Recommendations for "Obese" Women

The 2009 IOM Guidelines for Prenatal Weight Gain

Coming up with official prenatal weight gain guidelines is difficult. There's always a trade-off involved ─ too much weight gain increases the risk for large babies, but too little increases the risk for small babies.

(The effects of weight gain on cesarean rates and pre-eclampsia are harder to figure out because of multiple variables that influence outcomes, so we will limit our discussion for a moment to the influence of weight gain on fetal outcomes.)

This weight gain trade-off has been particularly difficult to figure out in women of size. We tend to have larger babies on average and a very big weight gain seems to increase fetal size particularly strongly in high-BMI women. Nor do we need to gain extra fat reserves for pregnancy and breastfeeding. As a result, the Institute of Medicine (IOM) recommends less weight gain on average for "obese" women (see chart above).

While I don't hate these recommendations, I do have some concerns with them, particularly for women in the borderline categories (see discussion below). Women in these categories may be particularly at risk for poor outcomes, yet they are given the same stringent guidelines (and are often told to gain even less than the guidelines).

I also question how much control women really have over gestational weight gains. Sure, we have control over how much we eat and exercise, but that impact on gain is fairly minimal. There have been many trials of interventions to help obese women keep their weight gains lower; some have had minimal success (about 5 lbs. difference), but many have made little difference in weight gain and do little to improve other outcomes. Even with the best support, many women of size gain above the guidelines ─ not because they are lazy or out of control, but because the guidelines aren't particularly realistic for them.

I am also concerned about harassment and over-intervention in the pregnancies of women who gain above these recommended ranges. I have heard many stories of women of size who are harassed or even punished with early inductions or planned cesareans because they "gained too much."

So while I agree in general with the IOM that obese women don't need to gain as much weight in pregnancy as other women, I do have some reservations about the IOM guidelines and in particular about how they are implemented. But sadly, even these guidelines are not stringent enough for some providers.

Taking The 2009 Guidelines Even Further

Some caregivers believe the 2009 IOM weight gain goals didn't go far enough for obese women. In recent years, unofficial prenatal weight gain advice has gotten progressively more extreme. I call this the "anorexation" of pregnancy weight gain guidelines.

The following are real-life headlines from media articles over the years. Notice how the headlines have changed. They have gone from "obese women should gain LESS weight".....

...to "obese women should gain NO weight"

....to "obese women should LOSE weight" during pregnancy.

Disturbingly, many experts have taken an extremist tone in the media and sold these draconian measures as a public health imperative, which alarms me greatly. Many news articles have pushed this weight restriction agenda, assuring us that very little gain was perfectly safe and even healthier for the plus-sized mother and her baby. Here are just a couple of examples.

One article about the IOM recommendations prominently featured the following quotes promoting even lower gains in high-BMI women:

"I think 11 to 20 pounds is way too much for an obese woman," said Dr. Thomas Myles, a professor of obstetrics and gynecology at Saint Louis University School of Medicine who was not involved in the current recommendations. "I usually tell my [obese] patients that gaining less than 10 pounds and even losing up to 10 pounds is appropriate, whereas for overweight women, gaining 10 to 15 and even up to 20 pounds is appropriate," Myles said. 

Gaining a little less weight than the recommended amount, especially for overweight and obese women, might be better, [Associate Professor, Dr. Emily] Oken [of Harvard University] said.

Another article promoting zero weight gain in obese women featured the following quote from one of its leading investigators in its study's press release (my emphasis):

It may seem counterintuitive to suggest that women control their weight during pregnancy, but these women are already carrying between 50 and 100 extra pounds — and for them any more weight gain could be very dangerous,” said Vic Stevens, PhD, principal investigator who has studied weight loss and weight maintenance for more than 30 years.

Another recent article quoted Dr. Sigal Klipstein, Chair of the American College of Obstetricians and Gynecologists committee on Medical ethics. Even as she discussed the importance of treating obese women humanely during pregnancy, Dr. Klipstein stated:

Although women should not to try to lose weight during pregnancy, “a woman who weighs 300 pounds shouldn’t gain at all,” Klipstein said. “This is not harmful to the fetus.”

But is it really true that very small or non-existent gains are not harmful?

Risks of Too-Small Gains

Those who suggest that gaining little or no weight is optimal for women of size are ignoring all the contrary research.

A significant amount of research has shown that very low weight gains and/or weight loss during pregnancy in women of size carries real risks, including

• prematurity (Dietz 2006, Potti 2010, Hasegawa 2012)
• too-small babies (Vesco 2011, Catalano 2014)
• more need for intensive care in the NICU (Potti 2010)

Tellingly, virtually NO media articles acknowledge that low weight gains have risks or cite the research that shows this. That there are so many articles promoting restricted gain in obese women while completely ignoring the potential harms of such a policy suggests a health agenda that places ideology over evidence.

And now there is even more research suggesting that very low gains may be risky.

A very recent study (Durst 2016) showed that weight gains below the IOM recommendations in obese women led to increased rates of  small-for-gestational-age ("SGA") babies and pre-term births. Another recent study (Cox Bauer 2016) found that gestational weight loss (GWL) was associated with low-birth weight babies. These are a concern because too-small babies are more at risk for future health problems like metabolic syndrome and insulin resistance.

Still another recent study (Hannaford 2016) shows that too-low weight gains, even in obese women, more than doubled the risk for too-small babies. The authors suggested that there may need to be a threshold of a minimum weight gain, even for very high-BMI women, which is a pretty radical suggestion given how many doctors are calling for zero gain or weight loss in this group.

But these new studies are far from the first to find reasons for concern. A brand-new meta-analysis (Xu 2017) of studies on weight gain below the 2009 guidelines in obese mothers found that low weight gain was associated with SGA babies in all obesity categories, not just in the borderline categories.

Yet another meta-analysis (Kapadia 2015) of studies on weight gain in obese pregnant women concluded that, because of its consistent association with too-small babies,

Gestational weight gain below the guidelines cannot be routinely recommended.

Too-small babies and prematurity may not be the only risks of very low weight gains; they may also be implicated in infant deaths.

A recent study (Bodnar 2016) found that weight loss and very low weight gains in Class I and II obese women were associated with a higher risk of infant death.

This is particularly important because research is very clear that SGA babies have a higher risk for stillbirth and neonatal mortality. In addition, some past research (Salihu 2009) shows that SGA babies of obese women are at particular risk for stillbirth.

Sorry, but SGA babies, prematurity, and infant death are pretty significant concerns. People like Dr. Myles, Dr. Oken, Dr. Stevens, and Dr.Klipstein who have been recommending weight gains well below the IOM recommendations have been playing Russian Roulette with the babies of their patients of size.

This is a common problem in medicine ─ taking a recommendation to extreme lengths without adequately studying its safety first.

Obese women as a group may benefit from gaining less weight on average than other women, but it does NOT automatically follow that even less is better. 

Sadly, while now there are years of data suggesting harms with very low gains and/or gestational weight loss, many experts are STILL telling women of size and their providers that "any weight gain in overweight and obese patients is detrimental to pregnancy outcome." Any weight gain, really?

This bias towards ever-lowered weight gain goals is so ingrained that it continues to deny the existence of any contrary evidence. The 2013 article quoted above advises OB-GYNs:

Weight maintenance and even weight reduction have not proven harmful in obese pregnant patients according to studies in the recent literature

Not proven harmful? This statement completely ignores numerous studies published before 2013 pointing out safety concerns with this advice (Bayerlein 2011, Bodnar 2010, Blomberg 2011, Vesco 2011, Dietz 2006, Potti 2010, Hasegawa 2012).

And now we have EVEN MORE studies showing that there are safety concerns, yet this low/no gain/weight loss advice continues to be given routinely by many providers who assure their patients falsely that there is no reason to worry.

But What About....?

Critics will undoubtedly point out that some of these same studies show benefits of lower gains such as a modestly lower cesarean rate or lower rates of pre-eclampsia. These are valid points. However, that's a whole different discussion because multiple variables influence these complications and it's difficult to tease out a causal relationship.

For example, caregivers are not blinded to their patients' gains. A bigger gain may mean a bigger baby. Fear of a big baby can strongly influence the perception of when a cesarean is "needed" and how many interventions like induction are used. Research shows that women with larger weight gains are induced at higher rates. Therefore it may not be weight gain that's the issue, but rather how the caregiver responds to the gain.

Pre-eclampsia is another situation where you can't jump to conclusions about weight gain. Women with pre-eclampsia typically have a lot of swelling, which means a higher weight gain. As Nohr 2008 states:

Any causal interpretation of the association between total weight gain and these complications is limited. For preeclampsia, high total gain most likely reflects pathologic fluid retention as part of the disease.

In other words, a higher weight gain doesn't necessarily cause pre-eclampsia, but rather it often results from pre-eclampsia. It certainly doesn't mean that a lower weight gain will prevent pre-eclampsia. We just don't know if deliberately restricting weight gain will lower the rate of pre-eclampsia in obese women.

However, it must be acknowledged that too much weight gain is probably also not ideal. Prenatal weight gain clearly influences fetal size, and higher gains seem particularly particularly potent for larger fetal size in high-BMI women. Postpartum, a larger gain may also be difficult to lose; multiple pregnancies with large gains can result in a net overall weight increase that might possibly affect the mother's health. So doctors have to find a balance between the very real risk/benefit trade-offs of too much or too little gain in pregnancy.

That's not easy, and I acknowledge that. But it seems to me that the debate is still very unbalanced, with too many experts still not willing to acknowledge the very real risks of too-small gains.

Deliberately ignoring contrary research is not an evidence-based approach. It smacks of a weight restriction agenda instead of a reasoned approach to best practices.

Summary

For too long, "experts" have been waging a campaign to lower the 2009 IOM guidelines even further for obese women. As a result, many care providers have used draconian pressure on women of size to gain very little or even to lose weight in pregnancy. But there are significant safety concerns with this approach, concerns that these so-called experts are conveniently ignoring.

The research makes several things clear:

1. Very low weight gain or weight loss is extremely consistent with too-small babies in multiple studies 
2. Too-small babies are at increased risk for adulthood diseases
3. Weight loss and very low weight gains may also be associated with a higher risk for infant death and prematurity 

These concerns means it's time for caregivers to STOP promoting extreme weight gain limits and to START acknowledging that very low gains also carry risks. 

Now, it may be that in time, different weight gains will be recommended for different levels of obesity. That seems like a possibility that is worthy of further consideration.

For example, "overweight" women (BMI 25-29) and women with Class I obesity (BMI 30-35) seem to be the most negatively affected by very small weight gains, whereas some research shows that women with Class III obesity (BMI 40-50) and Class IV obesity (BMI 50+) are less affected on average by very low gains.

So there may be some gradations in recommendations in the future, and I welcome discussions about this possibility ─ but given the established risks and the meta-analysis of studies that showed increased SGA risks across all class sizes of obesity, it would still behoove us to be very cautious about recommending very low weight gain even in women with Class III and IV obesity. We simply cannot assume that restricting gains is harmless even there.

Common Sense Recommendations

To me, what's missing from prenatal weight gain recommendations for obese women is nuance. It's time to pull back from prenatal weight gain extremism and show some common sense. Here are the things I think caregivers should take into account when discussing pregnancy weight gain with women of size.

Women of size should be informed in a neutral way of the IOM weight gain recommendations and why they were made. A neutral discussion, with research citations as appropriate, goes a lot further to helping women make informed and empowered decisions. A decision about weight gain goals that comes from the woman herself, rather than being imposed by external forces, is a lot more likely to result in reasonable gains.

How the message is communicated is important. Women should be given reasonable nutritional advice and strongly encouraged to exercise, but risks should not be exaggerated. Lecturing, scare tactics, and condescension means that people will simply tune out recommendations. Treat women as competent partners in their own care and avoid judgment. Emphasize healthy habits rather than numbers on the scale.

Consider tailoring recommendations by BMI. Women in the borderline BMI classes are the most at risk for poor outcomes with very low gains; they should be encouraged to gain nearer to the top of the IOM recommendations. It may even be that women with Class I obesity (BMI 30-35) do best with slightly more gain (15-25 lbs.). Women in Class III (BMI over 40) and Class IV obesity (BMI over 50) can be encouraged to gain towards the lower end of the recommendations or even slightly lower (5-15 lbs.) but great care should be taken that this message does not translate into pressure for restricted intake or extreme measures. Do not assume that very high BMI women have adequate nutritional reserves to make up for a lack of gain; good nutrition is always the priority.

Do not promote actively losing weight in pregnancy. Research shows there are too many potential harms to recommend pursuing gestational weight loss. Some women of size lose without trying; this is not a cause for panic as long as intake is adequate and the baby is growing well. But actively encouraging women to aim for weight loss during pregnancy is different than coincidental weight loss, is likely to result in restrictive behaviors, and probably has far greater risk.

Consider patterns of gestational weight gain. Has the weight gain pattern been relatively smooth? Was there a very large gain in the beginning? At the end? Different patterns may indicate different concerns. Also, don't forget to take pre-conception weight into account; many obese women lose weight in the first trimester and slowly gain that back to a small overall gain. If the initial loss is not counted, it looks like the woman has gained more weight than she actually has. Look at the whole picture.

Do not harass women about weight gain. Weight-related harassment is obnoxious and inappropriate, but it is sadly all too common. Women should not feel afraid to step on the scale at appointments, yet they often experience harassment. Medical assistants should record weight without comment. Care providers can ask neutrally about gains and can work with women on monitoring nutrition and troubleshooting worrisome trends, but judgment and belittling will only backfire. If a woman gains outside of guidelines despite good nutrition and regular exercise, consider other possible variables. Assume that a woman's body will gain what it needs for a healthy pregnancy.

Avoid food extremism. Women of size should not be pressured to strongly restrict calories or to eliminate entire food groups. They should be encouraged to eat reasonable amounts from a wide variety of foods. Nutritional advice should be evidence-based, not from unproven diet trends. Caregivers need to find a way to talk to clients about nutrition and weight gain concerns without condescension or judgment. Work with women and listen to their feedback about their needs.

Individualize care according to the woman's needs. People of size are not all alike. Some fit stereotypical images of fast food consumption and binge eating, others have very healthy habits, and many fall somewhere in between. Ask them respectfully about their habits and concerns; don't make assumptions. Believe what they tell you and advise them accordingly. If habits need improvement, encourage small and reasonable steps and recognize positive achievements.

Remember that weight gains among high-BMI women are highly variable. Research shows that weight gains in pregnancy are less predictable in larger women. Some have very large gains, some have very small gains, and some lose weight without trying. Often the women who gain the most are those who have recently lost weight or who are chronic dieters/weight cyclers, those with lipedema, or those who have swelling with pre-eclampsia. Many factors influence gestational weight gain besides the habits of the women. Acknowledge that some weight gain may be out of their control.

Look more at how the mother and baby are doing than at the scale. Guidelines are more for groups than individuals. While research shows that very high or very low gains are generally best avoided on average, some obese women gain more or less than recommended and have perfectly healthy babies. Some gain a lot and have average-sized babies; some gain almost nothing and have big babies; some lose weight with no obvious harmful effect. Gaining outside the recommendations is not necessarily a cause for alarm, as long as the mother's intake is normal and baby is growing well.

Women should not be subjected to extra interventions if they exceed their providers' weight gain goals. Some fat women are being consciously punished for "too much weight gain" by being subjected to extra interventions like inductions or planned cesareans. However, some of these interventions may occur because of providers' underlying fears about big babies. Care providers must actively examine their own biases so that they do not unconsciously use increased interventions on those who gain more.

Most importantly, focus on nutrition rather than on the scale. Too many providers use weight gain as a marker of pregnancy status and ignore nutrition altogether. What a woman is eating matters more than how much weight she has gained. Women can be given a weight gain goal range, nutritional advice, and exercise opportunities, but nutrition should not be manipulated in order to achieve an arbitrary number. The scale is a poor predictor of outcome and should not be used as a surrogate for nutritional adequacy or fetal status. Focus more on nutrition and concrete signs of how the mother/baby dyad is doing than on numbers on a scale.

Care providers need to bring common sense back into prenatal weight gain guidelines and take a more nuanced approach with women of size.


References

Very Low Gain and Too-Small Infants (Latest Studies)

Am J Perinatol. 2016 Jun 29. [Epub ahead of print] Gestational Weight Gain: Association with Adverse Pregnancy Outcomes. Hannaford KE1, Tuuli MG, Odibo L, Macones GA, Odibo AO. PMID: 27355980 DOI: 10.1055/s-0036-1584583

...OBJECTIVES: We investigated how weight gain outside the IOM's recommendations affects the risks of adverse pregnancy outcomes. STUDY DESIGN: We performed a secondary analysis of a prospective cohort study including singleton, nonanomalous fetuses. The risks of small for gestational age (SGA), macrosomia, preeclampsia, cesarean delivery, gestational diabetes, or preterm birth were calculated for patients who gained weight below or above the IOM's recommendations based on body mass index category....Women who gained weight below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm...Obese patients who gained inadequate weight were 2.5 times more likely to deliver SGA. CONCLUSIONS: ...Among obese patients, a minimum weight gain requirement may prevent SGA infants.

Am J Perinatol. 2016 Jul;33(9):849-55. doi: 10.1055/s-0036-1579650. Epub 2016 Mar 9. Impact of Gestational Weight Gain on Perinatal Outcomes in Obese Women. Durst JK, Sutton AL, Cliver SP, Tita AT, Biggio JR. PMID: 2696070

...STUDY DESIGN: A retrospective cohort of perinatal outcomes in obese women who gained below, within, or above the 2009 Institute of Medicine guidelines and delivered ≥ 36 weeks. Additionally, outcomes, according to the rate of GWG (kg/week; minimal [< 0.16], moderate [0.16-0.49], or excessive [> 0.49]) were compared among women delivering preterm. RESULTS: Overall, 5,651 obese women delivered ≥ 36 weeks. GWG above guidelines was associated with increased cesarean section (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI]: 1.21-1.72), gestational hypertension (aOR: 1.58, 95% CI: 1.21-2.06), and macrosomia (birth weight ≥ 4,000 g) (aOR: 2.08, 95% CI: 1.62-2.67). GWG below recommendations was associated with less large for gestational age infants (aOR: 0.60, 95% CI: 0.47-0.75)...Minimal weekly GWG was associated with increased spontaneous preterm birth (aOR: 1.56, 95% CI: 1.23-1.98) and more small for gestational age (SGA) infants (aOR: 1.55, 95% CI: 1.19-2.01). Excessive weekly GWG was associated with increased indicated preterm birth (aOR: 1.61, 95% CI: 1.29-2.01), cesarean section (aOR: 1.39, 95% CI: 1.20-1.61), preeclampsia (aOR: 1.83, 95% CI: 1.49-2.26), neonatal intensive care unit admission (aOR: 1.33, 95% CI: 1.08-1.63), and macrosomia (aOR: 2.40, 95% CI: 1.94-2.96).CONCLUSIONS: Obese women with excessive GWG had worse outcomes than women with GWG within recommendations. Limited GWG was associated with increased spontaneous preterm birth and SGA infants.

J Perinatol. 2016 Apr;36(4):278-83. doi: 10.1038/jp.2015.202. Epub 2016 Jan 7. Maternal and neonatal outcomes in obese women who lose weight during pregnancy. Cox Bauer CM, Bernhard KA, Greer DM, Merrill DC. PMID: 26741574

OBJECTIVE: To evaluate neonatal and maternal outcomes in obese pregnant women whose weight gain differed from the Institute of Medicine (IOM) recommendations. STUDY DESIGN: Maternal and neonatal outcomes associated with weight change in pregnancy were retrospectively investigated in women with obesity (body mass index (BMI) ⩾30 kg m(-2); N=10734) who gave birth at 12 hospitals...RESULT: Compared with IOM recommendations, weight loss was associated with twofold greater odds of low birth weight infants and a mean decrease in estimated blood loss of 30 ml; excessive weight gain was associated with doubled odds of gestational hypertension or preeclampsia, fourfold greater odds of macrosomia and a mean decrease in 5-min APGAR of 0.09....

J Matern Fetal Neonatal Med. 2017 Feb;30(3):357-367. Epub 2016 Apr 28. Inadequate weight gain in obese women and the risk of small for gestational age (SGA): a systematic review and meta-analysis. Xu Z, Wen Z, Zhou Y, Li D, Luo Z. PMID: 27033234

...We conducted a meta-analysis of original researches with sufficient information about inadequate GWG in obese women stratified by obesity classes. SGA as the chief outcome was extracted and assessed in our analysis...13 studies (437 512 obese women) were included. Obese women who gained weight below the guidelines had higher risks of SGA than those who gained weight within the guidelines (OR 1.28; 95% CI 1.14-1.43). The same conclusions were also confirmed in Class I, Class II and Class III of obese women: Class I (OR 1.37; 95% CI 1.22-1.54); Class II (OR 1.38; 95% CI 1.24-1.54); Class III (OR 1.25; 95% CI 1.14-1.36). CONCLUSIONS: From our analysis, the guidelines of IOM can be applied to all the classes of obesity. More accurate boundaries for each obesity class should be established to evaluate the maternal and fetal risks. Diverse populations are thus necessary for more studies in the future.

Low Weight Gain/SGA and Risk for Infant Death 

Obesity (Silver Spring). 2016 Feb;24(2):490-8. doi: 10.1002/oby.21335. Epub 2015 Nov 17. Maternal obesity and gestational weight gain are risk factors for infant death. Bodnar LM, Siminerio LL, Himes KP, Hutcheon JA, Lash TL, Parisi SM, Abrams B. PMID: 26572932

OBJECTIVE: Assessment of the joint and independent relationships of gestational weight gain and prepregnancy body mass index (BMI) on risk of infant mortality was performed. METHODS: This study used Pennsylvania linked birth-infant death records (2003-2011) from infants without anomalies born to mothers with prepregnancy BMI categorized as underweight (n = 58,973), normal weight (n = 610,118), overweight (n = 296,630), grade 1 obesity (n = 147,608), grade 2 obesity (n = 71,740), and grade 3 obesity (n = 47,277)...For all BMI groups except for grade 3 obesity, there were U-shaped associations between gestational weight gain and risk of infant death. Weight loss and very low weight gain among women with grades 1 and 2 obesity were associated with high risks of infant mortality....

Am J Perinatol. 2016 Aug 17. [Epub ahead of print] Morbidity and Mortality in Small-for-Gestational-Age Infants: A Secondary Analysis of Nine MFMU Network Studies. Mendez-Figueroa H1, Truong VT2, Pedroza C2, Chauhan SP1. PMID: 27533102

...Data from nine Maternal-Fetal Medicine Units Network studies were used and included nonanomalous singletons at 24 weeks or more and birth weight < 90% for EGA...Among SGA, the likelihood of stillbirth (8.8 vs. 2.5 per 1,000 births; adjusted odds ratio [aOR] 3.98, 95% confidence interval [CI]: 2.92-5.42) and neonatal mortality (14.0 vs. 5.5 per 1,000 births; aOR 3.18, 95% CI: 2.55-3.95) was threefold higher compared with AGA. For the subgroup of newborns of EGA of 32 weeks or more, SGA, compared with AGA, had significantly higher risk of stillbirth (aOR 3.32, 95% CI: 2.16-5.12) and neonatal mortality (aOR 2.50; 95% CI: 1.38-4.54). From 35 weeks onward, the risk of stillbirth among SGA is almost four times higher than for AGA. CONCLUSION: The risk of stillbirth and neonatal mortality is significantly higher with SGA than with AGA. Modification in practice or new management schema may be warranted.

Obstet Gynecol. 2009 Aug;114(2 Pt 1):333-9. Success of programming fetal growth phenotypes among obese women. Salihu HM, Mbah AK, Alio AP, Kornosky JL, Bruder K, Belogolovkin V. PMID: 19622995

...METHODS: This was a retrospective cohort study using the Missouri maternally linked cohort files (years 1978-1997)...Fetal growth phenotypes were defined as large for gestational age (LGA), appropriate for gestational age (AGA), and small for gestational age (SGA)...Neonatal mortality among LGA infants was similar for obese...and normal...weight mothers (OR 1.05, 95% confidence interval [CI] 0.75-1.48) and regardless of obesity subtype. By contrast, SGA and AGA infants programmed by obese mothers experienced greater neonatal mortality as compared with those born to normal weight mothers (AGA OR 1.45, 95% CI 1.32-1.59; SGA OR 1.72, 95% CI 1.49-1.98). CONCLUSION: Compared with normal weight mothers, obese women are least successful at programming SGA, less successful at programming AGA, and equally as successful at programming LGA infants.

Low Weight Gain and Risk for Prematurity

Obesity (Silver Spring). 2013 Dec;21(12):E770-4. doi: 10.1002/oby.20490. Epub 2013 Jul 5. Gestational weight loss and perinatal outcomes in overweight and obese women subsequent to diagnosis of gestational diabetes mellitus. Yee LM, Cheng YW, Inturrisi M, Caughey AB. PMID: 23613187

...Retrospective cohort study of 26,205 overweight and obese gestational diabetic women enrolled in the California Diabetes and Pregnancy Program. Women with GWL [Gestational Weight Loss] during program enrollment were compared to those with weight gain...RESULTS: About 5.2% of women experienced GWL. GWL was associated with decreased odds of macrosomia (aOR 0.63, 95% CI 0.52-0.77), NICU admission (aOR 0.51, 95% CI 0.27-0.95), and cesarean delivery (aOR 0.81, 95% CI 0.68-0.97). Odds of SGA status (aOR 1.69, 95% CI 1.32-2.17) and preterm delivery <34 weeks (aOR 1.71, 95% CI 1.23-2.37) were increased. CONCLUSIONS: In overweight and obese women with GDM, third trimester weight loss is associated with some improved maternal and neonatal outcomes, although this effect is lessened by increased odds of SGA status and preterm delivery. Further research on weight loss and interventions to improve adherence to weight guidelines in this population is recommended.

BJOG. 2011 Jan;118(1):55-61. doi: 10.1111/j.1471-0528.2010.02761.x. Epub 2010 Nov 4. Associations of gestational weight loss with birth-related outcome: a retrospective cohort study. Beyerlein A, Schiessl B, Lack N, von Kries R. PMID: 21054761

...DESIGN: Retrospective cohort study. SETTING AND POPULATION: Data on 709 575 singleton deliveries in Bavarian obstetric units from 2000-2007 were extracted from a standard dataset for which data are regularly collected for the national benchmarking of obstetric units...RESULTS: GWL was associated with a decreased risk of pregnancy complications, such as pre-eclampsia and nonelective caesarean section, in overweight and obese women [e.g. OR = 0.65 (95% confidence interval: 0.51, 0.83) for nonelective caesarean section in obese class I women]. The risks of preterm delivery and SGA births, by contrast, were significantly higher in overweight and obese class I/II mothers [e.g. OR = 1.68 (95% confidence interval: 1.37, 2.06) for SGA in obese class I women]. In obese class III women, no significantly increased risks of poor outcomes for infants were observed. CONCLUSIONS: The association of GWL with a decreased risk of pregnancy complications appears to be outweighed by increased risks of prematurity and SGA in all but obese class III mothers.

Epidemiology. 2006 Mar;17(2):170-7. Combined effects of prepregnancy body mass index and weight gain during pregnancy on the risk of preterm delivery. Dietz PM, Callaghan WM, Cogswell ME, Morrow B, Ferre C, Schieve LA. PMID: 16477257

...METHODS: Using data from the Pregnancy Risk Assessment Monitoring System in 21 states, we estimated the risk of very (20-31 weeks) and moderately (32-36 weeks) preterm delivery associated with a combination of prepregnancy body mass index (BMI) and gestational weight gain among 113,019 women who delivered a singleton infant during 1996-2001...RESULTS: There was a strong association between very low weight gain and very preterm delivery that varied by prepregnancy BMI, with the strongest association among underweight women (adjusted odds ratio = 9.8; 95% confidence interval = 7.0-13.8) and the weakest among very obese women (2.3; 1.8-3.1)...Women with very high weight gain had approximately twice the odds of very preterm delivery, regardless of prepregnancy BMI. CONCLUSIONS: This study supports concerns about very low weight gain during pregnancy, even among overweight and obese women, and also suggests that high weight gain, regardless of prepregnancy BMI, deserves further investigation.

J Matern Fetal Neonatal Med. 2012 Oct;25(10):1909-12. doi: 10.3109/14767058.2012.664666. Epub 2012 Mar 12. Gestational weight loss has adverse effects on placental development. Hasegawa J1, Nakamura M, Hamada S, Okuyama A, Matsuoka R, Ichizuka K, Sekizawa A, Okai T. PMID: 22348351

OBJECTIVE: To clarify whether mothers with gestational weight loss (GWL) were likely to have adverse effects on the placenta. STUDY DESIGN: Subjects who delivered viable singleton infants after 24 weeks of gestation were enrolled. A retrospective analysis to evaluate cases of GWL in association with the findings of the placenta and amniotic membrane after delivery was conducted. After consideration of confounders, a case-control study with matched pairs (1:2) was performed. RESULTS: Of all subjects (5551 cases), 83 cases (1.5%) with GWL were found. Since the pre-pregnancy maternal body mass index (BMI) was significantly higher in cases, 166 controls with a matched BMI were selected. The neonatal birth weights, placental weights and the umbilical cord length in cases were significantly smaller than in controls (p < 0.05). Preterm delivery and small for gestational age (SGA) infants were more frequently observed in cases compared with controls [odds ratio (OR) 6.3; 95% confidence interval (CI) 3.3, 12.1, OR 4.3; 95% CI 1.9, 9.9]. pPROM were observed in 10.8% of the cases and 1.8% of the control (OR 6.6; 95% CI 1.7, 25.1). However, the frequencies of chorioamnionitis and the cervical length at second trimester were not different between the two groups. CONCLUSION: GWL is associated with SGA, small placenta, short umbilical cord length, preterm delivery and pPROM.

Fundal Pressure: An Outdated Technique

Image from humanrightsinchildbirth.org  

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 tears, urinary 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 elpartoesnuestro.es

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 elpartoesnuestro.es 

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 Italy, Bulgaria, Brazil, Turkey, Japan, 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 elpartoesnuestro.es.



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.

Summary

Image from elpartoesnuestro.es

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:

• Simply get the mother more upright. This helps the mother work with gravity instead of having to push against it. A Cochrane review shows that this can shorten labor significantly
• Avoid routine epidurals. Research shows that epidurals are a significant risk factor for malpositions and stalled labor. Although women should always have the choice for epidurals if they want them, many could go without epidurals if they had better support during labor and alternative options for pain relief (like water immersion). 
• If an epidural is used, utilize delayed pushing and passive fetal descent. In many hospitals, once full dilation is reached, the mother is instructed to push immediately and forcefully. However, substantial research shows advantages to delaying pushing, letting the mother "labor down" first, using passive fetal descent before active pushing is begun
• Keep the mother mobile during labor. Encouraging the mother to be mobile during labor may help lower her chance for cesarean. In addition, certain positions may give more room in the pelvis or help poorly-positioned babies turn during labor into more optimal positions 
• Be more patient instead of rushing labor. Oftentimes, baby just needs time to shift into a better position for birth or for its head to mold more fully. Once that is done, many cases of "stalled labor" progress just fine. Avoid arbitrary timelines and judge each case individually
• Encourage spontaneous pushing efforts. Although holding the breath and bearing down ("Valsava pushing") is standard management of the pushing phase in many hospitals, research shows that encouraging spontaneous pushing works just as well or even better
• Be more proactive if the baby is malpositioned. Many cases of prolonged labor are due to a poorly-positioned baby. If mobility, positions, and more time do not work, consider manual rotation of the baby, as this has a high rate of success with far less risk than fundal pressure

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.


References

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

• http://www.aafp.org/afp/2004/0401/p1707.html - American Academy of Family Physicians
• http://www.acog.org/-/media/Districts/District-II/PDFs/Optimizing-Protocols-In-OB-HTN-Series-3.pdf - American College of Obstetricians and Gynecologists
• https://www.rcog.org.uk/globalassets/documents/guidelines/gtg42_25112013.pdf - Royal College of Obstetricians and Gynaecologists

*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.