Fundal pressure is a maneuver in which a clinician applies downward pressure with the hands or a device over the top of the uterus (the fundus) during the second stage of labor to try to help move the baby through the birth canal and expedite vaginal delivery. It is sometimes attempted when labor is not progressing, when there is concern about fetal status, or when prolonged pushing is undesirable, such as with maternal exhaustion or certain medical conditions.
Contemporary research has not shown clear benefits for routinely using fundal pressure, and evidence about safety is limited and low quality, which has led many experts and professional bodies to view the maneuver as controversial and to advise against its routine use. Concerns focus on reports that fundal pressure may be associated with maternal injuries (including severe perineal tears and uterine rupture) and neonatal injuries (including fractures and hypoxic-ischemic brain injury), especially when used inappropriately or in the setting of shoulder dystocia.
In the US, given all the evidence of its risks, applying fundal pressure during labor can be considered negligent. Families can look to file a medical malpractice claim against their provider/s to get legally compensated for any harm done to mothers and/or their babies.
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Understanding Fundal Pressure
Fundal pressure during the second stage of labor (often called the Kristeller maneuver, named after Samuel Kristeller who first described it in 1867) involves manual pressure directed from the uterine fundus toward the birth canal in an attempt to augment maternal pushing and facilitate spontaneous vaginal birth. Techniques described in the literature include hands-on pressure by a provider or assistant and the use of inflatable belts that compress the upper uterus during contractions.
Kristeller's maneuver gained popularity in the US in the late 19th century to early 20th century. Back then, many births still occurred at home. This technique was a means to expedite difficult deliveries, reducing the need for other labor tools. By the late 20th century, wherein most deliveries were done in medical facilities, experts began to question the safety and efficacy of the practice.
Today, many birthing facilities restrict this practice. It is widely discouraged within the medical community, which has since moved to a less interventionist approach. Doctors steer clear from this practice to avoid birthing injuries and malpractice liabilities.
When it is used and common alternatives
In practice, fundal pressure has been used when clinicians perceive slow progress in the second stage or wish to shorten pushing due to maternal exhaustion, medical comorbidities, or concerns about fetal status. However, clinical trials have not demonstrated a consistent benefit in reducing operative or instrumental deliveries. A recent study found that this practice was used in more than 200,000 births across the globe in the last couple of decades alone (23.2% of the 898,544 births studied). It was also found that this practice is more prevalent in lower-resource areas.
Commonly discussed alternatives in guidelines and reviews include allowing more time for physiologic second-stage labor, optimizing maternal position, use of vacuum or forceps when indicated, and proceeding to cesarean delivery when operative vaginal birth is not safe or feasible.
What research and guidelines say about fundal pressure
A 2017 Cochrane-style review and subsequent analyses concluded that there is insufficient evidence to support routine use of fundal pressure (manual or via inflatable belts), with no clear reduction in prolonged second stage, instrumental delivery, or cesarean birth, and inadequate data on serious maternal or neonatal outcomes. The same body of evidence emphasizes that available trials are small, heterogeneous, and of low methodological quality, and urges caution with the maneuver until safety and effectiveness are better established.
The Royal College of Obstetricians and Gynaecologists' guideline on shoulder dystocia specifically states that fundal pressure should not be used in managing shoulder dystocia because of its association with high neonatal complication rates and potential uterine rupture, recommending suprapubic pressure and position changes instead. Major clinical references on shoulder dystocia likewise advise against fundal pressure in that setting and describe HIE and death as potential sequelae of mismanaged shoulder dystocia. Although no dedicated ACOG practice bulletin solely on fundal pressure was identified, ACOG materials and U.S. obstetric safety initiatives emphasize adherence to evidence-based maneuvers for dystocia and avoidance of techniques associated with increased risk and minimal proven benefit.
Risk of Using Fundal Pressure in Labor
Fundal pressure during labor is associated with several risks for both the mother and the infant. Studies have linked fundal pressure to an increased risk of severe perineal lacerations (third- or fourth-degree tears), with one cohort finding an odds ratio of about 7.8 for severe perineal trauma when fundal pressure was used in conjunction with other interventions. Uterine fundal pressure has also been identified as a modifiable risk factor for uterine rupture in women with an unscarred uterus, with an adjusted odds ratio of about 5.2 in one large retrospective study.
In the shoulder dystocia context, professional bodies and guidelines (including the Royal College of Obstetricians and Gynaecologists and major clinical references) state that fundal pressure should not be used because it is associated with a high neonatal complication rate and may worsen impaction of the shoulders. Shoulder dystocia itself carries a risk of neonatal hypoxic-ischemic encephalopathy and death if not promptly relieved, so the use of disfavored maneuvers such as fundal pressure in that scenario is particularly scrutinized.
Potential Maternal Injuries
| COMPLICATION | DESCRIPTION |
|---|---|
| Uterine rupture | A tear in the uterine wall, often along previous surgical scars. Can cause severe bleeding, fetal distress, and requires immediate medical intervention. Fundal pressure has been identified as a modifiable risk factor with an adjusted odds ratio of about 5.2 in women with unscarred uteri. |
| Placental abruption | Premature separation of the placenta from the uterine wall before delivery. Can cause severe bleeding, fetal distress, and complications for both mother and baby. |
| Perineal trauma | Injury to the area between the vagina and anus during childbirth. Can range from minor tears to severe lacerations affecting muscles and sphincters. Studies show an odds ratio of about 7.8 for severe perineal trauma when fundal pressure is used. |
| Pelvic organ prolapse | Weakening of pelvic floor muscles causing organs (bladder, uterus, rectum) to descend. Can lead to discomfort, urinary issues, and sexual dysfunction. Reports describe levator ani muscle injury and subsequent prolapse. |
| Internal organ damage | Injury to abdominal organs like liver or spleen due to external force. Can cause internal bleeding, organ dysfunction, and require surgical intervention. |
Potential Child Injuries
| COMPLICATION | DESCRIPTION |
|---|---|
| Brachial plexus injury | Damage to nerves controlling arm and hand movement. Can cause weakness, loss of sensation, or paralysis. Often results from excessive stretching during delivery, particularly in complicated cases involving shoulder dystocia. |
| Hypoxic-ischemic encephalopathy | Brain injury caused by oxygen deprivation and reduced blood flow. Can lead to developmental delays, seizures, cognitive impairments, or cerebral palsy in infants. Professional guidelines warn that fundal pressure in shoulder dystocia may contribute to HIE. |
| Spinal cord injury | Damage to the spinal cord, potentially causing partial or complete paralysis. In newborns, it can result from excessive traction or trauma during delivery. |
| Intracranial hemorrhage | Bleeding within or around the brain. Can cause increased intracranial pressure, seizures, and developmental issues. May result from trauma during difficult deliveries. |
| Fractures | Broken bones, often involving clavicles or skulls in newborns. Can occur due to excessive force or difficult positioning during delivery. Case reports describe fractures associated with fundal pressure use. |
| Meconium aspiration | Inhalation of first fetal stool (meconium) into lungs before or during birth. Can cause respiratory distress, infection, and in severe cases, persistent pulmonary hypertension. |
It's important to note that the severity and likelihood of these risks can vary depending on factors such as the force applied, the duration of the maneuver, and pre-existing conditions. The potential for these complications is a primary reason why fundal pressure is discouraged by many medical organizations and healthcare facilities.
Is the Use of Fundal Pressure Illegal?
There is no federal statute in the United States that specifically prohibits the use of fundal pressure or Kristeller maneuver in labor and delivery; the technique itself is not categorically "illegal." Instead, providers are expected to follow professional standards, hospital policies, and state-law duties to exercise reasonable care and to rely on evidence-based practices, and deviation from those expectations can form the basis for malpractice liability if it causes injury.
Under New York law, medical malpractice generally turns on whether a practitioner departed from accepted standards of medical practice and whether that departure proximately caused harm, not on whether a particular maneuver is banned by statute. In at least one New York case involving alleged birth injuries, a plaintiff's expert opined that the hospital staff's use of fundal pressure was "always a violation of the standard of care," illustrating how experts may characterize the maneuver when it is inconsistent with current professional norms and evidence.
Medical state regulations urge medical providers to prioritize patient safety and to follow evidence-backed practices. Any injuries acquired by both mother and infant are the liability of their negligent healthcare provider. Professionals who partake in such practices face serious legal repercussions. State-wide regulations require hospitals to have quality assurance programs that review obstetrical practices. These programs typically discourage outdated practices like routine fundal pressure.
When a delivery complication may involve negligence
A delivery complication involving fundal pressure may raise negligence issues when evidence shows, for example, that fundal pressure was used in a situation where major guidelines recommend against it (such as shoulder dystocia), that it was applied with excessive force or without appropriate indication, or that safer alternatives were not attempted first. Negligence analysis will typically examine whether the providers followed accepted protocols, documented their decision-making, and responded appropriately when complications like fetal distress, uterine rupture, or shoulder dystocia arose.
What to do if you suspect fundal pressure caused injury
If a family suspects that fundal pressure contributed to a birth injury, obtaining and preserving complete medical records is critical, including labor and delivery notes, anesthesia records, nursing notes, fetal monitoring strips, neonatal records, and any operative or imaging reports. It is often helpful to create a detailed timeline of events from admission through delivery and immediate postpartum care, documenting who was present, what was explained, what maneuvers were attempted, and when signs of distress or injury were first recognized.
Families commonly seek an independent medical review from an obstetric or neonatal specialist who can analyze whether fundal pressure was used, whether its use was consistent with current standards, and how it may relate to the injuries in question. When consulting legal counsel, useful questions to explore include: what the standard of care was in the specific situation, whether the records and witness accounts support that fundal pressure occurred, how causation between the maneuver and the injury would be evaluated, and what deadlines (statutes of limitation and notice requirements) apply under New York law.
Can Medical Teams Be Held Liable for This Practice?
Medical teams can potentially be held liable for using fundal pressure during labor and delivery. Despite being routinary once, the use of this technique may be considered negligent due to the professional consensus regarding the restriction of interventional labor practices.
The extent of liability can vary based on specific circumstances, local laws, and the resulting outcomes. Note that legal teams must first investigate your case to establish and strengthen your claim. When seeking compensation, both economic and non-economic losses incurred by the family must be compensated.
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How liability is evaluated
In New York medical malpractice cases, liability generally requires proof that the provider owed a duty of care, departed from the accepted standard of care, and that this departure was a proximate cause of injury. The standard of care is typically established through expert testimony about what a reasonably prudent obstetrician, nurse, or hospital would have done in similar circumstances given current medical knowledge and guidelines.
Documentation plays a central role: juries and experts look to chart entries regarding indications for fundal pressure (if any), description of maneuvers used, timing, fetal heart rate patterns, and provider responses to complications such as fetal distress or suspected uterine rupture or shoulder dystocia. Causation analysis focuses on whether injuries such as HIE, brachial plexus injury, uterine rupture, or severe perineal trauma would likely have occurred absent the alleged misuse of fundal pressure, often relying on both medical literature and case-specific expert opinion.
FAQ
What are the disadvantages of fundal push?
Disadvantages described in the literature include a higher risk of severe perineal laceration, possible increase in maternal pelvic floor trauma, and an association with uterine rupture in some settings. For the newborn, reported concerns include fractures and potential brain injury, especially when fundal pressure is used inappropriately or in the context of shoulder dystocia, where guidelines advise against it.
Is fundal pressure legal?
Fundal pressure is not expressly prohibited by federal statute and is not per se illegal, but its use is judged under general medical malpractice standards that require practitioners to act in accordance with accepted medical practice. If a provider uses fundal pressure in a way that departs from current standards or ignores safer alternatives and that use leads to injury, it can form part of a negligence claim.
Can fundal pressure cause uterine rupture?
Uterine fundal pressure has been identified as a modifiable risk factor for uterine rupture in women with unscarred uteri, with one large study reporting an adjusted odds ratio of about 5.2 for rupture when fundal pressure was used. Guidelines on shoulder dystocia also warn that fundal pressure may contribute to uterine rupture and therefore should not be used in that context.
What injuries can fundal pressure cause to mother and baby?
For mothers, reported injuries include severe perineal lacerations, pelvic floor muscle avulsion, uterine rupture, and subsequent pelvic organ prolapse or incontinence. For babies, case reports and reviews describe fractures, brachial plexus and other nerve injuries, and hypoxic-ischemic brain injury in settings where fundal pressure was used, particularly in complicated deliveries such as those involving shoulder dystocia.
Can I sue if fundal pressure caused birth injuries?
Parents may pursue a medical malpractice claim if they can demonstrate that clinicians departed from accepted standards in using fundal pressure and that this departure caused or significantly contributed to their child's or the mother's injuries. In New York, this typically requires expert review of the records, timely filing within applicable limitation periods, and proof of damages such as medical costs, future care needs, and pain and suffering.
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