Fundal Pressure vs. Suprapubic Pressure during Delivery

Recently we had a case where shoulder dystocia occurred during delivery. The complaint involved whether or not fundal pressure was applied on the mother’s abdomen while shoulder dystocia was occurring. Shoulder dystocia is a very serious complication that happens in approximately 1% of deliveries. It occurs when the baby’s shoulder impacts against the mother’s pubic bone, therefore causing the baby to be stuck inside the uterus. Once shoulder dystocia occurs, the doctors have mere minutes to deliver the baby without serious injury. The most severe injury that can occur involves the baby’s brachial plexus. The brachial plexus is a bundle of nerves located in the armpit and shoulder area. These nerves supply the shoulder, arm, and hand, and if damaged, can cause paralysis to those areas.
There are several maneuvers that can be attempted to help deliver the baby once shoulder dystocia has occurred. Several different mnemonic devices exist to assist medical professionals in remembering these maneuvers. Examples of these are:
H: Call for help
E: Evaluate for episiotomy
L: Legs (the McRobert’s Maneuver)
P: Suprapubic pressure
E: Enter maneuvers (internal rotation of the baby)
R: Remove the posterior arm, and Roll the patient.
and
A: Ask for help
L: Leg hyperflexion (McRobert’s Maneuver)
A: Anterior shoulder disimpaction (suprapubic pressure)
R: Rubin maneuver
M: Manual delivery of posterior arm
E: Episiotomy
R: Roll over on all fours
Each of these mnemonic devices lists the same delivery maneuvers, which both include suprapubic pressure. Neither of them however lists fundal pressure as an appropriate maneuver to assist with shoulder dystocia. This is because fundal pressure can increase the risk of very serious injuries if applied during a delivery where shoulder dystocia has occurred. There is only a slight difference between fundal and suprapubic pressure, but when it involves shoulder dystocia that small difference is very significant. Suprapubic pressure is applied directly over the mother’s pubic bone and is meant to help push the baby’s shoulder downward and allow it to be freed from the mother’s pubic bone, therefore allowing the baby to be delivered through the birth canal.
Suprapubic Pressure during delivery

Suprapubic Pressure during delivery

Fundal pressure, on the other hand, is applied on the upper portion of the mother’s abdomen. Fundal pressure can be applied in a routine delivery to help assist the baby down through the birth canal, or if the baby needs to be delivered quickly in cases of distress, other than shoulder dystocia. If fundal pressure is applied during an instance of shoulder dystocia, the baby’s shoulder is further impacted against the mother’s pubic bone causing the brachial plexus additional stretching, which can damage the nerves and lead to serious injury as mentioned previously.
Fundal Pressure during delivery

Fundal Pressure during delivery

Delivering a baby that is experiencing shoulder dystocia is a very stressful, urgent situation. Staying calm and focused is the best way to manage the situation so that the correct maneuvers, such as McRobert’s maneuver and suprapubic pressure, are performed and the baby is delivered with as few complications as possible.
Resources:
http://www.aafp.org/afp/2004/0401/p1707.html
http://www.selfgrowth.com/articles/should-dystocia-birth-injuries-and-your-legal-rights
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