Letter to the editor: A comparison in maternal and neonatal outcomes between mild fundal pressure and vacuum extraction for shortening the second stage of labor—Fundal pressure maneuvers are not created equal

I commend Dominsky and colleagues for assembling a large cohort study comparing mild fundal pressure with vacuum extraction for shortening the second stage of labor. ¹ This type of research might help bring fundal pressure out of the shadows and allow for a long‐overdue, open discussion about the value of this century‐old procedure.

I feel compelled to share my own experience with fundal pressure, as never in my career have I encountered a procedure as controversial as this one. I still vividly recall an incident early in my career in the United States. One day, I walked into a delivery room to supervise a resident performing a vaginal delivery. An immigrant woman from Africa quickly grabbed my hand and placed it on her abdomen. To my surprise, she asked me to push. She had given birth to two babies in Africa, both of whom had been delivered only with the help of fundal pressure. Of course, I did not follow her request because fundal pressure during vaginal delivery had been completely banned in the United States for more than 20 years, and I had never witnessed the maneuver during my own training.

Why was fundal pressure banned in the United States and most developed countries? Violent or forceful fundal pressure is clearly associated with maternal and fetal injuries, including uterine rupture, severe perineal laceration, shoulder dystocia, and fetal asphyxia. Most importantly, alternatives to fundal pressure are easily available in developed countries. The ban on fundal pressure occurred long before evidence‐based medicine became the norm. Consequently, no randomized clinical trial on uterine fundal pressure has ever been conducted in the United States due to legal concerns.

Later, after assuming the role of academic chair at a large specialty hospital in China, I faced a dilemma regarding the widespread practice of fundal pressure. The Chinese practice guideline, consistent with World Health Organization recommendations and those of many developed countries, forbids its use during the second stage of labor. ² , ³ Yet previous efforts to eliminate fundal pressure had been unsuccessful. All obstetric providers know the guideline, but providers continue to use fundal pressure and simply do not document it. Why would anyone risk their professional career to perform a prohibited procedure? Because they believe that a small amount of fundal pressure might help a delivering woman avoid an emergency cesarean or operative vaginal delivery, both of which are clearly associated with maternal and fetal morbidities.

I had to decide whether to continue enforcing the ban, a policy that had already driven the practice underground. Rather than continue fighting a losing war, I changed my strategy. After consulting with my staff and hospital administrators, we decided to conduct a randomized clinical trial in an open and transparent manner. Our goals were to systematically investigate the risks and benefits of fundal pressure during the second stage of labor and, simultaneously, to educate our physicians and nurse midwives in the process. If our own study revealed clear risks that outweighed the benefits, then fundal pressure during vaginal birth would be banned.

To define and standardize gentle or mild fundal pressure, we asked our staff to assess their level of force using a blood pressure cuff. Eventually, all agreed that a maximum pressure of 120 mmHg would be reasonable. Based on the estimates of our birth attendants, fundal pressure applied during the trial was between approximately 80 and 120 mmHg. ⁴

Our trial only enrolled women with normal labor and initiated fundal pressure 30 min after complete cervical dilation. In the end, our study showed that gentle fundal pressure resulted in a non‐significant reduction in the duration of the second stage of labor but a significant reduction in forceps delivery and episiotomy, without an increase in adverse outcomes. ⁴

No randomized trial of fundal pressure has ever been conducted in women with non‐reassuring fetal heart rate and prolonged second‐stage labor because obtaining informed consent is challenging in an obstetric emergency. As increasing numbers of observational studies support the use of mild fundal pressure for the same indications as vacuum and forceps delivery, ¹ , ⁴ , ⁵ it would be feasible to conduct a randomized trial comparing fundal pressure with operative vaginal delivery.

Without an experienced obstetric team and a supportive environment, it would be difficult to conduct a randomized trial for any obstetric emergency. Most developed countries have largely abandoned fundal pressure during vaginal delivery. Therefore, the responsibility will fall on the obstetric teams and hospitals that still routinely perform fundal pressure during the second stage of labor.

In the meantime, we should refrain from issuing guidelines against the use of fundal pressure during labor. Continuing to malign a procedure without any strong evidence will only impede the progress of obstetrics. Instead, we should encourage more high‐quality studies to be conducted in this area in the future.

CONFLICT OF INTEREST STATEMENT

The author has no conflict of interest to declare.

DECLARATION OF GENERATIVE AI

DeepSeek AI was used to check grammar and sentence fluidity. After using this AI tool, the author reviewed and edited the content again and takes full responsibility for the content of this correspondence.

DATA AVAILABILITY STATEMENT

Research data are not shared.