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Fundal pressure exacerbates the risk of Erb’s palsy injury, why are maternity units still using this technique?

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    When shoulder dystocia occurs during birth it can be a medical emergency, but there are various recognised and effective techniques that are used to safely release the shoulder thereby avoiding any injury to the baby. The most common, and serious, of which is Erb’s palsy.

    By Rebecca Callard

When a baby’s shoulder becomes impacted against the mother’s pelvis during delivery, they will need some assistance from a clinician during the birth. Generally, first and foremost, the mother is told to stop pushing as this continual pushing could cause the shoulder to become further impacted making the delivery of the baby more complicated. The mother’s thighs are pushed back against her chest to widen and tilt her pelvis, a manoeuvre known as the McRoberts position, and pressure is applied by an appropriately trained clinician to the pubic bone area.  This pressure serves to help dislodge the shoulder from the mother’s pelvis and in most cases is enough to enable the baby to be born quickly and safely.

However, it is becoming increasingly evident that this pressure of the pubic bone area is actually being applied incorrectly and, most worryingly, negligently.

How fundal pressure can cause Erb’s palsy

I have been dealing with a number of Erb’s palsy cases recently where it has come to light that, despite medical records confirming “supra-pubic pressure” was applied during the delivery, in fact it was fundal pressure that was applied instead.

Fundal pressure amounts to pressure being applied to the top of the Mother’s bump (the fundus) instead of at the bottom in the pubic area. This pressure, instead of releasing the baby, can cause further impaction of the shoulder.

Because of the likelihood it exacerbating a problem instead of fixing it, fundal pressure has been associated with neonatal complications, including (according to a study by Mollberg in 2005) a 60% higher risk of brachial plexus injury, leading to Erb’s palsy. The Royal College of Obstetricians and Gynaecologists Guidelines specifically advises against fundal pressure being used for this very reason.

So why is fundal pressure ever applied in these emergency situations?  The short answer is, it shouldn’t be, and if it is, it is likely to amount to negligent care.  The most likely explanation, though, is likely to be a lack of training or understanding of the seriousness of this manoeuvre.

How does this happen?

It is vital that training is received annually by midwives, registrars and consultants so they are reminded of best practice when dealing with birth complications. In any event, a recent study (SAFE Study) showed that even where training had been received regularly, fundal pressure was applied in 2 training births but wasn’t actually documented anywhere. It found that many of those who applied fundal pressure in practice actually thought they were applying suprapubic pressure correctly. Accordingly, the medical records they completed showed that suprapubic pressure had been applied and in fact this was not an accurate record of events.

Often, in cases where shoulder dystocia occurs, the delivery room is flooded with medical professionals, including some who may not be well-versed in specific birth complications training (for example anaesthetists who may be called in case a C-section is necessary).

Having conducted investigations in relation to a number of Erb’s palsy claims, it is my understanding that fundal pressure is often not deliberately carried out, but rather applied ‘by mistake’ as a result of a lack of understanding on the clinician’s part.

However, it is concerning that, even where appropriate training is provided, incorrect manoeuvres are still being carried out in maternity units across the country, thereby increasing the risk of severe and permanent injury to babies, and their mothers. Therefore it is imperative that maternity units put into practice proper training and re-training programmes to protect newborns and their mothers from mistakes made under, what can be, intense pressure in a delivery room.

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