Gupta AS

Maternal morbidity and mortality is a serious concern for both developed and developing countries. Post partum hemorrhage (PPH) is a major cause of maternal mortality and morbidity globally. About 15 to 25 % women in India are lost due to PPH.
Four ‘T’’s are commonly taught to the medical students to remember the types and the causes of PPH. These are “Tone”, “Trauma”, “Thrombin”, and “Tissue”. It is essential for the obstetrician to identify the high risk factors that predispose to the various types of PPH.
Trauma may be spontaneous or iatrogenic. Today I will be highlighting the iatrogenic cause of traumatic PPH mainly fundal pressure. Injuries to the birth canal can cause crippling debilities or even death of the fetus, mother or severe birth asphyxia leading to long term sequelae. Instrumental deliveries, application of fundal pressure, improper management of the delivery wherein large diameters are allowed to pass the birth canal, internal podalic version, extension of episiotomy are some of the iatrogenic reasons for trauma to the birth canal and traumatic PPH. Methods like high and mid forceps, cervical incisions (Duhrssen), vaginal birth of a breech by total extraction are no longer recommended.
Fundal pressure given in the second stage of labor synchronous with the uterine contraction and along with maternal bearing down efforts is a controversial issue. There is no scientific evidence to prove that it reduces the duration of labor or the need for instrumental or cesarean deliveries. Literature regarding it is scarce. It is only in the form of case reports, review articles but hardly any well designed prospective randomized controlled trials are available regarding its efficacy and safety. Serious adverse events after its use have been documented by few authors but probably that reporting is only the tip of the ice berg as most adverse events do not get reported due to apprehension of litigation. The use of this method is almost never documented in the case records. The use of this method is never discussed with the patient nor her explicit consent for the same obtained.
Adverse maternal outcomes like extension of episiotomy, 3rd and 4th degree perineal tears, colporrhexis, rupture uterus, increased pressure on the inferior vena cava causing maternal hypotension and serious fetal asphyxia, fractured ribs, liver injuries, abdominal soft tissue injuries and uterine inversion all have been attributed to this method by several authors.
Adverse fetal outcomes reported as caused by fundal pressure are non reassuring fetal heart rate, severe bradycardia due to excessive pressure on the fetal skull, raised fetal intracranial tension, severe birth asphyxia, intracranial hemorrhages, nerve palsy, and shoulder dystocia.
Proponents of this method should first of all counsel the woman for the same, obtain her consent, document its use, the direction in which the pressure was given, the number of times it was given, the duration of each fundal pressure, the maternal injuries, neonatal outcomes in detail should be all recorded. No documentation in the patients medical records suggest that the users are aware about its risks, and want to do something dangerous and not get caught.
Unless these methods are documented and well designed scientific studies are conducted and evidence proving its efficacy and safety is established this controversial method should not be used either alone or in conjunction with instrumental delivery.
We bring to our readers in this issue one such case of uterine rupture and colporrhexis caused by fundal pressure and forceps delivery used concomitantly.