The Kristeller maneuver, also known as uterine fundal pressure (UFP), is a controversial obstetric practice that has sparked debates in modern obstetrics.
Despite being widely used in many delivery rooms around the world, scientific evidence supporting its effectiveness and safety is limited.
In this article, we will examine in detail what the Kristeller maneuver is, when it is used, the potential risks associated with it, and concerns related to obstetric violence.
What is the Kristeller Maneuver?
The Kristeller maneuver is named after German gynecologist Samuel Kristeller, who first described it in 1867. It involves applying manual pressure on the uterine fundus during contraction and maternal pushing, with the aim of facilitating fetal expulsion and reducing the duration of the second stage of labor.
The technique involves the obstetrician or another healthcare provider placing their hands on the upper part of the mother’s abdomen, exerting downward pressure towards the birth canal. This pressure can be applied manually or, in some cases, using an inflatable belt.
It’s important to note that there is no universally accepted standardized definition of the Kristeller maneuver. The methods of applying pressure can vary significantly from one practitioner to another and from one situation to another.
Factors such as fetal position, amniotic fluid volume, maternal pelvic structure, hand placement on the abdomen, and the mother’s physical characteristics (such as weight and abdominal circumference) can influence the execution of the maneuver.
The Kristeller maneuver should only be performed when the presenting part of the fetus is at the perineal plane, i.e., in the lowest part of the birth canal. Additionally, guidelines suggest not repeating the maneuver more than 3-4 times during the same delivery.
When is it used?
Despite the lack of solid scientific evidence supporting its effectiveness and safety, the Kristeller maneuver is still used in many delivery rooms for various reasons. The main clinical indications for the use of this technique include:
- Fetal distress: when monitoring indicates that the fetus is suffering and there is urgency to accelerate delivery.
- Failure to progress during the second stage of labor: when the baby is not descending in the birth canal despite contractions and maternal efforts.
- Maternal exhaustion: when the mother is too tired to continue pushing effectively.
- Contraindications to prolonged maternal pushing: in some cases, such as in women with cardiac conditions, it may be necessary to limit prolonged maternal efforts.
It’s important to emphasize that the prevalence of the use of the Kristeller maneuver is difficult to quantify accurately. In many Western countries, such as England, it is considered an obsolete practice and is not routinely used.
However, in some countries with limited economic resources, where other options such as vacuum extraction, forceps, or cesarean section might not be available, the Kristeller maneuver might be used more frequently.
In Italy, despite contrary recommendations, the Kristeller maneuver seems to still be practiced in many delivery rooms. However, its actual prevalence is difficult to determine, as it is often not documented in medical records, leading to an underestimation in official statistics.
Is it dangerous?
The safety of the Kristeller maneuver is a concern in the medical community. Several studies, although of limited quality, have suggested that this practice may be associated with numerous complications for both mother and newborn.
It’s important to note that the force applied during the maneuver is difficult to control and standardize, which increases the risk of complications.
Some of the potential risks and side effects associated with the Kristeller maneuver include:
For the newborn:
- Worsening of fetal condition
- Fractures
- Brain damage
- Brachial plexus injuries (in case of shoulder dystocia)
For the mother:
- Third and fourth-degree vaginal-perineal lacerations
- Rib fractures
- Uterine rupture
- Placental abruption
- Postpartum hemorrhage
It’s important to emphasize that the Kristeller maneuver is contraindicated in the presence of pre-existing uterine scars, such as those resulting from a previous cesarean section or myomectomy.
In addition to physical risks, the Kristeller maneuver can have a significant impact on a woman’s birth experience. Many women describe the pressure applied to the uterine fundus as uncomfortable or painful, and this experience can remain negatively imprinted in their birth narrative.
When is it considered obstetric violence?
The concept of obstetric violence is gaining increasing attention in the debate on quality of care during childbirth. The Kristeller maneuver can be considered a form of obstetric violence when it is performed without the woman’s informed consent or when it is practiced routinely without a clear medical indication.
In many cases, the maneuver is presented to women as necessary “help” to give birth to the baby. However, this presentation can mask potential risks and make the woman feel inadequate if she cannot push effectively on her own. When the maneuver is performed without an adequate explanation of the risks and benefits, or without obtaining the woman’s consent, it can be seen as a violation of patient autonomy and her right to make informed decisions about her body and her childbirth.
Moreover, the routine use of the Kristeller maneuver, which in some delivery rooms may affect a percentage of births much higher than the recommended 3-4%, can be considered a form of institutionalized obstetric violence. This practice not only deviates from recommendations based on scientific evidence but can also contribute to a negative birth experience for many women.
We’re with you.
At Parentalife, we are committed to supporting parents throughout their pregnancy and childbirth journey. We offer detailed guides, informative courses, and personalized consultations to help future parents make informed and conscious decisions regarding their parental life.
SOURCES
Youssef A, Salsi G, Cataneo I, Pacella G, Azzarone C, Paganotto MC, Krsmanovic J, Montaguti E, Cariello L, Bellussi F, Rizzo N, Pilu G. Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion. Ultrasound Obstet Gynecol. 2019 Gen;53(1):95-100. doi: 10.1002/uog.19085. Epub 2018 Dec 5. PMID: 29749657.