Postpartum fundal massage...thoughts?

[Wittyone]

Midwives...do you do this? If yes, routinely or just as indicated by lochia flow? If not, why not?

I have worked as an RN in an OOH birth center and am now precepting as a student CNM there. The mamas always get a very vigorous fundal massage with the delivery of the placenta (most delivered with cord traction following signs of separation), until they are no longer trickling. This is so uncomfortable for them, but the rationale from the midwives I work with is that it's better than bleeding too much. Babies are always put to breast asap, and IM Pit is only given for worrisome bleeds, never routinely. Fundal checks and lochia monitoring continues every 15-30 minutes or prn for a couple of hours. Vigorous massage is repeated only if bleeding is excessive, the uterus is boggy, or the fundus is rising and we suspect clots need to be expressed.

I guess I'm wondering if the initial vigorous massage is routinely necessary? What else are people doing? Thanks!

[MsBlack]

The adage I learned by is:

Don't fiddle with the fundus!

And I keep to that. THe only thing I do w/fundus in the first minutes following normal birth is put a gentle couple of fingers on mom's belly and see if I can feel the fundus firming. Very small and brief move, and I am JUST checking, NOT massaging. Even that can be painful to a woman who is contracting at that moment of my contact, however gently and briefly I probe.

I reserve massage only for times when there is too much bleeding AND nursing does not immediately bring that under control**. In other words, *very* rarely do I perform fundal massage! It is generally unnecessary and almost always painful to the mom--besides, some mws have indicated to me that with vigourous massage you can easily end up with 'rebound bleed': yes, fundus firms immediately w/massage, but relaxes excessively in reaction, when massage is done. Makes sense to me--although what makes the most sense to me is trusting birth, including delivery of placenta and control of pp bleeding, rather than interfering.

**'nursing' does NOT have to mean active sucking--as long as baby's face is to the breast, skin to skin contact on/near nipple, contrax will most always be stimulated (I also do not like forcing a first feed)

Sounds like 'something for mws to do to feel they were needed'. Sounds relatively untrusting of birth/women's bodies; sounds like a habit with no real evidence basis. Reminds me a lot of the way in hospitals, women are given routine pit as soon as baby is born, to 'prevent' placental hangup and PPH.

[MsBlack]

bump!
Anyone?

[Jane]

WittyOne, that's what I learned too, but it probably wasn't that vigourus, since most mama's didn't find it really uncomfortable, just "ooh"-y.

[mwherbs]

not much fundus fiddling- semi-relaxed hand probably as soft as you would smooth a baby's hair-to feel where the fundus is you aim for the top -- up and to the side mom needs to empty bladder- boggy - time to get that baby latched good reactive uterus with just a light touch will contract- mom moving it contracts- the only time I firmly hold a uterus is in a brisk bleed that is not being controlled in other ways -- and that is a grasp and no kneading - I think that just like with any other bundle of muscles - you rough them up too much you make swelling/engorgement and pain but no improvement in the situation I have been around and seen the rough stuff it just isn't any better infact I think it causes more bleeding

[sevenkids]

Not routinely, but I do check for height and firmness, very gently. if I see a fundus that is firm and rising, then yes, I grab it and squeeze to express clots. If it's boggy and baby has been nursing, then I hold it until it firms. If it's high and off to the side, get mom to pee, have her rub it.

I don;t think the rough massage does any better than a light touch or a good firm grasp to control a heavy bleed either. Often mom just rubbing her belly gently does the trick just fine.

[CarolynnMarilynn]

Yep, as above with mwherbs and sevenkids. Only massage the fundus with frank, heavy bleeding after a placenta. Otherwise barely touch it at all, except a quick check several times after the birth. I find that it makes *no* difference to rate of bleeding after a birth and is so uncomfortable for women. In fact, I think the small clot that stays in the uterus may actually help tamponade bleeding. Large clots can make a mom feel terrible (a vagal reaction, esp. when in the cervix) and can increase bleeding as the uterus can't clamp down on itself when too full.

[Wittyone]

Thanks for the replies ladies. My gut says that MrsBlack and mwherbs are correct...but having seen (many times) a constant trickle clear up with a good rub that expresses a bunch of clot leaves me still questioning, you know? I'd love to hear more!

[mwherbs]

could be population, genetics, diet.... for a while we had a ton of hemorrhages- looking over diets - corn and sometimes green beans were the only veggies-- so back to what we did in the 80's we started recommending chlorophyll and the hemorrhages way less- rarely can we get good diet changes--supplements are more likely to be used
I also like something salty- soup, broth... as well as a sweetened drink for hydration in labor as well as right after--
bag of ice on the fundus--and on the small of the back--
I think that veggies are more than clotting factors I think micro-circulation/connective tissue health
grand and great grand multips-- mother's cordial all the time because they are going to be pregnant in another year or 2-- belly binding to help make a funnel on the outside atleast- so that the babies are not just laying like in a sling- making extra stretching also lines the kidos up so labor isn't so protracted ...
ban phones/cell phones
herbs-- cotton root bark tincture + yarrow,
methergine

[MsBlack]

Thanks everyone! This is very good info/perspectives to have.

PHONES! My worst bleed was with a mom who got on the phone w/in 10min of birth and before placenta delivery....I think she missed those first placental expulsion cues, things got sticky, when placenta finally came at 90 min she flooded briefly. First time I ever did anything like what you might call vigourous massage--also nipple stim/nursing, and some Shepherd's purse. Was under control in about 1min.
Now, I tell everyone--no phone calls until the work is done! Baby out, placenta out, mom has pee'd and all are resting nicely.

And the only times I have seen those trickles is when bladder is full. I pay close attention to frequency of peeing during labor, therefore--some moms have no issues with this, will pee freely wherever they are (in tub, on a chux, go to bathroom). Some do not--privacy issue, 'confused sensations' so that the urge to pee is not felt as usual, pressure of baby, whatever--and then I will get a bit active in encouraging urination (no more than 2hrs from last time). Sometimes just talking about it, getting mom's attention on it is all that's needed. Sometimes more--position changes, privacy, warm water, holding up the belly....I don't like to be bossy about anything in labor, but generally the mom who doesn't think she has to pee (at 2hrs since last time) is willing to try when I remind her that a full bladder can impede pushing and/or placenta and bleeding. And such women are generally surprised to find that they were indeed holding quite a bit of pee in there, when they do put their attention to urinating and it starts to flow.

[Wittyone]

I just love coming here So much wisdom!!

[jenmidwife2b]

We just check the fundus and only do vigourous massage if there is a bleeding problem or the uterus feels boggy.