Fundal massage, a common procedure after childbirth, is a manual technique used by healthcare providers to ensure the mother’s safety in the immediate postpartum period. The practice involves using external pressure on the abdomen to stimulate the uterus. This article examines the clinical rationale for the procedure and evaluates the current research consensus on its effectiveness in preventing excessive bleeding.
Defining Fundal Massage and Its Clinical Goal
Fundal massage involves applying firm, external pressure to the top (fundus) of the uterus after the placenta is delivered. The goal is to stimulate the uterine muscle to contract strongly and remain firm, preventing uterine atony. Uterine atony, where the muscle loses its tone and becomes soft or “boggy,” is the leading cause of postpartum hemorrhage (PPH).
The physiological mechanism relates to how bleeding is controlled after the placenta separates, leaving an open wound with exposed blood vessels inside the uterus. The primary way the body stops this bleeding is by the uterine muscle contracting tightly, acting like a living ligature to compress these vessels.
Manually stimulating the fundus encourages the muscle fibers to clamp down immediately, which helps to constrict blood flow from the placental site. It also helps expel accumulated blood clots, which would otherwise prevent effective muscle contraction. Healthcare providers perform this procedure frequently to monitor uterine tone and ensure continued firmness.
Evaluating the Evidence for Fundal Massage Efficacy
The evidence for fundal massage effectiveness is nuanced, distinguishing between its prophylactic use (routine prevention) and its therapeutic use (after bleeding starts or the uterus is soft). For routine, prophylactic use, the evidence base is not as robust as for pharmacological methods. Systematic reviews have found that when fundal massage is added to a regimen including prophylactic oxytocin, it does not consistently show a significant added benefit in reducing the overall incidence of severe PPH (blood loss greater than 500 mL).
Some studies suggest that adding fundal massage to oxytocin may result in a statistically significant, though clinically minor, reduction in mean blood loss during the first hour postpartum. However, other analyses conclude that results are inconclusive due to the limited number of high-quality trials and variations in study procedures. The lack of compelling evidence for its routine use alongside modern pharmacological interventions has led some medical organizations to question its necessity.
Despite the ambiguity regarding its prophylactic role, the procedure is universally taught and recommended for its therapeutic and diagnostic value. Healthcare providers use the fundal check to rapidly assess uterine tone and diagnose uterine atony. If the uterus is soft, aggressive therapeutic fundal massage is an immediate, first-line intervention to stimulate a contraction and treat ongoing hemorrhage. This action can be performed quickly in any setting, making it a valuable tool when medications are not immediately available.
Pharmacological and Procedural Adjuncts in Preventing Postpartum Hemorrhage
Fundal massage is one element of the comprehensive strategy known as Active Management of the Third Stage of Labor (AMTSL), which is a multi-faceted approach to prevent PPH. The most effective and well-supported component of AMTSL is the prophylactic administration of a uterotonic drug immediately after birth. Oxytocin is the first-line medication globally because it is fast-acting, effective at causing the uterus to contract, and relatively safe.
Other pharmacological agents, such as ergometrine, misoprostol, and carbetocin, are also used to stimulate strong uterine contractions, especially when oxytocin is unavailable or ineffective. The use of uterotonics is considered the single most important action in PPH prevention.
Another standard procedural component of AMTSL is controlled cord traction (CCT). CCT involves a gentle, sustained pull on the umbilical cord, combined with counter-pressure on the uterus, to aid in the delivery of the separated placenta.
While mechanical procedures like fundal massage and CCT are traditional components, the strongest evidence for PPH prevention rests with the prophylactic use of uterotonic medications. Newer research also explores antifibrinolytic agents like tranexamic acid, which can be administered alongside uterotonics. PPH prevention relies on a layered strategy, where the primary defense is pharmacological, supported by procedural monitoring and intervention.