Fundal massage, also known as uterine massage, is a technique performed by healthcare professionals on the abdomen immediately following childbirth. This manual procedure involves applying firm pressure to the top of the uterus, called the fundus, to stimulate muscular contraction. The primary purpose of this intervention is to prevent or manage excessive blood loss, known as postpartum hemorrhage (PPH). It is a non-pharmacological method that helps the uterus begin the process of shrinking back toward its pre-pregnancy size.
Understanding Uterine Atony and Postpartum Hemorrhage
The primary condition that necessitates uterine massage is uterine atony, which refers to the failure of the uterus to contract adequately after the placenta has been delivered. During pregnancy, the placenta attaches to the uterine wall, where numerous blood vessels supply the fetus. After the placenta separates, these vessels are left exposed, requiring a natural mechanism to stop the bleeding.
Normally, the strong muscle fibers of the uterus, the myometrium, contract forcefully to constrict and compress these open blood vessels, effectively clamping them shut. When the uterus is atonic, these contractions are too weak or absent, and the vessels continue to bleed freely.
The failure to achieve a firm, contracted state leads directly to postpartum hemorrhage (PPH), defined as a cumulative blood loss of 1,000 milliliters or more, or any amount accompanied by signs of hypovolemia, within 24 hours of delivery. Uterine atony is responsible for the majority of PPH cases and is a leading cause of maternal mortality worldwide. The risk of rapid exsanguination from an atonic uterus is significant, highlighting the importance of immediate intervention.
When Healthcare Professionals Decide to Intervene
The decision to perform uterine massage is based on a clinical assessment of the patient’s risk factors and the current condition of the uterus. Healthcare professionals use the procedure in two distinct scenarios: as a prophylactic (preventative) measure and as a therapeutic (treatment) response.
Prophylactic use is often integrated into the active management of the third stage of labor, the period immediately following delivery of the baby and the placenta. Massage may be performed routinely right after the placenta is delivered, especially if the patient has known risk factors for PPH, such as prolonged labor or an overdistended uterus. Even when uterotonic medications like oxytocin are given routinely, the clinical team must still assess the fundus regularly to ensure tone is maintained.
The primary indication for uterine massage is therapeutic, to treat active bleeding caused by uterine atony. If the provider palpates the abdomen and finds the uterus to be soft or “boggy” instead of firm, the massage is initiated immediately and vigorously. This therapeutic action physically stimulates the muscles to contract and mechanically pushes out any pooled blood or clots. The massage is often performed while other treatments are being prepared, such as administering additional uterotonic drugs.
The Technique and Patient Experience
Uterine massage is a specific clinical maneuver performed only by trained nurses, midwives, or physicians. The provider places one hand just above the pubic bone to stabilize the lower segment of the uterus, preventing it from being pushed down. The other hand is placed on the fundus, the top of the uterus, which is located in the upper abdomen immediately after birth.
Firm, repetitive, and downward-directed circular motions are then applied to the fundus to stimulate the muscles. The goal is to generate a contraction that makes the uterus firm, at which point the massage may be stopped or reduced to a lighter assessment. In cases of severe hemorrhage, a more aggressive bimanual compression technique may be used, involving one hand internally and one externally, although this is reserved for emergency situations.
Patients often describe the sensation as intense pressure, deep abdominal discomfort, or painful cramping. The feeling is essentially a medically induced contraction, which is necessary to achieve hemostasis. The procedure is typically brief, lasting only seconds or minutes, but it is often repeated every 15 minutes for the first hour or two postpartum, and then less frequently as uterine tone improves. Communicating the necessity of the procedure can help manage the temporary discomfort.