Fundal Massage After Birth: is it Necessary?

What is a Fundal Massage

A fundal massage, or uterine massage, is performed typically by a nurse by placing one hand at the base of the uterus as support and while the nurse presses the other hand firmly at the top of your uterus, also called the “fundus.” The uterus is supported in-between the two hands. The top hand gently rubs/massages the fundus for about 30-45 seconds. Uterine massage promotes contraction of the uterine muscles to clamp down on the blood vessels to reduce postpartum blood loss. In some cases a sustained uterine massage may be necessary to help the uterus contract.

The below training video shows how to properly perform uterine massages to help you understand what to expect if you need a fundal massage after birth:

Why is a Fundal Massage Performed?

Fundal massage is performed to help the uterus contract after childbirth.  The placenta is attached to the inside of your uterus.  In the third stage of labor your uterus contracts to release the placenta leaving a large wound on the inside of your uterine wall. After the deliver of the placenta, whether by vaginal birth or c section, the uterus should continue to contract on it’s own to help the wound to clot by holding pressure on the wound and allow it to begin to heal. The action of contraction will prevent blood loss postpartum.

In some cases the uterus does not contract or contractions are inadequate in clamping the wound sustained after placental delivery, which is called uterine atony. This can lead to a potentially life threatening situation called postpartum hemorrhage, or PPH.

What Does a Fundal Massage Feel Like?

That all depends on your pain tolerance, but for most women that have no pain medication on board or their medication has worn off explain it as the most “excruciating pain.”  Just imagine you have just birthed your baby or been cut open to get your baby out and now someone is firmly rubbing your uterus every 15 minutes.  It can be extremely painful.  However, if you are actively hemorrhaging it could be life saving.

What is Postpartum Hemorrhage?

PPH is a leading cause of maternal deaths worldwide. Postpartum hemorrhaging is a heavier than normal bleeding following childbirth most often related to the uterus failing to contract sufficiently to prevent excess bleeding after delivery.

After the placenta is birthed it leaves an open wound on the uterine wall where it was once connected. When the uterus contracts it puts pressure on the bleeding vessels preventing excess blood loss and helping blood to clot. If not enough pressure is placed or pieces of retained placenta are present in the uterus the vessels may continue to bleed.

In these cases, additional interventions are needed to help stop or minimize the bleeding.

What are other Causes of Postpartum Hemorrhaging?

• Tear in the cervix or tissues of the vagina during vaginal birth
• Tear in a blood vessel in the uterus
• Inverted or ruptured uterus
• Bleeding into hidden tissue or space in the pelvis
• Blood clotting disorders
• Placental complications

What is the Treatment for PPH?

It depends on the reason for your postpartum blood loss. The goal is to find and stop the cause of bleeding and treating it as soon as possible to reduce bleeding and decrease risk of maternal mortality. Some necessary treatments may include:

• Removing pieces of retained placenta from uterine cavity.
• Use medication or uterine massage to stimulate contraction of the uterus if the uterus fails.
• examine the uterus, pelvic tissues, and vagina for any areas that need repairs.
• laparotomy if unable to find the source of bleeding
• hysterectomy as a last resort.
• IV fluids and blood transfusions to replace blood loss.

What is the Difference Between Fundal Check and Fundal Massage?

So how do you know if your uterus is doing what it should and contractions are sufficient to prevent excessive postpartum blood loss?

Your nurse, midwife, or OB will perform regular fundal checks after delivery of your baby. The provider may ask you to urinate prior to assessment, because a full bladder can contribute to uterine atony.

Then they will lay you flat while flexing your legs to get the most accurate fundal height. They will then measure the fundal height with their fingers by gently pressing the top of the uterus (aka the fundus) and measuring the distance between the belly button and the top of the fundus. At that time they will also be assessing if the fundus is soft or contracted.

If the uterus is soft, or boggy it is likely that it is not clamping down enough to prevent heavy bleeding. Your provider may ask to perform a fundal massage at that point. They will follow the steps in the above video to promote uterine contractions at that time. They may also discuss other treatment options to prevent PPH.

How Will Providers Assess My Bleeding?

Another important assessment at this time is to measure the amount of lochia present (vaginal discharge – blood, mucus, and uterine tissue). The amount of bleeding is important to assess over time to determine if mother may be in danger of PPH.

Your nurse will likely complete this assessment at the same time of your fundal checks. This requires looking at your postpartum pads to assess blood loss. They will often ask you to lift your bottom or roll to the side to see any hidden blood loss. While you are in bed gravity may cause pooled blood or clots to form underneath you and can limit your providers ability to accurately assess blood loss. They may also gently push on the fundus to help expel any clots sitting in your pelvis.

How often is a Fundal Assessment/Massage?

Fundal assessment is typically done every 10-15 minutes for the first hour after birth to ensure fundal tone is sufficient. Then every 30 minutes for the next hour, and every hour for the next 12 hours. This may vary slightly depending on the hospital’s policies, but that is a rough estimate of what you can expect.

If your uterus is firm and contracting on it’s own a fundal massage will not be necessary at each of those intervals. Routine use of uterine massage is not supported by recent research.

Are Fundal Massages Necessary for Every Postpartum Mom?

The answer is no, not every postpartum mom will need a fundal massage. Fundal massage after birth can be quite painful. Especially if you have had a cesarean section and have a fresh incision on your abdomen. Routine use of fundal massages is not recommend based on current research. Some studies showed no statistically significant difference between women who receive uterine massage and those using uterotonic medication. More trials need to be done that show statistically significant differences to promote it as a routine treatment as part of active management of the third stage of labor.

Based on current evidence uterine massage is an option and can promote uterine contraction if the uterus is not doing it’s job and the mother wants to prevent postpartum hemorrhaging. If a nurse or provider tries to tell you it is necessary, please ask questions so you can better understand their reasoning.  As a right every patient has the right to informed consent, which is explanation of the risks, benefits, and alternative courses of treatment. Every situation is different, and in some cases the pain will out weigh the risk of maternal mortality. It is important that you have that discussion so you can partner with them to make that decision that is best for you.

There are alternative options to promote uterine contractions. If you do need a fundal massage you can request that it is performed gently. Again this is your body so don’t be afraid to speak up.

Can I say No to Fundal Massage?

Yes, you always have the right to refuse any medical treatment as long as you are of sound mind and it is not a life threatening emergency.

There are two types of consent when it comes to medical care: informed consent and implied consent. Informed consent is a process in which a medical provider is required to educate a patient about the risks, benefits, and alternative treatments to a given procedure or intervention. Informed consent is an ethical and legal obligation of all medical practitioners in the US.

Implied consent is based upon your actions. In this case, your nurse enters the room and says we need to do a uterine assessment and fundal massage. If you pull down the blankets to expose your abdomen that is implied that you consent to the treatment requested.

You do not need a signed consent to perform a fundal massage like you would for anesthesia or surgery. So implied consent is often what is given for this course of treatment.

You do still have a right as a patient to be educated on the risks, benefits, and alternative treatment options from your nurse or provider. You then have the information to make an informed choice. You can say NO! They may not be happy with it, but it is your choice. There are a few excepts to the right to refuse (learn more about that here).

What are the Alternatives to Fundal Massage?

There are other options that are often less painful to assist the uterus. Oxytocin is a hormone that is released naturally in your body to promote contractions during labor. It is also released when breastfeeding to help stimulate milk production and promote bonding with your newborn. We can replicate this natural hormone to assist the uterus with medication, by breastfeeding our newborn, or nipple stimulation through pumping.  You can also be given oxytocin/pitocin through an IV postpartum to promote uterine contractions.

Two controlled trials were completed comparing the use of regular fundal massage vs uterotonics. One of those randomized controlled trials showed fundal massage to be effective while the other showed that regular use of oxytocin/Pitocin after delivery of the placenta was sufficient on it’s own to prevent postpartum hemorrhaging and help the uterus to contract sufficiently. Again more research needs to be done.

Other alternative you can try include:

Breastfeeding/Pumping: If you choose to breastfeed following birth, practicing the golden hour and spending the first hour after your birth doing skin to skin and promoting breastfeeding can help release oxytocin naturally in your body. The increased oxytocin will help with uterine contractions and reduce risk of PPH.

If you are not breastfeeding you can still stimulate that same process naturally with a breast pump. It is not as efficient as your newborn, but works very similarly to help release oxytocin naturally in your body.

Oxytocin/Pitocin: Pitocin is s synthetic oxytocin and is given frequently after birth to actively manage and promote uterine contractions in the third stage of labor. This decreases the risk of PPH.

Foley catheter or Bakri Balloon: This can be placed in the uterus and inflated to put pressure on the uterine wall to stop the bleeding.

Final Thoughts

Fundal Massage after birth is a simple inexpensive intervention to support the uterus if it is not actively contracting on it’s own to prevent PPH and decrease maternal mortality. It should not be used as a routine procedure as it can be very painful, and recent research suggest it is not always necessary. Birthing mothers should be given options if there is a concern for PPH, and allowed to choose the treatment that feels best for their situation. I encourage you to understand your rights, risks, benefits, options, and use your voice to make the right decision for you.