Application of Suprapubic Pressure and Fundal Pressure by RNs in Obstetrical Nursing Practice

It was the advisory opinion of the Board that the RN may NOT apply fundal pressure during the second stage of labor including, but not limited to, the following clinical circumstances:  a) in the presence of a non-reassuring fetal heart rate pattern, b) maternal exhaustion, or c) in instances of shoulder dystocia. 

Under specified conditions, it is within the scope of RN practice for a labor and delivery RN to perform fundal pressure and suprapubic pressure when stipulations for safe practice are present, as listed below.  The performance of such pressures is not within the scope of LPN practice. 

It is the advisory opinion of the Board that a RN may apply suprapubic pressure during the vaginal delivery of a fetus with suspected shoulder dystocia or breech delivery.  A RN may apply gentle fundal pressure for the purposes of preventing the upward displacement of the presenting part during fetal scalp electrode placement, and during an amniotomy when the vertex presentation is not ballotable.  A RN, who is scrubbed and is a member of the surgical team, may apply fundal pressure during a cesarean section. 

As referenced above, the Board advises that stipulations for safe practice include, but are not limited to, the following:

1. The RN is educationally prepared and clinically competent in the performance of the procedures.  The educational preparation should include, but not be limited to, instruction in the application of and rationale for the procedures and how the procedures differ.  The educational preparation for performance of pressures is directed by a licensed health care professional, such as a licensed physician with substantial specialized knowledge, judgment and skill related to obstetrics, or an ARNP designated nurse midwife, or a RN with documented clinical knowledge and competency in the application of pressure.
   
2. For each RN expected to perform pressures, the facility maintains written documentation of each RN’s initial and continued competency to perform pressures. 
   
3. The RN practices according to Kentucky Nursing Laws, generally accepted standards of care, and evidence based practice.
   
4. A licensed physician or an ARNP designated nurse midwife is present in the room and directing the performance of pressure.
   
5. All necessary resources are available.
   
6. The facility/agency has detailed policies and procedures in place addressing all aspects of this issue to include, but not be limited to, specific guidelines/criteria for these procedures and a mechanism of data collection for quality control.
   
7. The facility’s policy and procedures is reviewed and approved by the Departments of Nursing and Medicine both initially and at planned periodic intervals.
   
8. The labor and delivery RN documents the performance of pressure and the results of its application in the maternal medical record.

It is inappropriate for a RN to perform suprapubic pressure or fundal pressure when the application of these technical procedures is beyond the parameters of the RN’s education, capabilities or experiences. 

Although the determination of medical procedures and patient’s medical status is a medical decision, the RN has the right and the obligation to question orders and decisions that are contrary to acceptable standards and to refuse to participate in procedures that may result in harm to the patient.