Nurses pushing on a woman’s stomach after delivery serves several important purposes. In the first few moments after birth, the nurse’s priority is ensuring that the uterus contracts properly to minimize blood loss. Pushing down on the stomach helps the uterus contract and expel any remaining placental tissues or blood clots. This reduces the risk of postpartum hemorrhage, one of the leading causes of maternal mortality worldwide.
What are nurses checking for when they push on the stomach after delivery?
When nurses firmly massage the abdomen after delivery, they are checking for several things:
- Uterine contraction – The top priority is making sure the uterus contracts and remains firm. This closes off blood vessels and reduces bleeding.
- Placental fragments – Any remaining pieces of placenta need to be expelled to prevent infection.
- Blood clots – Firm pressure can help dislodge any large clots in the uterus.
- Bleeding – Nurses visually assess any bleeding as they massage the uterus.
- Uterine height – They feel for the fundus (top of the uterus) to ensure it is contracted and not enlarged.
- Bladder – A full bladder inhibits uterine contraction, so they may check for bladder distension.
By massaging the lower abdomen in a circular motion and pushing down at intervals, nurses can determine if there are any signs of uterine atony (poor contraction) or other complications requiring intervention.
What problems can occur if the uterus doesn’t contract properly?
If the uterine muscles fail to contract strongly after delivery, serious problems can occur such as:
- Hemorrhage – Heavy, uncontrolled bleeding is a medical emergency.
- Retained placenta – Fragments left inside can cause hemorrhage or infection.
- Uterine inversion – The uterus can partially collapse into itself.
- Hematoma – Blood collects inside the uterine wall, causing pain.
That’s why monitoring contraction and expulsion of placental remnants is so vital in the minutes following birth. The nurse’s manual pressure and massage of the uterine fundus helps assess the degree of contraction and encourage any necessary contraction.
When is fundal massage performed after delivery?
There are three main times nurses will massage the fundus after birth:
- Immediately after birth – This initial fundal massage helps the uterus clamp down and prevents heavy bleeding from an atonic uterus. It also allows assessment for placental fragments and clots.
- During delivery of placenta – Gentle massage during the third stage of labor helps the placenta detach and descend into the vagina.
- Post-delivery monitoring – Nurses continue to regularly massage and assess fundal height and firmness to ensure adequate contraction.
This ongoing fundal massage and monitoring happens at regular intervals for at least 1-2 hours after delivery, longer if hemorrhage occurs. Some providers may even recommend intermittent fundal massage for a few days postpartum to encourage continued uterine involution.
What techniques do nurses use when pushing on the stomach?
Nurses are specifically trained in proper fundal massage techniques. These include:
- Using an open hand or fingers to gently knead the fundus in a circular motion
- Applying more focused pressure by cupping the hand and pressing downwards
- Massaging from the pubic bone upwards toward the umbilicus
- Alternating light touch with deeper pressure
- Repeating every 5-10 minutes for up to 1-2 hours
- Coordinating with maternal exhales to minimize discomfort
Nurses also assess the uterus by palpating its height and contraction. If the fundus feels enlarged, boggy, or soft, increased massage is done until it firms up. Positioning adjustments, medication, or interventions may be needed if the uterus won’t contract.
Why does fundal massage hurt after delivery?
Fundal massage often creates strong cramping or uterine contractions to encourage the uterus to shrink. This can cause significant discomfort. Reasons it may hurt include:
- Pressure on the abdomen may be quite firm and feel abrasive
- Contracting uterus cramps as it shrinks down
- Afterpains worsen as oxytocin stimulates contractions
- Increased pain with bladder distension
- Discomfort from vaginal soreness if pushing too near perineum
While some discomfort is normal, if the pain is very intense or elicited with light palpation, the nurse should adjust technique. Many women also report decreased pain with subsequent births since the uterus has been “trained” to contract.
How long after delivery is fundal massage performed?
Fundal massage typically continues for:
- First 1-2 hours after birth
- Until uterus is firm and contracted to normal size
- As long as bleeding continues
- More frequent with complications like hemorrhage
- May continue in hospital and even after discharge
Nurses use their clinical judgement on how long to continue massaging based on the woman’s response. If bleeding subsides and the fundus feels contracted and is measuring at an appropriate height, massage may be decreased or stopped.
What is the normal fundal height after delivery?
The fundal height refers to the distance, in centimeters, from the pubic bone to the top of the uterine fundus. Normal fundal height after delivery is:
|Time after Delivery||Normal Fundal Height|
|Immediately after birth||Approx. umbilicus level|
|12 hours||7-8 cm below umbilicus|
|24 hours||Midpoint between umbilicus and pubic bone|
|2 days||3-4 cm above pubic bone|
|1 week||Non-palpable at pubic bone|
If fundal height is higher than expected, the nurse continues to massage and monitor. A fundus that remains boggy or enlarged can indicate bleeding or infection.
Does fundal massage help uterine involution?
Yes, fundal massage is considered beneficial for encouraging uterine involution – the process of the uterus shrinking back to normal size after delivery. Reasons it helps include:
- Stimulates release of oxytocin which increases uterine contractions
- Massaging aids in expelling blood, clots or placental debris
- Promotes blood vessel contraction to reduce bleeding
- Helps the uterus tone and regain muscle strength
- Facilitates the healing process as the uterus shrinks
Studies show women who receive routine fundal massage have faster involution times compared to those who do not. However, research is still needed on optimal massage duration, technique, and timing protocols.
What problems can occur with poor uterine involution?
If the uterus fails to involute at the expected pace, possible complications can include:
- Hemorrhage from poor uterine contraction
- Infection from retained debris and lochia
- Subinvolution – prolonged large boggy uterus
- Uterine rupture in future pregnancies if not fully healed
- Postpartum pain from blood clots or cramping
That’s why nurses monitor involution closely through fundal massage, measuring uterine height on physical exam, and assessing lochia patterns. Catching delayed involution early allows treatment.
What techniques can help reduce discomfort of fundal massage?
Nurses try to minimize pain from fundal massage while still adequately assessing the uterus. Comfort measures can include:
- Explaining the process so the woman knows what to expect
- Providing reassurance that cramping and pain is normal
- Massaging gently with gradual increasing pressure
- Positioning mother for comfort and using supportive pillows
- Offering analgesia, cold/warm packs, or music distraction
- Coaching mothers on breathing and relaxation techniques
- Timing massage with the postpartum uterine contractions
- Watching for facial grimacing or extreme pain
If fundal massage causes excruciating pain, nurses should stop and notify providers as this can indicatepotential complications, like uterine inversion.
What are the risks or complications of fundal massage?
Fundal massage is considered a safe, effective technique with minimal risks. However, potential complications can rarely occur such as:
- Excessive blood loss – Vigorous massaging could worsen bleeding in atony.
- Uterine inversion – If misdirected pressure is applied, it can invert the weakened uterus.
- Hematoma – Blood pockets may form from rough massage.
- Increased pain – Too firm pressure can heighten afterpain cramps.
- Extended massage – Prolonged rubbing may irritate the uterine lining and delay healing.
- Severe discomfort – Some women experience extreme pain with fundal massage.
Proper training in fundal massage technique minimizes risks. Nurses should use caution if risk factors for complications are present and closely monitor the response.
When should fundal massage be avoided?
In some situations, fundal massage may need to be minimized or avoided, such as with:
- Placenta accreta disorders where massage could disrupt placental implantation sites
- Uterine rupture or inversion where rubbing could worsen the tear
- Hematoma formation where pressure increases blood pooling
- Low-lying placenta with increased risk of bleeding
- Placental fragments adhered to the uterine wall
- Bleeding complications or coagulopathy where massage could increase hemorrhage
Clinical judgment on risks versus benefits guides proper fundal massage usage after complicated births. Alternative techniques like medications or compression wraps may be used for uterine contraction.
Fundal massage, where nurses intermittently apply firm pressure to the maternal abdomen after birth, provides essential uterotonic benefits. Massage encourages uterine contraction to expel placental remnants and blood clots, stimulating oxytocin release. This reduces the risk of haemorrhage, the leading cause of postpartum mortality. Along with assessing lochia and uterine involution, maternal fundal response offers key insight into postpartum recovery. When used correctly, fundal massage promotes normal placental delivery and postpartum uterine changes with minimal discomfort. Understanding the rationale for fundal massage empowers mothers to anticipate the process and communicate any concerns.