Hemoperitoneum and the Kristeller maneuver

Traditionally, many maneuvers have been used to favor childbirth. One of the most popular has been the Kristeller maneuver,¹ which involves applying pressure on the uterine fundus in the mother’s abdomen, from the ribs towards the pelvis and birth canal. Although its use is common and its main purpose is to facilitate delivery, either as a routine maneuver or to avoid complications (fetal distress, failure to progress, exhaustion of the mother),^2,3 its use is extensively debated. Meanwhile, the prevalence of its use is unknown. In addition, no confirmed benefits of the procedure have been documented, and adverse events have been reported in association with its use, including uterine rupture, cervical laceration, episiotomy, urinary incontinence, brachial plexus injuries, and neonatal fractures and brain damage.⁴

We document the case of a 35-year-old woman with a history of a very difficult labor and delivery, during which the Kristeller maneuver was performed. In the hour after delivery, the midwife observed sustained hypotension, which did not respond to fluid therapy, and signs of hypovolemic shock. Given the progressive warning signs, the patient was evaluated for urgent surgery. During emergency laparotomy, we observed hemoperitoneum of about 2–3 L and rupture of the right ovarian vein at its insertion in the vena cava was observed, which we ligated. The patient evolved favorably and was discharged 2 days later with no complications.

The application of fundus pressure during the second stage of labor (also known as the Kristeller maneuver) continues to be one of the most controversial, poorly studied and least reported maneuvers in obstetrics.^3,5 This maneuver, which is generally applied to accelerate labor, is used to a variable degree; in some hospitals it is never used and is considered obsolete, while in others it is considered a routine procedure.⁶ The truth is that data on its use are often not documented, yet many complications have been associated with the maneuver.^2,3,7 Many studies have not found any proven benefit to its application. The quality of the existing evidence on the benefits and risks of the maneuver is generally poor. A recent Cochrane review found that there is insufficient evidence to draw conclusions about the beneficial or harmful effects of fundal pressure, and these authors encouraged further research.³

In this context, and with the aim to reduce the number of procedures not based on evidence in childbirth care, in 2007, the Spanish Ministry of Health published the Strategy for Assistance at Normal Childbirth in the National Health System.⁸ More than 5 years after the implementation of the strategy, it was found that the maneuver was still used in 25% of vaginal deliveries in Spanish public hospitals. In 2014, the “Stop Kristeller” campaign tried to create social awareness about its use.⁹

Obstetric interventions with a poor level of evidence that does not justify their use are prevalent in many healthcare systems and can harm mothers and babies during labor and delivery.¹⁰ The Kristeller maneuver can cause serious complications that can even lead to death, and its use should be based on high-quality evidence that justifies this practice.