I believe it is necessary to discuss the risks of the Kristeller maneuver during childbirth (especially in the pushing stage) in more depth. This thought arose after a tragedy that occurred in Careggi, Italy. A 36-year-old woman ended up with a spleen injury after presenting to the hospital. Although the Kristeller maneuver has been cited as the cause of this injury, there are other possible reasons, and the incident is still under investigation.

Annalisa had a quite normal and healthy pregnancy, but after being discharged (while the baby was at home), she had to return to the hospital urgently due to complications. The clarification of events is awaited, so we will not delve too much into this issue; however, it is important to use this situation as an opportunity to explain what this intervention means.

What is the Kristeller Maneuver? (or invisible maneuver)

The Kristeller maneuver involves applying direct pressure to the fundus of the uterus (with hands or forearms) during the second stage of labor. This maneuver is used to shorten the pushing process and to "assist" the baby in descending through the birth canal. In practice, a midwife, gynecologist, or another specialist usually positions themselves next to the laboring woman and attempts to synchronize with the woman's contractions and pushes by applying strong downward pressure towards the upper part of the uterus.

Despite its past frequency (it is estimated to be used in about a quarter of births in certain contexts), WHO and the Ministry of Health do not recommend this maneuver. The reason is the risks it poses to both the mother and the baby, and the lack of proven benefits in most existing studies. Some surveys and analyses conducted in health centers in Spain indicate that this maneuver is used in about a quarter of births in certain contexts.

Kristeller: Why Take the Risk?

If the application of this maneuver carries significant risks and scientific evidence does not provide a clear benefit, why is it still being used? As I mentioned earlier, this maneuver is performed to "push" the fetus into the birth canal by applying pressure from above to facilitate the baby's head approaching or starting to exit the vagina.

In my opinion, childbirth is a physiological process, and unnecessary intervention only disrupts or alters this process, often serving the organizational or time-related interests of health professionals rather than the actual needs of the laboring woman and baby. I call this obstetric violence because it involves acting on a woman's body without proven benefits and often without information or consent.

Samuel Kristeller "invented" this maneuver in 1867, and it became popular for accelerating difficult births for decades. However, today we know that the balance between risks and benefits is quite negative, and therefore the Ministry of Health recommends that the frequency of this maneuver in normal births should be 0%.

Despite this, it is still being applied in many places and often without transparency: because it is not documented in medical records and is often performed without the informed consent of the pregnant woman. This lack of documentation and transparency makes it difficult for families to prove what happened when complications arise.

When is it Used and What Alternatives Exist?

In practice, the Kristeller maneuver or fundal pressure is used when professionals perceive slow progress during the second stage of labor, when maternal exhaustion occurs, or when they want to shorten the pushing time due to the medical condition of the mother or baby. Additionally, it has been seen to be inappropriately used in some cases of shoulder dystocia; however, clinical guidelines clearly contraindicate this in such situations.

However, existing clinical trials and systematic reviews have shown that the implementation of this maneuver does not provide consistent benefits in reducing cesarean sections, preventing instrumental births, or shortening the pushing duration; whether applied manually or through inflatable belts.

Current recommendations are shifting towards more suitable and safer alternatives to the physiology of birth when the pushing duration is prolonged: allowing more time in a safe environment, changing the mother's position (for example, upright, on the side, or on all fours), providing continuous support to the woman, using vacuum or forceps only when truly necessary, and if these options are not appropriate, considering a more controlled and protocolized cesarean.

In cases such as shoulder dystocia, scientific communities recommend evidence-based specific maneuvers (McRoberts maneuver, suprapubic pressure, position changes) and emphasize that pressure should not be applied to the fundus; as this can worsen the impaction of the shoulders and increase the risk of serious injury to the baby and the uterus.

What Do Scientific Evidence and Clinical Guidelines Say?

Recent reviews of the scientific literature indicate that there is insufficient evidence to support the routine use of fundal pressure during labor. The existing studies are small, heterogeneous, and of limited methodological quality, which prevents them from demonstrating robust benefits in important variables such as reducing instrumental birth or cesarean rates.

At the same time, more cases and clinical series are being described that associate the maneuver with serious maternal and neonatal injuries: from severe tears to uterine rupture or neurological damage in the baby, especially when applied with great force, for prolonged periods, or outside the situations recommended by guidelines.

Therefore, many organizations and professional bodies do not recommend its routine use and advise extreme caution even in situations where some teams still view it as a last resort. Modern obstetric practices show a clear trend towards reducing non-evidence-based interventions and prioritizing safe and valid maneuvers.

In some countries, the application of fundal pressure contrary to recommendations and leading to preventable harm may be legally regarded as negligent behavior. This underscores the importance of adhering to evidence-based protocols, informing women, and accurately documenting everything that occurs during labor.

Risks of Kristeller

Years ago, a campaign called Stop Kristeller was developed at Parto es Nuestro, and its content is still valid on the web. Risks to the baby include: hypoxia (lack of oxygen), hematomas, humerus or rib fractures, shoulder dystocia (and associated complications), increased intracranial pressure, and neurological injury when the maneuver is used inappropriately or persistently.

Risks for the mother include: bruising in the abdomen and rib area, premature separation of the placenta, uterine rupture and inversion, increased risk of perineal and vaginal tears, and also pelvic floor trauma, severe tears (third and fourth degree), and muscle injuries that can lead to issues such as urinary incontinence and prolapse.

The literature has identified fundal pressure as a modifiable risk factor for uterine rupture even in uteri without prior scarring; this reinforces that the maneuver is not an innocuous procedure. Some studies have found a relationship between the application of the maneuver and an increase in severe perineal injuries when combined with other interventions.

Beyond physical complications, it is also necessary to consider the emotional impact of feeling that procedures are performed on the body without the woman's consent, with intense pain and without explanation. Many mothers describe this maneuver as a severe and traumatic experience, affecting their birth experiences and subsequent recoveries, as well as their connections with the healthcare system.

From a legal and rights perspective, in cases where protocols that do not recommend fundal pressure exist, its use without clear demonstration, without previous alternatives, and without providing information can lead to malpractice lawsuits when a connection is proven between review in quality committees, formal complaints, and even injuries related to the maneuver.

How Can You Protect and Assert Your Rights?

You can take action to prevent or significantly reduce the likelihood of the Kristeller maneuver by preparing a Birth Plan, gathering up-to-date information, and discussing with the healthcare facility where you plan to give birth. Remember that you have the right to advocate for your rights within the framework of humanizing birth care and you can state in writing that you do not consent to the application of fundal pressure or the Kristeller maneuver except in very exceptional and properly explained circumstances.

During prenatal visits, it will be beneficial to ask whether this maneuver is used at that facility, what protocols are in place for the second stage of labor, and what evidence-based alternative maneuvers exist. The clearer the communication, the easier it will be for the team to respect your preferences and for you to trust the care you will receive.

According to the EPEN campaign, 29.1% of participants wanted to stop the maneuver being performed; however, in 90% of these cases, this was not taken into account. This rate shows how much women's voices are ignored in delivery rooms when it comes to painful and often unjustified interventions.

If you suspect that pressure is being applied to the fundus during labor and this concerns you, you can request a complete copy of your medical record, note your memories and feelings, and if you believe there has been malpractice or a lack of respect for your rights, you can seek advice from user associations, support groups, or professionals specialized in health law and obstetric violence.

Knowing what the Kristeller maneuver is, what risks have been identified, and what current guidelines say enables women to make informed decisions, better prepare their birth plans, and demand respectful care that focuses on the safety and well-being of both mother and baby.