Response: “First do no harm: Fundal pressure during labor—How safe is it?”

We would like to thank Professor Matthias David for his thoughtful and generous commentary on our article “First do no harm: Fundal pressure during labor-How safe is it?”1 We share his view that the maneuver historically known as the “Kristeller procedure” has been the subject of intense debate for decades and that carefully conducted studies are essential to inform current practice. We are grateful for the historical clarification regarding Samuel Kristeller's original description. As Professor David notes, Kristeller described a two-handed manual expression of the uterus, applied over the upper half of the uterine body, often before full cervical dilatation and irrespective of fetal presentation or head station.2, 3 Our study, in contrast, did not aim to reproduce the original Kristeller technique, but rather to evaluate the safety of contemporary fundal pressure as it is currently and narrowly practiced in our tertiary center. For this reason, we deliberately restricted the maneuver to the second stage of labor, with the fetal head at least +2 station, and performed it only by trained obstetricians following a standardized departmental protocol. The force was applied with the forearm over the fundus; in short, synchronized episodes during maternal pushing, and discontinued in case of pain or lack of effect. Our findings, therefore, should not be extrapolated to earlier stages of labor, to other fetal presentations, or to techniques that differ from the one we carefully described. The distinction that Professor David highlights between the historical Kristeller maneuver and modern variations of “fundal pressure” underscores one of the key challenges in interpreting the literature: heterogeneous techniques, indications, and thresholds for use. We fully agree that future clinical research should report the exact method, timing, and training requirements in detail, so that results can be meaningfully compared across studies. We also welcome the mention of the recent randomized clinical trial evaluating “gentle fundal pressure.”4 Together with our retrospective case–control data, such studies contribute to a growing but still incomplete body of evidence. However, as Professor David correctly points out, even when no increase in serious morbidity is observed, the decision to apply fundal pressure must be individualized. In our study we did evaluate several objective indicators related to maternal discomfort, including postpartum analgesic use (number of doses, need for opioid analgesia) and prolonged hospitalization, and found no significant differences between women who did and did not receive fundal pressure. Nevertheless, these are clinical proxies and do not fully capture the woman's subjective experience of the maneuver-such as perceived pain, fear, or sense of control during labor. We therefore agree that future research should incorporate structured patient-reported outcome measures and qualitative assessments of the birth experience in order to better understand the full impact of fundal pressure. In summary, we appreciate Professor David's historical perspective and his emphasis on cautious, patient-centered use of the maneuver. Our results support the view that, when fundal pressure is used sparingly, under strict protocol, and by trained obstetricians in the second stage of labor, it does not appear to increase adverse maternal or neonatal outcomes. At the same time, we agree that its use should never replace respectful communication, informed consent, and consideration of the woman's comfort and autonomy. Further well-designed studies-ideally including women's reported experiences-are needed to define the appropriate role, if any, of fundal pressure in modern obstetric practice. O.E. and G.S.M. reviewed the literature and drafted the response letter. The authors declare no conflicts of interest.