EBB 267 – Debunking Myths about Fundal Massage with Barbie Christianson, RN

Rebecca Dekker:

Hi, everyone. On today’s podcast, we’re going to talk with Barbie Christianson, a nurse, community educator, and advocate to debunk myths about fundal massage after birth, also known as uterine massage.

Welcome to the Evidence Based Birth Podcast®. My name is Rebecca Dekker, and I’m a nurse with my PhD and the Founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. My name is Rebecca Dekker, pronouns she, her, and I’ll be your host for today’s episode. I wanted to let you know that we will be talking about uterine massage, which can be a traumatic experience for some, and we’ll also be talking about obstetric violence.

If there are any other detailed content or trigger warnings, we’ll post them in the description or show notes that go along with this episode. Now, I’d like to introduce our honored guest. Barbie Christianson, pronouns they, she, is a nurse, community educator, and advocate, as well as a parent of four young children. Their mission is to communally dismantle oppressive structures, specifically in a reproductive perinatal healthcare while contributing to the expansion of existing Black and/or Indigenous-led community-based care structures. Barbie’s special focus is on addressing and eliminating obstetric violence using trauma-informed perinatal advocacy care and education.

Today, I’m so excited that Barbie is here to help us debunk some myths about fundal massage after birth, also known as uterine massage, and we’ll be talking mainly about fundal massage when it’s used in a preventative fashion, not when it’s used in a medical emergency. We will also address the misinformation on social media about this procedure, talk about what the evidence actually says about preventive fundal massage. We’ll also talk about informed consent, and how nurses and providers can bring a trauma-informed approach when the procedure is actually medically necessary, which spoiler alert, is not that often. So we are so thrilled that Barbie’s here. Welcome, Barbie, to the Evidence Based Birth® Podcast.

Barbie Christianson:

Oh, thank you so much. I love your spoiler alert. Yes.

Rebecca Dekker:

Yes, but we are here to give everybody all the details about this.

Barbie Christianson:

Yeah. I love that, and thank you so much for the introduction. It is truly a privilege to be here with you all today or whenever you’re watching or listening, or reading this, as I usually do.

Rebecca Dekker:

So before we get into the weeds with uterine massage or fundal massage, can you let us know a little bit about your background, what brought you to birth work, and more specifically, how you ended up as a nurse who focuses on obstetric violence and using trauma-informed care?

Barbie Christianson:

Thank you. Yes. I actually used to work in special education for many years, and then I fell down the rabbit hole when I became pregnant with our oldest. I think a lot of birth workers do, either come into birth work through their own or appear somebody’s experience, some kind of personal attachment sometimes, so I went to school to be a labor and delivery nurse while parenting and thankful for all the support that got me there, and the privileges, and the resources. I was fortunate enough to also go to doula training.

I’ll admit, it wasn’t with an organization that I support any longer necessarily, and I am so thankful for all the doulas who are really still in that work and thankful for what they provide, and we should support them more, certified or not, right? After becoming a doula during nursing school, realizing that wasn’t going to be sustainable kind of in any way, I was already on the nursing path. I continued in that journey, although I did still provide a lot of birth work support. When I went right into labor and delivery as a new grad, I felt very well-prepared with a lot of the evidence-based care, some personal experiences, and kind of knowing that there was a strong need for advocacy as well, knowing that I would bring a lot of privilege and responsibility into that. So I don’t want to say I went in with eyes closed or anything. However, I didn’t really know.

Within my first weeks, I came face-to-face with obstetric violence in a whole new way. A lot of barriers to reporting, just very traumatic throughout the whole process, especially as a newer nurse, without even knowing the term obstetric violence at the time. That came later through Birth Monopoly. I learned that the term came from South American activists and victims ourselves. Like it’s a victim-developed term, and I think that’s really important when we use the term obstetric violence to really orient that.

I worked in labor and delivery at bedside at several facilities, years as a staff nurse or per diem until I made the decision to support my family in a different way, and I went into Maternal, Child, and Adolescent Health Public Health Nursing, working with families and individuals in like a perinatal and early childhood period. It was really there that I actually learned about trauma-informed care and ACEs, adverse childhood experiences, and then I felt like this whole new wave of, or this world opened up, and this whole connection piece about how much trauma we’re causing in the birth setting with obstetric violence generationally and how it’s literally attachment trauma, feeding trauma, human rights violations abound, so it really became … That was one of the reasons I was grateful to go into public health, is not only were we there to address a lot of the post-obstetric complications and really refer and try to resource people, but I had hoped to work on more on the prevention side as well. Like this is preventable, right? We can stop abusing people.

It is possible, and using whatever resources in the unit we are able to do, we did our best. Unfortunately, after several years, the pandemic, priorities within the department, the organization change, resources weren’t really available or allocated to address obstetric violence at all despite us, many of us advocating that the ramifications of it are going to be worse during the pandemic, of course, which continues, right? We are still in it. Things are still happening, although we don’t have the same visitor. Yeah, I used some air quotes there, restrictions that we saw during the height of the pandemic, or the initial period, I should say, and so I did end up going back to bedside for a bit, and now, I find myself back in the community health setting, as well as educating, and that is really where I have found a lot of my passion and skills align, is in educating and collaborating, organizing around exactly those myths because so much of obstetric violence is rooted in the myth of white supremacy, the myth of that capitalism in healthcare works, all of these things, right? So here I am in this moment in time with, again, the privilege to be here and speak on these things, and really debunk some of the myths around simple things like routine uterine massage as prevention rather than intervention, which has its own risks as we’re going to talk about.

Rebecca Dekker:

Yeah, and something you said really stuck with me, the fact that you had pursued doula training before you finished nursing school, and then you went straight into labor and delivery nursing, and within the first couple weeks, you witnessed obstetric violence, but you didn’t have the terminology or words or tools on how to deal with it. What did you call it? If you had to describe it to someone before you knew what the term was, what were you witnessing? How were you feeling about it?

Barbie Christianson:

Well, when I spoke to what … Number one, I reported it internally. There’s internal, like incident reporting systems that almost every facility is going to have. Some of the facilities will use, programs like Quantros or whatever, various other things. So within that, in the moment, I called it assault, and I was instructed because, again, I was on orientation, I was instructed and essentially coerced in the moment to remove the word assault from my written report.

I did do that and I did remove the word, so I described that particular incident of obstetric violence. For what it was, I described like the actual physical action, what happened to the skin integrity, what the concerns were, the documentation fraud regarding what had happened. So I just very objectively said that. However, in all my verbal reports to Director of the Women’s Health Services, which it was called at that the facility, to the CNO to the CMO to California Department of Public Health, to the Glendale Police Department, to later on to Ventura County Public Health. I always called it assault, and because that’s what it is.

Rebecca Dekker:

Okay.

Barbie Christianson:

I later learned probably about, maybe a year later through the Know Your Rights Course, actually with Birth Monopoly, that in some places, legally you could call it medical battery, and then I was gaslit at different facilities, particularly that one when I was brand new and saw this particularly horrific thing. Not to call it assault, because, “That sounds so violent,” and my response was, “Well, yes, it was extremely violent,” like he … Whatever. He hurt her, essentially, and the manager kind of shuttered and said, “Well, don’t worry. He won’t be.”

“He said he knows he’s not supposed to do it again,” or whatever, and that that was pretty much their way of handling it, right? This assault, so that’s what I always called it before I knew the term, obstetric violence.

Rebecca Dekker:

I know at Birth Monopoly, they have a great poster that you can purchase that shows the upside down pyramid of obstetric violence, and there’s things ranging from outright assault to coercion and pressure, and one of the things we’re going to talk about today is something that is one of those routine procedures, that when it’s done without consent and without medical necessity, it could be considered on that spectrum of obstetric violence, and that’s fundal massage or uterine massage. So I was wondering if you could start off by sharing with our listeners, what is this procedure?

Barbie Christianson:

Yeah, absolutely. I want to start by kind of orienting to the fact that most nurses, well, the provider, whether that’s a midwife or the obstetrician or family nurse practitioner, whoever it is attending the birth, is usually going to provide that first fundal assessment or even fundal massage, if that’s what they’re doing as well.

Rebecca Dekker:

Yeah. Can we describe maybe the difference between a fundal assessment, a fundal massage? So I have my knitted uterus here with a little baby inside.

Barbie Christianson:

Wonderful.

Rebecca Dekker:

So where is the fundus on this?

Barbie Christianson:

Yeah, so that uterus … Oh, that’s a nice, big uterus.

Rebecca Dekker:

I’m holding it in front, so yeah.

Barbie Christianson:

Oh, yeah, it is, I guess. So the fundus is going to be the top of the uterus, and that’s what we’re kind of feeling when we’re pregnant. As your uterus grows, maybe you’re going in for regular prenatal care or just any prenatal care, and they’re kind of measuring where the top of your belly is. You’re actually feeling the top of that fundus right where, Rebecca, is that light blue section, right?

Rebecca Dekker:

Yeah, if you’re watching on YouTube, you can see our visuals.

Barbie Christianson:

Oh, thank you. And so that really just kind of requires, depending on where it’s located, a little bit of searching around, so that’s kind of what we talk people either through, if it’s taking a while or we stop and say, “How are you doing?,” after we’ve kind of, again, informed consent. Start there, so explaining what it is. Maybe I should start there. “I would like, if it’s okay with you, to check your uterus.”

“After birth, sometimes there should … Your uterus is very smart. It’s going to most likely do what it’s supposed to do, so however, sometimes, especially depending on the risk factor.” You know what? I might go into those. Maybe they were there for a very long induction, they were on high-dose continuous Pitocin infusion, which is going to put them at more risk for postpartum hemorrhage.

So I’m going to explain why I want to do this intervention, right? I’m going to start there.

Rebecca Dekker:

Yeah, and you’re not actually going to massage or rub the uterus. You’re just going to assess. It means you’re going to use your hands to find that top of the uterus from the outside, and I’m going to go ahead and take the baby out of here because-

Barbie Christianson:

Right.

Rebecca Dekker:

Yeah. It’s going to be, after the baby is born, it starts to shrink down and contract.

Barbie Christianson:

So quickly. So quickly. Within two weeks almost, you can hardly even feel it after birth, depending on where it kind of was at and what your uterus is doing, so what I would typically talk to to patients, depending on their risk factors, is how often I want to be assessing their uterus, so how often do I want to be checking it and why do I want to check it? So that’s where I’m going to start. Unfortunately, a lot of facilities will have requirements, like you have to check a fundus every so many hours.

I say unfortunately because although that is important to do assessments, that sometimes interferes with other things, like living.

Rebecca Dekker:

Like sleep.

Barbie Christianson:

Just living and whatever you’re trying to do after having a whole human come out of you, so it’s not really individualized to patients, but ideally, I’m going to provide them some kind of guidelines about why I want to, or provide this information about what I am expected to do, and also why this may be important for them, and then I’m going to explain that what I would like to do is take my hand. Well, two hands. One hand and place at the bottom, like near the pubic bone and just kind of hold some support. This is a little different depending if you’ve had a vaginal or a cesarean delivery, just that difference in support there, and then I take my other hand … I’m kind of talking to you as if you’re the patient a little bit or the client, and I find the top of your uterus.

Hopefully, this is going to be gentle. If you’ve already had them, I’m going to definitely ask you how they’ve been for you before also. Then, this is where it does get a little tricky because people are expecting that uterine massage, and then I’m offering a uterine assessment, which is different. All I’m doing is reaching my hand down into the abdomen, kind of far enough to feel, “Where is the uterus? Is it in the middle?,” ’cause that’s important, like-

Rebecca Dekker:

In the middle of your body, like in the center.

Barbie Christianson:

Yeah. Is it midline, I should say? Is it midline, is what we, nurses would use. We’re charting like midline. The reason this is important, if it’s not midline or if it is, and then later it’s not, we want to know like, “Why?”

Is maybe your bladder is full. That is a really simple thing that we can help you do, empty your bladder, and as soon as the bladder is empty, the uterus tilts back from usually the right back to the middle. That’s really important because the bladder can interfere with, what you talked about, the uterus shrinking back. We call it involution back into the cavity. So that’s really all I’m doing.

I’m looking for the top, and I’m always a little bit sad for people when they, “Oh, that was so easy. Oh my gosh, that didn’t hurt at all. You’re so gentle.” It’s not that I’m gentle, it’s that all I’m doing is assessing. All I’m doing is finding, “Where is your uterus?,” and also, “What does it feel like? Is it nice and firm?”

We do want, ideally, it to feel firm. If it’s not feeling firm, that could be assigned that it’s not contracting the way it’s supposed to. Sometimes people are surprised they may feel contractions or cramps after birth, especially if we haven’t supported people in learning that. I didn’t know. What is that?

Rebecca Dekker:

The after people call them after pains, right?

Barbie Christianson:

Of course.

Rebecca Dekker:

That’s essentially your uterus is contracting after the birth to try and prevent where the placenta peeled off from bleeding excessively. Correct?

Barbie Christianson:

Exactly. Exactly. So those contractions, they’re going to firm up the uterus. They’re going to keep it nice and firm. If it’s not doing that, the uterus will feel different.

It’ll start to feel a little soft. I’ve heard some nurses describe it as like a deflated dodge ball, something like that, other terms that people may have heard. Sometimes we’re not explaining it well, but maybe they’re talking, “This has happened to you … I’m sorry,” and they’re talking about a boggy uterus, maybe-

Rebecca Dekker:

Boggy, B-O-G-G-Y.

Barbie Christianson:

Yep, boggy, but what that feels like as I’m assessing, if I can’t find it and it doesn’t feel nice and firm, then I am going to switch to asking about an intervention, or I might pause and kind of assess further, “What’s happening when I’m assessing too?,” like, “Is the person painful?” So this is like a whole person assessment, like even with that slight little assessment and maybe a little bit of pressure just from assessing where it’s at and how we affirm its feeling. Am I seeing any active bleeding with that? Right? Again, I’m not trying to press very hard or massage, but even with that light pressure, there, am I seeing bleeding, so this is a whole person assessment.

This isn’t just like a little like, “Let’s just find the uterus and chart its midline. It’s firm. It’s plus one, or let’s look at the previous nurse’s charting,” or whatever it is. So that’s what I’m asking people or talking to them about when I’m coming in and talking about a fundal assessment with them.

Rebecca Dekker:

How is that different from a fundal massage or uterine massage?

Barbie Christianson:

Yeah. I am so grateful for the knowledge that has been protected about uterine massage. It is a very helpful intervention when there is active bleeding, so if there is active bleeding …

Rebecca Dekker:

Like you’re at risk for hemorrhaging?

Barbie Christianson:

Yes. Many people will probably be more familiar with the device, like if you are bleeding through a pad in an hour, or you are passing large clots with your bleeding, or if you were just seeing obviously streams of blood coming out, that would be concerning. This is not the, like trickles or those slight gushes that we may feel with some position changes, things like that, or even small clots and tissue. This is active heavy bleeding, so we are concerned now, right? We want to ask you to intervene because we know that if we intervene early with postpartum hemorrhage and postpartum hemorrhage has very strict definitions, depending on even …

We have the California or the CMQCC. I love their guidelines, so if you’ve had a vaginal delivery or a cesarean, it does change, but a lot of places are moving toward quantitative blood loss, so we’re measuring everything. We’re really looking at how much blood is lost during the actual delivery, and then based on that, and based on some other risk factors, we’re monitoring your blood loss for a certain amount of time after. If you’re kind of in that risk category and we see that act of bleeding, again, that and, and this is where there’s kind of a breakdown in that flow, at least in practices I see, we are very fear-based in nursing sometimes, and we’ll start intervening when it’s not necessary, and that carries its own risk. So if there is not active bleeding and we are not hemorrhaging, and that uterus is doing what it’s supposed to be doing and we’ve assessed it, there really isn’t any need to move into a higher-level of intervention, especially without informed consent, like just, “Oh, I’m right here.”

“I’m just going to massage anyway to make myself feel better.” I’ve heard some, even very experienced nurses and, goodness, I trust their gut feelings, but just say, “Wow, there’s just not enough bleeding for me. Let me just push and massage anyway and see what happens.” I’ve been taught that in some facilities before. As a new nurse, it was really hard to differentiate, “Is this a gap in evidence-based care? Is this actually what I’m supposed to be doing?,” so was really grateful for evidence-based birth resources.

Thanks, as a new nurse also. Again, that intervention is very helpful when we have that active bleeding. What it does is it is stimulating the uterus, hopefully. That’s the goal, and it’s going to work. If its uterine atony and the uterus is able to respond, it really is helpful, so what that’s going to feel like is us taking our hand, and I’m going to ask you, “Hey, I don’t really feel like your uterus is as firm as it should be.”

“You are having some trickling when I’m even pressing lightly. I’m a little concerned.” Sometimes the uterus just needs a little help to be stimulated. Maybe we’re not running … Well, I’m sure we’ll talk about that active high-dose bolus Pitocin or synthetic oxytocin after, because that is medically stimulating the uterus, but again, say we see that active bleeding, I’m going to ask, “Can I massage your uterus a little bit, and see if I can stimulate it to start contracting and really kind of stop this bleeding on its own?”

Then, I’m assessing, as that intervention is happening, “What’s happening when I’m massaging? Are larger clots coming out? Is the bleeding increasing? Did a large clot come out and now it’s slowing down?” So again, the massage is also being assessed, but it is not a fundal assessment. It is an actual intervention.

Rebecca Dekker:

So Barbie, what I’ve heard you say is there’s fundal assessment where you’re just kind of assessing the situation and what is the uterus doing right now, which is a light pressure to find the top of the uterus. Then, there is preventive massage, which is when somebody, a nurse or provider starts more forceful rubbing from the outside of the abdomen to try and stimulate the uterus to prevent postpartum hemorrhage, and then there is fundal massage when there is active bleeding, which is what the World Health Organization recommends as one of the first steps for a postpartum hemorrhage, so you kind of have the fundal assessment, you got preventive fundal massage or uterine massage, and you have the uterine massage when there is a active bleeding going on that needs to be stopped. Is that correct?

Barbie Christianson:

Yes, and I would almost reframe that preventative fundal massage to routine.

Rebecca Dekker:

Okay, so we’ll call it routine.

Barbie Christianson:

Yeah.

Rebecca Dekker:

I did want to share with our listeners, in preparation for this, I’ve pulled up our article at Evidence Based Birth® on the third stage in active versus expectant management, and I just kind of wanted to let, give everybody a brief picture, if that’s okay, of the evidence on the routine massage. We cover this in the section of the article on Pitocin during the third stage of labor, and there’s a section called, “Are There Benefits to Uterine Massage?,” so we’ll link to this article in the show notes. There was a Cochrane review with two randomized trials, where people were randomly assigned to either receive fundal massage or no massage after they birthed the placenta. In the first trial, they found, really, no difference in postpartum hemorrhage, so it was not effective at preventing postpartum hemorrhage. A second and much more larger trial had 2,000 birthing people in it, and they were assigned to receive synthetic oxytocin or Pitocin, uterine massage, or both, so there were three groups.

The group that received uterine massage alone had the most cases of heavy bleeding in 30 minutes. When synthetic oxytocin was used, meaning you’re given Pitocin after the birth, they found that the massage did not provide any additional benefit, and about one-third of people reported that the procedure was painful. Then, there is another study that was published after that Cochrane review, and they randomly assigned about 1,200 people to either get Pitocin shot after the birth, plus 30 minutes of continuous uterine massage, and then some people just got the shot of Pitocin. So actually, there were about 1,200 people in each group, so this was a really big study, and they found that doing the uterine massage did not reduce blood loss when you added that to Pitocin, so that the shot of Pitocin was all that was needed in that case. So all of this research on massage does not support using it routinely without a medical need.

Barbie Christianson:

Yup.

Rebecca Dekker:

But you’re seeing … How often would you say in the hospitals you’ve practiced, is it used routinely after the birth?

Barbie Christianson:

Boy, I-

Rebecca Dekker:

Is it common or is it rare, or is it almost all the time?

Barbie Christianson:

I would say almost every preceptor I’ve ever had during any orientation has always, at one point during an opportunity to do a whole recovery or anything has included routine fundal or “Preventative” fundal massage instead of assessment without-

Rebecca Dekker:

Yeah, so everywhere you’ve worked, the preceptors, meaning the people training the new nurses are telling people to do this routinely?

Barbie Christianson:

Yes, which is how they’re trained, right?

Rebecca Dekker:

Okay. Yeah.

Barbie Christianson:

It’s a cascade effect, and we’re very-

Rebecca Dekker:

Yeah. Yeah, it’s why we’re here. Can you tell … In the studies, they mentioned pain. Like in your experience of, you described trying to do it with informed consent, and people are often surprised if it’s their second or third baby.

They’re like, “Wow, that didn’t hurt,” ’cause you were just gently pressing to do the assessment. How forceful can it be when a nurse or provider is doing this preventatively?

Barbie Christianson:

I mean, everybody, of course, is different. I’ve seen people, or I’ve seen nurses do what I would consider very aggressive fundal massage when fundal assessment was indicated, and the person breathed through it and didn’t seem to be much affected by it, was expecting it or knew how to manage, or it just didn’t really bother them, whatever it was.

Rebecca Dekker:

They coped with it somehow.

Barbie Christianson:

Yup, yup. Then, I have seen people crawl away on the bed.

Rebecca Dekker:

Like trying to get away from the nurse?

Barbie Christianson:

Yes. Like unconsciously, consciously, both, like trying to stop it, just not managing well and …

Rebecca Dekker:

They’re trying to escape.

Barbie Christianson:

Yeah. Here they are sometimes, often chest feeding or skin to skin, or trying to bump their baby or having a moment away. As a autonomous, like free human for a second, yeah, and then they’re going to spend it in pain.

Rebecca Dekker:

I can say here at EBB, we get lots of messages and comments from people who are sometimes even traumatized by the massage because it was so forceful and painful and done without their consent.

Barbie Christianson:

Absolutely, or I think it’s also hard sometimes to learn later that something wasn’t necessary, and then to know that even if it wasn’t necessarily painful, maybe it interrupted something, maybe you just … It was interrupting what you were doing, like recovering again.

Rebecca Dekker:

Or to be woken out of sleep to have that being done to you?

Barbie Christianson:

That too, and so I always love to make a plan. Realistically, I hope, especially in California, at least they had ratios, right? We have some of the best ratios, especially for Couplet Care and postpartum, still too many in my opinion, especially if you’re going to support lactation at all, or anyway … That’s a whole ‘nother rabbit hole, but on that note, pain also can interfere with lactogenesis and lactation, as well as recovery and healing, bonding, all the things, attachment. I will say it’s very rare that I was ever not able to make a plan to protect rest, to protect autonomy, and also, at fundal assessment, we’re taught to do in a very specific way.

It can also … I love that you’ve mentioned that it can kind of be traumatic because it can also be triggering. We’re sometimes taught that the only way to do a proper fundal assessment is to put somebody in the lithotomy position again, which depending on what happened in their birth or before. Who knows? There’s so many resources out there now, thank goodness, and more coming on trauma-informed birth care.

We can mention one of them, the Trauma Informed Birth Nurse Program. I think they even offer CEUs in hospital programming now too, or reimbursement, I mean, but circling back, I have very rarely, again, been able to make that plan, and then also, a fundal assessment can be done and checked in, not just the lithotomy position.

Rebecca Dekker:

When we say lithotomy, you mean like legs up and stirrups on your back?

Barbie Christianson:

Yeah, on your back, or at least legs up on the bed and knees apart like, I mean, yeah, ’cause we’re checking for bleeding too sometimes, and yes, there are going to be times where that may be how I ask you to assess everything. Maybe there is a little. Maybe you have some more risk factors. Maybe we’ve already seen some concerning things. Maybe you told me you saw a big clot, or maybe, in that position while you’re chest-feeding your baby and having your snack, and I’m slipping my hand under both of you, not to interrupt your skin-to-skin and doing a light, ’cause you can assess like that.

I really can. I can find your uterus. I can tell if it’s kind of where it’s supposed to be, especially if I’ve felt it before, but even without, and then if I can’t find it, then I’m going to ask you, or if there’s actively, I want to ask you, “Is it okay if we do this or this?,” and always present the options. “If you don’t want to do it right now, can you please let me know when you’re ready?,” if they do want to do it, but not right then, whatever. We make a plan, and ultimately, it’s their decision.

Rebecca Dekker:

So I know you spend a lot of time on social media, so you’re kind of in touch with what people are saying, maybe what labor and delivery nurses are talking about on TikTok and Instagram. Can you talk a little bit about some of the misinformation that you’ve seen on these reels and TikTok videos?

Barbie Christianson:

Yeah, I would love to. I do want to also note that I love-hate social media, I think as many of us do, and I have also, over the last few years, curated my experience very carefully there to protect my own boundaries mostly. I will say that I’ve sort of bubbled myself, in that I don’t engage any longer in social media accounts that do promote many of those myths, I would say, so I really appreciate a lot of the work that Flor, with BadAssMotherBirther has done. She, I think, has just broken so many barriers. I mean, I, as a nurse, in all my experiences and as a doula and as a birthing person myself, I have seen things on her account that I would never see in my profession because of systemic barriers and things that nurses and residents wouldn’t see because of that, so social media, again, can be an amazing tool.

So it’s a little hard for me to answer that question because at this point, I usually stick to the places where the building is happening, I hope.

Rebecca Dekker:

Well, the ones that I was thinking of, in particular then, if you could talk about are when the nurses say things like it’s a necessary evil and you just need to suck it up and let the nurse do their job.

Barbie Christianson:

Yeah. Yeah.

Rebecca Dekker:

Even if it hurts, it’s in your best interest.

Barbie Christianson:

Yeah, we’re just trying to take care of you, right? Again, going back to Flor, she recently had a post on just that really abusive, dangerous care can be very sweet, and nice, and packaged, very, very nicely for us to accept and normalize. I think particularly, as a form of gender-based violence, we’re almost groomed throughout our lives into accepting this, whether that’s through the freeze, fight, flight, fawn response, however that is. We, as nurses, can be, and are complicit in that. “Oh, I know this isn’t any fun, sweetie.”

We’re just like rubbing, rubbing, rubbing, and mainly like … Sometimes I’m just standing there, especially always in the first week of orientation at a facility, right? I’m like, “Why? Just get through orientation,” and because even in those moments, yes, we can try to interrupt that, and also, realistically, you’re on a 90-day probation facilities. If you want to make change at a facility, especially as a staff nurse, when you want a union to protect you, you got to get through that 90 days. So it’s really hard, I think sometimes as nurses to balance that period.

Rebecca Dekker:

That brings me to, if you find yourself in that situation as the patient and you’re not actively bleeding, you’re not hemorrhaging, and the nurse just starts rubbing forcefully on your belly, what are some words that you could use to advocate for yourself or that the family could use?

Barbie Christianson:

Yeah. I had to take a little breath right there and release some tension, I think, because that question alone brings up a lot. For many people, speaking up and stopping an intervention carries its own risks, honestly, so I want to note that before I even start by simply saying, “Stop. Stop what you’re doing,” and then anybody who is in the room providing support, just repeating literally what the person just said. I have done that as a nurse myself, and sadly and gratefully, unfortunately, however you want to say that, providers, other nurses will often listen to the nurse or the other person, the partner, even a mother rather than the actual client. I chose that word, client because sometimes I wonder if even that language change could help us, at least in the inpatient setting.

Patient like in labor and delivery care, it has a certain connotation. These are our clients. We work for them. I’m paid by the hospital, but I’m providing the service to you. You are my client.

I am your service provider. I’m providing nursing service to you, so people can, again, repeat what is being said, or they can ask like, “Why do you need to do this?”

Rebecca Dekker:

“Am I actively bleeding right now? Am I hemorrhaging?”

Barbie Christianson:

Yes, and ask questions, “Are you concerned?” Like, “Why do you need to … Where …” So that’s maybe important for us to know, and again, in all the time that we have during pregnant and with pregnancy changes and all the things, and again, capitalism, all the things, how many people know what their uterus is supposed to be doing after birth? I also want to reorient that so much of this is unnecessary if we change the way we care for people during labor and delivery.

We literally increase the risk for postpartum hemorrhage with our routine care, bottom line.

Rebecca Dekker:

Yeah, and I think if our listeners want to learn more in our article on the Third Stage, which is available at ebbirth.com/thirdstage, there’s a table we created with all of the risk factors for postpartum hemorrhage and whether they’re major risk factors or minor, and if they are something that is done to you, or if it’s just something that you can’t control. So I encourage our listeners to check that out and educate themselves. Kind of on the opposite end of the spectrum, I think talking about speaking up when it’s already happening and you did not anticipate it, can someone assess their own fundus and massage their own fundus?

Barbie Christianson:

Oh my gosh, it’s one of my favorite parts of recovery and postpartum care in the places that do, what we call like LDRP, where you go from labor delivery to recovery to postpartum with your same nurse. It’s exciting when that can happen, for at least me. I love to ask people if I can show them where their uterus is, and have they ever felt it, and what should it feel like, so I often get talked to about talking too much ’cause we always are chatting about what we’re doing and taking the time, and I think that’s a real barrier too, is not having the time to have this discussion or not feeling like we have the time or we’re going to be disciplined for taking the time even on the whole spectrum of that. So I love teaching people how to find their own uterus, and usually, how I would do that is just hand over hand, if they’re comfortable and finding it together. People in larger bodies also sometimes do require a deeper fundal assessment, and that doesn’t necessarily have to be painful either, and that’s what I always …

Again, I find it so sad whenever a patient or a client would say, “Wow, that was so different.” Then, I also want to note that sometimes that can be concerning for patients as well, to have differences in care. They can create distrust even. Like, “Is this a bad nurse because they’re not massaging my uterus like all the other ones did? Am I okay?,” or, “Oh my gosh, why did all the other nurses do that to me if this isn’t necessary?”

So that’s kind of a careful conversation to have as well, and sometimes clients have flat out asked me, “Well, why did the other nurse do that?,” and sometimes that’s really hard to answer.

Rebecca Dekker:

Yeah, it’s hard to explain that evidence practice gap to somebody who just gave birth and doesn’t know all of the nuances of how old patterns and behaviors persist, even when they’ve been proven not to be helpful.

Barbie Christianson:

Right? Then, I’ve sometimes also probably been complicit in myself and normalized it and tried to smooth it over. “Oh, well, maybe she was concerned about, maybe at that moment there was something happening, and maybe there was, and then I go back in the chart, and then there probably wasn’t.

Rebecca Dekker:

When you’re feeling your own fundus, I know towards the end of pregnancy, it’s up super high like … Then, after you give birth in the first couple hours, where should the top of the uterus be when you’re looking for it, in relation to your belly button?

Barbie Christianson:

Yeah. So if you gave birth close to term or at term and had a, what we would call appropriate for gestational age baby, and it was a single pregnancy, most people’s uterus are going to be somewhere around their belly button.

Rebecca Dekker:

Okay, right after they give birth.

Barbie Christianson:

And maybe a little higher, almost every charting system, and this is just kind of interesting to see what’s always similar and what can be different, we usually measure plus three to minus two. That’s our range, and then it’s a little subjective here ’cause we’re literally just measuring by fingertips.

Rebecca Dekker:

And is zero your umbilicus, your belly button?

Barbie Christianson:

Yes. Thank you for getting there faster than I did.

Rebecca Dekker:

Okay.

Barbie Christianson:

So zero being the belly button, and then plus three would be like about three fingers above your belly button, minus one finger below your belly button.

Rebecca Dekker:

Okay.

Barbie Christianson:

That can change depending on your position. If you’re sitting up, it’s going to be a little bit higher. If you are laying flat down, it is going to be kind of at its lowest position, okay? So that it might be. This, again, looks very different in home births and in community-centered and traditional midwifery care, that fundal assessment is when somebody’s wrapped up in bed and having their whole body massage, and they’re feeling not just the fundus.

They’re checking everything, and it’s very gentle and supportive, so I just want to note that, that this can look very different, and you can do that yourself. You don’t just have to find the top of your uterus and move on. You can actually kind of just feel around your belly. Things are going to kind of feel different.

You can feel the whole kind of top shape of the uterus, especially in the first few days after birth, and then it’s going to, literally within one day, start to shrink down, and so we should be seeing a move from wherever it is above the belly button or around the belly button, moving, moving down all the way back under the pubic bone eventually, and-

Rebecca Dekker:

To where you can’t feel it no more?

Barbie Christianson:

Yeah, about two weeks almost.

Rebecca Dekker:

And if you are at home or say, you had a birth center birth and you went home, and then all of a sudden, you’re bleeding more, you can feel for your fundus yourself, see if it’s where it’s supposed to be, see if it feels soft or firm and feels soft, you can rub on the outside of your belly on the uterus to stimulate, correct?

Barbie Christianson:

You absolutely can. I mean, it’s your own body. Do it. If you did have a cesarean birth, I would caution you, hopefully, they talk to you about splinting during a knee, like lifting or coughing, sneezing, things like that. That would be another time to kind of splint as you’re-

Rebecca Dekker:

Like hold, like support your lower abdomen while you’re doing it.

Barbie Christianson:

Hold your lower abdomen, even onto the incision gently. You can use a pillow or a little towel rolled up, and then really start to look for your uterus, and you can just kind of … Hopefully you’ve already felt it ’cause that it is kind of nice to be able to tell the difference, right? We also, again, we don’t want to just see that it’s firm, and moving down, we also want to see that it’s sort of in the middle. If it’s to the right, that’s often maybe-

Rebecca Dekker:

Because you need to empty your bladder.

Barbie Christianson:

Often a bladder issue, and sometimes we have bladder issues if different things happen during birth. Epidurals can sometimes carry some bladder complications or urinary inflammations.

Rebecca Dekker:

Yeah. You retain the urine, and so your bladder gets too full. Yeah. Yeah.

Barbie Christianson:

And sometimes the uterus is tired. It needs to be stimulated, ’cause it was overworked or whatever it was.

Rebecca Dekker:

Yeah, so some of the myths that people might hear include that it’s a necessary evil, it’s no fun, but you should do it for the safety of your baby, and the nurse has to, whereas the truth is it does not help as a preventative or routine measure. It is evidence-based helpful intervention if you are hemorrhaging or it looks like you’re on the path to hemorrhage, and you can even do it yourself.

Barbie Christianson:

You can even do it yourself. I love that you said that nurses say they have to do this, because some nurses really believe that.

Rebecca Dekker:

Yeah, and hopefully they’re listening to this podcast and learning because I don’t want anybody to feel like, “Oh my God, I did that for 20 years. I’m a terrible person.” No. It’s like when you find out that something isn’t helpful, you can stop. It doesn’t mean you’re a bad person.

Barbie Christianson:

No.

Rebecca Dekker:

This means you had poor information at the time.

Barbie Christianson:

Yeah, and I think that is also being trauma-informed with ourselves as nurses and providers as well. Know better, do better, but you have to do the better, right? You can’t just learn that something you’re doing is harmful, and then not follow through with the responsibility to change it. Especially, if it’s your own practice, absolutely.

Rebecca Dekker:

I know we have some nurses who listen to this podcast at the nurses station at night or when there’s not a lot going on, so I was wondering, for the nurses who are listening who do want to do better, can you give us … You kind of said earlier what you would say to someone, but can you repeat it ’cause your scripting was so beautiful. You already kind of gave us the assessment. Can you say again … Talk to me as if I’m bleeding actively and it’s urgent.

How would you explain in a trauma-informed way what you need to do so that you can help keep me safe, but I’m not traumatized by not knowing what you’re doing?

Barbie Christianson:

Oh my gosh, I love that question. I love scripting also. I’ve found so many things helpful. I want to refer to the Feminist Midwife, who offers a lot of scripts and sort of just adapting those.

Rebecca Dekker:

Right, and the Feminist Midwife is an email substack that you can subscribe to. We’ll link to that in the show notes because she releases a new script every week on different subjects related to obstetric, and gynecology, and reproductive healthcare. So what would you say to me if I’m actively bleeding and look like I’m going to hemorrhage?

Barbie Christianson:

Yeah. I am hopefully going to have some help, number one, because that is, I want to recognize that as a barrier also, to really providing not only trauma-informed, but timely and effective interventions, right?

Rebecca Dekker:

Okay.

Barbie Christianson:

So sometimes we hit that timely and effective that cause trauma, by not taking the time or not having, feeling like we have the time or the resources to give that. So ideally, I’m going to be having somebody else, maybe would be my runner, go grab some things, because if you are actively bleeding, it’s likely that we may need to do more than this one intervention.

Rebecca Dekker:

Right, so you need adequate staffing, first of all, just enough hands.

Barbie Christianson:

Yeah. Yes. Yes, so I’m going to talk to you. I’m going to say, “Hey,” first, actively bleeding can also, I want to say, be a spectrum.

Actively bleeding can be kind of like a heavy trickle to a lot of gushing, a lot of tissue coming out. It can feel very scary by itself, so the patient is going to be having the sensation of blood coming out of them, so we’re going to talk about that too. We’re going to say, “Hey, I know this might feel scary. You are bleeding more than might be safe for you. This can cause some complications.”

“It carries some risks if we don’t stop it. The first thing I would like to do, if it’s okay with you, is put my hand on your uterus and see if I can stimulate it to contract.” Sometimes just that alone is going to help slow down the bleeding and stop it, and also, I’m going to call for help, okay, so you’re going to see some people come in with some things just in case we need them, okay? So I’m going to orient to the situation. “Here’s where we are.”

“I am concerned, right? I see you bleeding. If we’re in a hospital, most likely, we have informed consented you, but you do have active management of third stage of labor. We likely have synthetic oxytocin running at some sort of bolus rate and initially high rate for half an hour, a lower rate for …” I’ve seen a range of things, right?

That is probably still going. I’m going to check, “Is that actually going?,” so I’m going to do some more assessment. Now, I’m going to say, “Hey, I’m going to look at a few things. Interrupt me. Speak up any time.”

So I say that. If it’s appropriate, I also orient to the support people there. I say, “Hey, I need you to do this. You come over here, you be with them, you take the baby,” whatever it is. “Can you do this for me?”

We involve their support if they’re able to, or maybe I ask them, “Hey, do you want to step out while we get this?,” ’cause that’s okay too if it’s … Whatever it is. Again, so assessing the situation, being really fluid and grateful for those algorithms because we do have very clear guidelines and corresponding interventions to address postpartum hemorrhage, and they are very effective, and they start with uterine massage. So I’m going to start there and I’m going to continue to massage, while I talk to you,” and I’m going to …

Again, that assessment. “Okay. Hey, I’m seeing a lot of blood come out. How are you feeling?,” or, “Maybe I saw a clock come out. Hey, I saw a large clot come out.”

“Maybe that’s going to help this. Are you okay if I keep going? I’m going to talk you through. Do you want to take some deep breaths with me?” I’m going to make some eye contact.

Rebecca Dekker:

So you’re talking to them the whole time?

Barbie Christianson:

Oh my gosh, I’m a big narrator and-

Rebecca Dekker:

Yeah, and hands on talking and-

Barbie Christianson:

Yeah. I read the room and they don’t want it.

Rebecca Dekker:

Yeah, yeah, and some people don’t want to hear all the details.

Barbie Christianson:

Yes.

Rebecca Dekker:

They just want to close their eyes and-

Barbie Christianson:

So the narration is really key, though, I think for people because literally, knowing what’s going on with their own body can be helpful in reducing the trauma.

Rebecca Dekker:

Yeah, and you’re part of it. You’re not being treated like a piece of meat or somebody who, has no say, or doesn’t matter. Yeah.

Barbie Christianson:

Yeah.

Rebecca Dekker:

Yeah. I can see that seems so much more trauma-informed than somebody just starts doing stuff to you without explanation. I like how even you said, “Oh, is this okay?,” like getting a quick confirmation, and nobody’s going to say no, like, “Let me bleed to death,” but I think this has been a really important conversation, Barbie, because uterine massage or fundal massage is one of those things that when it’s used routinely without any medical need, it can be distressing and unnecessary, but it can also be lifesaving when it is necessary, so …

Barbie Christianson:

Absolutely.

Rebecca Dekker:

Yeah.

Barbie Christianson:

Like so many things, right? I didn’t want to interrupt you, but I actually did have somebody say no once.

Rebecca Dekker:

Oh, okay.

Barbie Christianson:

Yeah, and I stopped, and we promised…

Rebecca Dekker:

Yeah. You could ask them to rub their own…

Barbie Christianson:

Yeah, and they took a breath and they put their own hand on their belly.

Rebecca Dekker:

Okay.

Barbie Christianson:

They took another deep breath and they said, “Okay, go.”

Rebecca Dekker:

Oh.

Barbie Christianson:

And that was it, and we kept going, and they eventually needed bimanual, and we went to … Yeah, so we…

Rebecca Dekker:

Yeah, more interventions.

Barbie Christianson:

Oh, yeah. Like we did all the beds and all the things, but it wasn’t like that pause that caused her to need more interventions at all. She just needed a moment.

Rebecca Dekker:

Yeah, and that’s important.

Barbie Christianson:

Oh my gosh, so important. We were lucky enough in that situation, which almost has never happened actually, to be able to debrief not only with the patient, but kind of the team briefly, and she was coping so well.

Rebecca Dekker:

She was what?

Barbie Christianson:

She was coping well, like postpartum, like breastfeeding.

Rebecca Dekker:

Yeah.

Barbie Christianson:

Breastfeeding, and just saying like, “Oh, no, I felt great the whole time,” and I was like, “Wow,” ’cause that can be a lot, and she was like, “No. You guys had it.” I’m glad she felt that, ’cause we did have it. She had it.

Rebecca Dekker:

Yeah.

Barbie Christianson:

We had it together, yeah.

Rebecca Dekker:

One more thing I didn’t bring up while you were talking, and my sister, who’s a family medicine doctor, Dr. Shannon, who reviews most of our articles, had pointed out to me the other day that she thinks one reason it’s still so commonly used as a routine rather than medically necessary is because most providers and nurses are used to their patients having epidurals and they can’t feel anything anyways right after the birth.

Barbie Christianson:

There’s some of that.

Rebecca Dekker:

And so people are not feeling the pain, and they’re not complaining, so there’s no … Nurses don’t recognize, “Well, maybe I should look into why this is so painful and isn’t necessary,” but when someone’s unmedicated and has not had an epidural, the pain can be significantly worse.

Barbie Christianson:

Yeah, or as they move on into their postpartum recovery, and everything kind of wears off and everything else hits also.

Rebecca Dekker:

Yeah. Yeah.

Barbie Christianson:

I want to note too, that I think I mentioned this a couple times, again, we’re very fear-based in nursing sometimes, and unfortunately, we do see a lot of hemorrhages. I mean, it’s a leading cause of mortality. What is it? Like almost 80% of postpartum hemorrhages are related to uterine tone, so we’re very afraid, right?

Rebecca Dekker:

Right, and even if it’s only happening three or 4% of the time for a single nurse over a year, that could be dozens of people that … So it does make sense that you want to try and prevent it, but-

Barbie Christianson:

Yeah.

Rebecca Dekker:

Yeah, I’d encourage nurses and providers who are listening go to evidencebasedbirth.com/thirdstage. We have a lot of research there about active management and expected management, and the best ways to use both, and we have a podcast all about that too, so I’ll link to that in the show notes, but, Barbie, is there anything else you want to share with us today? Any final words?

Barbie Christianson:

I appreciate that you brought it back to the nurses listening who can hopefully change our practices or start to think about ways we can impact on the unit culture around this, because it really is kind of a culture of obstetric care as a systemic thing, and also, that we may have a lot of unaddressed trauma around this, around postpartum hemorrhages. Like yes, it only happens so many times, but we are doing a lot of things, especially in the more acute settings to increase the risk of hemorrhages, and we’re not just seeing them in our own clients, we’re usually the ones that are responding to other peoples, and it’s a very …

Rebecca Dekker:

It’s team thing. It’s not just you. There’s a lot of adrenaline. You’re calling all the other nurses to help.

Barbie Christianson:

Right, right, so there can be a lot of trauma or PTSD or vicarious trauma for ourselves, and I think addressing that is also really important, hand in hand with learning better practices and changing our practices.

Rebecca Dekker:

That’s awesome.

Barbie Christianson:

Thank you.

Rebecca Dekker:

For me, this is very timely because we’re recording this a few hours before Dr. Shannon is going to give our pro members a one-hour training all about the first steps for postpartum hemorrhage and safety, and how you stop the hemorrhage, so I’m really excited that we’re going to keep educating birth workers on this topic and parents as well. I’d encourage you to listen to that podcast episode on the Third Stage and learn a little bit more about this topic, and there’s lots of amazing resources at the California Maternal Quality Care Collaborative.

Barbie Christianson:

Thank you.

Rebecca Dekker:

Let’s get the letters a little bit mixed up.

Barbie Christianson:

Thanks.

Rebecca Dekker:

You’re a nurse in California, correct?

Barbie Christianson:

I recently relocated to Oregon and adapting, yeah.

Rebecca Dekker:

Okay. You’re adapting to different birth culture everywhere you go.

Barbie Christianson:

That’s okay.

Rebecca Dekker:

Yeah.

Barbie Christianson:

It’s all different, and I think that’s why these conversations are important too. These conversations are so important, so thank you so much.

Rebecca Dekker:

Thank you, listeners for joining us today as we talked with Nurse Barbie Christianson, all about fundal massage and uterine massage. Hopefully we were able to demystify this for you a little bit. Any nurses listening, we thank you for taking the time to educate yourself, and I love the scripts that Barbie shared with us, so thanks, everyone. We’ll see you next week. Bye.

Barbie Christianson:

Thank you. Bye.

Rebecca Dekker:

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