Leopold’s - Abdominal Palpation for Fetal Position

The lie is either: Longitudinal Transverse Oblique long axis of the fetus is aligned to the mother’s this is the only NORMAL position Transverse long axis of the fetus is perpendicular to that of the mother’s Oblique long axis of the fetus is 0-90 degrees (or 90-180 degrees) to that of the mother’s

Longitudinal Longitudinal Transverse

The presentation is either: Vertex head down in the pelvis Brow Facial Breech head is up in the uterine fundus and the buttock in the pelvis Shoulder

Attitude Relationship of fetal parts to each other: Flexed Deflexed Extended

Denominator The denominator is a “letter” that represents the presenting fetal part Used in the listing system Occiput O Sacrum S Mentum M Frontal F Acromion AC or Scapula SC

PRESENTATION ATTITUDE DENOMINATOR Vertex Flexed Occiput Brow Deflexed (vertex) Frontal Facial Extended (vertex) Mentum Breech Sacrum Shoulder ACromion/ Scapula

Lie Longitudinal Presentation Breech Denominator Sacrum

Flexed Vertex Presentation 8 Possibilities LOL ROL LOA ROA ROP LOP OP OA OA ROA LOA ROL LOL ROP OP LOP

Posterior (OP) Lateral (LOL)

Full/Complete Breech Incomplete Breech Frank Breech Footling Breech arms & legs flexed in the fetal position Incomplete Breech Frank Breech arms flexed but legs extended straight up over head Footling Breech one or both feet extended downward and may exit the birth canal first

Engagement Determined by the amount of head that is above or below the pelvic brim This is usually done by dividing the head into ”fifths” if the head is still palpable abdominally, it is “2/5” or less engaged Stations of Presentation

Leopold’s Maneuver Four-part process Determine the position of the baby in utero Determine the expected presentation during labor and delivery

Questions to ask yourself when performing the exam: Is the fundal height consistent with the fetal maturity? Is the lie longitudinal, transverse or oblique? Is the presentation cephalic or breech? If cephalic, is the attitude vertex or facial? What is the position of the denominator? Is the vertex engaged?

Preparation Woman is supine, head slightly elevated and knees slightly flexed Place a small rolled towel under her right hip If the doctor is R handed, stand at the woman’s R side facing her for the first 3 steps, then turn and face her feet for the last step (L handed, left side).

First Maneuver What part is in the fundus? Facing the mother, palpate the fundus with both hands Assess for shape, size, consistency and mobility Fetal head: firm, hard, and round Moves independently of the rest Detectable by ballotement Buttocks/breech: softer and has bony prominences Moves with the rest of the form

Second Maneuver Determine position of the back. Still facing the mother, place both palms on the abdomen Hold R hand still and with deep but gentle pressure, use L hand to feel for the firm, smooth back Repeat using opposite hands Once you’ve located the back, confirm your findings by palpating the fetal extremities on the opposite side (“lumpy”)

Third Maneuver Determine what part is lying above the inlet. Gently grasp just above symphisis pubis with the thumb and fingers of the R hand Confirm presenting part (opposite of what’s in the fundus) Head will feel firm Buttocks will feel softer and irregular If it’s not engaged, it may be gently pushed back and forth Proceed to the 4th step if it’s not engaged…

Fourth Maneuver Flexed/Deflexed/Extended? Turn to face the woman’s feet Move fingers of both hands gently down the sides of the abdomen towards the pubis Palpate for the cephalic prominence (vertex) Prominence on the same side as the small parts suggests that the head is flexed (optimum) Prominence on the same side as the back suggests that the head is extended

Intro to Using a Fetoscope

Fetal Monitoring Equipment Fetal heart Rate (FHR) can be determined by use of: Fetoscope or Leff scope specifically designed instruments Clinical stethescope Electronic Doppler

Doppler Method Employs a continuous ultrasound Can detect the fetal heart at 10-12 weeks’ gestation Amplifiers allow both the practitioner and parents to hear

Fetoscope Has a band that fits against the head of the listener makes handling of the instrument unnecessary aids in bone conduction of sound Can pick up the fetal heart rate at 17-19 weeks’ gestation

Fetoscope Fetal heart tones are best heard over the baby’s back Used in conjunction with Leopold’s maneuver Auscultation may be difficult if… Mother is overweight Placenta is in the front of the uterus *Always easier in later stages of the pregnancy

Where will you hear the FHTs?

Preparation Let her empty her bladder Be sure the room is quiet Patient lies supine If more than 28 weeks pregnant, place a small rolled towel under R hip relieves pressure on abdominal aorta

Procedure Place the padded cone just above the pubic bone Headpiece solid against the forehead Exert slight pressure into the abdomen Slowly rotate the cone 360 degrees, looking for the heart tones Must be directed at the baby’s heart to hear FHT If nothing is heard… Move the instrument up toward the umbilicus 1cm and repeat

If FHTs are still not heard… If you have not heard the heart tones when you reach a position half-way between the pubic bone and the umbilicus… Move 1cm to the side of midline Proceed back down to the pubic bone If FHTs are still not heard… Do the same on the other side Again, move the cone 1 cm at a time and rotate the instrument 360 degrees at each new position

Fetal Heart Rate Count the FHTs for 15 seconds Multiply by 4 ( ) x 4 = ___ per minute To be more accurate, you may want to take more than one 15 second “sample” sleeping = slower HR moving = faster HR