Leopold

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Leopolds - Abdominal Palpation for Fetal Position
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The lie is either

• Longitudinal
• long axis of the fetus is aligned to the mothers
• this is the only NORMAL position
• Transverse
• long axis of the fetus is perpendicular to that
  of the mothers
• Oblique
• long axis of the fetus is 0-90 degrees (or 90-180
  degrees) to that of the mothers

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Longitudinal
Longitudinal
Transverse
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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

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Attitude

• Relationship of fetal parts to each other
• Flexed
• Deflexed
• Extended

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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

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

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Flexed Vertex Presentation8 Possibilities

• LOL
• ROL
• LOA
• ROA

• ROP
• LOP
• OP
• OA

OA
LOA
ROA
LOL
ROL
ROP
OP
LOP
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Posterior (OP) Lateral (LOL)
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• Full/Complete 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

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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

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Leopolds Maneuver

• Four-part process
• Determine the position of the baby in utero
• Determine the expected presentation during labor
  and delivery

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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?

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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 womans
  R side facing her for the first 3 steps, then
  turn and face her feet for the last step (L
  handed, left side).

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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

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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 youve located the back, confirm your
  findings by palpating the fetal extremities on
  the opposite side (lumpy)

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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 whats in
  the fundus)
• Head will feel firm
• Buttocks will feel softer and irregular
• If its not engaged, it may be gently pushed back
  and forth
• Proceed to the 4th step if its not engaged

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Fourth Maneuver

• Flexed/Deflexed/Extended?
• Turn to face the womans 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

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Intro to Using a Fetoscope
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Fetal Monitoring Equipment

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

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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

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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

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Fetoscope

• Fetal heart tones are best heard over the babys
  back
• Used in conjunction with Leopolds 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

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Where will you hear the FHTs?
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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

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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 babys heart to hear FHT
• If nothing is heard
• Move the instrument up toward the umbilicus 1cm
  and repeat

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• 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

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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