Leopold’s - Abdominal Palpation for Fetal Position

1. Leopold’s - Abdominal Palpation for Fetal Position

2. The lie is either: • Longitudinal • 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

3. Longitudinal Longitudinal Transverse

4. 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

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

6. 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

8. Lie • Longitudinal • Presentation • Breech • Denominator • Sacrum

9. LOL ROL LOA ROA ROP LOP OP OA Flexed Vertex Presentation8 Possibilities OA LOA ROA LOL ROL ROP OP LOP

10. Posterior (OP) Lateral (LOL)

11. 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

12. 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

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

14. 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?

15. 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).

16. 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

17. 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”)

18. 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…

19. 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

20. Intro to Using a Fetoscope

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

22. 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

23. 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

24. 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

25. Where will you hear the FHTs?

26. 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

27. 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

28. 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

30. 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