Leopold Maneuvers: Fetal Position Assessment

• Leopold maneuvers are a physical examination to palpate the gravid uterus systematically, named after Christian Gerhard Leopold (1846-1911).
• Malpresentation occurs in 5% of deliveries and can lead to a high cesarean delivery rate.
• Detecting non-cephalic presentations before labor is essential to reduce maternal and neonatal risks.
• Ultrasound examination is the gold standard, especially in the third trimester, to confirm cephalic presentation.
• Palpation involves using fingers and hands to collect to check woman or child's uterine contractions, uterus size, masses, attitude, presentation, fetal-pelvic disproportions.
• Abdominal palpation is accurate for identifying presentation, especially with experienced healthcare professionals, can also identify fetal abnormalities, low placenta, hyperextension of the baby's head in the fetus.
• Palpation requires skill and gentleness due to fetal movements or neoformations, and should avoid long nails.
• Routine abdominal palpation should not be offered before 36 weeks.
• Leopold maneuvers can be complicated in obese women and women who have polyhydramnios.

Objectives

• Describe the normal fetal presentation and position
• Explain the four Leopold maneuvers.
• Summarize the clinical significance of abdominal palpation in the obstetric examination.
• Identify the importance of improving training in abdominal palpation to enhance the delivery of care for obstetric patients.
• To know how to do perform FHM and FHT

Fetal Presentation

• Fetal presentation refers to the first fetal body part being presented on the inlet cavity.
• Cephalic presentation is when the cephallic is at the forefront
• Shoulder presentation is when the shoulder is at the forefront
• Breech presentation is when the buttocks are at the forefront

Fetal Attitude

• Fetal attitude describes the relationship of fetal parts to each other to accommodate the shape of the uterine cavity.
• Vertex is when the head is maximally flexed
• Military is when the head is partially flexed
• Brow is when the head is maximally extended
• Face is when the head is partially extended

Degree of Engagement

• Ballottement refers to the bouncing of the baby in the uterus

Fetal Lie

• Fetal lie describes the relationship of the maternal long axis and fetal long axis.
• Longitudinal / Vertical is a “L”/ “V”
• Transverse / Horizontal is a “T” / “H”
• Oblique / Diagonal is a “O” / “D”

Fetal Reference Point

• Vertex presentation depends upon the degree of flexion of fetal head on chest:
  • Full flexion-occiput (O)
  • Full extension- chin (M),
  • Moderate extension-brow (B)
• Breech presentation will have sacrum (S) / Sa
• Shoulder presentation will have scapula (SC) / A (acromion)

Preparatory steps

• Instruct the client to void, and palpate with warm hands to avoid contraction.
• Use gentle but firm motions.

Four Standard Maneuvers

• LM1 determines the fetal body part present on the fundus.(Fundal Grip)
  • Facing the head part of the client
  • Palpate the superior surface of the fundus.
  • Determine consistency, shape and mobility.
  • A hard ballotable mass at the fundus means the fetus is in breech presentation and palpate the uterus fundus.
• LM2 determines the fetal back from fetal extremities.(Umbilical Grip).
  • Palpate the sides of the uterus to determine where the fetal back is facing.
  • The left hand is left stationary on the left side of the uterus while the right hand palapates opposite side of the uterus from top to bottom,
  • One hand is firm and the other is movable as the small parts and back of fetus are determined along the sides of maternal abomen
• LM3 determines the degree of engagement and presentation(Pawlik's Grip).
  • Palpate the part of the fetus at the inlet and its mobility
  • Grasp the lower portion of the abdomen above the symphysis pubis between the thumb and index finger.
  • If the presenting part moves upward, so an examining finger can be pressed together, the presenting part is not engaged.
  • Assess if the part firmness indicates the head, softness indicates the breech
  • Use Suprapubic palpitation to determine fetal presentation
• To know if the presenting part is engage or still ballotement
• LM4 is done to determine the fetal attitude.(Pelvic Grip)
  • Perform if the fetus is in cephalic presentation.
  • Place fingers on both sides of the uterus approximately 2 inches above the inguinal canal.
  • Gliding will determine if neck of the fetal back is indicated, an obstruction means it is the fetal brow

Fundal Height Measurement

• Fundal height refers to the height of the fundus of the uterus.
• Fundal height is measured by McDonald's rule (used in 2nd and 3rd trimester ).
• Fundal height measures the size of the uterus to assess fetal growth and development.
• Measured in cm from the top of the symphysis pubis to the highest point in the midline at the top of the uterus
• Reasons for difficult measurement of fundal height: Fibrosis, multi pregnancy, obesity
• Supine position relaxes abdominal muscles.
• If the bladder is descended, or the pt has the urge to pee, ask them to urinate because it can affect the accuracy of the measurement

Reasons for Smaller Fetus than Expected

• Slow fetal growth (SFG)
• Causes include myoma, fibrosis or a small amount of amniotic fluid (Oligohydramnios).

Reasons for Larger Fetus than Expected

• Macrosomia: gestational DM mom's, or baby is larger than average
• Increased amount of amniotic fluid ( Polyhydramnios )

Fetal Heart Tone

• Can be detected at 5th- 6th week of gestation through vaginal ultra sound.
• In 20 weeks of AOG the FHB is double HB of mother; soft and quiet but quick
• FHR usually auscultated at the midline of suprapubic region with Doppler ultrasound transducer at 10-12 weeks' gestation.
• Normal FHR is 120-160 bmp
• Fundic Souffle (Baby's Heart Beat), caused by blood rushing through the umbilical arteries that is synchronous with the FHR
• Uterine Souffle (Maternal Pulse) caused by blood passing through the uterine vessels that is synchronous with the maternal pulse