The Leopold Maneuver: Abdominal Palpation Guide PDF

Abdominal palpation...

Abdominal palpation A collaborative initiative by Abdominal palpation - Determining age of pregnancy Determining fetal lie and Determining fetal wellbeing Uterus tonus Regular abdominal palpation Does the measured fundal presentation How are the fetal movements? Are there any uterine contractions? remains an important part in height correspond to the age Where is the fetal head, where are What is the amount of amniotic examination of every pregnant of pregnancy calculated during the back and the small parts of the fluid? Did the fetal growth and The Leopold Maneuver woman. It is the easiest and history taking? child? Is there any suspicion of a fundal height increase since the cheapest method of fetal twin pregnancy? last examination? monitoring. Follow the 4 steps of the Leopold Maneuver for abdominal palpation to determine fetal lie and presentation. Follow Step 5 - a complementary diagnostic procedure after performing the Leopold Maneuver Determining fetal lie, position, presentation and attitude Auscultation of the fetal heart rate Step 1 Step 5 First maneuver After performing the Leopold Maneuver Fundal grip The fetal lie Auscultation of the fetal heart rate Finding the right spot The lie of the fetus is the relation of its long axis to the mothers’ vertical axis. After performing the Leopold Maneuver, the fetal heart Using both hands and facing the pregnant woman, palpate the upper abdomen by putting both hands on the Only a longitudinal lie is normal. Transverse and oblique lies are abnormal. rate (FHR) needs to be auscultated. Fetus in cephalic presentation top of the uterus, called the fundus. The sound transmission of the fetal heart rate is best, Since the sound transmission of the fetal heart rate is best where where the fetal back or chest - his heart - is close to the the fetal back lies anterior towards the mothers’ uterus wall in Use this maneuver to determine the mothers’ uterus wall. dorso anterior position, the fetal heart rate can be heard in the shape, size, mobility and consistence of lower lateral part of the mothers abdomen. what can be felt. The findings from the Leopold Maneuver about the fetal lie, presentation and position will be now confirmed by As further the fetus turns towards a dorso-posterior position, the With this first grip you will also determine detecting the best spot to listen to the fetal heart rate. heart rate will be found in the mothers’ lateral right or left flank. the height of the fundus related to the umbilic or costal arch, derive the age A well flexed head and dorso-anterior or lateral position is also of pregnancy and confirm longitudinal the most physiological position supporting the natural birth presentation. mechanism. Step 2 Cephalic Breech Oblique Transverse Second maneuver The fetal position Fetus in breech presentation Umbilical Grip In breech presentation, the fetal heart rate will be found around The position of the fetus is defined by the relationship of the fetal back to the mothers’ vertical axis. or above the mothers’ navel. After identifying the uterine shape, the To determine the position, you have to feel the difference between the regular, hard side presenting the fetal back and the smaller parts like feet presentation of the fetus must be determined. and hands on the other side of the mothers’ body. The cephalic dorso-anterior position is preferred. A fetal heart rate found at this spot can confirm the suspicion of a breech presentation, detected during the performance of the While still facing the woman, apply deep Leopold Maneuver. pressure with the palm of one hand to palpate the abdomen gently. Perform this maneuver by placing the right hand on one side of the woman’s abdomen while using the left hand to explore the woman’s uterus from the left side. Repeat this step on the opposite side using the opposite hand. Observe that the fetal back is smooth and firm, the extremities of the fetus feel like Fetus in transverse lie protrusion and small irregularities. The back should connect with the form felt in the Double-head fetoscope and traditional Pinard Horn If the fetus is in transverse lie, the fetal heart rate can be lower maternal inlet and upper abdomen. auscultated around the navel of the mother. Left occiput anterior Right occiput anterior Left occiput posterior Right occiput posterior position position position position Often, if the fetal back is posterior positioned (towards the Performing this maneuver will tell whether the fetal back is right or left, anterior or mothers back) the sound transmission is difficult, or the heart posterior positioned. rate can be heard as far away. The suspicion of a transverse lie The fetal presentation appearing during the performance of the Leopold Maneuver can be confirmed by the fetal heart rate auscultation. Actions to do Step 3 The presentation is the part of the fetus in the lower pole of the uterus overlying the pelvic brim, e.g. cephalic, breech. 1. Place the fetoscope Cephalic pole: round, hard, regular and moveable between the hands, separated from the rest of the body by the indent of the neck. Beyond that indent, the projection of the shoulder can be felt. 2. Auscultate – listen and count Third maneuver Breech pole: soft, larger and less regular than the cephalic pole, no neck indent. 3. Diagnose First Pelvic Grip 4. Let mother or family members listen The Leopold Maneuver will also indicate twins and their presentation. During this step of the process, the midwife must identify the part of the fetus that is above the pelvic inlet. A diagnostic tool Palpate the lower uterine segment, right The diagnostic power of using the Leopold maneuver in above the pubic symphysis in order to combination with fetal heart rate auscultation. determine the presenting part (cephalic or breech or empty in transverse and oblique Performing the Leopold Maneuver regularly and in combination presentation). with the fetal heart rate auscultation will help to detect abnormal fetal lie and presentation, twin pregnancy, fetal distress. It confirms longitudinal presentation and should validate what is determined in the Especially the added value of this complementary examinations first maneuver. will support health care providers in their management decisions during pregnancy and childbirth. Step 4 Cephalic Breech Twin pregnancy, cephalic Twin pregnancy, cephalic and breech Fourth maneuver Second Pelvic Grip The fetal attitude Diagnose The attitude is the relation between the fetus’s head to his back, e.g. flexion, neutral, deflexion, extension. Count for 60 seconds to have the fetal heart rate bpm (beats per minute) or count for 15 seconds and multiply by 4. This is the method of palpating the engagement of the fetal head to determine A well flexed head is preferred in order to support the natural birth mechanism. A normal heart rate is between 120 and 160 bpm. whether it is mobile, fixed or engaged. In neutral and deflected attitude the fetal head circumference is larger and becomes an obstacle to physiological birth. Signs of fetal distress and asphyxia are fetal bradycardia (FHR < 120 bpm for more than 3 minutes) and This step should be done while facing the tachycardia (FHR > 160 bpm for more than 10 minutes). woman’s feet. If any doubt, count longer and repeat after 15 minutes. The process involves locating the fetus’ brow. The midwife must gently move the fingers of both hands to the pubic area by sliding her fingertips between the woman’s iliac 180 180 180 crests and the fetal head. The side where 160 160 160 a great resistance to the descent of the fingers is perceived, indicates the location 140 140 140 of the fetal brow. 120 120 120 100 100 With a well flexed head the fetal front 100 80 can be touched on the opposite side of the 80 80 60 fetal back. 60 A head that cannot be felt, has likely engaged. Pathological presentation Fetal head well flex Physiological (FHR 120-160 bpm) Bradycardia (FHR below 120 bpm) Tachycardia (FHR above 160 bpm) (de-flex)