Leopold\'s Maneuver PDF

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Mabini College College of Nursing Daet Camarines Norte

Leopold’s Maneuver Purpose 

Systematically observe and palpate the abdomen to determine presentation and position of the fetus and aid in location of the fetal heart sound.

Reminders 

Explain the procedure to the woman and the rationale for each step as it is performed.

Rationale: explanation reduces anxiety and enhances cooperation 

Ask the woman to empty her bladder.

Rationale: an empty bladder promotes comfort and allows for more productive palpation because fetal contour will not be obscured by a distended bladder. 

Have her lie in her back with her knees slightly flexed. Place a small pillow or folded towel under one hip.

Rationale: flexing the knee relaxes the abdominal muscles. Using the pillow or towel tilts the uterus off the vena cava, preventing supine hypotension. 

Wash hands using warm water. Wear gloves if contact with secretion is likely.

Rationale: to prevent the spread of possible infection or contamination. Using warm water aids in patient comfort and prevents tightening of abdominal muscles during palpation. 

Provide privacy.

Procedure 1. First maneuver (Fundal grip) - stand at the foot of the woman, facing her. Palpate the superior surface of the fundus. Determine consistency, shape, and mobility Rationale: This maneuver determines whether the fetal head or breech is in the fundus. A head feels more firm than the breech is round and hard and moves independently of the body. The breech feels softer and moves on only in conjunction with the body 2. Second maneuver (Umbilical grip) - face the woman, hold the left hand stationary on the left side of the uterus while you palpate the right hand on the opposite side of the uterus from top to bottom. Repeat palpation using the opposite side. Rationale: This maneuver locates the back of the fetus. The fetal back feels like smooth, hard, and resistant surface; the knees and elbows of the fetus on the opposite side feels more like a number of angular bumps or nodules. 3. Third maneuver (Pawlik’s grip) – Gently grasp the lower portion of the abdomen just above the symphysis pubis between the thumb and the fingers and try to press the thumb and finger together. Determine any movement and whether the part feels firm or soft. Rationale: The maneuver determines which part of the fetus is at the inlet and its mobility. If the presenting part moves upward so your fingers and thumb can be pressed together, the presenting part is not engaged. If it is firm, it is the head; if soft it is breech. 4. Fourth maneuver-(Pelvic grip) -Place fingers on both sides of the uterus approximately 2 inches above the inguinal ligaments, pressing downward and inward in the direction of the birth canal. Allow fingers to be carried down ward.

1 Joanna Marie McPherson De Guzman RN

Rationale: This maneuver is only done if the fetus is in cephalic presentation because it determines the fetal attitude and degree of fetal extension in the pelvis. The fingers of one hand will slide along uterine contour and meet no obstruction, indicating the back of the neck. The other hand will meet the obstruction an inch or so above the ligament this is the fetal brow. The position of the fetal brow should correspond to the side of the uterus that combined the elbows and the knees of the fetus. If the fetus is in a poor attitude, the examining fingers will meet an obstruction on the same side as the fetal back; that is, the fingers will touch the hyperextended head. If the brow is very easily palpated, the fetus is probably in a posterior position.

Terms to Remember 1. Fetal Presentation- Describes the fetal part that will be first to pass through the cervix and be delivered. Primarily determined by fetal attitude, fetal lie, and fetal position.  Cephalic presentation- occurs when the head presents first. The most common type of presentation.

 Vertex presentation occurs when the head is flexed sharply so that the parietal bones or the space between the fontanels is the presenting part. (pic A)  Brow presentation occurs when the head is moderately flexed causing the brow to enter first. (pic B) 2

Joanna Marie McPherson De Guzman RN

 Sinsiput presentation occurs when the head is in neutral position, neither flexed nor extended (pic C)  Mentum presentation occurs when the fetal head is hyperextended causing the face or the chin to present first. (pic D) 

Breech presentation occurs if the buttocks or feet presents first.  Complete breech occurs when the thighs of the fetus is tightly flexed on the abdomen.  Incomplete breech occurs when one thigh of the fetus is tightly flexed and the other thigh is extended  Frank breech occurs when the fetal hips are flexed but the legs are extended and resting on the chest.  Footling breech occurs in the absence of hip or thigh flexion of one or both extremities such that one or both feet are the presenting part.  Knee presentation occurs when the presenting part is the knee.

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Shoulder presentation occurs when the presenting part is the shoulder, iliac crest, hand or elbow. The fetus is lying horizontally in the pelvis 2. Fetal Lie refers to the relationship of the long axis of the fetus to the long axis of the mother.  Longitudinal lie- the long axis of the fetus is parallel to the long axis of the mother  The fetus is lying vertical or top to bottom in the uterus.  Nearly 99% of fetus are in longitudinal lie at the onset of labor.  Can be further classified as cephalic or breech  Transverse lie- the long axis of the fetus is perpendicular to the long axis of the mother.  The fetus is lying horizontally or side to side in the uterus. 3

Joanna Marie McPherson De Guzman RN

 Less than 1% of fetus are in transverse lie at the onset of labor  Oblique lie- the fetal spine and the maternal spine are at 45 degree angles at each other.  Rare occurrence, it is considered abnormal if the fetus maintains this position after the onset of labor. 3. Fetal Position the relationship of the presenting part to a specific section of the mother’s pelvis.  Important to determine because it can influence the progression of labor and the possible need for surgical intervention  The patient’s pelvis is divided in to four sections based on her right and left and front and back.  Fetal position is described by using 3 letters  The first letter designates whether the presenting part is facing to the mothers right (R) or left (L).  Second letter is the presenting part of the fetus.  O-occiput  M-Mentum ,chin, face  S-sacrum  A- acromion  Position in vertex presentation includes: ROA, ROT, ROP, LOA, LOT, LOP  Position in face presentation includes: RMA, RMT, RMP, LMA, LMT, LMP  Position in breech presentation includes: RSA, R ST, RSP, LSA, LST, LSP

Mabini College College of Nursing Daet Camarines Norte

Assessing Fetal Heart Rate 

Fetal heart rate provides important information about fetal well-being. It can be assessed by auscultating the mother’s abdomen with a Doppler ultrasound, stethoscope, and fetuscope or pinnard horn.

Purpose: to evaluate the fetal condition and tolerance of labor. Procedure 1. Explain the procedure to give information to the woman and her partner. Wash your hands with warm water to reduce the transmission of microorganism and to make your hands more comfortable when touching the woman’s abdomen. 4

Joanna Marie McPherson De Guzman RN

2. Use Léopold’s maneuver to identify the fetal back because it usually is closest to the surface of the maternal abdomen where fetal heart sounds are clearest. (illustrations show approximate locations of the fetal heart rate in different presentations and positions) For

fetuscope Place the ear piece in your ears. Place the bell of the fetuscope over the fetal back with the head plate pressed against your forehead. Move the fetuscope until you locate where the sound is loudest. Use your forehead to maintain pressure during auscultation to enhance faint fetal heart sounds.

For Doppler transducer Review the manufacturer’s instructions for operating the Doppler device. Place water soluble conducting gel over the transducer to make an interface for clear signal transmission, and turn it on. Place the transducer over the fetal back and move it until you hear clear sounds that represent the fetal heart motion.

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Joanna Marie McPherson De Guzman RN

For Stethoscope Place the earpiece into your ears. Gently press the bell about 1l2 inch or 1 cm into the woman’s abdomen. Move the instrument slightly from side to side to locate the loudest heart tone.

For Pinnard horn Warm the pinnard horn if it is made up of metal. Press the pinnard horn over the fetal back. Listen until you hear clear sounds.

3. With one hand palpate the mother’s radial pulse to verify that the fetal heart rate is what is actually heard. If the sound is synchronized with the sound from the fetuscope or Doppler, try another location for the fetal heart. Other sounds that maybe represented by the Doppler are the funic soufflé (blood flowing through the umbilical cord) or uterine soufflé (blood flowing thru the uterine vessels) funic soufflé is synchronized with the fetal heart and is the same rate. The uterine soufflé is synchronized with the mother’s pulse. 4. Count the baseline fetal heart rate for 60 seconds. Note acceleration or slowing of rate. 5. Note reassuring signs that suggest the fetus is tolerating labor well.  Average rate 120 to 160 beats per minute  Regular rhythm 6. Note nonreassuring signs, and make more frequent assessment. Notify physician for further evaluation.

Mabini College College of Nursing Daet Camarines Norte

APGAR Scoring 

The Apgar score is a method of rapid evaluation of the infant’s cardiorespiratory adaptation after birth.

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At 1 minute and 5 minutes after birth, newborns are observed and rated according to an Apgar score, an assessment scale used as the standard for newborn evaluation since 1958. It was formulated by Dr. Virginia Apgar.

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The assessment is arranged from the most important (heart arte) to the least important (color)

Heart Rate  Auscultating a newborn heart with a stethoscope is the best way to determine rate. However, heart rate also may be obtained by observing and counting the pulsation of the umbilical cord at the abdomen if the cord is still uncut. 6

Joanna Marie McPherson De Guzman RN

Respiratory Effort  Respiration is counted by observing chest movements. A mature newborn usually cries and aerates the lungs spontaneously at about 30 seconds after birth.  By 1 minute, he or she is maintaining regular, although, rapid respirations. Difficulty with breathing might be anticipated in a newborn whose mother received large amount of analgesia or general anesthetic during labor or birth. Muscle Tone  Term newborns hold their extremities tightly flexed, simulating their intrauterine position  Muscle tone is tested by observing their resistance to any effort to extend their extremities. Reflex Irritability  One of two possible cues is used to evaluate reflex irritability: response to a suction catheter in the nostrils or response having the soles of the feet slapped.  A baby whose mother was heavily sedated for birth will probably demonstrate low score in this category. Color  All infant appear cyanotic at the moment of birth. They grow pink with or shortly after their first breath.  Cyanosis- bluish discoloration of the skin  Acrocyanosis- bluish hands and feet

Obtaining APGAR SCORE 

Follow these steps to determine the neonate’s APGAR score at 1 minute and 5 minutes intervals after birth.

1. Observe skin color, especially at the extremities (if the neonate is dark skinned, inspect the oral mucosa, conjunctiva, lips palms, and soles. 2. Assess the neonate’s heart rate using stethoscope. Listen to the heart beat for 60 seconds and then record the rate. 3. Assess reflex irritability by observing the neonate’s response to nasal suctioning or to flicking the sole. 4. Determine muscle tone by evaluating the degree of flexion and resistances to extension in the extremities (extend the limbs and observe their return to flexion). 5. Assess respiration by noting the volume and vigor of the neonates cry. Then using a stethoscope assesses the depth and rate of respirations. Begin with neonatal resuscitation if you detect abnormal respiration.

APGAR SCORE Assessment (Signs)

0 No heart rate

1 Heart rate present but < 100 bpm (beats per minute) Weak cry, slow or difficult respirations, grunting (noisy breathing) Minimal flexion of extremities

Heart Rate No respiratory effort Respiratory Effort Limp or flaccid Muscle Tone

Reflex Irritability

Color

No response to stimulation

Grimace when stimulated

Body and extremities blue (cyanosis) or completely pale (pallor)

Body pink extremities blue (Acrocyanosis)

APGAR Scoring 7

2 Heart rate present but > 100 bpm Strong vigorous cry

Maintains position of flexion with brisk movements Cries or sneeze when stimulated active movements Body and extremities pink...