http://nursingcrib.

com/nursing-notes-reviewer/maternal-child-health/how-to-perform-leopolds-maneuver/ Book: Maternal and Child Health Nursing Volume 1, Adele Pillitteri

Leopolds Maneuvers
Leopolds maneuvers are a systematic method of observation and palpation to determine fetal presentation and position. It is preferably performed after 24 weeks gestation when fetal outline can be already palpated. Preparation: 1. Explain procedure to the patient. 2. Instruct woman to empty her bladder first. 3. Place woman in supine position with knees slightly flexed to relax abdominal muscles. Place a small pillow under the head for comfort. 4. Drape properly to maintain privacy. 5. Wash your hands using warm water. 6. Observe the womans abdomen for longest diameter and where fetal movement is apparent. 7. Use the palm for palpation not the fingers. Purpose First Maneuver: To determine fetal Fundal Grip part lying in the fundus. To determine presentation. Procedure Findings

Stand at the foot of the client, Head is more firm, hard and round facing her, and place both hands that moves independently of the flat on her abdomen. body. Palpate the superior surface of Breech is less well defined that the fundus. Using both hands, moves only in conjunction with the feel for the fetal part lying in the body. fundus. Determine consistency, shape, and mobility.

Second To identify location Maneuver: of fetal back. Umbilical Grip To determine position.

Face the client and place the palms of each hand on either side of the abdomen. Palpate the sides of the uterus. One hand is used to steady the uterus on one side of the abdomen while the other hand moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts.

Fetal back is smooth, hard, and resistant surface. Knees and elbows of fetus feel with a number of angular nodulation.

|Prepared by: Lumba, Chared Joy D.

Use gentle but deep pressure. Third Maneuver: Pawliks Grip To determine engagement of presenting part. To determine the part of the fetus at the inlet and its mobility. Fourth Maneuver: Pelvic Grip Using thumb and finger, gently grasp the lower portion of the abdomen above symphysis pubis, press in slightly and make gentle movements from side to side. Determine any movement and whether the part is firm or soft. The presenting part is engaged (firmly settled into the pelvis) if it is not movable. It is not yet engaged if it is still movable. If the part is firm, it is the head. If the part is soft, it is the breech. The fingers of one hand will slide along the uterine contour and meet no obstruction, indicating the back of the fetal neck. The other hand will meet an obstruction an inch or so above the ligament- this is the fetal brow. Good attitude if fetal brow corresponds to the side of the uterus that contained the elbows and knees of the fetus. Poor attitude if examining fingers will meet an obstruction on the same side as fetal back (if the fingers will touch the hyperextended head) Also palpates infants anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards womans back)

To determine the Facing foot part of the woman, degree of flexion of place fingers on both sides of the fetal head. uterus about 2 inches above the inguinal ligament and palpate To determine fetal head pressing downward attitude or habitus. and inward in the direction of *It should be done only if the the birth canal. fetus is in a Use both hands and allow fingers cephalic to be carried downward. presentation. Information about the infants anteroposterior position may also be gained from this final maneuver.

|Prepared by: Lumba, Chared Joy D.

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Mechanisms (Cardinal Movements) of Labor

The seven cardinal movements are the series of positional changes made by the baby which assist its passage through the birth canal. (Cardinal means fundamentally important.) The positional changes made by the baby are specific, deliberate and precise. They allow the smallest diameter of the baby to pass through the mother's pelvic cavity. Neither you nor the mother is responsible for these positional changes. The baby has the responsibility for the seven cardinal movements.

1. Engagement
Engagement is when the fetal head enters into the pelvic inlet. The head is said to be engaged when the biparietal diameter (measuring ear tip to ear tip across the top of the babys head) descends into the pelvic inlet, and the occiput is at the level of the ischial spines in the mothers pelvis.

Moulding of the fetal skull may occur during descent; in this example, one parietal bone is overlapping the other at the sagittal suture. The occiput and the distance known as the bi-parietal diameter have been labelled.

|Prepared by: Lumba, Chared Joy D.

The pelvic inlet, viewed from above. Note the position of the ischial spines.

2. Descent
The term fetal descent is used to describe the progressive downward movement of the fetal presenting part (commonly the head) through the pelvis. When there is regular and strong uterine contraction, and the size of the babys head and the size of the mothers pelvic cavity are in proportion so the baby can pass through, there will be continuous fetal descent deep into the pelvic cavity. Since the pelvic cavity is enclosed with pelvic bones, when the uterus is strongly pushing down, occasionally the fetal scalp bones undergo overlapping at the suture lines in order to allow the head to pass through the narrow space. This overlapping is called moulding. The commonest types of moulding include one parietal bone overlapping over the other parietal bone along the sagittal suture, the occipital bone overlapping the temporal bone, and the frontal bone overlapping the parietal bones.

3. Flexion
The movement known as flexion occurs during descent and is brought about by the resistance felt by the babys head against the soft tissues and bones of the mothers pelvis. The resistance brings about a flexion in the babys head so that the chin meets the chest. The smallest diameter of the babys head presents into the pelvis.

4. Internal rotation
As the head reaches the pelvic floor, it typically rotates to accommodate the change in diameters of the pelvis. At the pelvic inlet, the diameter of the pelvis is widest from right to left. At the pelvic outlet, the diameter is widest from front to back. So the baby must rotate from lying sideways to turning its face towards the mothers backbone. When the rotation is complete, the back of the babys head is against the front of the mothers pelvis). The sagittal suture in the fetal skull is no longer at an angle, but points straight down towards the mothers backbone. This movement is called internal rotation because it occurs while the baby is still completely inside the mother.
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5. Extension
After internal rotation is complete, the babys head passes through the pelvis and a short rest occurs when the babys neck is under the mothers pubic arch. Then extension of the babys head and neck occur the neck extends, so the chin is no longer pressed against the babys chest, and the top of the head, face and chin are born.

6. External rotation (restitution)

After the head of the baby is born, there is a slight pause in the action of labour. During this pause, the baby must rotate so that his/her face moves from facing the mothers backbone to facing either of her inner thighs. This movement is called external rotation because part of the baby is already outside the mother (it is also called restitution). The rotation is necessary as the babys shoulders must fit around and under the mothers pubic bone.

7. Expulsion
Almost immediately after external rotation, the anterior (foremost) shoulder moves out from under the pubic bone. The mothers perineum becomes distended by the posterior (second) shoulder, which is then also born. The rest of the babys body is then born (expulsion), with an upward motion of the babys body assisted by the care provider.

In conclusion
Note that at every stage of labour there is descent. To be specific, after the fetal head undergoes flexion, there is descent; after internal rotation, there is descent; after extension, there is descent and so on. In the next study session, we will describe the progress of a normal labour in more detail.

|Prepared by: Lumba, Chared Joy D.