The lie
Relationship between the long axis of the fetus and the long axis of the centralized uterus or maternal spine
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
The presentation
The part of the fetus which occupies the lower pole of the uterus
Vertex
head down in the pelvis
Brow
Facial
Breech
head is up in the uterine fundus and the buttock in the pelvis
Shoulder
Attitude
Relationship of fetal parts to each other:
Flexed
Deflexed
Extended
Denominator
Arbitrary bony fixed point on the presenting part
PRESENTATION
Vertex
Brow
Facial
Breech
Shoulder
ATTITUDE
Flexed
Deflexed (vertex)
Extended (vertex)
DENOMINATOR
Occiput
Frontal eminence
Mentum
Sacrum
Acromion
Flexed Vertex Presentation 8 Possibilities
LOL
ROL
LOA
ROA
ROP
LOP
OP
OA
Leopold’s Maneuver
Four-part process
Aim
Determine the position of the baby in utero
Determine the expected presentation during labor and delivery
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?
- Is the vertex engaged?
Preparation
Woman is supine, head slightly elevated and knees slightly flexed
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).
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
Detectable by ballotement
Buttocks/breech: softer and has bony prominences
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”)
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…
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
Using a Fetoscope
Fetal heart Rate (FHR) can be determined by use of:
Fetoscope
specifically designed instruments
Clinical stethescope
Electronic Doppler
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
Fetoscope
Can pick up the fetal heart rate at 17-19 weeks’ gestation
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
Where will you hear the FHTs?
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