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Fetus in-utero

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”)

Third Maneuver

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?