LEOPOLDS MANUEVERPrepared By: Felipe A. Merano, RN, MSN

Calayan Educational Foundation, Inc.

Leopold’s maneuver is a method that determines the fetal position, fetal presentation, and engagement. This consists of four different actions that help determine the position and presentation. With correct assessment and findings, it can indicate whether the delivery would be complicated or if the mother would need to undergo Caesarian delivery.

Preparation for Leopold’s ManeuverAsk the mother to empty the bladder. The nurse should then warm the hands and apply it to the abdomen of the mother by using firm and gentle pressure.

Maneuvers

First ManeuverThis determines what part of the fetus is in the fundus.

1. Place palms on each side of the upper abdomen and palpate around the fundus.2. If the head is at the fundus, you would feel a hard, round, and movable object. If the buttocks is at the

fundus, you will feel a soft and irregular shaped mass that is difficult to move.

Second Maneuver

1. Move your hands downward, still on both sides of the abdomen, while applying firm and even pressure.

2. If you palpate a smooth hard surface on one side then it would be the fetal back. If you palpate irregular lumps it would be the hands, feet, elbows, and knees and should be on the opposite side of the abdomen.

Third Maneuver

This maneuver confirms the fetal position.

1. Place your hands above the symphysis pubis.2. Bring the thumb and fingers together and grasp the part of the fetus between them. Findings could be

the head or the buttocks.

Fourth Maneuver

This is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.

1. Place your hands on both sides of the lower abdomen close to the midline.2. Slide your hands downward, then press inward.3. If you palpated the buttocks in the fundus, then you shoul feel for the head. If one cannot feel the head,

then it probably has descended.

How to assess and manage postpartum bleeding

Pregnancy is the conception and development of an embryo or fetus inside the uterus of a female. Pregnancy can be divided into three trimesters, lasting for 9 months or an estimated 34-36 weeks. Gravida is a term commonly used to pertain to pregnancy and it refers to the number of times a women has been pregnant. Parity or para refers to the number of successful births of a woman. Embryo is used to describe a developing offspring for the first 8 weeks and fetus is used from 2 months until birth.

Signs of Pregnancy

Presumptive Signs of Pregnancy

This signs only presume the occurrence of pregnancy and is not comfirmatory. 1. Amenorrhea or the absence of menstruation.2. Nausea and vomiting3. Increased breast sensitivity and breast changes4. Increased pigmentation in localized areas5. Constipation6. Frequent urination7. Quickening or an initial motion8. Abdominal enlargement

Probable Signs of Pregnancy

This signs may or may not confirm pregnancy and further tests and observation are required. 1. Uterine enlargement2. Hegar’s sign or the softening of the lower uterine segment3. Goodel’s sign or the softening of the cervix4. Chadwick’s sign or the purplish discoloration of the vaginal mucosa5. Ballotment or rebounding upon palpation6. Braxton-Hicks Contraction7. Positive pregnancy test

Positive Signs of Pregnancy

This signs along with the presumptive and probable signs confirm pregnancy. 1. Fetal heart tone can be auscultated2. Ultrasound of the fetus3. Palpable fetal movements

Physiological Changes During Pregnancy

Reproductive System Changes

1. The uterus enlarges and painless contractions occur.2. Ovulation stops due to high levels of placental estrogen and progesterone.3. The vagina becomes softer, vaginal mucosa thickens, vascularity increases, and vaginal discharge

increases and becomes more acidic.4. The breast increase in size, become full and tender, and the areola darkens. Sometimes colostrum may

be excreted.5. The cervix softens (Goodel’s sign) and becomes congested with blood (Chadwick’s sign) proliferating

glands form mucous plug.

Musculo-Skeletal System Changes

Gradual softening of pelvic ligaments and joints to facilitate passage of the fetus.

1. Relaxation of joints2. Widening of symphysis pubis3. Waddling gait4. Lordosis or is known as the Pride of Pregnancy 5. Increased back strain6. Leg cramps may occur from an imbalance of calcium phosphorus ratio in the body and from pressure

of the uterus

Cardiovascular System Changes

1. The mother’s heart muscle enlarges.2. The heart rotates upward and to the left.3. Stroke volume increases.4. Cardiac output increases as a result of the expanded vascular volume.5. The pulse rate increases by about 10-15 beats per minute.6. Peripheral vascular resistance falls under the influence of progesterone and prostaglandins.7. Femoral venous pressure increases.8. Blood pressure remains essentially the same, despite increase in the blood volume.9. Blood volume increases to 1200-1500 mL above pre-pregnancy values.10. Total red cell mass increases, however, the increase in plasma volume is even more pronounced.11. White blood cell count increases to to an average of 10,000 per millimeter cube.12. Clotting factors increase, offering protection against invading microorganisms but also increases the

chance of thrombophlebitis.

Respiratory System Changes

1. Oxygen consumption increases by about 20 percent.2. Dyspnea is a common occurrence.3. Nosebleeds and nasal stuffiness are common.4. The mother’s rib cage widen.5. Respiratory depth increases.

Gatrointestinal System Changes

Changes in the Gastrointestinal system are significant because it creates some of the discomforts of pregnancy. Most of the changes are produced by progesterone, which relaxes the muscles of the stomach and intestine.

1. The gums appear red and swollen and bleed easier, this is caused by elevated levels of estrogen.

2. There is reduced tone of esophageal sphincter that allows reflux of acidic stomach contents, producing heart burns.

3. Decreased motility in the large intestine allows more water to be absorbed and may cause constipation and hemorrhoids.

4. Increased thirst and appetite.

Urinary System Changes

1. Increased urinary frequency on the first and third trimester because of pressure on the bladder.2. The Glomerular filtration rate increases by 50%.3. Glycosuria occurs because of the increased secretion of sugar by lowered renal threshold.4. Lower specific gravity as a result of increase urinary output.

Endocrine System Changes

1. Thyroid activity is increased.2. HCG reaches a peak in the third month.3. There is secretion of oxytocin which stimulates uterine contractions coupled with the drop of

progesterone that brings about labor.4. Uterine contractions increase in frequency and intensity culminating in fetal expulsion.

Discomforts of Pregnancy

Ankle Edema Backache Breast Tenderness Constipation Fatigue Headache Hemorrhoids Leg Cramps Urinary Frequency Vaginal Discharge Varicosities

Prenatal Care

The objective of prenatal care is to reach all pregnant women, to give sufficient care, and to ensure a healthy pregnancy and a birth of a full term healthy baby.

Schedule of first visit is as soon as the woman missed her menstrual period and pregnancy is suspected .

Follow-up visit of a mother should be once a month from 1st week to the 32nd week, twice a month for the 32nd week until the 36th week, and every week from the 36th week to the 40th week.

Common Laboratory Procedures during Pregnancy

Complete Blood Count (CBC), Hemoglobin (Hgb), Urinalysis, Urine test for Protein, Random blood sugar, and Blood typing are some of the common laboratory procedures done on a pregnant client. All pregnant women shall be given tetanus toxoid immunization.

Common Prescriptions during Pregnancy

Iron supplements shall be given from the 5th month of pregnancy up to 2 month post-partum. (100-200 mg orally per day daily for 210 days).

Danger Signs of Pregnancy

Vaginal bleeding Persistent vomiting Chills and Fever Sudden escape of fluid from the vagina Abdominal or chest pain Danger signs of Pregnancy Induced Hypertension

1. Swelling of the face and fingers2. Flashes of lights or dots before the eyes3. Dimness or blurring of vision4. Severe or continuous headache

Low–dose Vit.A supplements (10,000 IU in 2 weeks).

In areas with Malaria, 2 tablets of Chloroquine (150 mg/2 tablets every week for the duration of pregnancy).

The Mechanisms of Labor occur to the fetus during delivery. Knowledge of these mechanisms enables the nurse to proceed with normal delivery and detect if any abnormalities are occurring during delivery that can enable the health care team to perform measures that could prevent possible complications. You can be guided by the acronym EDFIERERE.

E = Engagement

It is the mechanism wherein the fetus ‘engages’ to the pelvis. It is also called lightening or dropping.

D = Descent

Descent is the mechanism where the fetal head begins its journey through the pelvis. Assessment measurement is termed as station.

F = Flexion

Is the mechanism where the fetal head is nodding or flexing forward toward its chest.

IR = Internal Rotation

This occurs from the occiput transverse position to the occiput anterior position while descending.

E = Extension

This enables the head to emerge when the fetus is in cephalic position. This begins when the head is crowning.

R = Restitution

It is the realignment of the head of the fetus with the body as the fetus’ head emerges.

ER = External Rotation

This mechanism is where the shoulders rotate externally once the head emerges and restitution occurs so that the shoulders would be in the anteroposterior diameter of the mother’s pelvis.

E = Expulsion

It is the birth of the entire body of the fetus.

Other Terminologies and Procedures

Crowning. The fetal head distends the labial and perineal tissue and the anus is stretched wide.

Ritgen Maneuver. Pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput. This aids the mechanism of extension as the fetal head comes under the symphysis.

LABOR

Labor is the coordinated sequence of involuntary uterine contractions. Understanding the stages of labor would allow the mother and the health care team facilitate a less stressful and safe childbirth. The four stages of labor are based on the changes that the uterus and cervix undergo as labor progresses.

First Stage of Labor

The first stage of labor usually have 20 t0 40 contractions.

Three Phases of the First Stage of Labor

1. Latent Phase. The mother is excited. This lasts from the beginning of labor until 3 cm of cervical dilatation.

2. Active Phase. The mother is anxious. The cervix dilates from 4-7 cm and dilates in a more rapid rate.3. Transition Phase. The mother is irritable. The cervix dilates from 8-10 cm and the fetus descends

further into the pelvis.

Second Stage of Labor

This is where the vulva is stretching. Contractions are at 40-60. This begins with complete dilatation and full effacement of the cervix and end with the birth of the baby.

Third Stage of Labor

This begins with the birth of the baby and ends with the expulsion of the placenta. The placenta is formed by the union of the chorionic villi and decidua basalis.

Types of Placental Separation

Schultz. The presenting part is the fetal side which is shiny. Duncan. The presenting part is the maternal side which is called “dirty” because it is raw and red.

Nursing Care During the Third Stage of Labor

Do not hurry the expulsion of the placenta. This usually takes around 20 minutes. Tract cord slowly. Inspect for missing cotyledons. There should be 30. Palpate the uterus. Inject oxytocin. Inspect the perineum. Put down the legs of the mother together to prevent injury. The mother should be flat on bed without pillows for 6 hours. If the client is experiencing chills, provide her with a blanket and NOT soup. Provide additional nourishment. Allow the mother to sleep to regain her strength.

Fourth Stage of Labor

The fourth stage of labor is the most critical stage. This lasts from the delivery of the placenta through the first 1-4 hours after birth. The nurse should assess the fundus, blood pressure and pulse rate, the lochia which should be moderate in flow, and the perineum. If the flow of the lochia is heavy the mother should be checked for lacerations and rechecked for retained placental fragments.

Nursing Care During Labor

Monitoring the fetus. Monitoring the laboring woman. Helping the woman cope with labor.

Condition Assessment with Fetal Compromise

1. Fetal Heart Rate. Lower limit is 110-120 bpm and the upper limit is 150-160 bpm.2. No variability in the electronic monitoring.3. Slowing of the fetal heart rate. This persists or preceeds after contraction.

4. Meconium stained. The amniotic fluid is green..5. If the amniotic fluid is yellow, cloudy, or has a foul odor, it may indcate infection.6. Contractions that last for 90 secs.7. Incomplete uterine relaxation.8. Maternal hypotension.9. Maternal hypertension.10. Maternal fever.

Evaluate Fetal Heart Rate

1. Baseline Rate. The range of contractions and its changes and fluctuations. This should be constant.2. Variability. The decreases and fluctuations.3. Periodic changes. The changes in baseline rate. Classified as acceleration and deceleration. Types:

o Early decelerations. The rate of decrease during contraction but return to baseline by end of contraction.

o Variable decelerations. 70 bpm or less for longer than 60 seconds. This may suggest fetal cord compression around the neck or inadequate amniotic fluid.

o Late deceleration. This is similar to early deceleration except it does not return to baseline until contractions end.

Inspection of Amniotic Fluid

Normal color is clear with flecks of vernix caseosa. Green stained fluid indicates the amniotic fluid is meconium stained. Cloudy or yellow amniotic fluid is infected.

The Fetal Position describes the location of a fixed reference point on the presenting bars in relation to the four quadrants. Also observed in the fetus is that the head is in flexion or is bowed, the back of the fetus is curved, and the limbs are bent and drawn up to the torso. The fetal reference is in the right or left of the mother’s pelvis. “O” is for Occiput where the fetus is in vertex presentation, “M” is for Mentum or chin where the fetus is in face presentation, “S” is for Sacrum where the fetus is in breech presentation, and Scapula or acronio the fetus is in shoulder presentation.

Different Fetal Positions

Vertex

LOA – Left Occipito Anterior LOP – Left Occipito Posterior LOT – Left Occipito Transverse ROA – Right Occipito Anterior ROP – Right Occipito Posterior ROT – Right Occipito Transverse

Breech

LSA – Left Sacro Anterior LSP – Left Sacro Posterior LST – Left Sacro Transverse RSA – Right Sacro Anterior RSP – Right Sacro Posterior RST – Right Sacro Transverse

Fetal Lie

Fetal Lie is the orientation of the long axis of the fetus and the long axis of the woman. It has three different types the longitudinal lie, transverse lie, and the oblique lie.

Face

LMA – Left Mento Anterior LMP – Left Mento Posterior LMT – Left Mento Transverse RMA – Right Mento Anterior RMP – Right Mento Posterior RMT – Right Mento Transverse

Shoulder

LADA – Left Acromion Dorsal Anterior LADP – Left Acromion Dorsal Posterior RADA – Right Acromion Dorsal Anterior RADP – Right Acromion Dorsal Posterior

Longitudinal Lie

The fetal spine is parallel with the mother’s spine. Usually the fetus is in cephalic or breech presentation.

Transverse Lie

The fetal spin is horizontal or is at a right angle with the mother’s spine. The presenting part of the fetus is the shoulder and delivery is usually caesarian.

Oblique Lie

The fetal spine is diagonal to the mother’s spine. Delivery is by caesarian section if uncorrected.