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?