Leopold’s Maneuvers

Leopold’s Maneuvers are methods to determine position, presentation and engagement of fetus.

They will include:

1. Determination of what is in the fundus
2. Evaluation of the fetal back and extremities
3. Palpation of the presenting part above the symphysis, and
4. Determination of the direction and degree of flexion of the head.

How to Perform Leopold’s Maneuver

Before performing Leopold’s Maneuver, ask the mother to empty the bladder, warm hands, and apply them to the mother’s abdomen with firm and gently pressure.

First Leopold’s Maneuver:

1. It will determine which part of the fetus is in the fundus.
2. Place pals on each side of the upper abdomen and palpate around the fundus
3. You would feel a hard, round, movable object if the head is in the fundus
4. You would feel soft and have an irregular shape and are more difficult to move if the buttock is in the fundus

Second Leopold’s Maneuver:

1. Move hand downward over each side of the abdomen, applying firm, even pressure.
2. The fetus’s back which is a smooth, hard surface should be felt on one side of the abdomen.
3. The hands, feet, elbows, and knees which are as irregular knobs and lumps will be felt on the opposite side of the abdomen.

Third Leopold’s Maneuver:

1. It will determine fetal position
2. Place hand above the symphysis pubis
3. Bring thumb and fingers together and grasp the part of fetus between them that may be the head or the buttocks

Fourth Leopold’s Maneuver:

1. It is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.
2. Place hand on the sides of the lower abdomen close to the midline
3. Slide hands downward and press inward
4. If you have determined that the buttocks are in the fundus, then feel for the head
5. If you cannot feel the head, it probably has descended

Mechanism of Labor

There are eight classical steps in the normal mechanism of labor as following here:

Engagement

• This is also called lightening or dropping
• The fetus nestles into the pelvis

Descent

• This process starts from the time of engagement until birth and is assessed by the station.
• The fetal head undergoes as it begins its journey through the pelvis.

Flexion

• The fetal head’s nodding forward toward the fetal chest
• While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis

Internal Rotation

• With further descent, the occiput rotates anteriorly and the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position.

Extension

• It begins after the head crowns
• This means that the fetal chin is no longer touching the fetal chest.
• It enables the head to emerge when the fetus is in a cephalic position
• The extension of labor is completed when the head passes under the symphysis pubis and occiput and the anterior fontanel, brow, face and chin pass over the sacrum and coccyx and are over the perineum

Restitution

• After the head emerges, the fetal head becomes in a realignment

External Rotation

• The shoulder of fetus externally rotates after head emerging and restitution
  
• The shoulder is in the anteroposterior diameter of the pelvis.

Expulsion

• This is the birth of entire body.

Fetal Presentation

Fetal position is defined as designation of landmark of fetal presenting part (occiput, mentum, sacrum, scapula) to right or left, and anterior, posterior, or transverse portion of the woman's pelvis.

A three-letter abbreviation is used to describe the relationship of the presenting part to the maternal pelvis.

• Sides of presenting part facing in the pelvis are described as: R (right) or L (left).
• Landmarks of presenting part are described as: O (occiput, or head), S (sacrum), Sc (scapula, or shoulders), M (mentum, or chin).
• Directions of presenting part facing in the pelvis are descreibe as: A (anterior, or front), P (posterior, or back), or T (transverse).

The first and third letters relate to the pelvis, and the second letter relates to the fetus.


Common possible fetal presentations are :

VERTEX / OCCIPITAL PRESENTATION
LOA = Left Occipital Aterior
LOT = Left Occipital Transverse
LOP = Left Occipital Posterior
ROA = Right Occipital Anterior
ROT = Right Occipital Transverse
ROP = Right Occipital Posterior

FACE PRESENTATION
LMA = Left Mentum Anterior
LMT = Left Mentum Transverse
LMP = Left Mentum Posterior

BREECH PRESENTATIONS
LSA = Left Sacrum Anterior
LST = Left Sacrum Transverse
LSP = Left Sacrum Posterior


Here are images of fetal presentation :



click image to enlarge.

Labor: True and False

There are pleliminary events to labor :

• Backache
• Cervix becomes soft and effaced and may begin to dilate
• Braxton Hicks contraction increase
• Lightening or dropping
• Membranes may rupture spontaneously
• Vaginal secretions increase
• Urinary frequency increases
• Passage of mucous plug occurs
• Weight loss of 1 – 3 lb
• “Bloody show” occurs
• Mother has a sudden burst of energy

How to differentiate between true labor and false labor?

True Labor:

• Contractions are in the back and abdomen
• Contractions are regular with decreasing intervals
• Contractions increase over time and increase with walking, and little or no effect from sedation
• Cervical dilation and effacement are progressive

False Labor:

• Contractions are in lower abdomen
• Contractions are irregular with unchanging or increasing intervals
• Contractions remain the same, unaffected by, or decrease with walking and relieved by sedation
• No dilation or effacement or cervix

COMPLICATION OF PREGNANCY

ABRUPTIO PLACENTAE
Abruptio Placentae is premature detachment of a normally situated placenta. Patient with abruption placentae will have bleeding, abdominal pain, boardlike uterus, maternal hypotension and tachycardia and fetal distress. Nursing managements will include: bed rest, monitor bleeding and shock, monitor fetal heart rate continuously.

ECLAMPSIA
Complication with seizures between 20th week of pregnancy and first postpartal week. Eclampsia can be happened with or following pregnancy-induced hypertension. Management of eclampsia will include giving magnesium sulfate, frequently assess vital signs, restrict fluid intake hourly to a total of 125 mL/h, and urinary output should be at least 30 mL/h.

GESTATIONAL DIABETES
Gestational diabetes occurs in 3–6% of all pregnancies, and although it typically resolves after delivery, it increases the risk of maternal pyelonephritis and of certain congenital anomalies, and is often associated with polyhydramnios and fetal macrosomia, with resultant dystocia. Patient will have polyuria, polydipsia and polyphagia. Gestational diabetes can be diagnosed with 3 hours Glucose Tolerance Test after 100 grams load. Management: exercise, dietary management, insulin (if needed), monitoring of weight, and teach and to assess glucose monitoring and diet.


PLACENTA PREVIA
Placenta previa is the condition in which the placenta is implanted in the lower segment of the uterus, extending to the margin of the internal os of the cervix or partially or completely obstructing the os. Clinical sign of placenta previa is painless vaginal bleeding. Management: monitor maternal vital signs, bed rest, monitor fetal heart rate, and not performing vaginal examination if placenta previa is suspected.

GROUP B STREPTOCOCCAL INFECTION
It would be 10-30% of pregnant women are colonized which are asymptomatic. It is recommended screening by rectovaginal swab at 37 weeks of gestation.

PREGNANCY-INDUCED HYPERTENSION (PIH)
PIH is a syndrome of hypertension, edema, and proteinuria that can occurs after 20th week of pregnancy. This patient will have headache, blood pressure of 140/90 or greater, or an increase of 30 mm Hg systolic or 15 mm Hg diastolic at two readings and edema that not relieved by bed rest, proteinuria, weight gain above 2 lb / weeks, visual disturbance, and epigastric pain. Patient who has pregnancy-induced hypertension will be managed by bed rest, control blood pressure, antihypertensive medicines, monitor intake and output, daily weight, and check urine for protein.

HELLP SYNDROME
This is a type of severe preeclampsia involving hemolysis, elevated liver function, and low platelets. Patient should delivery soon.

PRETERM LABOR
Preterm labor is a labor between 20 and 37 weeks of gestation.

Fundal Height Assessment - Prenatal Care

Fundal Height assessment is measured to evaluate the fetus's gestational age. Fundal height is measured from the top of the symphysis pubis to the top of the fundus. Height is assessed in centimeters.

At 16 weeks, the fundus can be found halfway between the symphysis pubis and the umbilicus. At 20 - 22 weeks, the fundus will be at the umbilicus, and at 36 weeks, the fundus is at xyphoid process. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 centimeters.

Remember that picture as it maybe questioned in NCLEX - CGFNS test.

1. To Measure Fundal Height :
2. Place the pregnant woment in the supine position
3. Place the end of the tape measure at the level of the symphysis pubis.
4. Stretch the tape to the top of the uterine fundus, and
5. Record / document the measurement.

Maternity Nursing - Pregnancy, Signs and Symptoms

Here the explanation of these signs and symptoms of pregnancy.




PRESUMPTIVE SIGNS OF PREGNANCY

1. Amenorrhea, more than 10 days elapsed since the time of expected onset of menstruation
2. Nausea and vomiting
3. Increase of urinary frequency
4. Fatigue and drowsiness
5. Breast changes : feeling of fullness, tenterness, enlargement, darkening of areola, prominence of veins, enlargement of montgomery's tubercles (it is a small gland around nipple)
6. Vaginal changes: bluish color (chadwick's sign)
7. Skin Changes : striae (stretch marks), dark pigmented vertical lines on abdomen (linea nigra), pigment formation on face (facial chloasma), and mother's perception of fetal movement (quickening)

PROBABLE SIGNS OF PREGNANCY

1. Uterine changes : Hegar's sign (softening of lower uterus), Goodell's sign (softening of cervix), and Braxton Hicks' Contraction (false labor)
2. Palpation of fetal body
3. Positive of horman test for pregnancy
4. Ballottement (rebounding of fetus in amniotic fluid)

POSITIVE SIGNS OF PREGNANCY

1. Fetal movement (felt by examiner)
2. Fetal heartbeat
3. Radiograph of fetus
4. Sonogram of fetus

These signs and symptoms of pregnancy always appears in NCLEX-CGFNS questions.