Mabini College

College of Nursing
Daet Camarines Norte

Leopold’s Maneuver

Purpose

 Systematically observe and palpate the abdomen to determine presentation and position of the fetus
and aid in location of the fetal heart sound.

Reminders

 Explain the procedure to the woman and the rationale for each step as it is performed.

Rationale: explanation reduces anxiety and enhances cooperation

 Ask the woman to empty her bladder.

Rationale: an empty bladder promotes comfort and allows for more productive palpation because fetal contour
will not be obscured by a distended bladder.

 Have her lie in her back with her knees slightly flexed. Place a small pillow or folded towel under one
hip.

Rationale: flexing the knee relaxes the abdominal muscles. Using the pillow or towel tilts the uterus off the
vena cava, preventing supine hypotension.

 Wash hands using warm water. Wear gloves if contact with secretion is likely.

Rationale: to prevent the spread of possible infection or contamination. Using warm water aids in patient
comfort and prevents tightening of abdominal muscles during palpation.

 Provide privacy.

Procedure

1. First maneuver (Fundal grip) - stand at the foot of the woman, facing her. Palpate the superior surface of the
fundus. Determine consistency, shape, and mobility

Rationale: This maneuver determines whether the fetal head or breech is in the fundus. A head feels more firm
than the breech is round and hard and moves independently of the body. The breech feels softer and moves
on only in conjunction with the body

2. Second maneuver (Umbilical grip) - face the woman, hold the left hand stationary on the left side of the
uterus while you palpate the right hand on the opposite side of the uterus from top to bottom. Repeat
palpation using the opposite side.

Rationale: This maneuver locates the back of the fetus. The fetal back feels like smooth, hard, and resistant
surface; the knees and elbows of the fetus on the opposite side feels more like a number of angular bumps or
nodules.

3. Third maneuver (Pawlik’s grip) – Gently grasp the lower portion of the abdomen just above the
symphysis pubis between the thumb and the fingers and try to press the thumb and finger together.
Determine any movement and whether the part feels firm or soft.

Rationale: The maneuver determines which part of the fetus is at the inlet and its mobility. If the presenting part
moves upward so your fingers and thumb can be pressed together, the presenting part is not engaged. If it is
firm, it is the head; if soft it is breech.

4. Fourth maneuver-(Pelvic grip) -Place fingers on both sides of the uterus approximately 2 inches above
the inguinal ligaments, pressing downward and inward in the direction of the birth canal. Allow fingers to
be carried down ward.

1
Joanna Marie McPherson De Guzman RN
Rationale: This maneuver is only done if the fetus is in cephalic presentation because it determines the fetal
attitude and degree of fetal extension in the pelvis. The fingers of one hand will slide along uterine contour and
meet no obstruction, indicating the back of the neck. The other hand will meet the obstruction an inch or so
above the ligament this is the fetal brow. The position of the fetal brow should correspond to the side of the
uterus that combined the elbows and the knees of the fetus. If the fetus is in a poor attitude, the examining
fingers will meet an obstruction on the same side as the fetal back; that is, the fingers will touch the
hyperextended head. If the brow is very easily palpated, the fetus is probably in a posterior position.

Terms to Remember

1. Fetal Presentation- Describes the fetal part that will be first to pass through the cervix and be delivered.
Primarily determined by fetal attitude, fetal lie, and fetal position.
 Cephalic presentation- occurs when the head presents first. The most common type of presentation.

 Vertex presentation occurs when the head is flexed sharply so that the parietal bones or the
space between the fontanels is the presenting part. (pic A)
 Brow presentation occurs when the head is moderately flexed causing the brow to enter first.
(pic B)
2
Joanna Marie McPherson De Guzman RN
  Sinsiput presentation occurs when the head is in neutral position, neither flexed nor extended
(pic C)
 Mentum presentation occurs when the fetal head is hyperextended causing the face or the chin
to present first. (pic D)

Breech presentation occurs if the buttocks or feet presents first.

 Complete breech occurs when the thighs of the fetus is tightly flexed on the abdomen.
 Incomplete breech occurs when one thigh of the fetus is tightly flexed and the other thigh is
extended
 Frank breech occurs when the fetal hips are flexed but the legs are extended and resting on the
chest.
 Footling breech occurs in the absence of hip or thigh flexion of one or both extremities such that
one or both feet are the presenting part.
 Knee presentation occurs when the presenting part is the knee.

 Shoulder presentation occurs when the presenting part is the shoulder, iliac crest, hand or elbow. The
fetus is lying horizontally in the pelvis
2. Fetal Lie refers to the relationship of the long axis of the fetus to the long axis of the mother.
 Longitudinal lie- the long axis of the fetus is parallel to the long axis of the mother
 The fetus is lying vertical or top to bottom in the uterus.
 Nearly 99% of fetus are in longitudinal lie at the onset of labor.
 Can be further classified as cephalic or breech
 Transverse lie- the long axis of the fetus is perpendicular to the long axis of the mother.
 The fetus is lying horizontally or side to side in the uterus.

3
Joanna Marie McPherson De Guzman RN
  Less than 1% of fetus are in transverse lie at the onset of labor
 Oblique lie- the fetal spine and the maternal spine are at 45 degree angles at each other.
 Rare occurrence, it is considered abnormal if the fetus maintains this position after the onset of
labor.
3. Fetal Position the relationship of the presenting part to a specific section of the mother’s pelvis.
 Important to determine because it can influence the progression of labor and the possible need
for surgical intervention
 The patient’s pelvis is divided in to four sections based on her right and left and front and back.
 Fetal position is described by using 3 letters
 The first letter designates whether the presenting part is facing to the mothers right (R)
or left (L).
 Second letter is the presenting part of the fetus.
 O-occiput
 M-Mentum ,chin, face
 S-sacrum
 A- acromion
 Position in vertex presentation includes: ROA, ROT, ROP, LOA, LOT, LOP
 Position in face presentation includes: RMA, RMT, RMP, LMA, LMT, LMP
 Position in breech presentation includes: RSA, R ST, RSP, LSA, LST, LSP

Mabini College
College of Nursing
Daet Camarines Norte

Assessing Fetal Heart Rate

 Fetal heart rate provides important information about fetal well-being. It can be assessed by
auscultating the mother’s abdomen with a Doppler ultrasound, stethoscope, and fetuscope or pinnard
horn.

Purpose: to evaluate the fetal condition and tolerance of labor.

Procedure

1. Explain the procedure to give information to the woman and her partner. Wash your hands with warm
water to reduce the transmission of microorganism and to make your hands more comfortable when
touching the woman’s abdomen.
4
Joanna Marie McPherson De Guzman RN
 2. Use Léopold’s maneuver to identify the fetal back because it usually is closest to the surface of the
maternal abdomen where fetal heart sounds are clearest. (illustrations show approximate locations of
the fetal heart rate in different presentations and positions)

For

fetuscope

Place the ear piece in your ears. Place the bell of the fetuscope over the fetal back with the head plate
pressed against your forehead. Move the fetuscope until you locate where the sound is loudest. Use your
forehead to maintain pressure during auscultation to enhance faint fetal heart sounds.

For Doppler transducer

Review the manufacturer’s instructions for operating the Doppler device. Place water soluble conducting
gel over the transducer to make an interface for clear signal transmission, and turn it on. Place the
transducer over the fetal back and move it until you hear clear sounds that represent the fetal heart motion.

5
Joanna Marie McPherson De Guzman RN
For Stethoscope

Place the earpiece into your ears. Gently press the bell about 1l2 inch or 1 cm into the woman’s abdomen.
Move the instrument slightly from side to side to locate the loudest heart tone.

For Pinnard horn

Warm the pinnard horn if it is made up of metal. Press the pinnard horn over the fetal back. Listen until you
hear clear sounds.

3. With one hand palpate the mother’s radial pulse to verify that the fetal heart rate is what is actually
heard. If the sound is synchronized with the sound from the fetuscope or Doppler, try another location
for the fetal heart. Other sounds that maybe represented by the Doppler are the funic soufflé (blood
flowing through the umbilical cord) or uterine soufflé (blood flowing thru the uterine vessels) funic
soufflé is synchronized with the fetal heart and is the same rate. The uterine soufflé is synchronized
with the mother’s pulse.
4. Count the baseline fetal heart rate for 60 seconds. Note acceleration or slowing of rate.
5. Note reassuring signs that suggest the fetus is tolerating labor well.
 Average rate 120 to 160 beats per minute
 Regular rhythm
6. Note nonreassuring signs, and make more frequent assessment. Notify physician for further evaluation.

Mabini College
College of Nursing
Daet Camarines Norte

APGAR Scoring

 The Apgar score is a method of rapid evaluation of the infant’s cardiorespiratory adaptation after birth.

 At 1 minute and 5 minutes after birth, newborns are observed and rated according to an Apgar score,
an assessment scale used as the standard for newborn evaluation since 1958. It was formulated by Dr.
Virginia Apgar.

 The assessment is arranged from the most important (heart arte) to the least important (color)

Heart Rate

 Auscultating a newborn heart with a stethoscope is the best way to determine rate. However, heart rate
also may be obtained by observing and counting the pulsation of the umbilical cord at the abdomen if
the cord is still uncut.
6
Joanna Marie McPherson De Guzman RN
Respiratory Effort

 Respiration is counted by observing chest movements. A mature newborn usually cries and aerates the
lungs spontaneously at about 30 seconds after birth.
 By 1 minute, he or she is maintaining regular, although, rapid respirations. Difficulty with breathing
might be anticipated in a newborn whose mother received large amount of analgesia or general
anesthetic during labor or birth.

Muscle Tone

 Term newborns hold their extremities tightly flexed, simulating their intrauterine position
 Muscle tone is tested by observing their resistance to any effort to extend their extremities.

Reflex Irritability

 One of two possible cues is used to evaluate reflex irritability: response to a suction catheter in the
nostrils or response having the soles of the feet slapped.
 A baby whose mother was heavily sedated for birth will probably demonstrate low score in this
category.

Color

 All infant appear cyanotic at the moment of birth. They grow pink with or shortly after their first breath.
 Cyanosis- bluish discoloration of the skin
 Acrocyanosis- bluish hands and feet

Obtaining APGAR SCORE

 Follow these steps to determine the neonate’s APGAR score at 1 minute and 5 minutes intervals after
birth.

1. Observe skin color, especially at the extremities (if the neonate is dark skinned, inspect the oral
mucosa, conjunctiva, lips palms, and soles.
2. Assess the neonate’s heart rate using stethoscope. Listen to the heart beat for 60 seconds and then
record the rate.
3. Assess reflex irritability by observing the neonate’s response to nasal suctioning or to flicking the sole.
4. Determine muscle tone by evaluating the degree of flexion and resistances to extension in the
extremities (extend the limbs and observe their return to flexion).
5. Assess respiration by noting the volume and vigor of the neonates cry. Then using a stethoscope
assesses the depth and rate of respirations. Begin with neonatal resuscitation if you detect abnormal
respiration.

APGAR SCORE
Assessment (Signs) 0 1 2
No heart rate Heart rate present but < Heart rate present but
Heart Rate 100 bpm (beats per > 100 bpm
minute)
No respiratory effort Weak cry, slow or difficult Strong vigorous cry
Respiratory Effort respirations, grunting
(noisy breathing)
Limp or flaccid Minimal flexion of Maintains position of
Muscle Tone extremities flexion with brisk
movements
No response to Grimace when stimulated Cries or sneeze when
Reflex Irritability stimulation stimulated active
movements
Body and extremities Body pink extremities Body and extremities
Color blue (cyanosis) or blue (Acrocyanosis) pink
completely pale (pallor)

APGAR Scoring

7
Joanna Marie McPherson De Guzman RN
7-10 indicates that the
neonate is in good
condition

4 to 8 in good condition

0-3 in danger (the neonate

needs immediate
resuscitation)

Mabini College
College of Nursing
Daet Camarines Norte

Menstrual Cycle

 Menstrual cycle is episodic uterine bleeding in response to cyclic hormonal changes.

 Ovulation: discharge of mature ovum from the ovary.

 Menstruation: periodic shedding of blood and mucous epithelial cells from uterus.

 The primary purpose of the menstrual cycle is to bring an ovum to maturity and renew a uterine tissue
bed that will be necessary for the ova’s growth should it be fertilized.
 In healthy women, menstrual cycle continue from puberty to menopause, interrupted only by
pregnancy and lactation.
 The length of menstrual cycle differs from woman to woman.
 Beginning (menarche)12.4 years, average 9 to 17 years
 Average length 28 days

8
Joanna Marie McPherson De Guzman RN
  Short cycle 23 days long cycle 35 days
 Length of menstrual flow average is 4 to 6 days. Menstrual flows can be as short as 2 days or
as long as 9 days.
 Amount of menstrual flow 30 to 80 ml
 Color of menstrual flow: dark red a combination blood, mucus, and endometrial cells.

 The ovary produces mature gametes and secretes the following hormones:

 Estrogen is secreted by the maturing ovarian graafian follicles and participates in several
functions including:
 Assist in maturation of follicle
 Expands the blood supply
 Inhibits FSH production
 Stimulates LH production
 Causes proliferation of the endometrium
 Increases contraction of myometrium
 Increases contraction of fallopian tubes

 Progesterone is secreted by the corpus luteum and participates in several functions including:
 Reduces contractions of the myometrium and fallopian tubes
 Prepares the endometrium for implantation by increasing glycogen, arterial blood,secretory
glands, amino acids and water
 Promotes growth of the acini cells of the breast
 Causes wt gain by promoting water retention
 Thermogenic effect, increases basal body temperature

 Prostaglandin act on the hypothalamus to effect gonadotropin secretion and are believed to
play a role in ovulation, progesterone withdrawal and degeneration of the corpus luteum when
pregnancy does not occur.

 Four body structure are involve in the physiology of the menstrual cycle: hypothalamus, pituitary
gland, ovaries, and the uterus

 CNS Level
 The hypothalamus stimulates the anterior pituitary by secreting gonadotropin-releasing
hormone; the anterior pituitary secretes two gonadotropins- follicle stimulating hormone (FSH)
and luteinizing hormone (LH)
 FSH stimulates the ovary to develop ovarian follicles; the developing follicles secrete estrogen,
which feeds back to the anterior pituitary gland to suppress FSH and trigger an LH surge.
 LH acts with FSH to cause ovulation and enhance corpus luteum formation.

 Ovarian Level
 An oocyte grows within the primordial follicle in two phases: follicular phase and luteal phase.
 In the follicular phase (days 1 to 14) the follicle matures due to FSH. This is the time before
ovulation.
 This is called follicular phase because the main event at this phase is the formation of Graafian
follicle
 In the luteal phase (15 to 22) the corpus luteum develops from a ruptured follicle.
 After ovulation, the empty follicle is transformed into yellowish body called corpus luteum that
produces large amount of progesterone and some estrogen under the stimulation of LH.
 The life span of corpus luteum is 7 days only. 8 days after ovulation, the corpus luteum begins
to regress resulting in declining serum progesterone level.

 Endometrial levels

 Menstrual phase (days 1 to 5), during which the estrogen level is low and cervical mucus is scanty.
The degeneration of the endometrium is shed.

 Total blood loss during menses ranges from 30 to 80 ml. In a woman lifetime, she loses 10 to
20 liters of blood due to menstruation

 Proliferative (follicular) phase (days 6 to 14), during which the estrogen level is high, the
endometrium and myometrium thicken, and changes in cervical mucosa occur.

9
Joanna Marie McPherson De Guzman RN
  Aside from the changes in the endometrium, estrogen also prepares the genital tract for sperm
migration by stimulating cervical glands to produce abundant mucus that is thin, watery,
stretchable and transparent.
 This phase is also called estrogenic phase.

 Secretory phase (days 14 to 26): following release of ovum, estrogen level drops, progesterone
level is high, increased uterine vascularity occurs, and tissue glycogen levels increase.

 Ovulation occurs 14(+2 or -2) before menstruation.

 Signs of ovulation:
Mittelschmerz refers to the lower abdominal pain felt at the side of the ovary that released
the ovum.
Spinbarkheit does not indicate the exact date of ovulation but signals the woman is nearing
ovulation or is ovulating. This sign is characterized by cervical mucus that is thin, watery or
transparent and highly stretchable

Spinbarkheit

 When dried and viewed under the microscope, the mucus reveals a fern pattern. The fern
pattern is due to elevated levels of sodium chloride.

Fern
pattern
(fertile)

Not fertile

 Increased basal body temperature. The surge of progesterone after ovulation results in
increased resting body temperature.
 Peak blood levels of luteinizing hormone occur 24 to 48 hours before ovulation. There are urine
test now that could determine the level of LH and thus predict when the woman is ovulating.

 Ischemic Phase (days 27 to 28 involving low estrogen and progesterone levels, arterial
vasoconstriction, pallor of endometrium and blood vessel rupture.

 Low progesterone level releases prostaglandin (endothelin-1). This substance causes

vasospasm of the spiral arteries and contraction of myometrium.
 Arteriolar spasm cuts blood supply to the uterus causing tissue ischemia, necrosis and
rupture of blood vessels than leads to endometrial sloughing

 The Cervical Levels

 Preovulation: increased estrogen level causes cervical os dilatation, abundant liquid mucus, high
spinbarkheit, excellent sperm penetration.
 Postovulation: increased progesterone level results in cervical os constriction, scant viscous mucus,
low spinbarkheit, no ferning, poor sperm penetration.
 During pregnancy: increased circulation

Ovarian follicles

10
Joanna Marie McPherson De Guzman RN
  Within the cortex of the ovary, the follicles at different phases of development are found. These are
the:
 Primordial follicles
 Graafian follicles
 Corpus luteum
 Corpus albicans

Primordial Follicle

 Are formed during intrauterine life. Most of them regresses before birth.
 The number of follicles in each ovary decreases in number as the woman ages
 2 months intrauterine- 600,000 oogonia
 5 months intrauterine- 6,800,000 oogonia
 At birth- 2 million oocyte
 Prepuberty/childhood -300,000 to 400,000
 36 years old 30,000 to 40,000
 Menopause- absent
 Are the immature follicles inside the ovary
 Every menstrual cycle several of these follicles develop under the influence of FSH.

Graafian follicle

 Is derived from the name of Regner de Graaf, the Dutch anatomist who first described it in 1672.
 After puberty, several follicles begin to develop under the influence of FSH. This developing primordial
follicle is termed Graafian follicle.
 It is described as a blister like structure barely visible to the naked eye.
 It secretes large amounts of estrogen under the influence of FSH.

Corpus Luteum

 After ovulation, the graafian follicles undergo certain changes. K cells from the theca migrate towards
the granulosa up to the empty space occupied by the ovum
 Cells inside the now empty follicle proliferates and enlarge until it becomes a dense mass of cell about
1-3 mm in diameter that produce a yellowish fluid called lutein
 Lutein fills the space one occupied by the ovum giving it a yellowish coloration. This is why the follicle is
termed corpus luteum after ovulation which means yellow body.

Corpus Albicans

 Complete regression of the corpus luteum occurs, later it will be seen as a white fibrous tissue, called
corpus albicans or corpus albicantia.

11
Joanna Marie McPherson De Guzman RN
 Mabini College
College of Nursing
Daet Camarines Norte

Weight Monitoring during Pregnancy

 During pregnancy, a woman must eat adequately to supply enough nutrients to the fetus, so it can
grow, as well as support her own nutrition.
 Weight gain in pregnancy occurs from both fetal growth and accumulation of maternal stores.

Recommended weight gain during pregnancy

 A woman who was average weight before getting pregnant should gain 25 to 35 pounds after becoming
pregnant.

 Underweight women should gain 28 to 40 pounds.

 Overweight women may need to gain only 15 to 25 pounds during pregnancy.

 Multiple pregnancies need to gain 40 t0 45 pounds during pregnancy.

First trimester Second trimester Third trimester

1 pound per month 1 pound per week 1 pound per week

 As a general rule, in the average woman, weight gain is considered excessive if it is more than
3 kg or 6.6 pounds during second and third trimester; it is less than usual if it is under 1 kg or
2.2 pounds.
 Women can be assured that most of the weight gained with pregnancy will be lost afterward.
 Women should not try to lose weight or diet during pregnancy.

Where Does the Extra Weight Go During Pregnancy?

 Baby: 8 pounds
 Placenta: 2-3 pounds
 Amniotic fluid: 2-3 pounds
 Breast tissue: 2-3 pounds
 Blood supply: 4 pounds
 Stored fat for delivery and breastfeeding: 5-9 pounds
 Larger uterus: 2-5 pounds
 Total: 25-35 pounds

12
Joanna Marie McPherson De Guzman RN
 13
Joanna Marie McPherson De Guzman RN