# Examination of the Pregnant Abdomen

## Overview

This module describes how to examine the pregnant abdomen using the Leopold Manoeuvres.

## Indications

1. Pregnant patients over

   34 weeks’ gestation
   34 weeks’ gestation

   At this point, the fetal lie should be fixed, and external cephalic version may be attempted in breech fetuses.

## Contraindications

1. No absolute contraindications, but palpation of fetal position may be unreliable before

   34 weeks’ gestation
   34 weeks’ gestation

   At this point, the fetal lie should be fixed, and external cephalic version may be attempted in breech fetuses.

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I am going to examine your tummy to determine the position of your baby.”

### What can my patient expect?

“I am going to look at and feel your tummy from top to bottom. I will listen to your baby’s heart with a special stethoscope.”

### What is my patient’s role?

“Try to stay relaxed. Let me know if anything is painful, and let me know if you feel faint during the examination. It will be more comfortable for you with an empty bladder. I can then also test your urine. ”

## Preparation

Ensure a female chaperone is present. Perform urinalysis if a midstream urine sample was collected.

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Measuring tape

3. Pinard stethoscope

## Site & Positioning

The patient should be positioned supine, with a pillow under the right hip to avoid

aortocaval compression syndrome

aortocaval compression syndrome

This occurs due to pressure on the aorta and inferior vena cava by the fetus. The patient may develop hypotension or even become unconscious.

.

## Procedure

Follow medical asepsis without gloves.

1. Perform hand hygiene.

2. Provide privacy and expose the abdomen.

3. Inspect the abdomen
   Inspect the abdomen

   Note:
   Size and shape of the uterus
   Linea nigra
   Surgical scars
   Striae
   Foetal movements (from 24 weeks)

   .

4. Perform a

   general palpation
   general palpation

   Palpate all quadrants of the abdomen to rule out non-obstetric pathology such as splenomegaly or appendicitis.

   .

5. Manoeuvre 1:

   Fundal Grip
   Fundal Grip

   Facing the patient’s head, place the ulnar surfaces of both hands on the upper quadrants of the abdomen, with the fingertips facing the xiphisternum. Palpate the fundus with fingertips to determine which fetal part is present. The head feels like a smooth, firm, ballotable ball. The breech feels like an uneven, unballotable mass.

6. Measure the symphysis-fundal height by placing a measuring tape from the edge of the pubic symphysis to the highest point of the palpated fundus — not necessarily in the midline.

7. Manoeuvre 2:

   Lateral Palpation
   Lateral Palpation

   Slide your hands down to the lateral uterine walls. Try to bring your hands closer to the midline to confirm longitudinal lie. If you cannot bring your hands closer to the midline, suspect an oblique or transverse lie. Palpate the fetal back and small parts to confirm longitudinal lie. The back feels like a smooth, full rounding. The small parts may feel less full and irregular.

8. Manoeuvre 3:

   Pawlik Grip
   Pawlik Grip

   Still facing the patient’s head, use the thumb and fingers of your dominant hand to grasp the presenting part just above the symphysis pubis. Slide the hand slightly towards the patient’s head and perform lateral and ballottement movements to confirm the presenting part, head size if applicable, and to determine whether the presenting part has engaged. The head feels like a smooth, firm, ballotable ball. The breech feels like an uneven, unballotable mass. An engaged presenting part does not move with lateral motions of the gripping hand.

9. Manoeuvre 4:

   Pelvic Grip
   Pelvic Grip

   Turn to face the patient’s feet. Place your hands on the presenting part as in the first manoeuvre, and move the fingers down to the pubis. In cephalic presentation, determine the flexion of the head. In a well-flexed head, the side of the head which offers most resistance to descent of the fingers is the brow, and it should be on the same side as the small parts. In a brow or face presentation, the side of the head which offers most resistance is the occiput, and it is on the same side as the back. Determine descent of the head. Descent is measured in fifths of the head felt above the brim of the pelvis. Each fifth corresponds to roughly a finger-breadth. If there is less than 3/5 palpable above the brim, the head is engaged.

10. Listen
    Listen

    Place the stethoscope, large cup down, on the fetal back between the shoulders. Release the stethoscope and press against it gently with your ear. Palpate the maternal radial pulse to help distinguish it from the fetal pulse.

    to the fetal heart with a Pinard stethoscope or bell of a standard stethoscope over the anterior fetal shoulder.

11. Record completion of the procedure in patient notes.

## Troubleshooting

The symphysis-fundal height measures more than the calculated gestational age

The patient needs an ultrasound assessment to confirm gestational age if less than 24 weeks, rule out multiple pregnancy and measure amniotic fluid index.

The symphysis-fundal height measures less than the calculated gestational age

The patient needs an ultrasound assessment to confirm the gestational age if less than 24 weeks, rule out intrauterine growth restriction and measure amniotic fluid index.

I feel uterine contractions when I palpate the abdomen.

This is likely due to uterine irritability, normal from 36 weeks. If the uterus is irritable before 36 weeks, it suggests intrauterine growth restriction.

The head feels too small for the size of the uterus.

This suggests multiple pregnancy. This patient needs an ultrasound assessment.

The head feels too hard for such a small head.

This suggests intrauterine growth restriction. This patient needs an ultrasound assessment.

It is very difficult to palpate anything.

This is common in obese patients, and in patients with polyhydramnios. This patient needs an ultrasound assessment.

## Risks

1. Aortocaval compression syndrome

2. Minor discomfort

## References

1. Superville SS, Siccardi MA. Leopold Maneuvers. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560814/

2. Woods D, Dyer S, Kennedy D. Women’s Health Care. Bettercare. 2021.