Lecture on Prenatal Assessment and Leopolds Maneuver

Prenatal Care
GTPAL
Naegele's Rule
Bartholomew's Rule
Haase's Rule
LMP

1. ANTE NATAL CARE PROF. MARA MAE DE GOROSTIZA - JABRICA, RN, RM, MAN

2. DEFINITION The care provided by a skilled Health care Professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy.

3. COMPONENTS RISK IDENTIFICATION PREVENTION AND MANAGEMENT OF PREGNANCY RELATED OR CONCURRENT DISEASE HEALTH EDUCATION HEALTH PROMOTION

4. OBJECTIVES REGULAR CHECK-UPS THAT ALLOW DOCTORS OR MIDWIVES TO TREAT AND PREVENT POTENTIAL HEALTH PROBLEMS THROUGHOUT THE PREGNANCY.

5. IMPORTANCE ENSURING A WOMAN HAS A HEALTHY PREGNANCY AND ALLOWING HER TO ASK QUESTIONS AND VOICE CONCERNS.

6. GOALS Promote the health of the mother, fetus, newborn, and family. Ensure a safe birth for mother and child by promoting good health habits and reducing risk factors. Teach health habits that may be continued after pregnancy. Educate in self-care for pregnancy. Develop a partnership with parents and family to provide continuous and coordinated health care. Provide physical care. Prepare parents for the responsibilities of parenthood.

7. PRENATAL ASSESSMENT

8. MEDICAL HISTORY Medical and surgical history Family history of the woman and her partner Psychosocial history of the woman and her partner

9. Medical and surgical history: Infections such as hepatitis or pyelonephritis; surgical procedures; trauma that involved the pelvis or reproductive organs Family history of the woman and her partner: To identify genetic or other factors that may pose a risk for the pregnancy Health history of the woman and her partner: To identify risk factors (e.g., genetic defects or use of alcohol, drugs, or tobacco) and possible blood incompatibility between the mother and the fetus Psychosocial history of the woman and her partner: To identify stability of lifestyle and ability to parent a child; significant cultural practices or health beliefs that may affect the pregnancy

10. OBSTETRICAL HISTORY Number and outcomes of past pregnancies; problems in the mother or infant

11. Menstrual history: Usual frequency of menstrual cycles and duration of flow; first day of the last normal menstrual period (LNMP) ; any “spotting” since LNMP Contraceptive history: Type used; whether an oral contraceptive was taken before the woman realized she might be pregnant; whether an intrauterine device is still in place

12. SCHEDULE OF PRENATAL VISITS (UNCOMPLICATED PREGNANCY) Conception to 28 weeks — every 4 weeks 29 to 36 weeks — every 2 to 3 weeks 37 weeks to birth — weekly

13. ROUTINE ASSESSMENT DURING PRENATAL CHECK UP • Review of known risk factors and assessment for new ones. • Vital signs: The woman’s blood pressure should be taken in the same arm and in the same position (horizontal and at heart level) each time for accurate comparison with her baseline value. • Weight to determine if the pattern of gain is normal: Low prepregnancy weight or inadequate gains are risk factors for preterm birth, a low-birth-weight infant, and other problems. A sudden, rapid weight gain is often associated with gestational hypertension. • Urinalysis for protein, glucose, and ketone levels. • Blood glucose screening between 24 and 28 weeks gestation: Additional testing is done if the result of this screening test is abnormal. • Hematocrit, group B streptococcus, and sexually transmitted infection testing may also be performed at 36 weeks gestation.

14. ROUTINE ASSESSMENT DURING PRENATAL CHECK UP • Fundal height to determine if the fetus is growing as expected and the volume of amniotic fluid is appropriate. • Leopold’s maneuvers to assess the presentation and position of the fetus by abdominal palpation (usually at about 36 weeks gestation). • Fetal heart rate: During very early pregnancy, the fetal heart rate is measured with a Doppler transducer; in later pregnancy, it may also be heard with a fetoscope. Beating of the fetal heart can be seen on ultrasound examination 8 weeks after LNMP. • Fetal activity (“kick count”) assessment may be done at 28 weeks and repeated as needed • Review of nutrition for adequacy of calorie intake and specific nutrients. • Discomforts or problems that have arisen since the last visit.

15. IMPORTANT TERMS TO REMEMBER Gravida : Any pregnancy, regardless of duration; also, the number of pregnancies including the one in progress. Nulligravida: A woman who has never been pregnant. Primigravida: A woman who is pregnant for the first time. Multigravida: A woman who has been pregnant before, regardless of the duration of the pregnancy. Para: A woman who has given birth to one or more children who reached the age of viability (20 weeks gestation), regardless of the number of fetuses delivered and regardless of whether those children are now living. Primipara: A woman who has given birth to her first child (past the point of viability), regardless of whether the child was alive at birth or is now living. The term is also used

16. IMPORTANT TERMS TO REMEMBER Multipara: A woman who has given birth to two or more children (past the point of viability), regardless of whether the children were alive at birth or are presently alive. The term is also used informally to describe a woman before the birth of her second child. Nullipara: A woman who has not given birth to a child who reached the point of viability. Abortion: Termination of pregnancy before viability (20 weeks gestation), either spontaneous or induced. Gestational age: Prenatal age of the developing fetus calculated from the first day of the woman’s LNMP. Fertilization age: Prenatal age of the developing fetus as calculated from the date of conception; approximately 2 weeks less than the gestational age. Age of viability : A fetus that has reached the stage (usually at 20 weeks) where it is capable of living outside of the uterus.

17. TPALM System to Describe Parity T P A L M Number of term infants born (infants born after at least 37 weeks gestation) Number of preterm infants born (infants born after 20 weeks or before 37 weeks gestation) Number of pregnancies aborted before 20 weeks gestation (spontaneously or induced) Number of children now living Multiple birth number of multiple gestations (optional)

18. Describing Pregnancy Outcome with GTPAL 1. G is gravidity, the number of pregnancies, including the present one. 2. T is term births, the number born at term (longer than 37 weeks’ gestation). 3. P is preterm births, the number born before 37 weeks’ gestation. 4. A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks’ gestation; included in parity if past 20 weeks’ gestation). 5. L is the number of current living children.

19. PRACTICE TEST A 23-year-old female is 25 weeks pregnant with triplets. She has a 4-year-old who was born at 36 weeks gestation. She has no history of miscarriage or abortion. What is her GTPAL? G2, T1, P0, A0, L1 G2, T0, P1, A0, L1 G3, T1, P0, A0, L1 G3, T0, P0, A0, L1

20. PRACTICE TEST A 23-year-old female is 25 weeks pregnant with triplets. She has a 4-year-old who was born at 36 weeks gestation. She has no history of miscarriage or abortion. What is her GTPAL? G2, T1, P0, A0, L1 G2, T0, P1, A0, L1 G3, T1, P0, A0, L1 G3, T0, P0, A0, L1

21. PRACTICE TEST 2. A 39 year old female is currently 18 weeks pregnant. She has two sets of twin daughters that were born at 38 and 39 weeks gestation and an 11 year-old son who was born at 32 weeks gestation. She has no history of miscarriage or abortion. What is her GTPAL? A. G4, T2, P2, A1, L5 B. G4, T1, P1, A0, L4 C. G4, T1, P2, A1, L4 D. G4, T2, P1, A0, L5

22. PRACTICE TEST 2. A 39 year old female is currently 18 weeks pregnant. She has two sets of twin daughters that were born at 38 and 39 weeks gestation and an 11 year-old son who was born at 32 weeks gestation. She has no history of miscarriage or abortion. What is her GTPAL? A. G4, T2, P2, A1, L5 B. G4, T1, P1, A0, L4 C. G4, T1, P2, A1, L4 D. G4, T2, P1, A0, L5

23. Nägele’s Rule

24. Nägele’s Rule Use to determine EDD (EXPECTED DATE OF DELIVERY) Must know the LMP ( Last Menstrual Period) FORMULA: January to March : + 9 Months +7 Days April to December: - 3 Months + 7 Days +1 Year

25. Question 1: LMP: January 5, 2024 01 05 2024 +9 months 10 + 7 days 10 12 2024 EDD:  October 12, 2024

26. Question 2: LMP: September 28, 2023 – 3 months June 28, 2023 + 7 days July 5, 2023 + 1 year EDD:  July 5, 2025

27. PRACTICE TEST LMP- March 20, 2023

28. PRACTICE TEST LMP: MARCH 20, 2023 03 20 2023 +9 +7 12 27 2023 December 27, 2023

29. PRACTICE TEST 2. LMP- August 26, 2024

30. PRACTICE TEST LMP: AUGUST 26, 2024 08 26 2024 -3 +7 +1 05 33 2025 +1 -31 06 02 2025 JUNE 02, 2025

31. McDonald's rule

32. McDonald's rule Measure uterine fundal height from symphysis pubis to top of uterine fundus. Between 18 and 32 weeks of gestation the fundal height measurements should approximate gestational age ( correlational) FIRST ACTION: EMPTY BLADDER FIRST POSITION: woman lie on her back with knees slightly flexed. EQUIPMENT: TAPE measure in "CM"

33. McDonald's rule: FORMULA AOG in weeks = Fundic height "cm" x 8/7 AOG in months = Fundic Height in "cm " x 2/7

34. Larger than Date Uterus M aternal Hydramnios M olar pregnancy M ultiple gestation M acrosomic baby ( LGA) M iscalculated AÓG

35. Larger than Date Uterus M aternal Hydramnios M olar pregnancy M ultiple gestation M acrosomic baby ( LGA) M iscalculated AÓG

36. Larger than Date Uterus M aternal Hydramnios M olar pregnancy M ultiple gestation M acrosomic baby ( LGA) M iscalculated AÓG

37. Larger than Date Uterus M aternal Hydramnios M olar pregnancy M ultiple gestation M acrosomic baby ( LGA) M iscalculated AÓG

38. Larger than Date Uterus M aternal Hydramnios M olar pregnancy M ultiple gestation M acrosomic baby ( LGA) M iscalculated AÓG

39. Larger than Date Uterus M aternal Hydramnios M olar pregnancy M ultiple gestation M acrosomic baby ( LGA) M iscalculated AÓG

40. Smaller than Date Uterus S GA baby / IUGR M issed abortion A nomalous baby L ength miscalculation L ow Amniotic Fluid (Oligohydramnios)

41. AOG based on check up date

42. DATE OF CHECK UP A pregnant mother with LMP of April 27 came for a clinic visit on AUGUST, 15. The mother is how many weeks pregnant?

43. LMP: April 27 April is 30 days -27 (Day of LMP) 3 days (April ) 31 days May 30 days June 31 days July 15 of AUGUST is the VISIT 110 days Visit: August 15 15 weeks and 5 days 7 ✔️ 110 7__ 40 35 ---------- 5

44. Bartholomew's Rule

45. Bartholomew's Rule calculates the estimated age of gestation ( aog ) of a fetus in relation to the the height of the fundus. According to this method, all you need to remember are 3 landmarks: S ymphysis pubis U mbilicus / Navel X iphoid process.

46. Bartholomews Rule of 4 12 weeks - Level of Symphisis pubis just above the Symphisis pubis just lies over the symphisis pubis uterus risen out of pelvic cavity uterus is considered now as abdominal organ 16 weeks - Midway between symphysis pubis and umbilicus 20-22 weeks - level of navel or level of umbilicus 28 weeks - *Midway between umbilicus and xiphoid process 36 - 38 weeks - Xiphoid process

47. Haase’s Rule

48. Haase’s Rule Used to determine length of fetus in cm Haase's rule: in first five months, crown heel length in cm = months squared in fifth to tenth month it is multiplied by 5

49. FORMULA  1-5 months (month) *(month) 1 month x 1 =1 cm 2 months × 2 = 4 cm 3 months x 3= 9 cm 4 months x 4 =16 cm 5 months x 5 = 25 cm

50. 6-10 months (month x5) 6 months × 5 = 30 cm 7 months x 5 = 35 cm 8 months x 5 = 40cm 9 months x 5 = 45 cm 10 months x 5 = 50 cm

51. Johnson's rule

52. Johnson's rule estimates fetal weight in grams which can only be used in cephalic vertex presentation Johnson's rule computation for (-) station Fundal height in cm - 12 × 155 Johnson's rule computation for (+) station Fundal height in cm - 11 × 155

53. LEOPOLD’S MANEUVER

54. a systematic four-step physical examination performed to evaluate the fetal lie, presentation, and position of the fetus in the uterus. These obstetric maneuvers are performed after 26 weeks of gestation .  It is when the fetus is matured enough that when you palpate the abdomen its outline can be easily distinguished.  According to studies, the accuracy of the Leopold maneuvers varies between 94% to 95% in a cephalic presentation when compared with ultrasonography. However, when the fetus is not in a cephalic presentation, the clinician’s ability to correctly determine the fetal position significantly decreases. ESSENTIAL SKILL TO ASSESS PRESENTATION, LIE AND POSITION OF THE BABY WITHIN THE UTERUS.

55. HISTORY The four classic obstetric grips known as  Leopold maneuvers  were first described and named after a German Gynecologist  Dr. Christian Gerhard Leopold  (1846–1911).

56. PURPOSE: TO DETERMINE 1. Fetal position - fetal position is described as fetal presentation in relation to mother’s pelvis. For example, right occiput anterior [ROA], left occiput anterior [LOA], left sacrum anterior [LSA], and more…) 2. Fetal lie - is described as where the fetus lies in relation to the mother’s back. For example, longitudinal lie, transverse lie, and oblique lie) - relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of the woman’s body.

57. PURPOSE: TO DETERMINE 3. Fetal presentation - first fetal part that presents into the maternal pelvis. - part of the fetus that overlies the maternal pelvic inlet 4. Fetal attitude - can be determined after head is engaged . - degree of extension/flexion of the fetal head during cephalic presentation 5. Fetal malposition 6. Approximate fetal weight and amount of amniotic fluid

58. PREREQUISITES BEFORE THE PROCEDURE Explain the Leopold maneuvers and their purpose to the pregnant mother Obtain verbal consent Ask the client to empty her bladder Position patient in supine and legs partially flexed from knees Ensure the patient is comfortable and relaxed Expose the tummy (from the xiphoid process to pubic symphsis ) and cover lower part of the body with a sheet to provide privacy Ensure your hands are warm prior to palpation

59. STEPS IN LEOPOLD’S MANEUVER

60. STEP 1: FUNDAL GRIP palpate the uppermost part of the abdomen. This maneuver answers the question “ What fetal part (i.e., head or buttocks) occupies the fundus (i.e., top of the uterus)? “ Hence, you will know the  fetal lie  by performing fundal grip or first Leopold maneuver. Additionally, at this step, fundal height is also measured. Purpose  of the  first Leopold maneuver  or the fundal grip is to determine  fetal lie  and  fundal   height .

61. STEP 1: FUNDAL GRIP How to perform the first Leopold maneuver – Fundal grip Stand client’s right side facing towards her face Warm-up both the hands Place both the hands over the fundal area Then, palpate from one hand while applying steady firm pressure with the other hand to make it easier to identify fetal parts

62. STEP 1: FUNDAL GRIP Findings If you feel broad, firm, irregular soft mass indicates fetal buttocks is in the fundus. It means  presentation is cephalic  and the  lie is longitudinal . This is the normal findings which promotes normal vaginal delivery. If you feel smooth, globular mass which is ballotable [bounces between the palpating hands – because head can move independently from its body] indicates fundus occupies the fetal head. It means presentation is breech – a malpresentation which must be documented and confirmed with ultrasonography for planning the safest mode of delivery for the mother and baby. If you feel the upper pole is empty, indicates a  transverse lie .

63. STEP 2: LATERAL OR UMBILICAL GRIP  answers “ On which maternal side   does the fetal back is located? ” The fetal’s back is the best location to auscultate its heart sound. Hence, the aim of this step is  to locate the fetal back and limbs . Additionally, you can determine the position (i.e., ROA, LOA, etc ) of the fetus at this step.

64. STEP 2: LATERAL OR UMBILICAL GRIP   How to perform the second Leopold maneuver – Lateral or Umbilical grip Stand facing the client as the first maneuver Place both hands on either side of the abdomen between flanks and umbilicus Then, while steadily supporting with the right hand, palpate with the left hand. Palpate using deep gentle pressure in slightly circular motion –  It will helps to easily identify the fetal parts . Repeat the steps on the other side as well using opposite hands

65. STEP 2: LATERAL OR UMBILICAL GRIP Findings If you feel continuous smooth structure indicates its fetal back. It is the best place to monitor fetal heart rate. You may use a fetoscope, stethoscope, or doppler to monitor fetal heart rate (FHR). If you feel irregular multiple knoblike structures indicates its fetal limbs Also, you will be able identify fetal body parts from amniotic fluids and the fetal position, whether its ROA, LOA, and more If the lie is transverse, head or breech may be palpable from one of the sides of maternal torso.

66. STEP 3: PAWLICK GRIP answers the question “ what is the presenting part? “ also referred as the first pelvic grip. The aim of this maneuver is  to evaluate presenting part into the pelvis and engagement .

67. STEP 3: PAWLICK GRIP How to perform the third Leopold maneuver – Pawlik’s grip Stand facing the client’s face same as the first and second maneuvers Wide open your right hand – thumb on one side and four fingers on the other side, grasp the lower pole of the uterus just above the symphysis pubis. Use your left hand to grasp the fundus at the same time. Then, try to move presenting fetal part between your thumb and four fingers. This maneuver usually causes some discomfort to the mother. So, be gentle and cautious during this step.

68. STEP 3: PAWLICK GRIP Findings If the lie is longitudinal and presentation is vertex, and head not engaged – you will feel the head of the fetus between your fingers. And it will be ballotable. If the presenting part is engaged ( i.e , presenting part has already descended into the pelvic inlet), you will feel the less distinct mass. If the presenting part is breech, the mass will feel much softer and smaller. Also, it won’t move independently of the body. If the lie is transverse, like the empty fundus, the lower pole of the uterus will also be empty. Hence no fetal parts will be palpable.

69. STEP 4: PELVIC GRIP answers the question “ Is the fetal head engaged in the pelvis and what is the attitude? “ This step will help you to confirm the presenting part of the fetus and its descent into the pelvis. If the presentation is vertex, you can determine the relation of the cephalic prominence to the fetal back to evaluate the  fetal attitude . Additionally, you can determine the degree of engagement. Hence, confirming the findings of the third maneuver.

70. STEP 4: PELVIC GRIP How to perform the fourth Leopold maneuver – Deep pelvic grip In this step, stand facing towards client’s feet. This is the only maneuver performed facing towards the woman’s feet. Place hands below the umbilicus, parallel to inguinal, and walk fingers around presenting part towards the midline and symphysis pubis.

71. STEP 4: PELVIC GRIP Findings If the fingers of both hands meet (converge) below presenting part indicates presenting part is floating (i.e., not engaged yet) If the fingers of both hands diverge below the presenting part indicates presenting part is now engaged. In vertex presentation, if cephalic prominence is felt on the opposite side of the back indicates that the fetal head is well flexed. If the head is deflexed or extended as in brow and face presentation – you can palpate cephalic prominence on the same side as the back, but you will feel a groove between the cephalic prominence and fetal back. You should be able to confirm the findings of Pawlik’s grip

72. CONSIDERATIONS Leopold maneuvers should not be performed during uterine contractions. do not have any significant complications. It may cause mild discomfort to the mother especially during the third maneuver. And some very rare cases, it may trigger uterine contractions. Leopold maneuvers are an easy and cost-effective method of assessing pregnant women. However, the accuracy of the findings is heavily dependent on the skills and competency of the examiner.

73. REVIEW OF TERMS LEOPOLD’S MANEUVER 1. FUNDAL GRIP 2. LATERAL GRIP/UMBILICAL GRIP 3. PAWLICK GRIP 4. PELVIC GRIP