Leopold Maneuver

Named after gynecologist Christian Gerhard Leopold, Leopold maneuver is used to determine the position, presentation and engagement of the fetus within the mother's womb. This technique may be used to determine the fetal weight too. It is usually performed by a qualified doctor. The maneuvers include four different moves or actions that are very important and critical as each of them helps determine the position of the fetus. Leopold maneuver is preferably performed after 24 weeks of gestation when the fetal line can be palpitated. Though this maneuver cannot be equated to an ultrasound, it can be useful if the person performing the technique is competent enough to make the right assessment.

Leopold's maneuver helps determine

• What is in the fundus
  
• Determination of the direction and degree of flexion of the head
  
• Evaluation of fetal back and extremities
  
• Palpation of the presenting part above the symphysis.
  

The mother is placed in the dorsal recumbent position, wherein the supine with the knees is flexed to relax the abdomen. The hands are usually rubbed together so that they don't get cold, as cold hands may lead to uterine contractions. Finger should not be used for palpation. Palms are used for palpation.

The four maneuvers

First maneuver fundal grip: Helps in determining the presentation and to understand the fetal part that is lying in the fundus. Both the hands are used to find the fetal part that is lying in the fundus.

• If a firm hard, round object that moves independently is felt, then it is the head.
  
• A soft, irregular shape that is more difficult to move means that the buttock is in the fundus and this means breech position.
  

Second maneuver Umbilical grip: Helps determine the spine of the fetus and helps determine the position of the baby. One hand is placed to steady the uterus while the other is moved slightly in circular motion from the top to the lower segment of the uterus to feel the back of the baby. Gentle yet deep pressure is used.

• Fetal spine is felt.
  
• Knees and elbows (small extremities) are felt like small protrusions.
  

Third maneuver Pawlik's grip: Determines the engagement of the presenting body. The thumb and finger is used to grasp the lower portion of the abdomen and slight movements are made from side to side by pressing lightly.

• Presenting part is engaged if it is not movable.
  
• Presenting part is not engaged if it is movable.
  

Fourth maneuver Pelvic grip: Determines the degree of flexion of the fetal head. Using both hands, palpate fetal head pressing downward about 2 inches above the inguinal ligament.

• If the cephalic prominence is felt on the same side as the small parts it indicates that the fetus is in vertex presentation.
  
• If the cephalic prominence is on the same side as the back it indicates that the head is extended and the fetus is in face presentation.

Breech baby

By 8 months, the baby in the womb positions itself as it does not have much place to move about. Most babies position themselves head-down otherwise known as cephalic position during this time. In very few cases the baby positions itself feet-down or in breech presentation.

By the beginning of the third trimester, the medical practitioner will physically feel the mother's abdomen and will be able to tell the positioning of the baby. This is usually done using Leopold's maneuver. Location of the heart beat, position of the baby's bottom and head helps the doctor determine the position of the baby. About 25% babies are positioned breech during this time but they turn to normal position on their own within the next couple of months.

When the mother is approaching full term and the baby is still positioned breech, the medical practitioner may conduct a pelvic examination or an ultrasound to confirm the positioning of the baby. At 37 weeks about 3-4% babies are in breech position. Even after 37 weeks if the baby is presenting breech position then it might not turn on its own to the cephalic position. In general breech babies are delivered through a cesarean section. Generally normal delivery is not advised for a breech position baby when:

• The baby is large
  
• Baby is very small
  
• Mother has narrow pelvis
  
• Mother has a low lying placenta
  
• Baby's feet are below its bottom.
  

Breech types

Frank breech: Bottom first with feet up near the head (feet straight up).

Complete breech: Bottom first with legs crossed in Indian style.

Footling breech (incomplete breech: One or both feet are positioned to come out first.

Stargazers: When the baby is in any one of the above mentioned positions but is extending its neck completely as though it is watching a star it is called as stargazer. Babies positioned like this are usually delivered using c-section.

Helping baby from breech to cephalic

ECV: External Cephalic Version is a procedure wherein pressure is applied to the mother's abdomen for manual manipulation of the baby's position. The pressure helps the baby take a head-down position. ECV has its own limitations and many a times the baby moves back to the breech position. Women with pregnancy complications like low amniotic acid, bleeding and twins cannot undergo this procedure.

Tilt position: The Breech Tilt inversion technique is used to help a breech baby flip to a head-down position. The mother is asked to lie on a couch placing her feet up on an ironing board. The head is positioned down while the feet are placed up. 20 minutes a day is the recommended duration. This exercise needs to be done only after approval from the authorized medical personnel or midwife.

Chances of having a breech baby

A mother who has had one or more of the following conditions may have a breech baby: multiple pregnancies, excessive amniotic fluid, baby having anomalies, placenta lying low, uterus anomalies and Placenta previa.

Macrosomia

Macrosomia is a condition in which a baby is unusually large before birth. The baby's weight could be more than 8-9 pounds. Babies born with macrosomia might suffer from jaundice, low blood sugar, respiratory distress, etc. Pregnant women who gain weight rapidly and have a heavy stomach might be at risk for macrosomia. Women with large fundal height, the distance from top of the uterus to the pubic bone might indicate Macrosomia.

Managing Macrosomia

Gestational diabetes or diabetes mellitus is usually the main cause for macromasia. Obesity and genetic factors also play a role. Ultrasound during the third trimester to measure the child's head, femur and abdomen gives an indication of possible Macrosomia. A Leopold maneuver wherein the fetal weight is estimated by pushing the stomach through the abdomen is another diagnostic measure. Often a non-stress test is done to measure the baby's heart rate based on its movements. A cesarean delivery is usually conducted when macrosomia is noticed.