Maternity - L&D, part 5: Fetal Assessment: Leopold Maneuvers, Fetal Heart Rate Monitoring

by Meris Shuwarger BSN, RN, CEN, TCRN September 18, 2021 Updated: June 16, 2022 9 min read

This article continues our discussion of fetal assessment, specifically Leopold maneuvers and fetal heart rate monitoring during labor and delivery.

The Maternity Nursing series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Leopold maneuvers

Named for the gynecologist Christian Gerhard Leopold, Leopold maneuvers are a technique used to assess a pregnant patient to determine where and how the baby is lying, without an invasive procedure.

This assessment provides helpful information about fetal attitude, fetal presentation, and fetal position. Leopold maneuvers use external palpation (touch) of the uterus through the abdomen to determine the presenting part, fetal lie, fetal attitude, and point of maximal impulse, also known as PMI, which is the optimal location for listening to the baby’s heartbeat.

Leopold maneuvers are also used to determine the placement of external transducers for fetal monitoring.

Leopold maneuvers — technique

Step 1. With the patient supine, palpate the uterine fundus (the top of the uterus) to distinguish the fetus’s position. Is the baby lying in a cephalic (head down) or breech (feet down) position?

Step 2. Starting at the top, feel along both sides of the uterus to identify the location of the fetal back. The baby’s back will feel smooth, versus the pointier parts of the fetus like the knees and elbows.

Step 3. Palpate above the pubic bone and “pinch” the presenting part in an attempt to distinguish how engaged the fetus is in relation to the pelvis. If part of the fetus is pushed upward, that means it is not fully engaged in the pelvis; if there is difficulty moving the pinched part, that indicates that the fetus is engaged in the maternal pelvis.

Step 4. For a cephalic presentation, face the patient's feet and use your fingers to feel for the baby’s face. Is the fetal head flexed (in a vertex position with chin and limbs tucked, i.e., normal) or extended (face up)?

Fetal heart rate monitoring: external and internal

The fetal heart rate may be monitored or assessed either externally or internally.

External fetal heart rate monitoring

The most common way to monitor the fetal heart rate is using an ultrasound transducer, a non-invasive procedure. A transducer is placed over the point of maximal impulse (PMI), the location on the patient’s abdomen where fetal heart tones can be heard best. A water-soluble gel is applied to the abdomen (and/or on the ultrasound device) to promote sound transmission, and the transducer is held in place with an elastic belt.

Additionally, a pressure-sensitive device known as a tocodynamometer (sometimes shortened to tocometer) is placed at the fundus (top) of the uterus. This is used to measure the strength of the patient’s contractions. Contractions may be viewed on the device as they occur, and the tocometer indicates the strength of each contraction, as well as how long they last.

Used in combination, these two monitors help to assess the fetus’s well-being during labor. For example, how are contractions affecting the baby’s heart rate?

Placement of the heart rate transducer

The heart rate transducer should be placed based on the baby’s position.

If the baby is breech, the transducer is placed on the upper quadrants of the patient’s belly, depending on which way the fetus is facing.

If the baby is cephalic or vertex (head down), then the transducer is placed on the lower quadrant to best assess the fetal heart rate.

Additionally, “listening,” is done through the baby’s back. This is because, if the baby is tucked tightly, it is hard to get a good reading from the front.

Internal fetal heart rate monitoring

Occasionally, it is hard to get an external FHR reading. Perhaps the baby keeps falling off the monitor, forcing frequent adjustments. When the external monitor cannot give an adequate explanation, or if it is disrupting the patient’s rest, or in the event of a high-risk situation or emergency, an internal fetal heart rate monitor may be used.

The internal fetal heart rate monitor is a small electrode that is placed on the presenting part of the fetus and may be used with intrauterine pressure catheter (IUPC). That means it could be placed on a foot or the scapula, for example. Typically, it will be the head. The internal heart rate monitor, when in place, provides a good assessment of what’s going on with the fetus and allows for continuous monitoring.

Risk for infection when using an internal fetal heart rate monitor

The electrode is a tiny needle that will be going inside the patient to get an FHR reading. Because it is penetrating the patient, there will be a concern about the potential for infection.

An internal heart rate monitor should never be used on a patient with HIV/AIDS. This is because, when using an internal heart rate monitor, the membranes must be ruptured when inserting the needle, and that could cause blood mixing, which increases the risk of infection and injury to the patient and/or fetus.

Nursing care when using an internal fetal heart rate monitor

Patients may become concerned about the use of this invasive device. Because of the environment inside of the womb — everything is wet, the baby is covered in fluids and membranes — it is not enough to simply stick an electrode in as, for example, electrodes are put in a patient’s chest for EKG monitoring. When using an internal fetal heart rate monitor, the device must be lightly screwed into the skin, fractionally, to keep it in place. This is what allows for continuous monitoring.


Full Transcript

Hi, I'm Meris, and in this video, I'm going to be talking to you about Leopold maneuvers along with fetal heart rate monitoring during labor and delivery. I'm going to be following along using our maternity flashcards. These are available on our website, LevelUpRN.com, and I would very much encourage you to get a set for yourself because there's so much more great information than I cover in these videos. If you have a set for yourself, I would definitely invite you to follow along with me. Okay, let's get started.

So first up, we're talking about Leopold maneuvers. So they're named after a guy, Dr. Leopold, who developed a technique to assess a pregnant patient to determine where the baby is, essentially. So this is going to give us some information about the fetal attitude, fetal presentation and position, all of those sorts of good things, without doing anything invasive. So it's a really great assessment tool. So you'll see here that we actually do have two cards on it.

The first card is going to be step by step instructions and then the second one uses drawings, a graphic representation to help it make sense.

So the first step is to palpate the fundus, which is the top of the uterus, to help to determine what's up at the top, right? Am I feeling feet, meaning that the head is down? Or am I feeling a nice round structure, meaning that the head is up at the top of the uterus? So this isn't a cool chicken hint in here. This is just how I remember it. You start at the top, right? Whenever you tell a story, they're like, all right, tell me from the top, start from the top. So that's how I remember this. The first thing you're going to do is place your hands at the top of the patient's uterus, which is the fundus, to assess what is there.

Moving on. Then we're going to feel along both sides of the uterus. And what I'm feeling for here is basically, where is the baby's back? Because that is going to be smooth. I can feel that versus kind of the jagged pointy edges and things of the baby being all curled up with their hands and feet and knees and elbows. That's going to feel differently. So start at the top, then feel along the sides, feeling for the fetal back.

Then the next thing I'm going to do is palpate above the pubic bone and kind of pinch it. It's not pinching, but you're grabbing it, right? You're trying to see if you can identify what exactly is there. And also, is it something that is going to be pushed up if it's not engaged? But if I can't move it when I'm pinching it, that means we're fully engaged in the pelvis.

And then lastly, if I have a cephalic presentation, meaning that the baby is head down, right, the good position, then the next thing I'm going to do is I'm going to use my fingers to feel, basically, where is the baby's face, right? I'm going to see, is the head flex? Is it extended? What's going on here? This is going to help me to establish the fetal attitude because again, I don't want baby presenting like this, right? I don't want that going through mom's pelvis. That's not a good position. I want it to be nice and tucked in.

So that's Leopold maneuvers, and you can see here that we have-- I just think, again, I think these little illustrations are just beautiful in this deck and really, really helpful because these are really complex ideas and they're not easy to understand if you haven't seen it before. So I really, really like our illustrations, but here you can see we start at the top. We feel along the sides of the uterus. Then we're going to pinch the part that's right above the pubic bone. And then if we're cephalic, then I'm going to try and identify the fetal attitude.

Now, moving on to fetal heart rate assessment. So FHR. And we have different ways of doing this. We have external fetal heart rate assessment and internal monitoring.

So external is what you're probably used to seeing. This is going to be the straps that are going across the patient's belly. There's usually two transducers there measuring two different things, and that's what you're used to seeing. So that's external. And what's going on here is we have the tocometer is going to be at the top of the fundus of the uterus and that's going to measure the strength of contraction. So we'll actually be able to see these contractions happening. We can tell how strong they are, how long they last. Very helpful diagnostic tool. The other is going to be the fetal heart rate transducer, which requires ultrasound jelly, and that's going to actually tell us about what the fetus's heart rate is, right? And the two things in combination allow us to assess the fetus's well-being during labor. So during contractions, what's happening to the baby's heart rate? Very important to understand, too, that the place where I put the heart rate transducer changes, and I'm going to skip ahead one card and show you.

We have this nice illustration that shows you where I should be putting the heart rate transducer based on baby's positioning. So if baby is breech, we're going to be in these upper quadrants here, depending on which way they're facing. But if baby is cephalic or vertex, head down, then I'm going to be using this lower quadrant in order to identify the fetal heart rate. Now, where am I going to be doing this? It's a little counterintuitive, but it's where the fetal back is. I'm going to be listening to the heart rate through the baby's back versus through-- when they're all tucked in nice and tight like this, it's hard to get a good reading there. So along the fetal back is where we're going to place that transducer. Now, sometimes we have babies who just keep falling off the monitor. We're adjusting them every five and a half seconds, and it's not giving us adequate explanation of what's going on, and it's disrupting our patient's rest, right? That's not good. And then sometimes we also have some other things going on, maybe a high risk situation or maybe we're seeing things happening, but we want to investigate, is that really what's going on?

We then can place an internal fetal heart rate monitor. And now this is a little electrode that is placed on the presenting part of the fetus, so it could be the foot or the scapula, whatever. But typically it's going to be the head and it has a very, very tiny needle. Patients can get really concerned about this, totally understandably. But we can't just-- everything's wet in there, right? Baby's covered in fluids and membranes. So it's not enough to just stick an electrode the way you would on a patient's chest for EKG monitoring, it actually just very lightly screws into the skin just a little bit to keep it in place. This is going to give us a really good assessment of what's going on with the fetus and allow us to have that continuous monitoring.

But what did I just tell you? It's going inside the patient and has a needle. I am concerned about what? Infection, right? So this is not something I would ever want to do if I'm concerned that the patient is already at risk for infection, or I would never want to do this with a patient who has which condition? Pause it for a minute and think about it. Okay, I hope you paused it. HIV or AIDS, right? Very important. We would hopefully be doing a C-section, but let's say that this were an emergency delivery or a precipitous delivery. We would not want to put that internal electrode because that could cause blood mixing, right? And the other thing is that we do have to have the membranes ruptured in order to place this. I can't place it through the membrane. So this would be something that would need to be done beforehand or have to have happened beforehand.

So I hope all of that was helpful. If it was, please like this video so that I know. I would love to hear if you have a great way to remember something. Leave me a comment. I read all the comments, so I would love to see how you remember things. Thanks so much and happy studying.


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