The presentation of the foetus can usually be determined by external examination from the 28th week of pregnancy onwards. Try to obtain as much information as possible by making the palpation as specific as possible.
Procedure
- Stand facing the head of the supine woman.
- Place your hands on both sides of the fundus and apply careful pressure to make contact with the foetus in the fundus, using the flat of the hand (second part of the first Leopold’s manoeuvre [Figure 16]). A large, moderately firm mass that feels irregular is indicative of the rump; the child is then in the head presentation. If the head is in the fundus, it will feel hard, smooth and round. If it is pushed away with one hand, then it can be felt coming against the other hand (ballottement).
Figure 16
- Next, support the uterus contralaterally with the non-palpating hand.
- With the flat of your fingers and keeping your fingers together, feel the lateral region. Feel for uniform or non-uniform resistance (second Leopold’s manoeuvre [Figure 17]). Determine the position of the back of the foetus. This is the position with the most uniform resistance. The determination of the position of the back is simpler if the fundus is pushed downwards, as a result of which the curvature of the back increases (Ahlfeld’s manipulation [Figure 18]). The back is then easier to feel.
Figure 17
Figure 18
- Now, stand with your back to the woman’s head.
- Place the palms of the hands next to the presenting part and carefully feel this. If the presenting part is hard, smooth and round it is probably a head presentation. The more the presenting part has dropped (engaged), the more difficult it will be to determine the presentation. The skull has dropped (engaged) if the widest part of the skull has passed through the pelvic brim. If during an internal examination the head is in the occiput posterior position, it will be located just beyond the third Hodge’s plane. Hodge’s planes are explained in “The Management of Child Birth – Supervision of the Dilation Phase“. If it is above or just in the pelvic brim, ballottement can often be induced in the case of a head presentation. An alternative method is, still facing the woman, to cover the presenting part with the entire right hand and by doing this to try to induce ballottement (third Leopold’s manoeuvre [Figure 19]).
Figure 19