These maneuvers are important adjuncts to palpation of the pregnant abdomen beginning at 28 weeks of gestation. They help determine where the fetus is lying in relation to the woman's back (longitudinal or transverse), what end of the fetus is presenting at the pelvic inlet (head or buttocks), where the fetal back is located, how far the presenting part of the fetus has descended into the maternal pelvis, and the estimated weight of the fetus. This information is necessary to assess the adequacy of fetal growth and the probability of successful vaginal birth.
First Maneuver (Upper Pole). Stand at the woman's side facing her head. Keeping the fingers of both examining hands together, palpate gently with the fingertips to determine what part of the fetus is in the upper pole of the uterine fundus.
Common deviations include breech presentation (the fetal buttocks presenting at the outlet of the maternal pelvis) and absence of the presenting part well down into the maternal pelvis at term. Neither situation necessarily precludes vaginal birth. The most serious findings are a transverse lie close to term and slowed fetal growth that could represent intrauterine growth retardation (IUGR).
Most commonly, the fetal buttocks are at the upper pole. They feel firm but irregular, and less globular than the head. The fetal head feels firm, round, and smooth.
Second Maneuver (Sides of the Maternal Abdomen). Place one hand on each side of the woman's abdomen, aiming to capture the body of the fetus between them. Use one hand to steady the uterus and the other to palpate the fetus.
The hand on the fetal back feels a smooth, firm surface the length of the hand (or longer) by 32 weeks of gestation. The hand on the fetal arms and legs feels irregular bumps, and also perhaps kicking if the fetus is awake and active.
Third Maneuver (Lower
Pole). Turn and face the woman's feet. Using the flat palmar surfaces of the fingers of both hands and, at the start, touching the fingertips together, palpate the area just above the symphysis pubis. Note whether the hands diverge with downward pressure or stay together. This tells you whether or not the presenting part of the fetus, head or buttocks, is descending into the pelvic inlet.
If the fetal head is presenting, the fingers feel a smooth, firm, rounded surface on both sides.
If the hands diverge, the presenting part is descending into the pelvic inlet, as illustrated.
If the hands stay together and you can gently depress the tissue over the bladder without touching the fetus, the presenting part is above your hands.
If the presenting fetal part is descending, palpate its texture and firmness. If not, gently move your hands up the lower abdomen and capture the presenting part between your hands.
Fourth Maneuver (Confirmation of the Presenting Part). With your dominant hand grasp the part of the fetus in the lower pole, and with your nondominant hand, the part of the fetus in the upper pole. With this maneuver, you may be able to distinguish between the head and the buttocks.
The fetal head feels smooth, firm, and rounded; the buttocks, firm but irregular.
Most commonly, the head is in the lower pole and the fetal buttocks are in the upper pole. If the head is above the pelvic inlet, it moves somewhat independently of the rest of the fetal body.
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