PERFORMING FUNDIC HEIGHT MEASUREMENT, LEOPOLD’S MANEUVER

AND DETERMINATION OF THE POINTS OF MAXIMAL INTENSITY FOR FHT

( FETAL HEART TONE )
Purpose:
1. To estimate fetal size and 3. To determine the number of
height of the fundus fetus in the uterine cavity.
2. To systematically observe and 4. To determine the landmark for
palpate the abdomen to fetal heart tone.
determine fetal presentation
and position.

Materials/ Equipment needed/ required:

1. Examining table with bed 3. Tape measure
sheet cover, pillow with pillow 4. Stethoscope
case. 5. Wristwatch with second hand
2. Bed sheet to cover the client 6. Screen

Assessment:
1. Assess Client’s age of gestation
( AOG)
2. Assess for general appearance
of the abdomen and abdominal
scar’s
3. Assess client general
appearance and condition
4. Assess the urinary bladder area
for distention.
Nursing Diagnoses:
1. Anxiety related to findings of fetal presentation and position
2. Potential for injury to mother and fetus related to manipulation during the maneuver.

Outcome Identification and Planning:

1. Washes hands
2. Prepares materials needed.
3. Ask client to empty bladder if able; if unable serve a bed pan.

Expected Outcome:
1. Client will verbalize acceptance on the present condition gradually
2. Client will report no untoward signs of injury.

DETERMINATION OF PMI OF FHT

Wash hands .
Perform Leopold maneuvers.
Auscultate fetal heart tones (FHTs)based on fetal presentation RUQ LUQ
identified with Leopold maneuvers. The PMI is the location where
the FHTs are heard the loudest, usually over the fetal .

Chart PMI of FHTs using a two-line figure indicate the four

quadrants of he maternal abdomen , as follows; right upper RLQ LLQ
quadrant (RUQ) left upper quadrant (LUQ), left lower quadrant
(LLQ) and right lower quadrant (RLQ).

The umbilicus is the reference point for the

quadrants ( point where the lines cross). The PMI for
the fetus in vertex presentation in general flexion with
X 140
the back on the mother’s right side , commonly is
found in the mother’s right lower quadrant and is
recorded with an “ X “ or with the FHT, as follows
FUNDIC HEIGHT MEASUREMENT
IMPLEMENTATION
Nursing Action Rationale
Assessment  To determine month/ weeks of
1. Assess the client AOG gestation
(7 mos. Or 28 weeks.)
2. Assess general appearance of the  Previous surgery can leave
abdomen and condition of the client. adhesion.
 An overall impression of the child’s
mother health and well-being can
provide information and guidance on
ways to alleviate discomforts of
pregnancy.
Planning
3. Washes hands
4. Prepares materials needed
5. Explains procedure to the client.  Reduces anxiety and ensures
cooperation of client.
6. Asks client to empty bladder.  A distended bladder would interfere
with the findings and would increase
maternal discomfort during
examination
7. Washes hands before starting  Prevents the spread of
microorganism.
8. Provides privacy by using screen/  Avoids embarrassment
closing the door.

9. Asks client to lie flat on back  Relive tension on the abdominal

( supine/dorsal recumbent position) muscles and for clients comfort.

10. Covers client with bed sheet, expose  Ensures privacy and dignity of
the area to be examined, by folding down client.
to the symphysis pubis the bed sheet,
lower down to symphysis pubis the
underwear and folder up to the xiphoid
process the clothes.
11. Rubs both hands together or  Cold hands will contract abdominal
submerge hands in warm water before muscles and for clients comfort.
touching the client.
12. The top of the fundus is palpated and  Estimate fetal size; should be at the
a tape measure in centimeters is level of the xiphoid process at term 36
stretched from the top of the symphysis weeks; over the symphysis pubis at 12
pubis over the abdominal curve to the weeks; at the umbilicus at 20 weeks.
top of the fundus.

LEOPOLDS MANEUVER

1st Maneuver  Facilitates examination by using the

13. Stand facing the head part of the dominant hand.
client. If right handed stand on the right
side, if left handed stands on the left side
of the client.
14. Palpates the upper abdomen by  Identifies fetal lie and presentation
putting palms of both hands on the side
of the upper abdomen.
15. Identifies the fetal part that occupies  One finds a mass which is either
the fundus. the hand or the buttocks of the fetus
2nd Maneuver  Helps in detecting the fetal back
1. Still facing the client put both hands and fetal small parts.
on either side of the abdomen and
apply gentle but deep pressure.
17. Holding on side of the abdomen
steady with the other hand or the
opposite side, gradually palpate from top
to the lower segment of the abdomen, to
feel the fetal outline with a slightly
circular motion.
18. Repeats the same procedure on the
opposite side.

19. Identifies the fetal parts.  A smooth hard resistant plane

would mean that the fetal part is the
back-landmark for checking fetal heart
tone. Numerous, angular nodulations
would mean that the fetal parts are the
knees and elbows.

20. Auscultates fetal heart tone for one  Normal FHT is 120-160 beats per
full minute correctly. minute. Determines fetal well-being.
3rd Maneuver  Confirms presenting part and helps
21. With the right hand gently grasps the identify degree of descent.
lower portion of the abdomen just above
the thumb and the fingers of the hand
pressing together with a downward
upward movement ( pawlicks grasp)


22. Identifies the presenting part  Head – Hard, round, smooth, freely
ballotment
 Buttocks – if breech, presentation,
soft, globular, non-ballotable.

4th Maneuver  Helps in identifying the degree of

23. Turns and faces the client’s thighs. flexion, position and station of the
Put both palms on the sides of the fetus.
abdomen just above the inguinal
ligament, grasping snugly the lower
abdomen with your fingers meeting
below the lower abdomen and the
outstretched thumbs meeting at the
umbilical level.

Evaluation:

1. Client claimed no untoward sign of injury felt during the maneuver.

2. Client showed evidence of gradual acceptance on the findings/ present condition.

Documentation:

The following findings must be recorded on the client’s chart:

a. Fundic Height in cm.
b. Fetal presentation
c. Fetal Position
d. Number of fetus
e. Fetal Heart tone per minute
Reference:
 Silbert-Flagg and Pillitteri (2018).Maternal & Child Health Nursing, Care of the Childbearing
and Childrearing Family 8th Ed.
 Pillitteri, Adele (2014). Maternal & Child Health Nursing, Care of the Childbearing and
Childrearing Family 7th Ed.
 Pilliteri A. (2007) Care of the Child Bearing and Child Rearing Family. 5 th Edition Lippincott
Williams & Wilkins.
 Doenges, H. & M. ( 2006). Nurses Pocket Guide Diagnoses Prioritized Intervention and
Rationale 10th Edition.
 Smith T., Jean & Johnson, Young, J. (2006). Nurses Guide to Clinical Procedures. 5 th Edition.
Philadephia: Lippincott Williams & Wilkin.
 Woodring B.C. (2005)Pediatric Nursing Made Incredibly Easy. Lippincott, Williams & Wilkins.
 Udan Q.J. (2004) Mastering Fundamentals of Nursing Concepts and Clinical Application 2 nd
Edition. Educational Publishing House.
 Engstrom, J. ( 2004). Maternal-Neonatal Nursing, Made Incredibly Easy. Lippioncott Williams
& Wilkins.

PERFORMING FUNDIC HEIGHT MEASUREMENT, LEOPOLD’S MANEUVER

AND DETERMINATION OF THE POINTS OF MAXIMAL INTENSITY FOR FHTs
( FETAL HEART TONE )
Evaluation Tool

1 2 3 4 5
Assessment
1. Assess clients AOG
2. Assess general appearance of the abdomen and condition of the
client.
Planning
3. Washes hands.
4. Prepares materials needed.
5. Explain the procedure to the client.
6. Ask client to empty bladder.
7. Washes hands before starting.
8. Provide privacy by using screen/ closing the door.
9. Ask client to lie flat on back (supine/ dorsal recumbent position)
10. Cover client with bed sheet, expose the area to be examined, by
folding down to the symphysis pubis the underwear and folder up to
the xiphoid process the clothes.
11. Rub both hands together or submerge hands in warm water
before touching the client.
FUNDAL HEIGHT MEASUREMENT
12. The top of the fundus is palpated and a tape measure in
centimeters is stretched from the top of the symphysis pubis over
the abdominal curve to the top of the fundus.
LEOPOLDS MANEUVER
1ST Maneuver
13. Stand facing the head part of the client. If right handed stand on
the right side, if left handed stands on the left side of the client.
14. Palpate the upper abdomen by putting pals of both hands on
the side of the upper abdomen.
15. Identify the fetal parts that occupy the fundus.
2nd Maneuver
16. Still facing the client put both hands on either side of the
abdomen and apply gentle but deep pressure.
17. Holding one side of the abdomen steady with the other hand or
the opposite side, gradually palpate from top to the lower segment
of the abdomen, to feel the fetal outline with a slightly circular
motion.
18. Repeat the same procedure on the opposite side.
19. Identify the fetal parts.
20. Auscultate fetal heart tone for one full minute correctly.
3rd Maneuver
21. With the right hand gently grasp the lower portion of the
abdomen just above the thumb and the fingers of the hand pressing
together with a downward upward movement ( paw licks grasp)
22. Identify the presenting part
4th Maneuver
23. Turn and face the client’s thighs. Put both palms on the sides of
the abdomen just above the inguinal ligament, grasping snugly the
lower abdomen with your fingers meeting below the lower abdomen
and the outstretched thumbs meeting at the umbilical level.
24. Identify the degree of flexion, position and station of spring
presenting parts.
Evaluation
25. Evaluates the response of the client on the procedure.
Documentation
26. The following findings must be recorded on the client’s chart:
a. Fundic Height in cm.
b. Fetal presentation
c. Fetal Position
d. Number of Fetus
e. Fetal Heart tone
( checked one full minute )location

Legend: (5) Performs the task excellently

(4) Performs the task Very Satisfactory
(3) Performs the task Satisfactory
(2) Performs the task fairly
(1) Performs the task poorly

Rating Score

1.0 ---- 124 --130 Total Score :_____________

1.25 ---- 117 ---- 123

1.5 ---- 111 ---- 116 Rating: ________________

1.75 ---- 104 ---- 110

2.0 ---- 98 ---- 103 Student Signature : _____________

2.25 ---- 91 ---- 97

2.5 ---- 85 ---- 90 C.I. Signature : ________________

2.75 ---- 78 ---- 84

3.0 ---- 72 ---- 77 MPL Date : ____________________