Leopold's Maneuvers

Leopold's maneuvers are four specific steps in palpating the uterus through the abdomen in order to
determine the lie and presentation of the fetus. In summary the steps are :

Step 1. The top of the uterus (fundus) is felt (palpated) to establish which end of the fetus (fetal pole) is
in the upper part of the uterus. If either the head or breech (buttocks) of the fetus are in the fundus
then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.

Step 2. Firm pressure is applied to the sides of the abdomen to establish the location of the spine and
extremities (small parts).

Step 3. Using the thumb and fingers of one hand the lower abdomen is grasped just above the pubic
symphysis to establish if the presenting part is engaged. If not engaged a movable body part will be felt.
The presenting part is the part of the fetus that is felt to be in closest proximity to the birth canal.

Step 4. Facing the maternal feet the tips of the fingers of each hand are used to apply deep pressure in
the direction of the axis of the pelvic outlet. If the head presents, one hand is arrested sooner than the
other by a rounded body (the cephalic prominence) while the other hand descends deeply into the
pelvis. If the cephalic prominence is on the same side as the small parts, then the fetus is in vertex
presentation. If the cephalic prominence is on the same side as the back , then the head is extended and
the fetus is in face presentation.

OB SCORE GPTAL

1. Definitions

a. Gravida = pregnant woman

b. Gravidity = number of pregnancies

c. Parity = the number of births carried to a viability (at least 20 weeks)

i. Whether or not the fetus was born alive

d. Nullipara = never given birth

i. Includes miscarriage or abortion prior to 20 weeks

2. G/P

a. Used in clinical setting to record the gravidity and parity

b. Often written ie: G2/P1

i. Someone in second pregnancy with 1 successful birth previously

Nursing Points
General
1. Use of GTPAL acronym
a. More detailed breakdown of  parity
b. G-Gravidity = Number of pregnancies, including any current pregnancies
(regardless of current gestational age)
c. T-Term births = Number of pregnancies carried to 37+ weeks
d. P-Preterm births = Number of births between 20-37 weeks
e. A-Abortions/Miscarriages = number of pregnancies which ended in
miscarriage or abortion. Include in parity if past 20 weeks.
f. L-Living children = the number of living children (this is where multiples
count individually)
Assessment
1. Gather the patient’s pregnancy history and note gestation of current pregnancies
2. Examples
a. A woman with a history of 5 pregnancies: 2 births at 39 and 40 weeks, and
3 miscarriages before 20 weeks
i. G5 T2 P0 A3 L2
ii. *note – error in the video, if this patient is ALSO currently
pregnant, she would actually be a G6 T2 P0 A3 L2
b. A woman currently pregnant with a history of 1 miscarriage (22 weeks)
i. G2 T0 P1 A0 L0
c. A woman with twins born at 32 weeks, history of 2 miscarriages (11 and 9
weeks), and currently pregnant
i. G4 T0 P1 A2 L2
Therapeutic Management
1. Knowing GTPAL helps the OB team to know whether the mother is at high risk
for complications, whether it is her first birth, etc.
2. This helps to tailor interventions and management specific for each patient  based
on their needs.
Nursing Concepts
1. Reproduction
2. Human development

FAQ’s
What does gtpal stand for?
GTPAL stands for Gravidity (number of pregnancies including current), Term (number of
pregnancies carried to 37+ weeks), Preterm (number of pregnancies carried between 20 and 36.6
weeks ), Abortion (number of losses prior to 20 weeks), and Living (number of living children).
Why is gtpal important?
GTPAL is important to understand the woman’s pregnancy history, which will help the providers
to be aware of things such as; concerns with many losses, if there have been twins, or
pregnancies that have been preterm. This will help the providers to better plan care.
What does gtpal mean in pregnancy?
In pregnancy GTPAL is used to identify the total number of pregnancies, including current
pregnancies (Gravidity), the number of pregnancies that have gone to term (Term), the number
of pregnancies that have been preterm (Preterm), the number of abortions (Abortion), and the
total number living (Living).
How to read gtpal?
GTPAL is read as Gravidity, Term, Preterm, Abortion, and Living. For example, I’m currently
39 weeks pregnant, I have had two childre born at 37 and 35 weeks. I lost 3 pregnancies prior to
12 weeks and have 2 living children, this would be read G6 T1 P1 A2 L2.
How do you write gtpal?
The number of pregnancies including current is G (gravidity), pregnancy total carried to term (37
weeks) as T, the preterm (20-36.6 weeks) pregnancy total as P, the abortion total as A (if it after
20 weeks it is counted as preterm), and number of living children is L.
In pregnancy terms, quickening is the moment in pregnancy when the pregnant woman starts
to feel or perceive fetal movements in the uterus.

Braxton Hicks Contractions

Deborah A. Raines; Danielle B. Cooper.

Author Information

Last Update: August 11, 2020.

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Introduction
Braxton Hicks contractions are sporadic contractions and relaxation of the uterine muscle.
Sometimes, they are referred to as prodromal or “false labor" pains. It is believed they start
around 6 weeks gestation but usually are not felt until the second or third trimester of the
pregnancy. Braxton Hicks contractions are the body's way of preparing for true labor, but they do
not indicate that labor has begun or is going to start.
Braxton Hicks contractions are a normal part of pregnancy. They may be uncomfortable, but
they are not painful. Women describe Braxton Hicks contractions as feeling like mild menstrual
cramps or a tightening in a specific area of the abdomen that comes and goes.[1][2][3]
Braxton Hicks contractions can be differentiated from the contractions of true labor. Braxton
Hicks contractions are irregular in duration and intensity, occur infrequently, are unpredictable
and non-rhythmic, and are more uncomfortable than painful. Unlike true labor contractions,
Braxton Hicks contractions do not increase in frequency, duration, or intensity. Also, they lessen
and then disappear, only to reappear at some time in the future. Braxton Hicks contractions tend
to increase in frequency and intensity near the end of the pregnancy. Women often mistake
Braxton Hicks contractions for true labor. However, unlike true labor contractions, Braxton
Hicks contractions do not cause dilatation of the cervix and do not culminate in birth.
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Etiology
Braxton Hicks contractions are caused when the muscle fibers in the uterus tighten and relax.
The exact etiology of Braxton Hicks contractions is unknown. However, there are known
circumstances that trigger Braxton Hicks contractions including when the woman is very active,
when the bladder is full, following sexual activity, and when the woman is dehydrated. A
commonality among all these triggers is the potential for stress to the fetus, and the need for
increased blood flow to the placenta to provide fetal oxygenation.[4][5][6]
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Epidemiology
Braxton Hicks contractions are present in all pregnancies. However, each woman's experience is
different. Most women become aware of Braxton Hicks contractions in the third trimester, and
some women are aware of them as early as the second trimester. Sometimes Braxton Hick
contractions occurring near the end of the third trimester of pregnancy are mistaken as the onset
of true labor. It is not unusual, especially in a first pregnancy, for a woman to think she is in
labor only to be told it is Braxton Hicks contractions and not true labor.
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Pathophysiology
Braxton Hicks contractions are thought to play a role in toning the uterine muscle in preparation
for the birth process. Sometimes Braxton Hicks contractions are referred to as "practice for
labor." Braxton Hicks contractions do not result in dilation of the cervix but may have a role in
cervical softening.
The intermittent contraction of the uterine muscle may also play a role in promoting blood flow
to the placenta. Oxygen-rich blood fills the intervillous spaces of the uterus where the pressure is
relatively low. The presence of Braxton Hicks contractions causes the blood to flow up to the
chorionic plate on the fetal side of the placenta. From there the oxygen-rich blood enters the fetal
circulation.
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History and Physical

When assessing a woman for the presence of Braxton Hicks contractions, there are some key
questions to ask. Her response to these questions will assist the healthcare provider to
differentiate Braxton Hicks contractions and true labor contractions.[7][8][9]
 How often are the contractions? Braxton Hicks contractions are irregular and do not get closer
together over time. True labor contractions come at regular intervals, and as time goes on, they
get closer together and stronger.
 How long are the contractions? Braxton Hicks contractions are unpredictable. They may last less
than 30 seconds or up to 2 minutes. True labor contractions last between 30 to less than 90
seconds and become longer over time.
 How strong are the contractions? Braxton Hicks contractions are usually weak and either stay
the same or become weaker and then disappear. True labor contractions get stronger over time.
 Where are the contractions felt? Braxton Hicks contractions are often only felt in the front of the
abdomen or one specific area. True labor contractions start in the midback and wrap around the
abdomen towards the midline.
 Do the contractions change with movement? Braxton Hicks contractions may stop with a change
in activity level or as the woman changes position. If she can sleep through the contraction, it is
a Braxton Hicks contraction. True labor contractions continue and may even become stronger
with movement or position change.
During the physical assessment, the provider may palpate an area of tightening or a "spasm" of
the uterine muscle, but the presence of a uterine contraction in the uterine fundus is not palpable.
The woman will be assessed for the presence of uterine bleeding or rupture of the amniotic
membrane. An examination of the cervix reveals no change in effacement or dilatation as a result
of the Braxton Hicks contractions.
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Evaluation
There are no laboratory or radiographic tests to diagnose Braxton Hicks contractions. Evaluation
of the presence of Braxton Hicks contractions is based on an assessment of the pregnant woman's
abdomen, specifically palpating the contractions.
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Treatment / Management
By the midpoint of pregnancy, the woman and provider should discuss what the woman may
experience during the remainder of the pregnancy. Braxton Hicks contractions are one of the
normal events a woman may experience. Teaching her about Braxton Hicks contractions will
help her to be informed and to decrease her anxiety if they occur.[10][11][12]
There is no medical treatment for Braxton Hicks contractions. However, taking action to change
the situation that triggered the Braxton Hicks contractions is warranted. Some actions to ease
Braxton Hicks contractions include:
 Changing position or activity level: if the woman has been very active, lie down; if the woman
has been sitting for an extended time, go for a walk.
 Relaxing: take a warm bath, get a massage, read a book, listen to music, or take a nap.
 Drinking water to rehydrate.

If these actions do not lessen the Braxton Hicks contractions or if the contractions continue and
are becoming more frequent or more intense, the patient's healthcare provider should be
contacted.
Also, if any of the following are present the healthcare provider should be contacted
immediately:
 Vaginal bleeding
 Leaking of fluid from the vagina
 Strong contractions every 5-minutes for an hour
 Contractions that the woman is unable to "walk through"
 A noticeable change in fetal movement, or if there are less than ten movements every 2 hours.
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Differential Diagnosis
 Abdominal distention
 Amenorrhea
 Ascites
 Full bladder
 Hematometra
 Nausea
 Ovarian cysts
 Pseudocyesis
 Uterine fibroids
 Vomiting
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Pearls and Other Issues

In addition to Braxton Hicks contractions, there are other causes of abdominal pain during
pregnancy. Some normal reasons for abdominal pain during pregnancy, in addition to Braxton
Hicks contractions and true labor contractions, include:
 Round ligament pain or a sharp, jabbing feeling felt in the lower abdomen or groin area on one
or both sides.
 Higher levels of progesterone can cause excess gas during pregnancy.
 Constipation may be a source of abdominal pain.

Circumstances in which abdominal pain is a sign of a serious condition that requires immediate
medical attention include:
 Ectopic pregnancy.
 Placental abruption. A key symptom of placental abruption is intense and constant pain that
causes the uterus to become hard for an extended period without relief.
 Urinary tract infection symptoms include pain and discomfort in the lower abdomen as well as
burning with urination.
 Preeclampsia is a condition of pregnancy occurring after 20-weeks gestation and characterized
by high blood pressure and protein in the urine. Upper abdominal pain, usually under the ribs on
the right side, can be present in preeclampsia.

If a woman is unsure if she is experiencing Braxton Hicks contractions or another condition, a
discussion with a healthcare provider is needed. The healthcare provider may recommend a visit
to the office setting or labor and delivery for an examination by a healthcare professional
to determine the cause of the abdominal pain.
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Enhancing Healthcare Team Outcomes

Braxton hicks contractions are fairly common and it is important for the emergency department
physician labor & delivery nurse and nurse practitioner to be aware that this is not true labor. If
there is any doubt, the obstetrician should be consulted. However, at the same time, the onus is
on the healthcare workers to rule out true labor. Other organic disorders like appendicitis, urinary
tract infection or cholecystitis must also be ruled out. With the right education, patients with
braxton hicks contraction will not needlessly rush to the ED every time they sense a contraction.

Chloasma is a common skin condition among pregnant women. It usually presents as dark,
brownish patches of skin, mostly on the forehead, nose, upper lip, and cheeks.\

Linea nigra (Latin for "black line"), often referred to as a pregnancy line, is a linear
hyperpigmentation that commonly appears on the abdomen. 

Pregnancy stretch marks, also known as striae gravidarum, are a specific form of scarring of
the skin of the abdominal area due to rapid expansion of the uterus as well as sudden weight
gain during pregnancy. About 90% of women are affected.

Naegele’s rule

Naegele’s rule involves a simple calculation: Add seven days to the first day of
your LMP and then subtract three months.

For example, if your LMP was November 1, 2017:

1. Add seven days (November 8, 2017).

2. Subtract three months (August 8, 2017).
 3. Change the year, if necessary (to the year 2018, in this case).

In this example, the due date would be August 8, 2018.