Obstetrics & Gynecology

DE LEON
ESGUERRA
OPD
GARCIA
PAMITTAN
REYES
VARIN
 Presentation Outline
OB-GYN Examination First & Third
01 Leopold’s Maneuver
03 Trimester Bleeding

Normal & Abnormal Case Report

02 Labor & Delivery 04 Ameloblastoma during
Pregnancy
01

OB-GYN
Examination
Fetal Lie
 Fetal Lie
● Describes the relationship of the fetal long axis to
that of the mother.
● In more than 99 percent of labors at term, the fetal
lie is longitudinal
● A transverse lie is less frequent
 Fetal
Presentation
 Fetal Presentation
● The presenting part is the portion of the fetal body
that is either foremost within the birth canal or in
closest proximity to it.
● can be felt through the cervix during vaginal
examination.
● in longitudinal lies, the presenting part is either the
fetal head or the breech, creating cephalic and breech
presentations
Cephalic Presentation
 Cephalic Presentation

● Vertex or Occiput presentation

- The head is flexed sharply so that the
chin contacts the thorax.
- The occipital fontanel is the presenting
part.
 Cephalic Presentation

● Sinciput Presentation
- When the neck is only partly flexed, the
anterior (large) fontanel may present
 Cephalic Presentation

● Brow Presentation
- When the neck is only partially
extended, the brow may emerge
 Cephalic Presentation

● Face Presentation
- Fetal neck may be sharply extended so
that the occiput and back come into
contact, and the face is foremost in the
birth canal
 Cephalic Presentation
● Fetal head at term is slightly larger than the breech
● Podalic Pole
- breech and extremities
- bulkier and more mobile
● Cephalic Pole
- composed of the fetal head only
● 32 weeks - the amniotic cavity is large compared
with the fetal mass, and the fetus is not crowded by
the uterine walls.
 Breech Presentation

● Breech presentation may result from circumstances that

prevent normal version from taking place.
● eg. septum that protrudes into the uterine cavity
● If the placenta is implanted in the lower uterine segment,
it may distort normal intrauterine anatomy and result in a
breech presentation.
Fetal
Attitude
 Fetal Attitude
- The fetus assumes a characteristic posture described as
attitude or habitus
- The fetus forms an ovoid mass that corresponds roughly
to the shape of the uterine cavity.
 Fetal Attitude
● The fetus becomes folded upon itself to create a convex
back.
● The head is sharply flexed; the chin is almost in contact
with the chest; the thighs are flexed over the abdomen;
and the legs are bent at the knees.
● In all cephalic presentations, the arms usually lie across
the thorax or parallel to the sides.
● The umbilical cord fills the space between the
extremities.
Fetal
Position
 Fetal Position

- Refers to the relationship of an arbitrarily chosen

portion of the fetal presenting part to the right or
left side of the birth canal.
- Accordingly, with each presentation, there may be
two positions-right or left.
-
Leopold’s
Maneuvers
Leopold’s Maneuvers
- Used to determine the
position, presentation, and
engagement of the fetus in
utero.
 Indications
● Abdominal palpation is accurate in identifying the
presentation.
● The entire palm and fingers are useful for detecting
myometrial activity, fetal movements, or any
neoformations (fibroids), or the degree of edema.
 Contraindications
● Routine evaluation of the presentation with abdominal
palpation should not be offered before 36 weeks, due
to any inaccuracies and inconvenience to the woman.
● These maneuvers may be difficult to perform and
interpret if the patient is
❖ obese,
❖ if amniotic fluid volume is excessive, or
❖ if the placenta is anteriorly implanted
 Preparation
Wash hands
Equipment
Explain steps Supine Position

Obtain consent
Exposure of gravid
abdomen
Empty bladder
Inspect gravid
Provision of privacy abdomen
 1st Maneuver
● Assesses the uterine fundus
● Identification of fetal lie
● Determination of which fetal
pole (cephalic or podalic)
occupies the fundus.
○ Breech gives the sensation
of a large, nodular mass
○ Head feels hard and round
and is more mobile.
 2nd Maneuver
● Palms are placed on either side
of the maternal abdomen, and
gentle but deep pressure is
exerted.
● On one side, a hard, resistant
structure is felt-the back.
● On the other, numerous small,
irregular,mobile parts are
felt-the fetal extremities.
 3rd Maneuver
● Aids confirmation of fetal
presentation.
● The thumb and fingers of one
hand grasp the lower portion
of the maternal abdomen
just above the symphysis
pubis.
 4th Maneuver
● Helps determine the degree of
descent.
● The examiner faces the
mother's feet, and the
fingertips of both hands are
positioned on either side of the
presenting part.
● They exert inward pressure and
then slide caudad along the
axis of the pelvic inlet.
02

Normal & Abnormal

Labor & Delivery
Normal
Labor & Delivery
 First Stage of Labor (0-10cm)
What do we expect?

● Begins with regular uterine contractions and ends with

complete cervical dilatation at 10 cm

● Divided into a latent phase (0-6cm dilatation) and an

active phase (6-10cm dilatation).

● The latent phase begins with mild, irregular uterine

contractions that soften and shorten the cervix

● Contractions become progressively more rhythmic and

stronger

● The active phase usually begins at about 3-4 cm of

cervical dilation and is characterized by rapid cervical
dilation and descent of the presenting fetal part
 Second Stage of Labor
● Begins with complete cervical dilatation and ends with the delivery of the
fetus
● Cardinal Movements: descent, flexion, internal rotation, extension, external
rotation, and expulsion
 On the Third Stage Of Labor
● The period between the delivery of the fetus and the
delivery of the placenta and fetal membranes

● Delivery of the placenta often takes less than 10 minutes,

but the third stage may last as long as 30 minutes

● Expectant management involves spontaneous delivery of

the placenta

● The third stage of labor is considered prolonged after 30

minutes, and active intervention is commonly considered

● Active management often involves prophylactic

administration of oxytocin or other uterotonics
(prostaglandins or ergot alkaloids), cord clamping/cutting,
and controlled traction of the umbilical cord
Abnormal
Labor and
Delivery
DYSTOCIA
4 P’s To diagnose an abnormal labor:
● Passage or Pelvic Architecture
● Passenger or fetal size, presentation and
position
● Power or uterine action and cervical
resistance
● Patient
Passage(Obstetric Pelvis)
Passage(Obstetric Pelvis)
 Passage(Obstetric Pelvis)
Obstetric Conjugate
-shortest distance between the
sacral promontory and pubic symphysis

Contracted Pelvis
- Less than 10 cm
- Less than 12 cm (greatest
transverse diameter)
Passage(Obstetric Pelvis)
Other conditions to consider
● Kyphosis
● Scoliosis
● Dwarfism
● Soft tissue abnormalities in
pelvis: Uterine myoma
 Passenger or Fetus(size, presentation and
position)
Biparietal diameter ( BPD) used to assess
fetal size.

9.5-9.8 cm average smallest transverse

dimension of a term fetal skull
9.5 cm suboccipitobregmatic diameter
Passenger or Fetus(size, presentation and
position)

Fetal Macrosomia
Birth weight greater than 400g g(4 kg)
Passenger or Fetus(size, presentation and
position)
Normal fetal presentation is vertex,
with the occiput anterior

Occiput posterior presentation

The most common abnormal
presentation is occiput posterior.
Passenger or Fetus(size, presentation and
position)
Face or brow presentation
In face presentation, the head is hyperextended,
and position is designated by the position of the
chin (mentum).
Breech presentation
The 2nd most common abnormal presentation is
breech (buttocks before the head
● Frank breech: The fetal hips are flexed, and the
knees extended (pike position).
● Complete breech: The fetus seems to be sitting
with hips and knees flexed.
● Single or double footling presentation: One or
both legs are completely extended and present
before the buttocks.
Shoulder presentation
POWER orUterine
contraction
Tocodynamometer- provides
frequency and duration of uterine
contraction

Intrauterine Pressure
catheter(IUPC)- provides resting
uterine tone, duration, frequency,
and intensity of contractions

There should be 3 to 5 contractions in the 10-minute window, each

lasting 30 to 40 seconds. The monitoring of uterine contractions
should be continuous during labor.
 Patient

Emotional state of the mother

during labor.

Factors to consider:
Levels of stress
Underlying anxiety
Protracted labor stages indicate that labor is
progressing but at a slower pace than expected

Arrest Disorders indicate the complete cessation of

the progress of labor

Abnormal third-stage labor warrants intervention

when the placenta is retained >30 minutes.
Diagnostic
First Stage Protraction and Arrest
● Latent Phase
Protraction:

Criteria for ●

●
In nulliparas women: Not entered the active phase by 20 hours after
onset of the latent phase.
In multiparas women: Not entered the active phase by 14 hours after
the onset of the latent phase.

Abnormal Arrest: Due to its slow progression, latent phase arrest is not considered a
clinical entity.
Active Phase

Labor
●
Protraction: Women at ≥6 cm dilation, dilating less than approximately 1 to 2
cm/hour
Arrest: Cervical dilation ≥6 cm in a patient with ruptured membranes and

Patterns No change in the cervix for ≥4 hours despite adequate contractions (defined
as >200 Montevideo units [MVU])

● No change in the cervix for ≥6 hours with inadequate contractions

Diagnostic
Second Stage Protraction
There is no appropriate length defined for the diagnosis.
However, the following criteria can be utilized in the

Criteria for presence of favorable maternal and fetal condition:

● For nulliparous women: More than four hours for the

Abnormal ●
second stage or three hours of pushing.
For multiparous women: More than three hours for
the second stage or two hours of pushing.

Labor
Patterns
Third Stage of Labor
Retained Placenta
Undelivered greater
than 30 minutes
03

First & Third

Trimester Bleeding
First Trimester
The first trimester of
pregnancy is counted from the
first day of your last period until
the end of 12th week of
pregnancy.
 First Trimester Bleeding
● About 20% of pregnant women experience bleeding during the first
trimester of pregnancy.
● Etiology of Bleeding during the First Trimester of pregnancy:
○ Local lesions of the vagina or cervix
○ Threatened abortion
○ Inevitable abortion
○ Incomplete Abortion
○ Implantation bleeding
○ Ectopic pregnancy
 First Trimester Bleeding
LOCAL LESIONS
- Local lesions include cervical polyps or erosions, cervical neoplasia, and vaginitis.
 First Trimester Bleeding
LOCAL LESIONS

- Cervical infection or inflammation can also cause bleeding at any

time during pregnancy.

- Diagnosed by direct visualization as well as culture or biopsy of a

suspicious lesion.
 First Trimester Bleeding
THREATENED ABORTION
- Bleeding through a closed cervical os during the first half of pregnancy.
- Often painless but may be accompanied by suprapubic
pain.
- Condition wherin the process of abortion Internal os
has started but recovery is still possible.

External os
 First Trimester Bleeding
UPON EXAMINATION:
- Uterine size is appropriate for gestational age
- Cervix is long and closed
- Fetal cardiac activity can be detectable if the gestation is
sufficiently advanced.
Cervical os
MANAGEMENT OF THREATENED ABORTION:
- Bed rest
- Abstinence from sexual intercourse
- Progesterone therapy
 First Trimester Bleeding
INEVITABLE ABORTION
- Increased bleeding when abortion/miscarriage is
pending.
- Bleeding during the first trimester with presence
of an open internal os.

Open Internal os
 First Trimester Bleeding
INEVITABLE ABORTION
- Bleeding
- Intensely painful uterine cramps
- Dilated cervix
- The gestational tissue can often be felt or
Visualized through the internal cervical os.

Open Internal os
Management:
- Suction Dilation and Curettage (D&C)
 First Trimester Bleeding
INCOMPLETE ABORTION
- The fetus is passed, but significant amounts of
Placental tissue may be retained.
- A.K.A. abortion with Retained Products of Conception.
(RPOC)
- Commonly occurs after 12 weeks’ gestation.

Products of conception
 First Trimester Bleeding
INCOMPLETE ABORTION
- Heavy bleeding
- Can cause hypovolemic shock
- Intense cramps
Products of conception
- Cervical dilation

Management:
- Uterine curettage - used to scrape or suction uterine lining to remove
products of conception.
 First Trimester Bleeding
COMPLETE ABORTION
- When abortion/miscarriage occurs and the entire contents of
the uterus are expelled.
- vaginal bleeding
- cramps

Expelled products of
Complete Abortion
 First Trimester Bleeding
IMPLANTATION BLEEDING
- Occurs approximately 4 weeks after
the last menstrual period or 10-14
days after conception.
- Light spotting or bleeding
- Light cramps
First Trimester Bleeding
IMPLANTATION BLEEDING
vs
Normal Menstruation

Implantation bleeding requires

no treatment.
 First Trimester Bleeding
ECTOPIC PREGNANCY
- Implantation of gestational products outside the uterine cavity, usually in
the fallopian tube.
- Fatal for the fetus
- Can cause the fallopian tube to burst
If not managed early.
 First Trimester Bleeding
ECTOPIC PREGNANCY
- Causes light bleeding
- Pelvic pain
- Nausea
- Breast discomfort
- Absence of an intrauterine
gestational sac on abdominal ultrasound
in conjunction with a β-hCG level of
greater than 6,500 mIU per mL
 First Trimester Bleeding
ECTOPIC PREGNANCY
Management:
● Expectant Management
- Ectopic pregnancy is expected to resolve naturally without
any intervention.
● Medication
- Methotrexate - stops cells from growing.
● Surgical Treatment
- Laparoscopy with salpingostomy
 THIRD TRIMESTER
BLEEDING

The third trimester is the last phase of

pregnancy. It lasts from weeks 29 to
40, or months 7, 8, and 9.

During this trimester, the baby grows,

develops, and starts to change
position to get ready for birth.
- Spotting during the third trimester is common and not
usually cause for concern.
- It can also be due to a “bloody show,” or a sign that labor
is starting.
- Bleeding often happens as the lower part of the uterus
during the third trimester of pregnancy. This causes the
area of the placenta over the cervix to bleed.
- The risk of bleeding is higher if a lot of the placenta
covers the cervix.
Different Diagnosis of 3T Bleeding
 Uterine Rapture
- spontaneous tearing of the
uterus that may result in the
fetus being expelled into the
peritoneal cavity.
- Uterine rupture is rare.
- It can occur during late
pregnancy or active labor.
- Uterine rupture occurs most
often along healed scar lines
in women who have had
prior cesarean deliveries.
 Placental Abruption
- Placental abruption occurs
when the placenta separates
from the inner wall of the
uterus before birth.
- Placental abruption can
deprive the baby of oxygen
and nutrients and cause
heavy bleeding in the mother.
- Preterm labor
- In some cases, early delivery
is needed.
 Placental Previa

- occurs when a baby's

placenta partially or
totally covers the
mother's cervix

- Placenta previa can

cause severe bleeding
during pregnancy and
delivery.
 Vasa Previa
Vasa previa is when unprotected umbilical
vessels run through the amniotic membranes,
and pass over the cervix.

Two types:
Type I: Velamentous cord insertion and fetal vessels
that run freely within the amniotic membranes
overlying the cervix or in close proximity of it (2cm
from os).
Type II: Succenturiate lobe or multilobe placenta
(bilobed) and fetal vessels connecting both lobes
course over or in close proximity of cervix (2cm from
os).
 Management
● Continue to take prenatal vitamins.
● Stay active unless, experiencing swelling or pain.
● Work out your pelvic floor by doing Kegel exercises.
● Eat a diet high in fruits, vegetables, low-fat forms of protein, and fiber.
● Drink lots of water. Get plenty of rest and sleep.
● Eat enough calories (about 300 more calories than normal per day).
● Keep your teeth and gums healthy. Poor dental hygiene is linked to
premature labor.
Week 29
- vertical position with the head down towards the
cervix.
Week 30
- The baby is fully developed
Week 31
- The baby is very active, moving around, sucking
their fingers, and doing the odd somersault.
Week 32
- The baby's fingernails are growing.
Week 33
- Unborn baby's brain and nervous system are
fully developed.
Week 34
- Baby's pupils can dilate and constrict, and their
lungs are well developed.
Week 35
- The kidneys are developed and your baby's liver
is functional
Week 36
- a fetus is gaining body fat and will have less room
to move in the uterus
Week 37
- positioned head down, and most, face their
mother's back
Week 38
- the head facing downward in the pelvis.
Week 39
- head-down and facing the spine
Week 40
- baby's head has likely dropped lower into your
pelvis, and his body is curled up tightly.
- If the baby is in breech position the doctor may
advise caesarean delivery.
Week 41
- The baby is overdue.
 Signs and Symptoms
Braxton Hicks contractions
- Pregnant woman feel mild, irregular
contractions as a slight tightness in abdomen.
- They're more likely to occur in the afternoon
or evening, after physical activity.

Backaches
- During pregnancy, the ligaments in a
woman’s body naturally become softer and
stretch to prepare for labour.
- This can put a strain on the joints of your
lower back and pelvis, which can cause back
pain.
 Shortness of breath
- The amount of blood in a woman's body increases
significantly during pregnancy.
- The heart has to pump harder to move the blood
through the body and to the placenta.
- The increased workload on the heart can make a
pregnant woman feel short of breath.

Spider veins, varicose veins and Hemorrhoids

- Increased blood circulation might cause tiny
red-purplish veins (spider veins) it appears in face,
neck and arms.
- You might also notice swollen veins (varicose veins)
on the legs.
- Painful, itchy varicose veins in your rectal area
(hemorrhoids).
Frequent Urination
- Needing to go to the toilet more often during
pregnancy is normal and is caused by the
hormonal and physical changes occurring in
your body.

Swollen ankles, fingers, or face

Tender breasts that may leak watery milk

Difficulty sleeping
 Oral Manifestation
Most dental procedures, including dental x-rays,
tooth extractions, dental fillings, and oralprophylaxis,
can be done during pregnancy safely, tooth
extractions recommended during second or third
trimester.

Treatment during trimester is safe. However, the

second trimester is the safest trimester in which to
get dental treatment. The third trimester is safe, but
the patient might have a hard time laying back for
extended period of time.
Pregnancy can lead to dental problems in some
women, including gum disease and tooth decay.
During pregnancy, hormones affect gingiva and teeth.
Hormonal changes can increase the acidity in the
mouth, leading to an increase in cavities. This also can
be due to an increased sugar intake caused by cravings
and a decrease in attention to preventive dental care.
04
Ameloblastoma
during pregnancy:
A case report
 Patient History
PATIENT INFORMATION
- 27 years old female
- 12-weeks pregnant

CHIEF COMPLAINT
Pt had been complaining of “pain and
bleeding for months and feeling
uncomfortable on my face when sleeping on
the right side”
 Patient History
HISTORY OF PRESENT ILLNESS
Initial observation of throbbing pain on the
right side of the face that radiates to the
cheek occurred about 5 weeks ago, 5/10 on
the pain scale and increased since then,
prompted Pt to consult a public dental clinic.
Pt was later referred to the Dental Medicine
Department of the Makati Medical Center
after observation until week 22. Surgical
procedure was recommended only after the
first trimester of pregnancy.
 Patient History
MEDICAL HISTORY
Denied relevant systemic comorbidities,
allergies, and surgeries. Flu immunization was
received last June 2021

OBSTETRICS HISTORY
Primipara pt attended 16 prenatal appointments
due to the fetal diagnosis of alobar
holoprosencephaly at week 30 of pregnancy. Pt
reported no pregnancy complications and
exhibited normal values in blood tests.

SOCIAL & PERSONAL HISTORY

Warehouse office secretary
Non-cigarette smoking and non-alcoholic
Clinical Examination
INTRAORAL EXAMINATION
Mandibular buccal expansion in the right
alveolar process, close to the molars, with
deviation of right mandibular third molar.

Ulcerated and bleeding mucosa due to

trauma due to the maxillary teeth cusps

Pt had the right mandibular second molar

extracted on an unknown date due to
extensive tooth decay and pain. Imaging
lesion region back to 2005 revealed no
abnormalities from the surgery.
Radiographic Examination

Initial radiograph with radiolucency at the right side of the ascending branch of the mandible
Histological Examination

Cords and network of

odontogenic
epithelium arranged in
palisade exhibiting
reversed polarity of
nuclei
Histological Examination

Cells with squamous

differentiation can be
observed in the center
Histological Examination

n
⭐ ⭐
⭐
⭐
 Diagnosis
Clinical examination
UNICYSTIC
Radiographic evaluation AMELOBLASTOMA
Histopathological analysis
 AMELOBLASTOMA
It is a benign aggressive infiltrating odontogenic tumor with high
recurrence rates and represents 11 % of all odontogenic tumors and less
than 1 % of all tumors affecting the jaws, with a rare ability to metastasize

It is an asymptomatic slow-growing tumor characterized by cortical bone

expansion or perforation and infiltration to soft tissues

The disease commonly appears in the third to seventh decades of life, with
no gender preference and mainly occurs in the mandibular bone (85 %
prevalence) with predilection for the posterior region of the molars.
 LITERATURE ON
AMELOBLASTOMA & PREGNANCY

Herberts and Sandstrom (1957)

● Study conducted on a 7-weeks pregnant woman.
● Pregnancy hormones may influence the growth and development of tumors

Gordy et al. (1996)

● Study conducted on a 36-weeks pregnant woman.
● Hormonal action modulates the lesion during pregnancy, promoting
rapid growth of the ameloblastoma
MANAGEMENT OF AMELOBLASTOMA

CONSERVATIVE FORMS RADICAL FORMS

Curettage Marginal resection
Enucleation En-bloc resection
Cryosurgery Segmental/hemiresection
 Treatment Plan

FIXATION OF A
EN-BLOC RESECTION RECONSTRUCTIVE
NON-LOCKING PLATE
 Pre-operative Phase
● Pt was admitted and submitted under general anesthesia

● Pt was in a supine position and was monitored and pre-oxygenated.

● Anesthesia was induced by rapid sequence of Sellick’s maneuver with fentanyl 200
mg, propofol 150 mg, Quelicin (succinylcholine) 60 mg and nasal intubation.

● Maintenance was performed with oxygen, nitrous oxide, and sevoflurane.

Operative Phase
● Surgical access was provided with
Erich arch bar applications in both
dental arches and through
intramuscular incision in the right
cervical region.

● Prior to tumor removal, a 2.7 mm

reconstructive nonlocking plate by
boring holes in it was adapted. The
plate was removed and the
maxillomandibular fixation was
released for intrasulcular incisions and
gingiva detachment.
 Operative Phase
● Osteotomy was performed from the mesial of her second premolar to half of the
ascending ramus.

● Maxillomandibular fixation was redone and the 2.7 mm reconstructive non-locking

plate was re-installed.

● Extraoral suturing, fixation release and intraoral suturing were performed in

sequence.

● At the end of the surgery, elastics were used for occlusal maintenance.
Fragment of the mandible removed after surgery and submitted to confirm the initial biopsy
Post-operative Phase
● Pt was monitored for 24 months at the Dental Medicine Department of the hospital,
having evolved well without any signs of recurrence.

● Presented no motor deficits, chewing difficulties, or relevant asymmetries.

● The tumor showed no recurrence after the first year (pregnancy period) and
postsurgery radiographic follow-up revealed a reduction of surgical area after
osseous growth in the margins of the lesion.
Post-operative Phase

Panoramic radiography at 24-month follow-up

 CASE CONCLUSION

The influence of pregnancy hormones on the growth and

development of tumors, particularly ameloblastoma, is not
explained in the literature.

En-bloc resection surgery is an effective alternative for

ameloblastoma removal, presenting lower recurrence rates.
 Presentation References
● Cunningham, G. F., Leveno, K., Bloom, S., Spong, C., Dashe, J., Hoffman, B., & Casey, B. (2018). Williams
Obstetrics, 25th Edition (25th ed.). McGraw-Hill Education / Medical.
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10.3843/GLOWM.10132
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Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK544290/
● McLean-Holden AC, Magliocca K. Ameloblastoma. PathologyOutlines.com website.
https://www.pathologyoutlines.com/topic/mandiblemaxillaameloblastoma.html. Accessed
November 17th, 2021.
● Miltons, S. (2019) Normal Labor and Delivery.
https://emedicine.medscape.com/article/260036-overview
 Presentation References
● Salera, L., & Tabije, J. 2017. “Acanthomatous Ameloblastoma”. PJP 2 (1), 42.
https://philippinejournalofpathology.org/index.php/PJP/article/view/57. Accessed November
17th, 2021.
● Shervonne, S. (2021, September 15). Leopold Maneuvers. StatPearls.
https://www.statpearls.com/ArticleLibrary/viewarticle/24190
● Silva, Helbert & Costa, Erika & Medeiros, Antônio & Pereira, Paulo. (2016). Ameloblastoma during
pregnancy: A case report. Journal of Medical Case Reports. 10. 10.1186/s13256-016-1025-1.
● Stanislavsky, A., Jones, J. Biparietal diameter. Reference article, Radiopaedia.org. (accessed on 17 Nov
2021) https://doi.org/10.53347/rID-26429
● Superville SS, Siccardi MA. Leopold Maneuvers. [Updated 2021 Sep 15]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
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● Swer M, Glob. libr. Women’s Med.., The Continuous Textbook of Wom
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 Obstetrics and Gynecology

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