_Second Maneuver._ Having determined whether the head or the breech is in the fundus, the next step is to locate the child’s back and the small parts in their relation to the right and left sides of the mother. This is accomplished by slipping the hands down to a slightly lower position on the sides of the abdomen than they occupy in the first maneuver, and making firm, even pressure with the entire palmar surface of both hands. The back is felt as a smooth, hard surface under the palm and fingers of one hand, and the small parts, or hands, feet and knees, as irregular knobs or lumps, under the hand on the opposite side. (Fig. 58.) [Illustration: FIG. 60.—Fourth maneuver in abdominal palpation. (This series of pictures is from photographs taken at Johns Hopkins Hospital.) ] _Third Maneuver._ Unless the presenting part is engaged, the third maneuver virtually amounts to a confirmation of the impression gained by the first maneuver, by showing which pole is directed toward the pelvis. The thumb and fingers of one hand are spread as widely apart as possible, applied to the abdomen just above the symphysis and then brought together to grasp the part of the fetus which lies between them. If not engaged, the head will be felt as hard, round and movable, while the breech will be less clearly defined. (Fig. 59.) [Illustration: FIG. 61.—Diagrams showing relation of nurse’s hands to fetus in the four maneuvers of abdominal palpation. ] _Fourth Maneuver._ The fourth maneuver is of particular value after the presenting part has become engaged. The nurse faces the patient’s feet in this position, and directs the first three fingers of each hand down into the pelvis, on either side of the fetus, to ascertain whether it is a face or vertex presentation, by discovering whether chin or occiput is the higher cephalic prominence in the mother’s pelvis. (Fig. 60.) If it is a vertex presentation, the neck will be flexed, with the chin on the chest and consequently higher in the pelvis than the occiput. The nurse’s fingers of one hand will accordingly come in contact with the chin on the side opposite to the child’s back, before the fingers of the other hand reach the occiput. If, however, it is a face presentation, the neck will be bent sharply backward and the nurse’s fingers will feel the occiput first, and on the same side as the baby’s back. This maneuver tells, also, how far into the pelvis the presenting part has descended. [Illustration: FIG. 62.—Diagram showing method of ascertaining position of fetus by means of rectal examination. Examining finger palpates head through recto-vaginal septum. ]