Leopold’s Maneuver

Leopold’s Maneuver
The Leopold maneuvers, named after the German
obstetrician and gynecologist Christian Gerhard
Leopold
It is used to determine the position, presentation
and engagement of the fetus in the utero.
Part of the physical examination of pregnant
women.
Four classical maneuvers are used to palpate the
gravid uterus systematically.
 Leopold’s Maneuver
• Maneuver is preferably performed after 24
weeks gestation when fetal outline can be
palpated.
• Fetal presentation refers to the fetal anatomic
part proceeding first into the pelvic inlet.
• When the fetal head is approaching the pelvic
inlet, it is referred to as a cephalic
presentation.
 Leopold’s Maneuver
• All presentations of the fetus other than
vertex, includes the breech presentation,
transverse and oblique lie.

• Spontaneous vaginal delivery is most common

when a cephalic-presenting fetus is in the
occiput anterior position.
 Leopold’s Maneuver
• Palpation is the contact of the operator's fingers
and hands with the body of the woman or child.
It offers the possibility of collecting data on an
area, structure, or function by touch.
• Uterine contractions, the size of the pregnant
uterus, any uterine masses, and attitude,
presentation, degree of commitment of the fetus,
and any fetal-pelvic disproportions can be
detected.
 Leopold’s Maneuver
• Abdominal palpation is accurate in identifying the
presentation, mainly if performed by experienced
healthcare professionals. If in doubt about the presentation
part, obstetric ultrasound should be used to confirm the
results of the palpation.
• Ultrasound can also rule out fetal abnormalities, low
placenta, hyperextension of the baby's head, and the
presence of the umbilical cord around the neck of the
fetus.
• Palpation can be superficial or deep (the superficial one
must always precede the deep one since the latter can
cause pain); avoid having long nails because they can cause
discomfort or injury.
 Leopold’s Maneuver
• The aim of Leopold maneuvers is to determine
the fetal presentation and position by
systematically palpating the gravid abdomen.
 Initial Steps
• Wash hands
• Explain the steps of the examination to the
patient as this reduces anxiety and enhances
cooperation
• The patient should be advised to void as an
empty bladder promotes comfort and allows
for more productive examination, and the
distended bladder can obscure fetal contour
• Provision of privacy
 Initial Steps
• Prepare the equipment
• Have the woman lie on her back, with a pillow
under her head and her knees slightly bent,
arms at her side.
• In palpating the abdomen, use the pads of the
fingers rather than the fingertips in a deep,
smooth movement instead of a sudden
pressure or rough manipulation.
 First Maneuver
• Fundal Grip – to determine fetal part lying in
the fundus and presentation.
• If either the head or breech of the fetus are in
the fundus then the fetus is in a vertical lie.
• Otherwise the fetus is most likely in transverse
lie
 First Maneuver
• i. Face the patient’s head
• ii. Use both hands to palpate the fundus
• iii. A mass is felt – is it head or buttocks?

Fetal head – hard, firm, round and moves

independently of the trunk
Buttocks – softer, symmetric, and has small
bony prominences; moves with the trunk
 First Maneuver

• The breach gives the sensation of a large,

nodular mass, and its surface is uneven, non-
ballotable, and not very mobile whereas the
head feels hard and round with a smooth
surface of uniform consistency, is very mobile
and ballotable.
First Maneuver
First Maneuver
 Second Maneuver

• Umbilical grip – establish the location of the

spine and extremities. This is to identify the
location of fetal back and determine position.
 Second Maneuver
• i. Face the patient’s head
• ii. Use the palms of both hands, one on either
side of the abdomen, so that one hand
steadies the uterus while the other palpates
using a slight circular motion from the top of
the uterus to the lower segment, feeling for
fetal outline
• iii. Palpate the other side, reversing the
functions of the hands
 Second Maneuver
• The uterine fundus is pressed with force using
one hand, which accentuates the curvature of the
fetal back, allowing for easier palpation with the
other hand.
• The fetal heart can be auscultated at this time,
which can also provide information on fetal
orientation.
• The heart is well perceived when the stethoscope
or the doppler transducer is placed on the back
of the fetus.
 Second Maneuver
Consider:
• The back will feel smooth and hard
• The knees and elbows will have numerous
angular nodulations, small irregularities and
protrusions
Second Maneuver
Second Maneuver
 Third Maneuver
• Pawlik grip – sometimes called, first pelvic
grip. This maneuver aids in the confirmation
of fetal presentation.
• To determine what is lying in the pelvic inlet
or the engagement of the presenting part
• To define which presenting part of the fetus is
situated in hypogastrium.
 Third Maneuver
• i. Face the patient’s head
• ii. Gently grasp the lower portion of the
abdomen just above the symphysis pubis,
using the thumb and fingers of one hand

The presenting part is grasped at the lower

portion of the abdomen and draws the thumb
and finger near to clasp the lower uterine
segment including its contents.
Third Maneuver
Third Maneuver
 Fourth Maneuver
nd
• 2 pelvic grip – to locate the cephalic
prominence to assist in diagnosing descent
into the pelvis; the degree of flexion of fetal
head
 Fourth Maneuver
• i. Face the patient’s feet
• ii. The fingers of both hands are used to apply
deep pressure in the direction of the axis of
the pelvic outlet down the sides of the uterus
toward the pubis
• iii. The cephalic prominence is located on the
side where the greatest resistance is felt
 Fourth Maneuver
Consider:
• If the prominence is located on the opposite side from
the fetal back, the head is said to be well flexed
• If the prominence is located on the same side as the
back, the head is said to be extended (face
presentation)

To assess the degree of engagement of the presenting

part, while the woman is slowly exhaling, the fingers are
directed further down into the pelvis.
Fourth Maneuver
Fourth Maneuver
 Complications
• A breech presentation occurs when the presenting
part is either the buttocks and/or the feet. On
examination, the head is felt in the upper uterine pole
and the breech in the pelvic cavity. The fetal heart
tones are auscultated higher than anticipated with a
vertex presentation.

• When the longest axis of the fetus is oriented

transversely, the presenting part is typically the
shoulder. In the transverse lie on palpation, neither the
head nor the buttocks can be palpated in the lower
uterine pole inlet, and the fetal head can be felt in the
flank.
 Complications
• Occiput posterior position occurs when the fetal occiput is
at or posterior to the sacroiliac joint. On examination, there
is a lower abdomen flattened, fetal limbs are palpable
anteriorly, and the fetal heart tones may be auscultated in
the flank.
• Brow presentation occurs with some extension of the fetal
head. On palpation, the fetal occiput is higher than the
sinciput, and more than half the fetal head is felt above the
symphysis pubis.
• Face presentation results from hyperextension of the fetal
head. On palpation, the fold of the neck is felt as a deep
indentation between the occiput and the back; however, in
face presentation, this depression is limited.