Leopold’s Maneuver
NCMA 217 RLE
Systemic way to evaluate:
✓ Determine fetal presentation, position, attitude, lie, and degree of engagement
✓ Location of best place to auscultate fetal heart sounds
✓ Estimate fetal size
✓ Locate fetal parts
INITIAL APPROACH TO PATIENT:
• Explain the procedure to the patient (series of palpations to determine the)
• Ask her to empty her bladder = fetal contour will not be obscured
• Patient should be in supine position with both legs flexed to the thighs and abdomen bared to relax the abdominal muscles
• Palpate with warm hands = cold hands cause abdominal muscles to contract
• Use gentle but firm motions
For the first three maneuvers: Examiner should face the patient
For the last maneuver: Examiner face the feet of the patient
FOR EACH MANEUVER:
• State the significance of the maneuver (what questions does it answer?)
• How to do or demonstrate the maneuver/procedure
• Describe the expected findings
LM1: FUNDAL GRIP
• Purpose: determine fetal body part present on
fundus
• Where: uterine fundus
• How: Use tips of fingers of both hands to palpate
fundus
• Findings:
✓ head should be firm, round and hard
✓ buttocks soft and round
LM2: UMBILICAL GRIP
• Purpose: Determine fetal back from fetal
extremities (Knees and elbows)
• Where: sides of maternal abdomen/uterus
• How: Using palms placed on either side of the
abdomen. The left palm is left stationary on the
left side of the uterus while the right hand
palpates and pushes the right maternal side
toward left palm with deep pressure from top to
bottom. Do on opposite side.
• Findings:
✓ Fetal back is smooth, flat, hard, and resistant
✓ Fetal extremities are irregular and nodular
• Ideal: fetal back on right or left maternal side
Important estimates:
Bartholomew’s method – determine age
of gestation
Haase’s rule – determine fetal size (utilize
age of gestation)
LM3: PAWLICK’S GRIP
• Purpose: Determine degree of engagement
(engaged or floating) and presentation (cephalic,
breech, shoulder)
• Where: lower uterine segment/uterine pole/
suprapubic (above the symphysis pubis)
• How: Using thumb and fingers of one hand, the
lower portion of maternal abdomen is grasped just
above the symphysis pubis to determine the
presenting part, then perform ballottement
• Findings:
✓ Presenting part is firm = head = cephalic
✓ Presenting part is soft = buttocks = breech
✓ Presenting part moves upward (examining fingers can be pressed together) = not engaged/floating
= not firmly settled into pelvis
✓ Does not move = engaged
• Ideal: cephalic, ballotable / non-ballotable
PRESENTATION:
• Part of the fetus that enters the maternal pelvic inlet
• Cephalic/vertex – head presentation (>95% of labors)
• Breech – bottom presentation
✓ Complete – flexion of hips and knees
✓ Frank (most common) – flexion of hips and extension of
knees
✓ Footling/incomplete – extension of hips and knees
DEGREE OF ENGAGEMENT:
• Ballottement – bouncing of the baby
• (+) ballottement is (-) engagement
• (-) ballottement is (+) engagement
LM4: PELVIC GRIP (for cephalic only)
• Purpose: Determine fetal attitude (degree of
flexion or extension)
• Where: bilateral lower quadrants, palpating for
cephalic prominence
• How: Facing the feet part of the patient, place tips
of fingers on both sides of the uterus
approximately 2 inches above the inguinal canal
pressing downward and inward in the direction of
the birth canal. Allow fingers to be carried
downward.
• Findings:
✓ hand slides along the uterine contour & meet no obstruction = neck of the fetal back
✓ other hand meets an obstruction an inch or so above the ligament = fetal brow, which should be on the same side of
the elbows and knees of the fetus.
• Poor attitude: the examining finger will meet an obstruction on the same side as the fetal back = the fingers will touch the
hyperextended head
• Ideal: cephalic prominence is on the same side as the fetal back = extension or cephalic prominence is on the same side as
the fetal small parts = flexion
ATTITUDE:
• Relationship of fetal parts to each other
• flexion of head and extremities on chest and abdomen = accommodate shape of uterine cavity
• Full flexion, partial flexion, poor flexion, hyperextension
✓ Vertex – head is maximally flexed
✓ Military – head is partially flexed
✓ Brow – head is maximally extended
✓ Face ¬– head is partially extended
FETAL LIE:
• Relationship of spine of fetus to spine of mother
✓ Longitudinal (parallel) / vertical
✓ Transverse (right angles) / horizontal
✓ Oblique (slight angle off a true transverse lie) / diagonal
POSITION:
• orientation of the fetal head or butt within the birth canal
• Relationship of fetal reference point to mother’s pelvis
• Fetal reference point:
✓ Vertex presentation – dependent upon degree of flexion of fetal head on chest
a. Full flexion – occiput (O)
b. Full extension – chin (M)
c. Moderate extension – brow (B)
✓ Breech presentation
a. Sacrum (s) / Sa
✓ Shoulder presentation
a. Scapula (SC) / A (Acromion)
• Maternal pelvis is designated per her right/left and anterior/posterior
o standard three letter abbreviation
o ex. LOA Left Occiput Anterior = vertex presentation with fetal
occiput on mother’s left side toward front of her pelvis
• Anterior fontanel “Soft spot”
o Gap over the forehead where the bones meet
o Open at birth but will close during the 1st year of life
o Landmark: diamond shape → feeling this on pelvic exam tells you
that the forehead is just beneath your fingers
o Difficult (if not impossible) to feel during early labor unless the
patient is completely dilated
o When attaching a fetal scalp electrode, avoid attaching it to the
area of the fontanel
o Bones of fetal scalp are soft and meet at the “suture lines”
• Posterior fontanel
o This junction of suture lines in a Y shape
o Fetal scalp swelling or significant molding makes the landmark
obscured but still identifiable = bc it is engaged in the birth
canal.