Leopold’s Maneuver

Mariam J. Morales RN, RM

Determining the Fundal Height
1. In first few weeks – primarily increase in anterior posterior diameter of
the uterus
2. 12 weeks – uterus becomes globular and attains a size approximately 8
cm
• In initial stage of pregnancy the cervix may appear firm
• With increasing period of gestation, the cervix becomes softer in
consistency

3. 3rd trimester onwards – uterine height starts corresponding to the period

of gestation
Determining Size of the Uterus
through estimation of Fundal Height
1. Fundus is palpable above the symphysis pubis (AOG 12 weeks)
2. Fundus reaches half way between the symphysis pubis and the umbilicus
(AOG 16 weeks)
3. Fundus at the same height as the umbilicus (AOG 22 weeks)

• One finger under umbilicus (20 weeks)

• One finger under umbilicus (24 weeks)
Determining Size of the Uterus
through estimation of Fundal Height
4. Distance between xiphisternum and
umbilicus (divided into three equal parts)
• Upper 1/3 (28 weeks)
• Upper 2/3 (32 weeks) whereas the tip of
xiphisternum corresponds to 36 weeks
• 40 weeks – due to the engagement of fetal head
• The fundal height is same at 32 weeks and 40
weeks AOG
• At 32 weeks the fetal head is free floating
• It is engaged at 40 weeks AOG

5. At every antenatal visit from 28 weeks of

gestation onwards, the wellbeing of the fetus
must be assessed
Palpation of the Fetus
The lie and presenting part of the fetus only becomes important when the
gestational age reaches 34 weeks. The following must be determined:
1. Fetal Lie
2. Fetal Presentation
3. Presenting Part
4. Fetal Attitude
5. Fetal Position
Fetal Lie
• Fetal lie refers to the relationship of cephalocaudal axis or long axis (spinal
column) of fetus to the long axis of the centralized uterus or maternal
spine.
• Relation of the long axis of the fetus to the long axis of the mother
Fetal Lie
• Longitudinal lie: The long axes of the fetus and of the mother are parallel.
• Transverse or oblique lie: The long axis of the fetus is perpendicular to the
long axis of the mother.
Fetal Presentation
• Determined by the pole of the fetus that first enters the pelvic inlet
• Cephalic: head first (95% of term deliveries)
• Breech: pelvis first (3% of term deliveries)
• Shoulder: shoulder first (2% of term deliveries)
Fetal Presentation
Presenting Part
• The specific fetal structure lying nearest to the cervix
• Determined by the attitude of the fetus
• Each presenting part has an identified denominator that is used to
describe the fetal position in the pelvis.
Presenting Part
Cephalic presentations
• Vertex (denominator is occiput)
Flexion
• Normal fetal position, with infant’s
chin resting on the chest
• Presents optimal fetal dimensions
during labor
• At term, the position of 95% of
fetuses
No flexion and no extension
• Known as a military attitude
• Presents slightly larger diameters
than full flexion
• Usually converts to flexion or full
extension
• Prognosis for labor and delivery
generally favorable
Presenting Part
Frontum or brow (denominator is frontum)
• Partial extension
• Incidence less than 1%
• May be related to fetal anomaly
• May be associated with polyhydramnios or a small fetus
• Presents relatively larger fetal diameters to pelvis
• [Spontaneous delivery possible if pelvis is large, contractions are adequate,
and infant is small
• Delivery expedited by conversion to vertex or face presentation
Presenting Part
Face (denominator is mentum-chin)
• Full extension
• Incidence less than 1%
• More frequent in multiparas
• May be secondary to fetal factors that cause hyperextension, such as
enlarged thyroid or multiple nuchal cords
• Fetal diameters essentially the same as with a vertex presentation
• Vaginal delivery possible only if mentum is anterior
Fetal Presentation
Presenting Part
Breech presentations (denominator is sacrum)
• Complete breech: flexion at hips, flexion at knees
• Frank breech: flexion at hips, extension at knees
Presenting Part
• Footling breech: extension at one or both hips, extension at one or
both knees
• Kneeling breech: extension at hips, flexion at knees
Presenting Part
Compound presentation
• The infant assumes a unique posture, usually with the arm or the hand
presenting alongside the presenting part
• Presents increased fetal diameters
• May interfere with the cardinal movements of labor
Fetal Position
1. The relation of the denominator to the maternal pelvis
2. In practice, eight points are demarcated.
3. The denominator is assigned right or left, depending on which side of
the maternal pelvis it is in.
4. The denominator is assigned anterior, posterior, or transverse according
to maternal front, back, or side
5. The occiput anterior position is most facilitative of vaginal delivery.
6. The occiput transverse position typically requires rotation to anterior or
posterior position for delivery.
Fetal Position
• The occiput posterior position presents slightly larger diameters to pelvis.
• May slow progress of descent
• Usually converts to anterior position during descent for delivery
• An increased degree of internal rotation is required to align occiput
beneath the maternal symphysis.
• Typically causes increased back pain during labor
• Associated with higher rates of cesarean delivery
Fetal Position
A.
 Left Occipito Posterior (LOP)
 Left Occipito Transverse (LOT)
 Left Occipito Anterior (LOA)
B.
 Right Occipito Posterior (ROP)
 Right Occipito Transverse (ROT)
 Right Occipito Anterior (LOA)
OBSTETRIC GRIPS OR LEOPOLD’S
MANEUVERS OF ABDOMINAL
PALPATION
Obstetric Grips or Leopold’s Maneuvers of Abdominal
Palpation
• Obstetric grips which help in determining fetal lie and presentation are also
known as Leopold’s Maneuvers. Abdominal examination can be conducted
systematically employing the four maneuvers described by Leopold and Sprolin in
1894.
• Leopold’s maneuver, named after the German obstetrician and gynecologist
Christian Gerhard Leopold (1846-1911), are part of the physical examination of
pregnant women.
• The mother should be in supine and comfortably positioned with her abdomen
bared. These maneuvers may be difficult to perform and interpret if:
1. the patient is obese,
2. there is excessive amniotic fluid, or
3. the placenta is anteriorly implanted
Procedure
1. Prior to abdominal palpation, ask the mother to empty her bladder
2. Have the woman lie on her back, with a pillow under her head and her knees
slightly bent (flex), arms at her side. Be alert for symptoms of supine
hypotension. Turn the woman to her side if she experiences dizziness, faintness,
nausea or pallor. The woman’s abdomen should be completely exposed from
below the breasts to the symphysis
3. The examiner’s hands should be washed and warmed
4. Standing on the woman’s right side, inspect the abdomen for uterine shape. A
low and broad uterus will be an indication of transverse lie
5. Using a tape measure, measure the symphysis/fundal height in centimeters.
After 20 weeks gestation the fundal height in centimeters should approximately
the weeks of gestation ± 4 centimeters in a singleton pregnancy
6. 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
Maternal Position
• The mother should be comfortable lying in supine position and her
abdomen is to be bared.
• She should be asked to semi flex her thighs in order to relax the abdominal
muscles.
• Theses maneuvers can be performed throughout the third trimester and
between the contractions, when the patient is in labor. These grips help in
determining fetal lie and presentation.
• Besides estimating the fetal lie and presentation, many experienced
clinicians are also able to estimate fetal size and weight through these
maneuvers.
Nursing Considerations
• Instruct woman to empty her bladder first.
• Place woman in dorsal recumbent position, supine with knees slightly
flexed. Place a small pillow under the head for comfort.
• Drape properly to maintain privacy.
• Explain procedure to the patient.
• Warm hands by rubbing together.
• Use the palm for palpation not the fingers.
Fundal Grip
(Leopold’s First Maneuver)

• What is in • Facing the mother, the nurse should

palpate the upper abdomen with both
the fundus? consistency of the palpated part to
hands noting the mobility, shape and

determine if the fetus’ head or buttocks

are at the fundus (top of the abdomen).
• The head will feel round and solid and will
move separately from the larger trunk,
• while the buttocks are soft with bony
knobs (hip bones) and they move with the
trunk
Lateral Grip
(Leopold’s Second Maneuver)

• Locate the fetal back by using palms to palpate

the abdomen with gentle deep pressure.
• Where is
• Hold the right hand stable while exploring the
right side of the uterus with the left hand.
the back?
• Repeat the step holding the left hand stable and
exploring the left side of the uterus.
• The fetal back is smooth and firm and should
lead from the presenting part noted in the first
maneuver.
• The fetal extremities feet small and
bumpy/uneven and should be opposite the back
Second Pelvic Grip (Pawlik’s Grip) or Third
Leopold’s Maneuver
• Determine the fetal part that lies just
above the pelvic outlet (presenting part)
by gently squeezing the lower abdomen • What is the
just above the symphysis pubis with the
thumb and fingers. presenting
• Note if the part feels like the hard head
or the soft buttocks and if it can be part?
gently pushed forward and back (not
engaged) or is firmly in place (engaged).
• The findings should be the opposite of
those found in the first maneuver (if the
head was noted in the first maneuver,
the buttocks would be noted in the third
maneuver)
First Pelvic Grip
(Fourth Leopold’s Maneuver)

• Facing the woman’s feet, place hands

• Where is the cephalic on the maternal lower abdomen and
gently feel the sides of the uterus
prominence? while sliding both hands down
toward the symphysis pubis.
• Feel for the fetal brow by noting the
side with the highest resistance to
fingers moving downwards.
• Note if the brow is on the side
opposite the back (the fetal head is
flexed) or on the same as the back
(the fetal head is extended)
Auscultation of Fetal
Heart Sounds
Auscultation of Fetal Heart Sounds
• Fetal heart sounds are transmitted best through the convex portion of a fetus
because that is the part that lies closest with the uterine wall
• A baseline FHR is determined by analyzing the pace of fetal heartbeats recorded
in a minimum of 2 minutes obtained between contractions. A normal rate is 110
to 160 beats/min
 Decreased variability may indicate fetal sleep (increases with stimulation)
 Absence of variability is a serious warning sign

• As a rule:
• Determine the FHR every 30 minutes during the beginning latent labor
• Every 15 minutes during active first stage labor, and
• Every 5 minutes during the second stage of labor
• In a vertex or breech presentation, fetal heart
sounds are usually best heard through the fetal back
• In a face presentation, the back becomes concave
so the sounds are best heard through the more
convex thorax
• In breech presentation, fetal heart sounds are
heard most clearly high in the uterus, at a woman’s
umbilicus or above
• In cephalic presentation, they are heard loudest
low in a woman’s abdomen
• In an ROA position, sounds are heard best in the
right lower quadrant
• In a LOA position, sounds are heard in the left lower
quadrant
• In posterior positions (LOP/ROP), heart sounds may
be loudest at a woman’s side
• Hearing fetal heart sounds in these positions not only confirms that the
fetus is responding well to labor but also provides confirmatory
information about fetal position

• Recognizing fetal positions aids in locating fetal heart sounds

Auscultation of Fetal Heart Sounds
• Is vital during the labor and delivery period to determine fetal tolerance of
the labor and general well-being

• Fetal Heart Rate (FHR) Monitoring

• Performed through:
• Auscultation of the fetal heartbeat using a fetoscope
• A Doppler ultrasound device can be used to monitor fetal heart rate
intermittently in low risk labor
• Using of Pinard stethoscope
Electronic methods of FHR assessment

Electronic assessment or electronic fetal monitoring (EFM) uses electronic

techniques – non-invasive method of fetal heart rate monitoring
• For identification of the fetus experiencing well-being and the fetus
experiencing compromise

1. Doppler ultrasound for FHR assessment – minimal assessment is done by

the nurse dopples the FHR for 1 full minute and records the audible rate
2. Doppler ultrasound transducer – secured over the pregnant uterus with a
stretchable, soft belt
Electronic methods of FHR assessment
Electronic FHR monitoring can be:
 External using a transducer on the mother’s abdomen, or
 Internal using a probe attached to the fetal presenting part
1. Mother must be confined to bed
2. Membranes must have ruptured
3. Cervix must be dilated 2 cm or greater
4. Presenting fetal part must be against the cervix
Thank You!