What are Leopold's maneuvers?

Leopold's Maneuvers: A Clinical Technique for Determining Fetal Position

Leopold's maneuvers are a systematic set of four palpation techniques used to determine fetal presentation, position, and engagement in the maternal abdomen during pregnancy, particularly in the third trimester. 1

The Four Leopold Maneuvers

1. First Maneuver (Fundal Grip)

   • Examiner faces the mother's head and palpates the fundus of the uterus with both hands
   • Purpose: To determine which fetal part (head or breech) occupies the fundus
   • Technique: Gently palpate the upper abdomen to feel whether the fundus contains the fetal head (firm, round, and ballotable) or the breech (softer, irregular shape) 2, 3

2. Second Maneuver (Lateral Grip)

   • Examiner moves hands down the sides of the maternal abdomen
   • Purpose: To locate the fetal back and small parts (limbs)
   • Technique: Place hands on either side of the abdomen and determine which side contains the smooth, firm surface of the back versus the irregular, nodular feeling of the extremities 2, 4

3. Third Maneuver (Pawlik's Grip)

   • Examiner grasps the lower portion of the abdomen just above the symphysis pubis
   • Purpose: To determine which fetal part is presenting at the pelvic inlet
   • Technique: Using thumb and fingers to grasp the presenting part, assess whether it's the head (hard, round, and possibly ballotable if not engaged) or breech 2, 5

4. Fourth Maneuver (Pelvic Grip)

   • Examiner faces the mother's feet and places hands on the lower abdomen
   • Purpose: To determine the degree of head descent/engagement in the pelvis
   • Technique: Using fingertips, attempt to determine how much of the presenting part has descended into the pelvis 3, 4

Clinical Utility and Accuracy

• Leopold's maneuvers have high sensitivity (88-93%) but lower specificity (30-94%) for determining vertex presentation 3, 4
• Overall accuracy for determining fetal presentation ranges from 89-96% 3
• Accuracy decreases with increased fetal abdominal circumference (≥33.01 cm) 3
• More accurate when performed by experienced clinicians 4

Factors Affecting Accuracy

• Maternal factors:

  • Obesity
  • Excessive amniotic fluid (polyhydramnios)
  • Tense abdominal muscles 3, 4

• Fetal factors:

  • Large fetal abdominal circumference (adjusted OR 0.821,95% CI 0.703-0.959) 3
  • Multiple gestation
  • Unusual fetal positions 4, 5

Clinical Applications

• Part of structured intermittent auscultation during labor to determine optimal placement of Doppler for fetal heart rate monitoring 1
• Screening tool for fetal malpresentation, especially in settings where ultrasound is not readily available 4
• Helps determine the need for further evaluation with ultrasound when malpresentation is suspected 3, 6

Limitations

• Less accurate than ultrasound for definitive determination of fetal presentation 1, 6
• Some studies show poor performance with sensitivity as low as 28% 6
• Should be confirmed with ultrasound when malpresentation is suspected, especially when planning mode of delivery 1, 3

Modified Approaches

• Sharma's modified Leopold's maneuvers have shown improved accuracy over traditional Leopold's maneuvers:
  • 95% vs 84.4% accuracy for occipito-anterior positions
  • 96.3% vs 66.6% accuracy for occipito-posterior positions
  • Uses fingers, hands, and forehand for enhanced palpation 5