What are the steps to perform Leopold's maneuvers (a series of four abdominal palpations) on a pregnant woman?

How to Perform Leopold's Maneuvers

Leopold's maneuvers are a systematic four-step abdominal palpation technique used to determine fetal presentation, position, and engagement in late pregnancy, typically performed after 28 weeks gestation when the fetus is large enough to palpate reliably.

Prerequisites and Patient Positioning

• Have the patient empty her bladder completely before examination to improve palpation accuracy and patient comfort 1
• Position the patient supine on the examination table with knees slightly flexed to relax the abdominal wall 2
• Stand facing the patient at her side for optimal hand positioning and leverage 2
• Warm your hands before beginning to enhance patient comfort and reduce abdominal muscle guarding 2

First Maneuver (Fundal Grip)

Purpose: Determine which fetal pole (head or breech) occupies the fundus

• Face the patient's head and stand at her side 3
• Place both hands on the upper abdomen, palpating the uterine fundus with the palmar surface of your fingers 3
• Gently palpate to identify the fetal pole in the fundus 3
• The fetal head feels hard, round, and ballotable (moves independently when pushed) 3
• The breech feels soft, irregular, and non-ballotable (moves with the entire fetal body) 3

Second Maneuver (Lateral Grip)

Purpose: Determine the location of the fetal back and small parts

• Keep both hands on either side of the maternal abdomen 3
• Apply gentle but firm pressure with the palmar surface of your hands, moving from the fundus downward 3
• The fetal back feels smooth, firm, and continuous—this is the side where you will hear the fetal heart tones best 4, 3
• The fetal limbs feel irregular, with multiple small nodular parts that may move independently 3
• Identifying the back position is critical for proper fetal heart rate monitoring placement 4

Third Maneuver (Pawlik's Grip)

Purpose: Confirm the presenting part and assess engagement

• Use your dominant hand only for this maneuver 5
• Grasp the lower portion of the maternal abdomen just above the symphysis pubis between your thumb and fingers 3
• Gently attempt to move the presenting part from side to side 3
• If the head is presenting and unengaged, it will be ballotable and mobile 3
• If the head is engaged in the pelvis, it will be immobile and fixed 3

Fourth Maneuver (Pelvic Grip)

Purpose: Determine the degree of descent and flexion of the fetal head

• Turn to face the patient's feet 3
• Place both hands on either side of the lower abdomen, with fingers pointing toward the pelvis 3
• Slide your hands downward and inward along the pelvic brim 3
• If your fingers converge (meet easily), the head is flexed and the occiput is the presenting part 3
• If your fingers diverge (do not meet), the head is extended or the presenting part is not the occiput 3
• The cephalic prominence (forehead in flexed position) will be felt on the opposite side from the fetal back 3

Accuracy and Clinical Considerations

• Leopold's maneuvers have 93.2% sensitivity for detecting vertex presentation but only 30% specificity, meaning they are better at confirming vertex than ruling out non-vertex presentations 6
• Overall accuracy for determining fetal presentation is approximately 89% in late third trimester 6
• Accuracy decreases significantly when fetal abdominal circumference exceeds 33 cm—in these cases, ultrasound confirmation is warranted 6
• The maneuvers correctly diagnose occipito-anterior position in 95% of cases and occipito-posterior position in 96.3% of cases when performed correctly 3

Common Pitfalls to Avoid

• Maternal obesity significantly reduces accuracy—consider ultrasound confirmation in obese patients 6
• Performing the examination with a full maternal bladder degrades accuracy and causes patient discomfort 1
• Excessive force causes abdominal guarding and prevents adequate palpation 2
• Large fetal size (AC ≥33.01 cm) reduces diagnostic accuracy—maintain a lower threshold for ultrasound confirmation 6
• Attempting Leopold's maneuvers before 28 weeks gestation when the fetus may be too small to palpate reliably 2

When to Confirm with Ultrasound

• Any non-vertex presentation detected by Leopold's maneuvers should be confirmed by ultrasound for delivery planning 6
• Fetal abdominal circumference ≥33.01 cm measured on ultrasound warrants ultrasound confirmation of presentation rather than relying solely on Leopold's maneuvers 6
• Uncertain or equivocal findings on Leopold's maneuvers require ultrasound verification 6
• Multiple gestations require ultrasound to identify each fetal back position for proper surveillance 4