Leopold's Maneuvers in Obstetrics

Leopold's maneuvers (note the correct spelling - named after Christian Gerhard Leopold, a German obstetrician) are a systematic set of 4 abdominal palpation techniques used from 30 weeks gestation onward to assess fetal lie, presentation, position, and engagement.

Purpose

Determine fetal lie (longitudinal / transverse / oblique)
Identify fetal presentation (cephalic / breech)
Locate the fetal back (for auscultation of fetal heart tones)
Assess engagement and degree of descent into the pelvis
Determine attitude (flexion/deflexion of the head)

The 4 Maneuvers

Leopold's maneuvers - 4 steps illustrated

Maneuver 1 - Fundal Grip (Examiner faces the patient's head)

Technique: Both hands are placed on the uterine fundus and palpate the fetal part occupying it.

Findings:

Breech in the fundus: soft, irregular, non-ballottable mass = fetal buttocks
Head in the fundus: hard, round, ballottable mass = cephalic presentation (baby in breech lie)

Maneuver 2 - Lateral/Umbilical Grip (Examiner faces the patient's head)

Technique: Both hands glide down laterally along the sides of the uterus with firm pressure.

Findings:

Fetal back: firm, smooth, continuous resistance on one side
Fetal limbs (small parts): irregular, knobby, harder to pin down on the other side

Fetal heart tones are best heard through the fetal back - in the lower left uterus for LOA/LOP/LOT positions, and in the lower right uterus for right occiput positions.

Maneuver 3 - Pawlik's Grip (Examiner faces the patient's head)

Technique: One hand grasps the lower pole of the uterus just above the symphysis pubis between the thumb and fingers.

Findings:

Head (cephalic presentation): hard, round, ballottable
Breech: soft, broader, less defined
Determines the presenting part and whether it is engaged (fixed/not ballottable = engaged; mobile/ballottable = not engaged)

Maneuver 4 - Pelvic Grip (Examiner turns 180° to face the patient's feet)

Technique: Both hands are placed on the lower abdomen, pressing downward and inward toward the pelvic inlet. The fingers glide toward the pelvis.

Findings:

Determines the degree of flexion (attitude) of the presenting part
The cephalic prominence is the part of the head that is felt first:
- If cephalic prominence is on the same side as small parts - head is well-flexed (vertex presentation - normal)
- If cephalic prominence is on the same side as the back - head is extended (face presentation)

Quick Memory Aid

Maneuver	Position	Examiner Faces	Determines
1st	Fundus	Patient's head	What's in the fundus (pole)
2nd	Lateral	Patient's head	Location of fetal back
3rd	Lower pole (Pawlik's)	Patient's head	Presenting part + engagement
4th	Lower abdomen	Patient's feet	Attitude (flexion) of head

Clinical Notes

Performed at ≥30 weeks gestation when the fetus is large enough to palpate
Done with the patient in dorsal recumbent position with knees slightly flexed
Bladder should be emptied before examination
By end of pregnancy, both the practitioner and the patient should know the fetal presentation - to avoid emergency management if a non-vertex presentation appears during labor
Internal digital cervical exam can confirm presentation when palpation is uncertain

(Sources: Rosen's Emergency Medicine, Textbook of Family Medicine 9e)

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