Pelvic grips obsterics practicals mbbs
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Pelvic grips in obstetric abdominal examination
“Pelvic grips” usually refers to the 3rd and 4th Leopold manoeuvres, done to identify the fetal presenting part and assess engagement of the head. The Leopold manoeuvres are systematic abdominal palpations used to determine fetal lie, presentation, position, and engagement (StatPearls overview).
Before starting
- Explain procedure, obtain consent.
- Ask the woman to empty her bladder.
- Position: supine, legs slightly flexed, with a small wedge under the right hip to avoid supine hypotension.
- Examiner faces the woman's head for the first 3 grips; faces her feet for the 4th grip.
- Warm hands and palpate gently.
1. First pelvic grip: Pawlik's grip / third Leopold manoeuvre
Position: Stand facing the woman's head.
Method
- Place the thumb and fingers of one hand just above the symphysis pubis.
- Grasp the lower uterine pole between thumb and fingers and move it gently from side to side.
What it tells you
- Identifies the presenting part.
- Assesses whether it is mobile or fixed/engaged.
Findings
- Head: hard, smooth, round, ballotable, moves independently from the trunk.
- Breech: soft, broad, irregular, less ballotable.
- If the presenting part is freely movable, the head is usually not engaged.
- If fixed in the pelvis, it is likely engaged.
Practical statement:
“I can feel a hard, round, ballotable mass at the lower pole, suggesting cephalic presentation. It is mobile/fixed, indicating the head is unengaged/engaged.”
“I can feel a hard, round, ballotable mass at the lower pole, suggesting cephalic presentation. It is mobile/fixed, indicating the head is unengaged/engaged.”
2. Second pelvic grip: fourth Leopold manoeuvre
Position: Turn to face the woman's feet.
Method
- Place both hands on either side of the lower uterus, with fingers directed downward toward the pelvic inlet.
- Press deeply and gently toward the inlet.
What it tells you
- Confirms the presentation.
- Assesses descent and flexion of the fetal head.
- Helps determine whether the head is engaged.
Findings in cephalic presentation
- One hand may descend farther than the other:
- The hand that descends farther is usually on the side of the fetal occiput.
- A prominent cephalic prominence on the same side as the small parts suggests a deflexed head.
- A cephalic prominence on the side opposite the small parts suggests a well-flexed vertex.
- If both hands meet resistance above the pelvic brim and cannot converge, the head is engaged.
- If fingers can be approximated below the presenting part, the head is not engaged.
Viva points
| Question | Short answer |
|---|---|
| What are pelvic grips? | Third and fourth Leopold manoeuvres. |
| What is Pawlik's grip? | Third Leopold manoeuvre, used to identify the presenting part and its mobility. |
| Which grip assesses engagement best? | Fourth Leopold manoeuvre. |
| A ballotable head means? | Usually not engaged. |
| What does a hard, round lower-pole mass suggest? | Fetal head, hence cephalic presentation. |
| In which presentation is Pawlik's grip especially useful? | Cephalic presentation, to identify and assess mobility of the head. |
One-line exam answer
Pelvic grips are the third and fourth Leopold manoeuvres used to palpate the lower uterine pole, identify the presenting part, and assess descent, flexion, and engagement of the fetal head.
Explain all four Leopold manoeuvres for MBBS practicals
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Leopold manoeuvres for MBBS practicals
Leopold manoeuvres are four systematic abdominal palpation steps performed in late pregnancy, usually after 28 weeks, to determine:
- Fetal lie
- Presentation
- Position of fetal back
- Degree of engagement of the presenting part
- Approximate fetal size
They are a clinical aid. If findings are uncertain, ultrasound confirms presentation and position (StatPearls review).
Preparation and examination position
- Introduce yourself, confirm identity, explain and obtain consent.
- Ask the patient to empty her bladder.
- Position her supine with knees slightly flexed. Put a small wedge under the right hip or tilt her slightly left to reduce supine hypotension.
- Expose the abdomen from xiphisternum to symphysis pubis while preserving privacy.
- Warm hands before palpation.
- Stand on the right side of the patient. Face her head for the first three grips and face her feet for the fourth grip.
In practicals, say:
“After inspection and measurement of symphysiofundal height, I will perform Leopold manoeuvres to determine fetal lie, presentation, position, and engagement.”
“After inspection and measurement of symphysiofundal height, I will perform Leopold manoeuvres to determine fetal lie, presentation, position, and engagement.”
First Leopold manoeuvre: Fundal grip
Technique
- Face the patient's head.
- Place both hands over the uterine fundus.
- Palpate gently but firmly to identify which fetal pole occupies the fundus.
What does it assess?
- Fetal pole at the fundus
- Fetal lie and likely presentation
Interpretation
| Finding in fundus | Suggests |
|---|---|
| Soft, broad, irregular mass | Breech |
| Hard, round, smooth, ballotable mass | Head |
Example
If you feel a soft, irregular breech in the fundus, and a hard head at the lower pole, it indicates longitudinal lie with cephalic presentation.
Practical statement:
“On fundal palpation, I feel a soft, broad, irregular mass suggestive of the breech. This is consistent with a longitudinal lie and cephalic presentation.”
“On fundal palpation, I feel a soft, broad, irregular mass suggestive of the breech. This is consistent with a longitudinal lie and cephalic presentation.”
Second Leopold manoeuvre: Lateral / umbilical grip
Technique
- Continue facing the patient's head.
- Place both hands on the lateral sides of the uterus at the level of the umbilicus.
- Stabilize one side with one hand and palpate the opposite side with the other.
- Repeat on the other side.
What does it assess?
- Location of the fetal back
- Location of fetal limbs
- Fetal position
Interpretation
| Palpated structure | Feel |
|---|---|
| Fetal back | Smooth, firm, broad, resistant curved surface |
| Limbs | Small, irregular, nodular parts, often mobile or kicking |
Example
- Back on maternal left and limbs on maternal right suggests the fetal back is to the left.
- In a cephalic fetus, this may be described as left occipito-lateral position, depending on the complete findings.
Practical statement:
“The fetal back is felt as a smooth, resistant plane on the left side, while small irregular parts are felt on the right. Therefore, the back is on the maternal left side.”
“The fetal back is felt as a smooth, resistant plane on the left side, while small irregular parts are felt on the right. Therefore, the back is on the maternal left side.”
Third Leopold manoeuvre: Pawlik's grip / first pelvic grip
Technique
- Face the patient's head.
- Using thumb and fingers of one hand, grasp the lower uterine pole just above the symphysis pubis.
- Identify the presenting part and assess whether it is mobile or fixed.
What does it assess?
- Presenting part
- Mobility of the presenting part
- Whether the head is likely engaged
Interpretation
| Finding | Meaning |
|---|---|
| Hard, round, smooth, ballotable mass | Head, hence cephalic presentation |
| Soft, broad, irregular mass | Breech presentation |
| Presenting part moves freely or is ballotable | Not engaged |
| Presenting part is fixed | Likely engaged |
Practical statement:
“Pawlik's grip reveals a hard, round, smooth presenting part at the lower pole, suggestive of the fetal head. It is mobile/fixed, indicating that the head is unengaged/engaged.”
“Pawlik's grip reveals a hard, round, smooth presenting part at the lower pole, suggestive of the fetal head. It is mobile/fixed, indicating that the head is unengaged/engaged.”
Fourth Leopold manoeuvre: Second pelvic grip
Technique
- Turn to face the patient's feet.
- Place both hands on either side of the lower abdomen with fingertips directed toward the pelvic inlet.
- Press deeply downward and inward along the lower uterine segment.
What does it assess?
- Descent and engagement of the presenting part
- Flexion or extension of the fetal head
- Location of occiput and cephalic prominence
Interpretation
Engagement
- Fingers can be approximated below the presenting part: head is usually not engaged.
- Fingers cannot be approximated because the head is deep in the pelvis: head is likely engaged.
Flexion of head
- Cephalic prominence on the same side as small parts: head is usually deflexed.
- Cephalic prominence on the side opposite the small parts: head is usually well flexed, consistent with vertex presentation.
Practical statement:
“On the fourth manoeuvre, the presenting part is fixed in the pelvis and my fingers cannot be approximated below it, suggesting engagement. The cephalic prominence is on the side opposite the fetal back, suggesting a well-flexed vertex.”
“On the fourth manoeuvre, the presenting part is fixed in the pelvis and my fingers cannot be approximated below it, suggesting engagement. The cephalic prominence is on the side opposite the fetal back, suggesting a well-flexed vertex.”
Easy memory aid
| Manoeuvre | Main question answered |
|---|---|
| 1. Fundal grip | What is in the fundus? |
| 2. Lateral grip | Where is the fetal back? |
| 3. Pawlik's grip | What is presenting at the pelvic inlet? |
| 4. Pelvic grip | Is the head engaged and flexed? |
Mnemonic:
Fundus - Back - Presenting part - Engagement
Fundus - Back - Presenting part - Engagement
Model presentation for a normal cephalic fetus
“On abdominal examination, the uterus corresponds to the period of gestation. The first Leopold manoeuvre reveals a soft, broad, irregular mass, likely breech, in the fundus. The second manoeuvre reveals the fetal back on the left side and small parts on the right. On the third manoeuvre, a hard, round head is palpated at the lower pole. On the fourth manoeuvre, the head is fixed in the pelvis, suggesting engagement. Findings are consistent with a singleton live fetus in longitudinal lie, cephalic presentation, with the back on the left side.”
The first, second, third, and fourth manoeuvres respectively identify the fundal pole, fetal back, presenting part at the pelvic inlet, and confirmation of presenting part or engagement, consistent with the description in ROSEN's Emergency Medicine Concepts and Clinical Practice, section “Second Stage of Labor,” lines 2390-2402.
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