Continuing Education Activity

The Leopold maneuvers are a systematic method of abdominal palpation used to assess fetal position, presentation, and engagement in the third trimester of pregnancy. This noninvasive, low-cost technique involves 4 distinct maneuvers to palpate the gravid uterus. Leopold maneuvers are crucial for guiding obstetric management, especially for detecting malpresentation, which can increase the risk of complicated vaginal deliveries or cesarean sections. Although experienced practitioners can achieve accurate assessments through these maneuvers, ultrasonography remains the gold standard for confirming fetal presentation. This activity for healthcare professionals is designed to enhance the learner's competence in recognizing the significance of Leopold maneuvers, performing the recommended technique, and implementing appropriate interpretation of this assessment to improve patient outcomes.

Objectives:

• Identify the appropriate indications for using Leopold maneuvers in the assessment of fetal position, presentation, and engagement during the third trimester of pregnancy.

• Apply knowledge of Leopold maneuvers to make informed decisions about further diagnostic procedures or interventions based on the assessment results.

• Interpret the findings of Leopold maneuvers accurately.

• Implement interprofessional team strategies to improve care coordination and patient outcomes when performing Leopold maneuvers.

Introduction

The Leopold maneuvers are a systematic method of abdominal palpation used to assess fetal position, presentation, and engagement during the third trimester of pregnancy.[1][2][3] Four classical maneuvers are used to palpate the gravid uterus systematically. This abdominal palpation method is low-cost, easy to perform, and noninvasive. 

The Leopold maneuvers, developed by German obstetrician and gynecologist Christian Gerhard Leopold (1846–1911), have traditionally been used to assess fetal position, presentation, and lie and estimate fetal weight. Fetal presentation refers to the position of the fetal anatomic part closest to the pelvic inlet. The cephalic presentation is the most common and is characterized by the fetal head positioned at the pelvic inlet. Other presentations include breech and shoulder, in which the fetal buttocks or feet and the fetal shoulder are closest to the material pelvic inlet. Fetal lie refers to the position of the fetal spine relative to the maternal spine, including longitudinal, transverse, and oblique. Spontaneous vaginal delivery is most common when a cephalic-presenting fetus is in the occiput anterior position.[4] Breech presentation is the most common malpresentation, with an incidence of 3% to 4% of fetal deliveries.[5] Identifying noncephalic presentations before the onset of labor is essential to mitigate the maternal and neonatal risks associated with complicated vaginal delivery or cesarean section. Detection of malpresentation in late pregnancy allows for counseling on adequate care measures.[6][7][8]

Leopold maneuvers are also used to estimate fetal weight, although the accuracy is debated. In a study, clinical estimation of fetal weight overestimated birth weight in 58.2% of patients and underestimated birth weight in 41.2%.[9] Fetal macrosomia, typically defined as a fetal weight of ≥4000 g, is associated with a high risk of birth injury, shoulder dystocia, and brachial plexus injury.[10] Clinical estimation of fetal weight to identify fetal macrosomia aids clinicians and patients in making informed management decisions.[11] Evaluating fetal weight, presentation, and position is crucial in guiding obstetric management. However, the accuracy of Leopold maneuvers varies depending on many factors, especially examiner experience. Therefore, an ultrasonographic examination is typically used to support clinical estimations of fetal weight and to determine whether the fetus is in the cephalic presentation during the third trimester of pregnancy. This technique is recommended to confirm the diagnosis when any malpresentation is even slightly suspected.[12][13][10][14][10]

Indications

Clinicians assess fetal presentation and weight with clinical assessment or ultrasound examination. Abdominal palpation should be performed to evaluate fundal height at each antepartum visit after 20 weeks of gestation to monitor fetal growth and fetal presentation at 36 weeks of gestation to guide delivery preparation.[15] Leopold maneuvers are the most frequently used method for clinical assessment; however, studies have mixed results regarding the accuracy of the technique compared to ultrasound. 

Contraindications

Other than the lack of consent by the patient to undergo the procedure, performing Leopold maneuvers has no absolute contraindications as this procedure is noninvasive and low-cost.[16] However, due to the subjective nature of this evaluation method, suspected fetal growth or presentation abnormalities should be further evaluated by ultrasound imaging.[10][14] Moreover, the accuracy of Leopold maneuvers may be affected by several factors. Polyhydramnios and oligohydramnios are considered confounding factors in the clinical assessment of fetal weight. Overestimation of fetal birthweight occurs more frequently in patients with maternal obesity, maternal short stature, hypertensive disorders, oligohydramnios, a male fetus, and who smoke tobacco. Underestimation of fetal weight is associated with increasing gestational age.[17] Clinician experience and fetal position may also affect fetal weight and presentation clinical evaluation.[3][18][10][19][20]

Preparation

Trained clinicians perform Leopold maneuvers by systematically palpating the gravid abdomen to determine fetal position and estimate fetal weight. Therefore, clinicians should use standard protocol when performing a physical examination, including cleaning hands before each patient encounter. The procedure steps and purpose should be explained to the patient to reduce anxiety and enhance cooperation. Patient consent should be obtained before Leopold maneuvers are performed.[16][21] 

In addition, the patient should be advised to void if needed, as an empty bladder promotes comfort and allows for more productive examination. The distended bladder can obscure fetal contour. The patient should be positioned supine with the head of the bed raised to 15° and a small pillow or rolled towel placed on her right side. A measuring tape can be used to measure fundal height.[3]

Technique or Treatment

Leopold maneuvers consist of 4 palpation methods used to assess the gravid abdomen, aiming to determine fetal position and estimate fetal weight (see Image. Leopold Maneuvers).

First Maneuver

The first maneuver, also called the fundal grip, assesses the uterine fundus to determine its height and which fetal pole—cephalic or podalic—is present in the fundus. The examiner should stand facing the maternal xiphoid cartilage and outline the uterine contour, placing the palms of each hand on either side of the fundus with their fingers placed close together near the maternal xiphoid cartilage. The fundus is gently palpated using the fingertips to identify which fetal part is located in the uterine upper pole, known as the fundus.[21] A fundus containing a fetal head in a breech position typically feels hard and round, with a smooth surface and uniform consistency. In a fetus in the vertex position, the fundus has a sensation consistent with a large, nodular, nonballotable mass. 

The first maneuver can also help estimate fetal gestational age using the fundal height or McDonald's rule, although various methods are used worldwide.[1] Palpation of the uterine fundus at the following anatomic locations corresponds to approximate gestational ages:

• Public symphysis: 12 weeks of gestation
• Midway between the pubic symphysis and the umbilicus: 16 weeks of gestation
• Umbilicus: 20 weeks of gestation

Using McDonald's rule, every transverse finger breath above the umbilicus is approximately 1 cm or 1 additional week of gestational age between weeks 16 to 32 and increases by 1 cm every 2 weeks thereafter. However, estimating gestation age using fundal height has a wide margin of error and is less clinically useful in settings where ultrasound imaging is available.[22]

Second Maneuver

The second maneuver involves palpating the lateral uterine surfaces to determine the position of the fetal spine and limbs, such as right or left, and the fetal lie, such as longitudinal, transverse, or oblique. This maneuver is performed while facing the maternal xiphoid cartilage with the clinician's hands placed flat against the abdominal wall. The examiner slides both hands down from the uterine fundus to the lateral uterine walls until at the level of the umbilicus. As the examiner exerts gentle pressure, the fetal back and small parts are palpated by each hand, respectively. A firm, nonmobile structure along the lateral curve of the uterus is characteristic of the fetal spine, whereas small or nodular mobile structures are consistent with fetal limbs.[21] The fetal heart can also be auscultated at this time, providing information on fetal orientation. The heart is better heard when the stethoscope or the Doppler transducer is placed on the fetal back.

Third Maneuver

The third maneuver, also known as the Pawlik grip, was modified by Karel Pawlík (1849–1914), a Czech gynecologist and obstetrician. This maneuver aids in identifying fetal presentation. The lower uterine segment and presenting fetal part are grasped using the thumb and fingers of one hand above the pubic symphysis. The clinician then exerts gentle pressure upward to estimate the engagement of the presenting part. If the palpated part moves, the presenting part is not engaged.[21]

Fourth Maneuver

This fourth maneuver resembles the first maneuver; however, the examiner faces towards the maternal pelvis. During this maneuver, the examiner places the palms of both hands on either side of the lower abdomen, with the tips of the fingers facing downward toward the pelvic inlet. The fingertips of each hand are used to apply deep pressure from the outside to the inside and in a craniocaudal direction along the lower contour of the uterus towards the birth canal. Using this technique, the clinician can palpate the presenting part and confirm the findings detected with the third Leopold maneuver. The fingers of both hands move gently along the sides of the uterus towards the pubis and exert gentle pressure; greater resistance to the movement of the fingers towards the pubis typically indicates the location of the fetus's forehead, which is opposite to the fetal spine. Subsequently, the fetal occiput is palpable on the same side the fetal spine is identified. In addition, the degree of descent can be assessed if the anterior fetal shoulder can be palpated at or above the pelvic inlet.[21]

Complications

No significant complications directly result from Leopold maneuvers. However, misdiagnoses of malpresentation and inaccurate fetal weight estimation may complicate decisions based on Leopold maneuvers. Some studies have found that clinical assessment misses a large percentage of malpresentation.[23][4] In addition, the accuracy of Leopold maneuvers in estimating fetal weight varies, with some studies demonstrating comparative accuracy using ultrasound and other studies reporting poor predictive value compared to ultrasound examination. Inaccurate fetal weight estimation can result in obstetric complications as overestimation of fetal weight is associated with the induction of labor and cesarean delivery, and underestimation is associated with shoulder dystocia and third- or fourth-degree perineal lacerations.[17]

Clinical Significance

Abdominal palpation has a reported sensitivity of 70% in determining noncephalic fetal presentations, although some studies have also found that clinical assessment misses a large percentage of malpresentations.[23][4] The accuracy of Leopold maneuvers in estimating fetal weight varies, with some studies demonstrating comparative accuracy with ultrasound and other studies reporting poor predictive value compared to ultrasound examination. Moreover, the accuracy of Leopold maneuvers may vary depending on clinician experience and maternal body weight index, with some studies indicating that the accuracy increases with increased experience and lower maternal body weight.[3][18][10][19] Therefore, ultrasound is typically recommended to confirm suspected fetal malpresentation.[23] Due to the subjective nature of this evaluation method, suspected fetal growth or presentation abnormalities should be further evaluated using ultrasound imaging.[10][14][10]

Suspected fetal malposition or macrosomia can result in delivery injuries, which can cause anxiety for patients and clinician concerns. For patients with a fetus in the breech position, an external cephalic version may be considered. Please see StatPearls' companion resource, "External Cephalic Version," for more information. In addition, induction of labor is often considered for fetal macrosomia. However, fetal weight estimations are frequently inaccurate, even with ultrasound measurements. Therefore, many experts debate the benefit of labor induction for suspected fetal macrosomia. A recent Cochrane review concluded that labor induction for suspected fetal macrosomia did result in fewer birth injuries and shoulder dystocia; however, due to inaccurate fetal weight estimates, many patients underwent induction of labor unnecessarily. Therefore, these risks and benefits should be thoroughly discussed with patients when considering obstetrical management interventions.[10]

Enhancing Healthcare Team Outcomes

Leopold maneuvers, a low-cost, noninvasive method of abdominal palpation, are vital in determining fetal position, presentation, and engagement. Skill in these maneuvers enhances patient-centered care and outcomes, with physicians, advanced practitioners, nurses, and midwives playing key roles. Their responsibilities include performing the maneuvers accurately, interpreting findings, and coordinating care with obstetricians and radiologists for ultrasound confirmation when needed. Effective interprofessional communication ensures the timely sharing of information, improving patient safety and team performance. Coordinated care, including patient education, supports maternal and fetal health, enhancing the overall pregnancy experience.

All healthcare practitioners should be competent with the methods to perform abdominal palpation of a gravid uterus and understand the significance of the findings. Documented findings can guide further obstetric management, and identifying pregnancies complicated by malpresentation and referring them to appropriate facilities may lead to improved outcomes for both neonate and mother. Offering an external cephalic version for breech presentation can significantly lower the primary cesarean delivery rate. Training for existing or new staff transitioning to midwifery-obstetric care is necessary, as experienced clinicians can effectively use abdominal palpation as a screening tool for fetal malpresentation, especially in settings where ultrasound may not be readily available.