LEOPOLD’S MANEUVER

Leopold’s Maneuvers are a systematic method of observation and palpation to determine fetal position, presentation, lie and attitude.
The maneuvers are important because they help determine the position and presentation of the fetus, which in conjunction with correct
assessment of the shape of the maternal pelvis can indicate whether the delivery is going to be complicated, or whether a Cesarean
section is necessary. Keen observation of abdomen should give data about:
1. Longest diameter in appearance (longest diameter (axis) is the length of the fetus)
2. Location of apparent fetal movement (the location of the activity most likely reflects the position of the feet)
PREPARATION
1. CARDINAL RULE: instruct woman to empty bladder first. This will promote comfort and allows for more productive palpation
because fetal contour will not be obscured by a distended bladder.
2. Place woman in dorsal recumbent position, supine knee flexed to relax abdominal muscles. Place a small pillow under the
head for comfort.
3. Drape properly to maintain privacy.
4. Explain procedures to gain patient’s cooperation
5. Warm hands first by rubbing them together before placing them over the woman’s abdomen to aid comfort. Cold hands may stimulate
uterine contractions.
6. Use the palm for palpation, not fingers.
7. During the first three maneuvers, stand facing the patients. For the last maneuver, stand facing the patient’s feet.

FIRST MANEUVER: Fundal Grip: what fetal pole or part occupies the fundus?
Palpation of the fundal area to determine which fetal part is in the uterine fundus
To determine the presenting part of presentation (part of the fetus lying over the inlet) Procedures
1. Nurse stand at the side of the bed, facing the patient
2. Using both hands, feel for the fetal par lying in the fundus

Findings
 The nurse-midwife should ascertain what is lying at the fundus by feeling the upper abdomen (fundus) with tips of both hands.
generally, she will find there is a mass, which will either be the head or the buttocks (breech) of the fetus. The nurse-midwife
must decide which pole of the fetus; it is by observing three points:  Relative consistency- the head is harder/firmer than
the breech
• Shape- if the head, it will be round and hard, and the transverse groove of the neck may be felt. The breech has no groove
and usually feels more angular.
• Mobility- the head will move independently of the trunk; but the breech moves only in conjunction with the body.
If the nurse-midwife feels the head, the fetus is in breech presentation; if the nurse-midwife feels the buttocks, it means the fetus is in
vertex presentation.

SECOND MANEUVER: Umbilical Grip: Which side is the fetal back?

 To locate/identify the fetal back in relation to the right and left sides of the mother
 To determine the fetal position (the relationship of the presenting part to one of the quadrants of the mother’s pelvis)
Procedures

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 1. The nurse-midwife places the palmar surfaces of both hands on either side of the abdomen
2. With left palm stationary on the left side of the abdomen to steady the uterus, the right palpates the right side of the uterus on a
circular motion from top to lower segment of the uterus applying gentle but deep pressure to palpate the fetal outline and small
fetal parts
3. The nurse-midwife the reverses her hands Findings
 Small fetal parts (knee and elbows) feel nodular with numerous angular nodulations  Fetal back feels smooth, hard, like a
resistant surface

THIRD MANEUVER: Pawlik’s Grip: What fetal part lies above the pelvic inlet?
 Determine if the presenting part has entered the pelvis (engagement of presenting part)
 To find the head at the pelvis and to determine the mobility of the presenting part Procedures
1. The nurse-midwife stands at the side of the bed, facing the patient
2. It should be conducted by gently grasping the lower portion of the abdomen, just above the symphysis pubis, between the thumb
and the two fingers of one hand and then pressing together slightly and make gentle movements from side to side
Findings
 If the presenting part moves, round, ballotable and easily displaces it is not yet engaged.
If the presenting part not movable felts as relatively fixed, knoblike part, it is engaged.  If it is firm, it must be the head. If soft, it
could be breech

FOURTH MANEUVER: Pelvic Grip: Which side is the cephalic prominence?

 Cephalic prominence is a part of the fetal head that prevents the deep descent with one hand
 To determines the degree of fetal head flexion or extension
 To determine the attitude or habitus (degree of flexion of the fetal body, head and extremities, or the relationship of fetal parts to
each other)
 To determine the fetal descent
 Should only be done if fetus is in cephalic presentation. Information about the infant’s anteroposterior position may also be gained
from this final maneuver Procedures
1. The nurse-midwife faces the feet of the patient
2. Place one hand each on either side of the lower pole of the uterus
3. Palpate the fetal head by pressing downward about 2 inches above the inguinal ligament
4. Use both hands
Findings
 If descended deeply, only a small portion of the fetal head will be palpated.
 If cephalic prominence or brow or the baby is on the same side of the small fetal parts, the head is flexed.
 If the cephalic prominence is on the same side of the fetal back, the head is extended.

LEOPOLD’S MANEUVER

Leopold’s Maneuver Rationale

Preparation To relieve the patient’s anxiety and enhance cooperation.

1. Explain the procedure and instruct the mother To promote comfort and allows for more productive palpation because fetal contour will not be
to void to empty her bladder. obscured by distended bladder.

2. Wash your hands using warm water. Drape To aid comfort and cold hands may stimulate uterine contraction. To provide privacy.
properly.
3. Position the client in a dorsal recumbent To relax abdominal muscles.
position, supine with knees slightly flexed.
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Procedure To determine whether the fetal head or breech. When palpating, a head feels firmer than a breech.
A head is round and hard; the breech is less well defined. A head moves independently of the body;
First maneuver: (Fundal grip)
the breech moves only in conjunction with the body.
1. Stand at the foot part of the client, facing her
and place hands above the abdomen just
below the xyphoid process.
2. Gently move your hands downward and
palpate the superior surface of the fundus.

Second maneuver: (Umbilical grip)
1. Face the client, hold the left-hand stationary
of the uterus while you palpate
To determine the location of the fetal back. One hand will feel a smooth, hard, resistant surface (the
back), while on the opposite side, a number of angular nodulations (the knees and elbows of the
fetus) will be felt.

with the right hand on the opposite side of

the uterus from top to bottom. Repeat
palpation using the opposite side.
Third maneuver: (Pawlik’s grip) To determine if the presenting part has entered the pelvis (engagement of presenting part)
1. Gently grasp the lower portion of the
abdomen just above the symphysis pubis
between the thumb and fingers and try to
press the thumb and fingers together.
2. Determine any movement and whether the If the presenting part moves, round, ballotable and easily displaces it is not yet engaged. If the
part feels firm or soft. presenting part not movable felts as relatively fixed, knoblike part, it is engaged.

If it is firm, it must be the head. If soft, it could be breech.

Fourth maneuver: (Pelvic grip) To determines the degree of fetal head flexion or extension.
1. Place fingers on both sides of the uterus
approximately 2 inches about the inguinal
To determine the attitude or habitus (degree of flexion of the fetal body, head and extremities, or the
pressing downwards and inward in the
relationship of fetal parts to each other).
direction of the birth canal.
2. Allow the fingers to be carried downward to
determine the fetal attitude and degree of
fetal extension into the pelvis. To determine the fetal descent.

FETAL HEART TONE MONITORING

Fetal Heart Tone/Rate
• Fetal well-being or fetal health is best measured by evaluating fetal heart tones (FHT).
• A normal fetal heart tone (FHT) usually ranges from 120 to 160 beats per minute (bpm) in the in utero period. Mild bradycardia is
considered to be 100 to 119 BPM (beats per minute). Marked bradycardia is considered as 99 or fewer BPM. Marked tachycardia
is considered to be 180 BPM or higher. This is only a guide; some authorities will use different parameters for diagnosis; be familiar
with what is used at your facility to diagnose these conditions.
• This method of testing fetal well-being can be used commencing with the 18th to 20th week of pregnancy. A fetoscope is used for
counting the rate. In some cases, ultrasonic equipment may be used to detect fetal heart tones, as early as the 10th week of
gestation. However, most nurses will use the standard fetoscope for heart tones.
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When to check FHT
• Typically, FHT drops somewhat with the onset of uterine contraction but recovers promptly as the contraction ends.
Changes in FHT that are most likely to be ominous always are detectable immediately after a contraction. It is therefore
imperative to auscultate FHT immediately after a contraction.
• Fetal distress is suspected if FHT immediately after a contraction is repeatedly below 120/minute and fetal distress very likely exists
if FHT is less than 100/minute even though there is recovery to a normal rate before the next contraction.

Frequency of FHT Auscultation

Normal labor, first stage: at least every 30 minutes, immediately after a contraction. High- risk pregnancy/labor: every 15 minutes in
an acceptable alternative continuous electronic monitoring

Auscultation of Fetal Heart Rate

Auscultation is the direct auditory monitoring and interpretation of the fetal heart in utero. The number of fetal heart beats per
minute (beats/min) is referred to as the fetal heart rate (FHR). Auscultation uses a handheld instrument, such as a fetoscope or
ultrasound Doppler, to listen to and count the FHR. Each instrument uses slightly different technology. Fetoscopes magnify actual fetal
heart sounds, whereas Dopplers (most common external method) use ultrasound to convert fetal myocardial movement into sound waves
that are then amplified and sent through a speaker from which the heart rate can be counted. Some Dopplers display a digital readout in
addition to the audible sound produced.
Before listening to the FHR the first time, the nurse may choose to perform Leopold’s maneuvers to determine the probable
location to best hear the FHR. The FHR is heard most clearly at the fetal back (Cunningham et al., 2010). Thus, in a cephalic
presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation it is heard at or above the
level of the maternal umbilicus. In a transverse lie the FHR may be heard best just above or just below the umbilicus. As the presenting
part descends and rotates through the maternal pelvis during labor, the FHR tends to descend and move toward the midline. In some
instances, the monitor may track the maternal heart rate instead of the FHR. However, the nurse can avoid the error by comparing the
maternal pulse with the FHR.
After the FHR is located, it is usually counted for 30 to 60 seconds to obtain the number of beats per minute. The nurse should
listen before, during, and just after a contraction to detect any abnormal heart rate, especially if the FHR is over 160 (tachycardia), under
110 (bradycardia), or if irregular beats (such as a deceleration) are heard (Cunningham et al., 2010). Listening through a contraction may
be difficult because of maternal movement or a muffling of the FHR sounds. It is especially important to listen during and after the
contraction to detect any deceleration that might occur. It is also important to listen immediately after each contraction when the woman is
pushing during second stage, because fetal bradycardia frequently occurs as pressure is exerted on the fetal head during descent.

Preparation
 Explain the procedure, the indications for it, and the information that will be obtained.
 Uncover the woman’s abdomen.

Equipment and Supplies

Doppler device
Ultrasonic gel
Fetoscope
Stethoscope

Clinical Tip
The fetal heart rate (FHR) is heard clearly through the fetal back. Locate the fetal back using Leopold’s Maneuvers.

AUSCULTATION OF FETAL HEART RATE

Procedure Rationale

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 1.To use the Doppler:

• Place the ultrasonic gel on the diaphragm od the Doppler. Gel is use to maintain contact with the maternal abdomen and enhances
• The diaphragm should be warmed prior to the using the conduction of sound.
Doppler.
• Place the Doppler diaphragm on the woman’s abdomen
halfway between the umbilicus and symphysis pubis and in
the midline. Listen carefully for the sound of the heartbeat.
You are most likely to hear the FHR in this area.

2. Check the woman’s pulse against the fetal sounds you hear. If If the rates are the same, you are probably hearing the maternal pulse and not
the rates are the same, reposition the Doppler and try again. FHR.

3. If the rates are not similar, count the FHR for 1 full minute. Note that the FHR has a double rhythm and only one sound is counted.

4. If you do not locate the FHR, move the Doppler laterally.

5. Auscultate the FHR between, during, and for 30 to 60 seconds This detects abnormal heart rate.
following a uterine contraction (UC).

6. Frequency recommendations: This evaluation provides the opportunity to assess the fetal status and response
to labor.
• Low risk women: Every 30 minutes during the first stage,
and every 15 minutes in the second stage.
• High risk women: Every 15 minutes during the first stage,
and every 5 minutes in the second stage.

7. Documentation Document that the procedure was explained to the woman and that she
verbalized understanding. The location of the FHR, FHR baseline, changes in
FHR that occur with contractions, and presence of accelerations or
decelerations should be included. Other characteristics should include variability,
maternal position, type of device used, uterine activity, maternal pulse, and
nursing interventions that were performed.
8. To use fetoscope
The bell should be warmed prior to using the fetoscope.

9. Place the fetoscope earpieces in your ears and the device support
against your forehead; use the handpiece to position the bell of the
fetoscope on the mother’s abdomen.

10. Place the diaphragm halfway between the umbilicus and You are most likely hear the FHR in this area.
symphysis and in the midline.
11. Without touching the fetoscope, listen carefully to the FHR.

12. Frequency recommendations: This evaluation provides the opportunity to assess the fetal status and response
to labor.
• Low risk women: Every 30 minutes during the first stage,
and every 15 minutes in the second stage.
• High risk women: Every 15 minutes during the first stage,
and every 5 minutes in the second stage.

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13. Documentation Document that the procedure was explained to the woman and that she
verbalized understanding. The location of the FHR, FHR baseline, changes in
FHR that occur with contractions, and presence of accelerations or decelerations
should be included. Other characteristics should include variability, maternal
position, type of device used, uterine activity, maternal pulse, and nursing
interventions that were performed

14. To use Stethoscope Tell the mother that you will check the fetus by listening to its heartbeat. Explain
that frequent check of the FHT is routine.
 Explain the procedure to the mother.

15. Perform the Leopold’s maneuvers. To detect the area of fetal back – best site for locating the FHT.

16. With the bell of the stethoscope placed over the area of fetal
back, count FHT for 1 whole minute.

17. Observe care in holding the stethoscope over the mother’s Keep fingers odd bell. Make sure that friction noises from the fingers or
abdomen. abdominal surface do not distort the sounds.

18. Differentiate FHT from other sounds:

 FHT: distinct in sound, resembling the ticking of a watch

placed under a pillow;
rapid with rate of 120-160/minute.
• Maternal soufflé: from uterine arteries
pulsation; described as soft, blowing with
“sh” sound the rate which resembles that of To check if it is really FHT and not maternal soufflé, carefully listen to the FHT using a
maternal pulse. wellfunctioning stethoscope and at the same time check the maternal pulse.
The identification of maternal soufflé does not guarantee fetal life.
The identification of funic soufflé indicates fetal life.
• Funic Souffle or cord whistle: soft, whistling
sound occurring at the same rate as the
FHT.
• Maternal peristalsis may also be heard
because a woman in labor is usually
hungry.
19. Encourage the mother and father (if present To promote bonding between the fetus and the father, allow him to listen to the FHT.
during labor) to listen, too to the FHT.
20. Record accordingly.

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21. Report abnormalities of FHT. a. Late Decelerations: FHT decreases where the range of drop maybe within normal and the
decelerations occur after the onset of contraction (usually after acme) and persists beyond
completion of contraction. This is an ominous sign of fetal hypoxia caused by uteroplacental
insufficiency.
b. Variable Deceleration: FHT decreases at any point during or between contractions where
the range of drop in FHT is large and extends below normal. This is another ominous sign of
umbilical cord compression.
 For both late decelerations and variable decelerations, the healthcare provider should act
fast: repose the mother to her left side, give oxygen and summon the physician.