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Leopold's manoeuvres

5 steps3 videos

Four hand positions on the abdomen that give the lie, presentation, position and engagement of the fetus from about 28 weeks.

Leopold's manoeuvresUBC CPD on YouTube

The four manoeuvres, filmed as a fetal health surveillance fundamental.

Four drawings of Leopold's manoeuvres from the 1894 original: the fundus, the sides, the presenting part and the pelvic grip
Pregnant abdomen examination (OSCE guide)Geeky Medics on YouTube

Inspection, fundal height, lie, presentation, engagement and the fetal heart, in the order a clinician examines.

Consent and trauma-informed practice

  • Explain and ask; expose only the abdomen; a chaperone is offered though this is not an intimate examination

The sequence

5 steps
  1. 01

    First: the fundus

    Both hands on the fundus. A hard, round, ballotable head or a soft, irregular breech? This gives the lie (longitudinal if a pole is in the fundus) and what is at the top.

  2. 02

    Second: the sides

    Hands on either side of the uterus, one steadying while the other palpates. A long firm curve is the back; small irregular parts are the limbs. This gives the position (which side the back lies).

  3. 03

    Third: the presenting part

    Thumb and fingers of one hand grasp the presenting part just above the symphysis. A hard, ballotable head is unengaged; a fixed part is engaged. Confirms presentation.

  4. 04

    Fourth: engagement

    Facing the feet, fingers press into the pelvic inlet on either side of the presenting part. If the fingers converge below the head it is unengaged; if they diverge, the head has entered the pelvis. The cephalic prominence on the side of the limbs means a flexed head.

  5. 05

    Then

    Auscultate the fetal heart over the back, and measure the fundal height.

Indications

  • Every visit in the third trimester
  • Before labour, before external cephalic version, and to place the monitor's transducers

Preparation

  • Consent; empty bladder; supine with knees slightly bent and a small lateral tilt after 20 weeks
  • Warm hands; face the patient for the first three manoeuvres and her feet for the fourth

Complications

  • Supine hypotension if left flat too long
  • Unreliable with obesity, polyhydramnios, an anterior placenta or multiple pregnancy: confirm with ultrasound when it matters

Watch for

  • A hard pole in the fundus at 36 weeks: breech, confirm with ultrasound and offer version
  • Nothing in either pole: transverse lie

More to see

First Leopold manoeuvre: both hands on the fundus
Second Leopold manoeuvre: hands on either side of the uterus to find the back
Third Leopold manoeuvre: one hand grasps the presenting part above the pubis
Fourth Leopold manoeuvre: facing the feet, fingers press either side of the presenting part
Types of fetal positions (OSCE guide)Geeky Medics on YouTube

Lie, presentation and position on a model, the vocabulary the board and the partogram use.

Sources

  • Cunningham et al.: Williams Obstetrics, 26th edition (maternal physiology, labour mechanics, placental anatomy) (2022).

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