The art of palpating the uterus of a pregnant woman through the abdomen
Are four specific steps in palpating the uterus through the abdomen, from the fundus all the way down to the pelvic brim, named after the gynecologist Christian Gerhard Leopold.
1. First Maneuver
Question to ask ourselves: What is in the fundus?
Objective: identify the fetal pole in which the fundus is located.
Facing the mother, palpate both sides of the fundus of the uterus with both hands and curve your fingers around the top of the uterus.
– Assess for shape, size, consistency and mobility.
Determine: The presenting part
If you feel the head in the fundus: It is a breech presentation
– Firm, hard, and round.
– Moves independently from the rest of the body.
– Detectable by ballottement.
– Well delineated.
– Baby is in a longitudinal lie.
– Denominator: occiput
If you feel the buttocks: It is a cephalic (vertex) presentation
– Butt is softer and has bony prominences
– Fetal part: Irregular, larger or bulkier, and less firm than a head.
– Moves with the rest of the body
– Cannot be well delineated
– Baby is in a longitudinal lie
– Denominator: Sacrum
Neither the head or the buttocks is felt in the fundus
– Baby position may be in a transverse or oblique lie
Related: Fetal Lie
2. Second Maneuver
Question to ask ourselves: On what side is the fetal back?
Objective: identify location of the fetus spine (back of the baby) and extremities (fetal small parts).
Still facing the mother, place both palms on the side of the abdomen.
– Hold the right hand still and with deep but gentle pressure, use the left hand to feel the back or the small parts.
– Repeat using opposite hands
– If you cannot feel the back, the baby may be in a posterior or anterior position.
Determine: The location of the back
– Is firm, convex, continuously smooth.
– Is resistant mass extending from the breech to the neck.
Fetal small parts (hands, feet, knees and elbows)
– Small, knobby, irregular masses
– Moves or kick when pressed with examining hand
Determining the location of the back
Just below the umbilicus feels a saucer-like depression and above the symphysis pubis feels a bulge like a full bladder
3. Third Maneuver
Question to ask ourselves: What is the presenting part in the lower pole?
Objective: identify what fetal part lies over the pelvic inlet.
Still facing the mother, use the thumb and fingers of one hand (making a wide C-shape) gently grasp the lower portion of the abdomen (just above symphysis pubis), bring thumb and fingers together.
– Assess for shape, size, consistency and mobility
Determine: What is in the lower pole?
This maneuver is the same as for the first maneuver but in the opposite pole.
Gently grasp the fundus with the other hand at the same time you grasp the lower portion to compare what is in the two poles.
4. Fourth Maneuver
Question to ask ourselves: On which side is the cephalic prominence?
Objective: identify the direction and degree of flexion of the head.
Facing the mother feet, apply gently, deep pressure down the sides of the abdomen towards the symphysis pubis, using the tips of the first three fingers of each hand.
– Assess descent of the presenting part.
If presenting part is the head
One hand is arrested sooner than the other by a hard-rounded mass (the cephalic prominence) while the other hand will descend deeply into the pelvis.
Cephalic prominence = Forehead
If the cephalic prominence is on the same side as the small parts
The head is well flexed and the fetus is in cephalic (vertex) presentation.
Cephalic prominence = Occiput
If the cephalic prominence is on the same side as the fetal back
The head is extended and the fetus is in face presentation.
Both hands simultaneously palpates the forehead and the occiput as a hard-rounded mass equally prominent on both sides.
A Sincipital or Military presentation.
If presenting part is engaged or “dipping”
When the cephalic prominence can’t be felt because it is out of reach in the pelvis.
The cephalic prominence has entered the pelvic inlet but has not yet descended.
It may be gently pushed back and forth in the pelvic inlet or the head may be floating.
– It may be gently pushed back and forth in the pelvic inlet or the head may be floating.