Maternal abdominal examination of the fetus by Leopold’s maneuvers is a common and systematic way to determine the position of a fetus inside the woman’s uterus.
• The lie is the relationship between the longitudinal axis of fetus and mother: longitudinal, oblique, and transverse.
• Presentation is the relationship between the leading fetal part and the pelvic inlet: cephalic, or breech. The presenting part may be the fetal heard or the breech. Ordinarily, the head is flexed sharply so that the chin is in contact with the thorax. In this circumstance, the occipital fortanel is the presenting part, and such a presentation is usually referred to as a vertex or occiput presentation.
• Position is the relationship between definite part of the fetus (back) to the right or left side of maternal pelvis. With each presentation there may be two position: right (II-second) or left (I-first). About two thirds of all vertex presentations are in the left occiput position and the one third in the right.
• Variety is the relation of the back of fetus to the anterior and or posterior side of the mother’s pelvis. There may be two variety anterior or posterior.
• Engagement – the fetal is engaged if the widest leading part (typically the widest circumference of the head) is negotiating the inlet.
With the mother lying comfortably on her back, the examiner faces the patient for the first 3 steps, and faces towards her feet for the fourth.
1. FIRST maneuver. Having established the height of the fundus, the fundus itself is gently palpated with the fingers of both hands, in order to discover which pole of the fetus (breech or head) is present. The head feels hard and round, and is easily movable and ballotable. The breech feels soft, triangular and continuous with the body. A professional can also determine the level of the uterine fundal height (but not in cm, on the levels; on the level of umbilicus, ribs, xiphoid process).
2. SECOND maneuver. The palms hands are now placed on the sides of the abdomen. On one side there is the smooth, firm curve of the back of the fetus, and on the other side are fetal extremities (arms, legs) that are felt like small irregularities and protrusions. It is often difficult to feel the fetus well when the patient is obese, when there is a lot of liquor or when the uterus is tight, as in some primigravidas.
3. THIRD maneuver. The examiner grasps the lower portion of the abdomen, just above the symphysis pubis, between the thumb and fingers of one hand. The objective is to feel for the presenting part of the fetus and to decide whether the presenting part is loose above the pelvis or fixed in the pelvis. If the head is loose above the pelvis, it can be easily moved and balloted. The head and breech are differentiated in the same way as in the first step.
4. FOURTH maneuver. The objective of the step is to determine the amount of head palpable above the pelvic brim, if there is a cephalic presentation. The examiner faces the patient’s feet, and with the tips of the middle 3 fingers palpates deeply in the pelvic inlet. In this way the head can usually be readily palpated, unless it is already deeply in the pelvis. The amount of the head palpable above the pelvic brim can also be determined.