Building the picture maneuver by maneuver
Leopold's maneuvers are four steps of abdominal palpation that reveal fetal lie, presentation, position, attitude, and engagement. In the first maneuver, a soft, broad, irregular mass in the fundus is the buttocks. In the second maneuver, a smooth, firm, continuous surface on the mother's left is the fetal back, and small irregular parts on her right are the limbs. In the third maneuver, a hard, round mass above the symphysis pubis is the head. Together these findings show a cephalic presentation with the back on the mother's left.
Reading the fourth maneuver
In the fourth maneuver, the nurse faces the mother's feet and moves her fingertips down toward the pelvic inlet on both sides of the presenting part. Two findings come from this step. First, the cephalic prominence: if it is felt on the side opposite the back (the side of the small parts), it is the forehead, which means the head is flexed; if it is on the same side as the back, it is the occiput, which means the head is extended. Here the prominence is on the mother's right, opposite the back, so the head is flexed. Second, engagement: fingertips that converge as they move down mean the head is still above the inlet and not engaged; fingertips that diverge mean the widest part has entered the pelvis. This fetus is cephalic, back on the left, head flexed, and not yet engaged.
| Maneuver | Finding | Interpretation |
|---|
| First | Soft, broad, irregular mass in fundus | Buttocks in fundus |
| Second | Smooth, continuous surface on left | Back on mother's left |
| Third | Hard, round mass above symphysis | Cephalic presentation |
| Fourth | Prominence on right, opposite the back | Head flexed |
| Fourth | Fingertips converge | Not engaged |
Why the other conclusions are wrong
Options placing the back on the right misread the second maneuver, since the smooth, continuous surface was on the left. Options describing the head as extended misread the prominence: it is on the side of the small parts, opposite the back, so it is the forehead of a flexed head. Options calling the head engaged ignore the converging fingertips. Watch out! The rule for attitude is relative to the back: opposite side means flexion, same side means extension.
Clinical meaning
A flexed head presents its smallest diameter, which favors normal labor. Lack of engagement at 39 weeks in a primigravida in early labor deserves attention, because engagement often occurs before labor in first pregnancies, but it can still occur as labor progresses. The nurse records the findings, listens to the fetal heart on the side of the fetal back below the umbilicus, monitors contractions and progress, and reports the unengaged head to the attending provider for continued assessment.