The correct order of Leopold's maneuvers
Leopold's maneuvers are four systematic steps of abdominal palpation used to determine fetal lie, presentation, position, and descent. The correct order is: first, palpate the fundus to identify which fetal part occupies it; second, palpate both sides of the abdomen to locate the fetal back and small parts; third, grasp the lower abdomen just above the symphysis to identify the presenting part; and fourth, face the client's feet and press toward the pelvic inlet to find the cephalic prominence. The sequence 3, 4, 1, 2 moves from the top of the uterus, to the sides, to the presenting part, and finally to its degree of descent.
What each maneuver tells the nurse
| Maneuver | Technique | Finding |
|---|
| First (fundal grip) | Both hands palpate the upper uterus | Which fetal part is in the fundus: the softer, irregular breech or the hard, round head |
| Second (lateral grip) | Hands palpate each side of the abdomen | Location of the fetal back and small parts |
| Third (Pawlik's grip) | Grasp the lower abdomen just above the symphysis | The presenting part and whether it is movable or engaged |
| Fourth (pelvic grip) | Nurse faces the client's feet and presses toward the pelvic inlet | The cephalic prominence and degree of descent |
Preparation and positioning
The client empties her bladder first so the presenting part can be felt and she is more comfortable. She lies supine with her knees slightly flexed to relax the abdominal muscles. The nurse uses warm hands and the palmar surfaces of the fingers, and palpates between contractions. A small wedge under one hip can be used to reduce the risk of supine hypotension during a longer examination.
Why the distractors are wrong
The option 3, 1, 4, 2 grasps the presenting part before the sides are examined, but the sides are palpated second. The option 3, 4, 2, 1 has the nurse face the client's feet before grasping above the symphysis, yet turning toward the feet is reserved for the last maneuver. The option 4, 3, 1, 2 begins at the sides instead of the fundus. Watch out! The two maneuvers in the lower abdomen are easy to confuse: the third grasps the presenting part while the nurse faces the client, and the fourth is done facing the client's feet.
Exam takeaway
Top, sides, bottom, then facing the feet: fundus, back and small parts, presenting part, and descent. Key point! The findings of Leopold's maneuvers also guide where to place the fetoscope or Doppler, because fetal heart tones are usually heard best over the fetal back.