STRU^NI ^LANCI

PROFESSIONAL PAPERS
Gynaecol Perinatol 2007;16(2):79–82

*Department Obstet. & Gynecol, Faculty of Medicine & Health Sciences,

United Arab Emirates University, United Arab Emirates,
**Department Obstet & Gynecol, Tawam Hospital, Al-Ain, United Arab Emirates,
***Department Obstetrics & Gynecologist, Women Hospital, Hamad Medical Coporation, Doha, Qatar.

LEOPOLD’S MANEUVERS:
HOW COMMON IS IT IN OUR DAILY PRACTICE?
LEOPOLDOVI HVATOVI:
KOLIKO SU ^ESTI U NA[OJ SVAKODNEVNOJ PRAKSI
Hisham M. Mirghani (MRCOG),* Howaida Khair (MRCOG),**
Badreldeen Ahmed (MRCOG)***

Professional paper
Key words: Leopold’s maneuvers, ultrasound, fetal orientation
SUMMARY. Objective. To determine how frequent obstetricians use Leopold’s maneuvers in their practice. Subjects and
Methods. A questionnaire with numerical scale was distributed among practicing obstetricians. They examined how
frequent the symphyseal fundal height (SFH) measurement, Leopold’s maneuvers and ultrasound examination for fetal
orientation were performed. Results. A total of 165 obstetricians completed the questionnaire. Only 56 (33.9%) respon-
dents indicated that they use SFH. The first and third Leopold’s maneuver were the most frequent abdominal grips
performed. Only 36 (21.8%) respondents regularly perform all four maneuvers. Seventy seven (46.7%) respondents use
ultrasound to determine fetal orientation. The use of ultrasound was significantly higher (p=0.02) in those practicing for
less than 10 years (62.6%) compared to those practicing for 10 years or more (43.3%). Conclusion. Leopold’s maneuvers
are still common in daily obstetrics practice. Abdominal palpation remains a common method to estimate the uterine size.
The first and third Leopold’s maneuver were the most frequent abdominal grips performed. Ultrasound examination is
commonly used to determine fetal orientation.
Stru~ni ~lanak
Klju~ne rije~i: Leopoldovi hvatovi, ultrazvuk, fetalni polo`aj i stav
SA@ETAK. Cilj rada je ustanoviti koliko ~esto opstetri~ari u svojoj praksi rabe Leopold-Pavlikove hvatove. Materijal i
metode. Upitnik s broj~anim podatcima je podijeljen opstetri~arima iz prakse. Oni su pokazali koliko ~esto izvode
mjerenje udaljenosti fundus simfiza, Leoplodove hvatove i pregled ultrazvukom za prosudbu fetalnog polo`aja i stava.
Rezultati. Ukupno je 165 opstetri~ara ispunilo upitnik. Samo 56 (33,9%) njih mjere udaljenost fundus simfiza. Prvi i tre}i
Leopoldov hvat su naj~e{}e rabljeni hvatovi. Samo 36 (21,8%) ispitanika redovito izvode sva ~etiri hvata. Sedamdeset
sedam (47,7%) rabe ultrazvu~ni pregled da odrede polo`aj i stav djeteta. Uporaba ultrazvuka je bila signifikantno ~e{}a
(p=0,02) u onih koji rade manje od 10 godina (62,6%) od onih koji rade dulje od 10 godina (43,3%). Zaklju~ak. Leopol-
dovi hvatovi su jo{ uvijek uobi~ajeni u svakodnevnoj opstetri~noj praksi. Palpacija trbuha trudnice je uobi~ajena metoda
za prosudbu veli~ine maternice. Prvi i tre}i Leopoldov hvat su naj~e{}e rabljeni hvatovi. Pregled ultrazvukom se obi~no
rabi za prosudbu polo`aja i stava fetusa.

Introduction Moreover, its accuracy depends on the examiner’s expe-

rience.3 In this study we aim to determine how common
Determining the fetal gestational age, lie and presen- Leopold’s maneuvers are in current obstetrical practice.
tation are essential for managing and planning preg-
nancy care. Leopold’s* four maneuvers are to determine
fetal orientation. This systematic approach has a great Materials and Methods
deal of information about the fetus: the fetal pole occu- A questionnaire was distributed among obstetricians
pying the fundus, the position of the fetal back, the attending the 7th Congress of Perinatal Medicine
presenting part and its engagement, and fetal attitude. (Zagreb, Croatia, 21–24 September, 2005), 15th World
These maneuvers have become one of the core skills for Congress on Ultrasound in Obstetrics & Gynecology
medical students and residents to acquire during their (Vancouver, Canada, 25–29 September, 2005) and Ian
training. The American College of Obstetricians and Donald Congress (Doha, Qatar, 4–8 January, 2006). De-
Gynecologists (ACOG) recommends Leopold’s maneu-
vers and the measurement of uterine fundus as the pri- * Opaska uredni{tva: u hrvatskom porodni~arskom nazivlju Leo-
mary method for clinical estimation of fetal weight.1 pold-Pavlikovi hvatovi – Editorial remark: in Croatian obstetrical
However, its sensitivity and specificity are variable.2 terminology known as Leopold-Pavlik’s maneuvers.

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Gynaecol Perinatol 2007;16(2):79–82 Mirghani H. M. et al. Leopold’s maneuvers: How common is it in our daily practice?

mographics included current post, country of certifica-

tion of specialization and number of years in practice
(obstetrics). In addition, a serial of statements examin-
ing how frequent the obstetrician performs symphyseal
fundal height (SFH) measurement, Leopold’s maneu-
vers and ultrasound examination for fetal orientation
were recorded. The options provided for these state-
ments were as follow. A: maneuver is never used; B:
rarely used (only in 25% of patients); C: occasionaly
used (in 50% of patients); D often used (in 75% of pa-
tients); E: always used (in 100% of patients).

Results
A total of 165 obstetricians properly completed the Figure 1. Percentage of respondents performing Leopold’s first maneuver
questionnaire. Respondents were from 15 different na- Slika 1. Postotak ispitanika koji rade 1. Leopoldov hvat
tionalities (Table 1). Eighty eight (53.3%) respondents Explanation – tuma~enje. Y axis: per cent, x axis: frequency of usage of Leopold’s
were practicing general obstetrics and gynecology, maneuver – u~estalost kori{tenja Leopoldovih hvatova: A. never – nikad; B. rare –
rijetko (25%); C. occasionally – povremeno (50%); D. often – ~esto (75%); E.
whereas 45 (27.3%) were of maternal fetal medicine in- always – uvijek (100%)
terest (Table 2). The mean years in obstetrics practice
was 13.3 years (95% CI, 12.0-14.6).
Only 56 (33.9%) respondents indicated that they al-
ways assess the uterine size by measuring the sym-
physial fundal height, compared to 81 (48.5%) respon-
dents who palpate the abdomen to determine uterine
size. The first and third Leopold’s maneuver were the
most frequent performed grips, 93.3% and 92.7%, re-
spectively. The first Leopold’s maneuver was the most
regular (always) performed grip (72.7%). The second
pelvic grip was the least frequent (39.4%) maneuver
performed (Figures 1–4). Only 36 (21.8%) respondents
indicated that they regularly perform all four Leopold’s
maneuvers. Seventy seven (46.7%) respondents use ul-
trasound to determine fetal lie, position or presentation.
Thirty two (19.3%) respondent use ultrasound with ev-
ery pregnant woman they examine (Figure 5). Three
Figure 2. Percentage of respondents performing Leopold’s second
(1.8%) respondents determine fetal orientation exclu- maneuver
sively by ultrasound. Slika 2. Postotak ispitanika koji rade 2. Leopoldov hvat
The use of ultrasound was related to years of practice. Explanation like in Figure 1. – Tuma~enje kao u slici 1.
The number of respondents who never used ultrasound

Table 1. Origin of certification of respondents

Tablica 1. Porijeklo specijalizacije ispitivanih

Middle East 60 (36,4%)

United Kingdom 40 (24,2%)
Other European countries 23 (13,9%)
Indian Subcontinent 22 (13,3%)
North America 14 (8,6%)
South America 4 (2,4%)
Australia / New Zealand 2 (1,2%)

Table 2. Type of training of respondents

Tablica 2. Vrsta sub/specijalizacije ispitivanih

General Obstetrics and Gynecoogy 88 (53,3%)

Maternal-fetal medicine 45 (27,3%) Figure 3. Percentage of respondents performing Leopold’s third maneuver
Infertility 22 (13,3%) Slika 3. Postotak ispitanika koji rade tre}i Leopoldov hvat
Ultrasound 10 (6,1%)
Explanation like in Figure 1. – Tuma~enje kao u slici 1.

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Gynaecol Perinatol 2007;16(2):79–82 Mirghani H. M. et al. Leopold’s maneuvers: How common is it in our daily practice?

Ultrasound was more regularly used by respondents

with ultrasound and maternal fetal medicine interest
(25.5%) than by general obstetrician and gynecologist
(14.7%). However, this was not statistically significant.
Ultrasound was significantly more regularly used by re-
spondents from North America (p=0.02) than by those
from the Indian subcontinent (Figure 6).

Discussion
Leopold’s maneuvers remain a popular method for
assessing fetal attitude, lie, position and presentation. Its
accuracy depends mainly on the experience of the exam-
ining physician.4 This is particularly true in identifying
Figure 4. Percentage of respondents performing Leopold’s fourth maneuver the upper most border of the uterine fundus.5 Its sensitiv-
Slika 4. Postotak ispitanika koji rade ~etvrti Leopoldov hvat ity is not related to maternal height, maternal body mass
Explanation like in Figure 1. – Tuma~enje kao u slici 1. index, parity, gestational age, placental position or fetal
presentation.6
Although the impact of symphysial-fundal height
(SFH) measurements on prenatal outcome remains con-
troversial, it has replaced, in many settings, abdominal
palpation.7 The symphyseal fundal measurement is more
accurate than abdominal palpation in estimating the ges-
tational age.8 And yet, only 33.9% of the respondents in-
dicated that they regularly measure the SFH. The poor
sensitivity of abdominal palpation is due to three main
factors. First, finger breadth is inaccurate in measuring a
distance between two landmarks. Second, the anatomi-
cal position of the umbilicus varies among mothers.
Finally, the gestational age at which the uterine fundus
reaches the umbilicus varies among pregnant women.
Figure 5. Percentage of respondents performing ultrasound for fetal The first and third maneuvers were the most regularly
orientation
Slika 5. Postotak ispitanika koji rabe ultrazvuk za dijagnozu polo`aja i
performed grips. The reason for this might be that they
stava fetusa provide most of the required information, particularly
Explanation like in Figure 1. – Tuma~enje kao u slici 1. fetal lie, presentation, and engagement. In contrast, the
forth maneuver was the least performed grip among the
for fetal orientation was significantly lower (p=0.02) in respondents. This might be due to uncomfortableness of
those practicing for less than 10 years (43.3%) com- the method, or because it does not provided any signifi-
pared to those practicing for 10 years or more (62.6%). cant additional information to the obstetrician.

Figure 6. Percentage of respondents performing

Leopold’s maneuvers and ultrasound examination
according to region of certification
Slika 6. Postotak ispitanika koji rade Leopoldove
hvatove i pregled ultrazvukom prema porijeklu
specijalizacije

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Gynaecol Perinatol 2007;16(2):79–82 Mirghani H. M. et al. Leopold’s maneuvers: How common is it in our daily practice?

More than a third of the respondents indicated that 4. Nahum GG. Predicting fetal weight. Are Leopold's ma-
they use ultrasound to determine fetal orientation. This neuvers still worth teaching to medical students and house staff?
trend will most likely increase in the coming years.9 The J Reprod Med 2002;47:271–8.
availability of ultrasound machines might explain the 5. Engstrom JL, Sittler CP, Swift KE. Fundal height mea-
significantly higher usage of ultrasound among North surement. Part 5. The effect of clinician bias on fundal height
American obstetricians compared to those from the In- measurements. J Nurse Midwifery 1994;39:130–41.
dian Subcontinent. The high rate of ultrasound usage 6. Engstrom JL, McFarlin BL, Sampson MB. Fundal height
among respondents with less than 10 years of practice measurement. Part 4. Accuracy of clinicians' identification of the
compared to those of more than 10 years might be due to uterine fundus during pregnancy. J Nurse Midwifery 1993;38
the background training. Many residency programs, in (6):318–23.
the past decade, have included ultrasound training in 7. Neilson JP. Symphysis-fundal height measurement in preg-
their curriculum.10 The accuracy of ultrasound in deter- nancy. Cochrane Database Syst Rev 2000;(2):CD000944.
mining fetal presentation,11 position12 and engagement13 8. Engstrom JL. Measurement of fundal height. J Obstet Gy-
compared to manual abdominal palpation might be an- necol Neonatal Nurs 1988;17:172–8.
other factor. These findings indicate that ultrasound is a 9. Lee W, Hodges AN, Williams S, Vettraino IM, McNie
common tool among obstetricians to determine fetal ori- B. Fetal ultrasound training for obstetrics and gynecology resi-
entation. Indeed, for some obstetricians (1.8%), it has dents. Obstet Gynecol 2004;103:333–8.
replaced Leopold’s maneuvers. Nevertheless, manual 10. Calhoun BC, Hume RF. Integrated Obstetric Curricu-
abdominal palpation remains a useful tool for antenatal lum for Obstetrics and Gynecology Residency, Radiology Resi-
care.14 In fact, Leopold’s maneuvers, when used by ex- dency and Maternal-Fetal Medicine Fellowship Program at an
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11. Thorp JM Jr, Jenkins T, Watson W. Utility of Leopold
maneuvers in screening for malpresentation. Obstet Gynecol
Conclusion 1991;78:394–6.
Abdominal palpation remains a common method to 12. Akmal S, Tsoi E, Nicolaides KH. Intrapartum sonogra-
estimate the uterine size. Leopold’s maneuvers are still phy to determine fetal occipital position: interobserver agree-
common in daily obstetrics practice. The first and third ment. Ultrasound Obstet Gynecol 2004;24:421–4.
Leopold’s maneuver are the most frequent abdominal 13. Dietz HP, Lanzarone V. Measuring engagement of the
grips. Ultrasound is commonly used by obstetricians to fetal head: validity and reproducibility of a new ultrasound tech-
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14. Stuart JM, Healy TJ, Sutton M, Swingler GR. Symphy-
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Paper received: August, 17, 2006; Accepted: March, 20, 2007. Address for correspondence: Dr. Hisham M Mirghani, Depart-
ment Obstetrics & Gynecology, Faculty of Medicine & Health Sci-
ences, United Arab Emirates University, PO Box 17666, Al-Ain,
United Arab Emirates. E-mail: hmirghaniºuaeu.ac.ae

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