CONCURRENT VALIDITY OF LEOPOLD'S MANEUVERS IN DETERMINING FETAL PRESENTATION AND POSITION

Barbara L. McFarlin, CNM, MS, Janet L. Engstrom, CNM,MS, PhD, Milo B. Sampson, MD, and Frances Cattledge, RT

ABSTRACT The accuracy of Leopold's maneuvers in the assessment of fetal presentation and position was studied in 176 subjects. The maneuvers were performed by clinicians during the routine prenatal examination of women who were scheduled for an ultrasound immediately after their prenatal visit. The actual fetal presentation and position were determined during the sonographic examination. Clinicians were correct in their assessment of fetal presentation and position in 85.23 % and 60.31% of determinations, respectively. However, only 53% of all malpresentations were assessed correctly. CIinicians with I or less than 5 years of experience had higher percentages of correct assessments than clinicians with 3 to 4 years of experience. Overall, the accuracy of the assessments was higher in late pregnancy. However, the percentage of malpresentations assessed correctly decreased near term. Assessments were less accurate for overweight women. Parity did not influence the accuracy of the assessments.

The accurate assessment of fetal presentation and position is essential to the appropriate management of the intrapartal patient. Knowledge of the fetal presentation and position facilitates the appropriate choice of the route of delivery, place of delivery, and labor position for the mother. There are four methods that can be used to assess fetal presentation and position: x-ray, sonography, pelvic examination, and palpation of the fetus through the maternal abdomen. X-ray assessments are accurate, however, e x p o s u r e of the fetus to radiation is undesirable. 1-3 S o n o g r a p h i c assessments of fetal presentation and position also are accurate4; however, the m e t h o d requires considerable skill, is costly, and is not available in all settings.
Address correspondence to: Barbara L. McFarlin, CNM, MS, 301 East Springfield, Champaign, IL 61820.

The accuracy of pelvic examination in the assessment of fetal presentation and position has not b e e n studied but is probably influenced by the extent of cervical dilatation and fetal descent into the pelvis. Additionally, there are instances when pelvic examinations are contraindicated, such as in cases of placenta previa or premature rupture of the m e m b r a n e s . Abdominal palpation for the assessment of fetal presentation and position has the advantages of being readily available, inexpensive, easy to perform, and noninvasive. However, the accuracy of such assessments has not been studied extensively.
HISTORY OF THE USE OF ABDOMINAL PALPATION

has been performed since antiquity. Its advantages were e n d o r s e d by Roederer et al 5 in the 17th century. In 1878, Pinard 6 developed a systematic technique for examining the gravid a b d o m e n to determine fetal presentation and position. Crede and Leopold expanded Pinard's method of abdominal palpation and in 1892 published their technique in a German text entitled Text-Book of Obstetrics for Midwives.7 Later that year, Edgar translated and published two chapters of Leopold and Crede's book into Englishfi This article contained a detailed description of the technique and illustrations of the four maneuvers of abdominal palpation. This method of abdominal palpation to determine fetal presentation and position became known as Leopold's
m a n e u v e r s . 5,8,9

Determination of fetal presentation and position by abdominal palpation

In 1894, A Short Guide to the Examination of Lying-ln Women by

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Crede and Leopold was translated into English by Wilson. i Wilson stated that he found the maneuvers to be very accurate except perhaps on "nervous primiparous women." He asserted that the primary motivation to the development of a systematic approach of abdominal palpation to determine fetal presentation and position was to prevent puerperal infection and rupture of the membranes, by decreasing the number of vaginal examinations of women during pregnancy and labor. After the publication of Leopold's maneuvers in Europe and the United States in 1892, the technique was accepted widely and was described in obstetric and midwifery textbooks thereafter.S i~ In fact, Leopold's maneuvers were accepted as a standard of practice for midwives in Germany and adopted as a law for the practice of midwifery by the government of Saxony. Noncompliance could result in fines and loss of the right to practice. lo

Barbara L. McFarlin, MS, CNM, is a certified nurse-midwife in private practice in Champaign, lllinois, and is also a clinical faculty member of the University of lllinois College of Medicine at Urbana-Charnpaign. She is interested in research concerning ultrasound in premature labor. Janet Engstrorn, CNM, MS, PhD, Lecturer of nurse-midwifery sequence at the University of lllinois College of Nursing at Chicago. Milo B. Sampson, MD, is an obstetrician-gynecologist with a specialty in maternal-fetal medicine at the University of lllinois College of Medicine, Department of Obstetrics & Gynecology at Chicago. Frances Cattledge is an ultrasonographer in the Department of Obstetrics & Gynecology at the University of lllinois-College of Medicine-Chicago and participates in clinical ultrasonography and research regarding obstetrics and gynecology.

Despite the widespread publication and use of the method, a review of the literature found no published studies that have evaluated the accuracy of fetal presentation and position assessments by the use of Leopold's maneuvers. There is one anecdotal report and one small unpublished study of the accuracy of the maneuver. In 1897, Pinard 14 wrote that he used the maneuvers on over 10,000 parturients in whom he successfully diagnosed fetal position, presentation, and progression of labor. However, he did not provide any statistical evidence of his experience with the maneuvers. In 1980, Troxell I~ reported the inter-rater reliability of fetal presentation and position assessments obtained by Leopold's maneuvers in 40 subjects. Fetal presentation and position were verified by a second examiner and by a vaginal examination. However, only cephalic presentations and occiput-anterior or occiput-transverse positions were included in the study. Assessments verified with another examiner by either abdominal palpation or vaginal examination were correct in 82.5% of the cases.
PURPOSE OF THE STUDY

The purposes of this study were to determine: 1) the accuracy of Leopold's maneuvers in assessing fetal presentation and position; 2) if fetal malpresentations are associated with lower rates of accurate assessment; 3) if the experience of the clinician influences the accuracy of the assessments; 4) if the length of gestation influences the accuracy of assessments; and 5) if maternal weight influences the accuracy of the assessments.
METHODS

the study were included in the sample. The clinicians responsible for conducting the prenatal visit were instructed to assess fetal presentation and position by Leopold's maneuvers. The following verbal description of the four maneuvers was given to each clinician: 1) palpate the uterine fundus with both hands to determine the fetal part occupying the fundus; 2) palpate the lateral borders of the uterus to determine the location of the fetal back and small parts; 3) spread the fingers of one hand and palpate the area above the symphysis pubis to determine the presenting part; and 4) face the woman's feet and palpate the lateral uterine borders above the symphysis pubis to determine the position of the presenting part. Clinicians were instructed to record their assessment of fetal presentation and position on the prenatal record. Immediately after the Leopold assessments, ultrasound determinations of fetal presentation and position were made within the antepartum clinic. The sonographer was blinded to the clinicians' assessments of fetal presentation and position. Clinicians were blinded to the sonographic assessment of presentation and position except in those cases where the sonogram was ordered for the purpose of determining the fetal presentation or when the clinican was present during the sonogram. Accurate assessments of fetal presentation and position by Leopold's maneuvers were defined as those assessments that agreed with the sonographic assessment.

RESULTS

Study participants were selected from the antepartum clinic of a large midwestern perinatal center. Only women scheduled for an ultrasound examination for purposes other than

Data were collected from 176 women. Characteristics of the sample are summarized in Table 1. Twenty clinicians participated in the study. Eight physicians completed a total of 72 assessments. The number of assessments per physician ranged from 2 to 59 (mean = 9). The physicians'
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TABLE 1 Description of the sample

Mean +_ SD Range

Height (in) Pregravid weight (Ib) Present weight (Ib) Weeks' gestation (wk) Parity 0 I 2 3 I>4 SD = standard deviation. years of clinical experience ranged from 2 to 6 years (mean = 3.1). Five certified nurse-midwives completed a total of 51 assessments. The number of assessments per nurse-midwife ranged from 2 to 18 (mean -- 10.2). The certified nurse-midwives' years of clinical experience ranged from 1 to 10 years (mean = 4.8). Six student nurse-midwives and one nurse practitioner completed a total of 53 assessments. The number of assessments ranged from I to 39 (mean = 5.7). The student nurse-midwives and the nurse practitioner all had 1 year or less of clinical experience. The frequency of fetal presentations were as follows: 140 cephalic (79.5%), 22 b r e e c h (12.5%), 7 transverse (4%), and 7 oblique (4%). The accuracy of the clinicians' assessments of fetal presentation is summarized in Table 2. The examiners were correct in their assessment of fetal presentation in 150 (85.2%) of the cases. However, only 19 of the

67.8 134.5 160.3 33.6

+ 2.8 _+ 33.8 _+ 35.3 _+ 4.3

50-70 85-299 104-301 20-42 (%) (42.86) (29.14) (16.57) (5.71) (5.71)

n 75 51 29 10 10

36 (52.8%) malpresentations were assessed correctly. For analysis, these data were grouped into the dic h o t o m o u s categories of cephalic presentations versus malpresentations. A one-tailed McNemar test demonstrated that the number of errors was statistically significant (Xm 2 = 2.46, p = .058). The accuracy of fetal presentation assessments grouped by the number of years of clinical experience is summarized in Table 3. Clinicians with more than 5 years of experience had the highest percentage of correct assessments and clinicians with 3 to 4 years of experience had the lowest percentage. The differences in the rates of correct assessment among these four groups of clinicians was statistically significant (X2(3) = 20.13, p = .0002). The accuracy of assessments of presentation by weeks of gestation is summarized in Table 4. The accuracy ranged from 66.7% at 20 to 24

weeks to 100% at 41 to 42 weeks' gestation. However, only five assessments were made at 41 to 42 weeks and malpresentations were not represented in this group. To provide sufficient numbers for analysis, these data were grouped into the following categories: 28 weeks, 29 to 32 weeks, 33 to 36 weeks, and greater than 37 weeks' gestation. The differences in the rate of accurate assessments b e t w e e n these four groups were not statistically significant (X2(3) -- 4.37, p = . 2241). The percentage of fetal malpresentations assessed accurately decreased as p r e g n a n c y a d v a n c e d (Table 4). These data were grouped into less than or equal to 28 weeks and greater than or equal to 29 weeks' gestation to provide sufficient numbers for analysis. The difference between these two groups was not statistically significant (2(1) = .579, p = .4467). Maternal height and weight were recorded in 171 of the cases. Fetal presentation was assessed correctly in 103 (88.8%) of 116 w o m e n of normal weight and in 43 (78.1%) of the 55 overweight women (pregravid weight greater than the 75th percentile of weight for height for 18 to 24 years of age as determined by the National Health S u r v e y 1971 to 1974). 16 Although the percentage of accurate assessment in overweight w o m e n was lower, this difference was not statistically significant (2(1) = 2.57, p = .109). Fetal presentation was assessed accurately in 66 of the 75 nulliparous

TABLE 2 Accuracy of Leopold's maneuvers in assessing fetal presentation

Correct assessment

TABLE 3 Effect of clinician experience on accurate assessment of fetal presentation

Correct assessment

Presentation

(%)

Cephalic 131/140 Malpresentations 19/36 Breech 13/22 Transverse 5/7 Oblique 1/7 Total 150/176

(93.6) (52.8) (59.1) (71.4) (14.3) (85.2)

Clinician experience (yrs)

All presentations n (%)

Malpresentations n (%)

~1 2 3-4 I>5 Total

58/64 52/59 14/25 26/28 150/176

(90.6) (88.1) (56.0) (92.9) (85.2)

9/13 6/10 0/8 4/5 19/36

(69.2) (60.0) (0) (80.0) (52.8)

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TABLE 4 Effect of gestational age on accurate assessment of fetal presentation

Correct assessment All presentations Weeks' gestation n (%) Malpresentations n (%)

2 0 - 24 25-28 29-32 33-36 37-40 41-42

4/6 12/16 31/38 59/67 39/44 5/5

(66.7) (75.0) (81.6) (88.1) (88.6) (100.0)

3/5 6/9 4/8 3/7 3/7 0

(60.0) (66.7) (50.0) (42.9) (42.9)

women (88%) and in 83 of 100 multiparous women (83%). This difference was not statistically significant (2(I) = .498, p = .480). Fetal position was documented on 131 of the cephalic presentations. Accurate assessments were made in 79 (60.3%) of the cases. The highest percentages of accurate assessments were as follows: left occiput-transverse, 38 (79.2%); right o c c i p u t transverse, 18 (72%); and occiputposterior, 4 (66.7%). For all other positions, the percentage of accurate assessments was less than or equal to 50%. The accuracy of fetal position assessments grouped by the number of years of clinical experience is summarized in Table 5. Clinicians with less than or equal to i year or greater than or equal to 5 years' experience had the highest percentage of accurate assessments, and clinicians with 3 to 4 years of experience had the lowest percentage. The difference between the four groups of clinicians

was not statistically significant (2(3) = 3.02, p = .388). The accuracy of fetal position assessments by weeks of gestation is summarized in Table 6. The accuracy ranged from 0% at 20 to 24 weeks to 80% at 41 to 42 weeks' gestation. T o provide sufficient n u m b e r s for analysis, these data were grouped into the following categories: less than or equal to 28 weeks, 29 to 32 weeks, 33 to 36 weeks, and greater than or equal to 37 weeks. Although the percentages of accurate assessments were higher near term, these differences were not significantly different (X2(3) = 3.97, p = .264). Maternal height and weight, and the fetal position were documented on 126 of the records. Assessments were correct in 62 (68.1%) of 91 women of normal weight and in 16 (45.7%) of the 35 overweight women. This difference was statistically significant (2(1) = 4.48, p = .034).

The accuracy of the assessments of the relation of the fetal back to the mother are as follows. The fetal back was correctly assessed as being on the right side of the m o t h e r in 33 (86.8%) of the 38 cases, and on the left side of the mother in 66 (82.5%) of the 80 cases. A one-tailed McN e m a r test d e m o n s t r a t e d that the number of errors was statistically significant (2 m = 4.26, p = .0197). None of the four o c c i p u t - a n t e r i o r positions were assessed correctly and four (66.7%) of the six occiput-posterior positions were assessed correctly.
DISCUSSION

TABLE 5 Effect of clinician experience on accurate assessment of fetal position

Clinician experience (yrs) Correct assessment n (%)

TABLE 6 Effect of gestational age on accurate assessment of fetal position

Correct assessment n (%)

Weeks' gestation

~1 2 3-4 ~5 Total

31/49 31/51 3/9 14/22 79/131

(63.3) (60.8) (33.3) (63.6) (60.3)

20-24 25-28 29-32 33-36 37-40 41-42

0/1 4/6 11/25 36/58 24/36 4/5

(0) (66.7) (44.0) (62.1) (66.7) (80.0)

The accurate assessment of fetal presentation and position is essential to the appropriate m a n a g e m e n t of a woman's labor and birth. Clinicians must know the fetal presentation and position to determine the appropriate setting and route of birth, the choice of positions for the mother during labor, the appropriateness of patient m a n a g e m e n t by clinicians who are not obstetricians, and whether or not version of the fetus is indicated. Additionally, malpresentations are associated with an increased incidence of fetal anomalies and placenta previa, 9 both of which require specialized facilities and medical expertise. The use of Leopold's maneuvers to determine fetal presentation and position is attractive for clinical use because the method is noninvasive, inexpensive, readily available, easy to perform, and acceptable to patients. In this study, fetal presentation was assessed correctly by Leopold's maneuvers in 85.2% of the cases. However, only 52.8% of all malpresentations were assessed accurately. This low rate of identifying malpresentations accurately is of concern and raises questions about the validity of m a n a g e m e n t decisions based on the results of L e o p o l d ' s maneuvers. The finding that clinicians with 1 or less or 5 or more years of experience had the highest percentages of 283

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accurate assessments of fetal presentation is interesting. Even though increased accuracy among the most experienced clinicians was expected, it was surprising to find the most inexperienced clinicians had rates of accurate assessment similar to the most experienced. A plausible explanation for this finding is that inexperienced clinicians may d o u b t their skills and, therefore, be more careful when performing their assessments. Overall, the percentage of accurate assessment of presentation increased after 33 weeks of gestation, reaching 100% accuracy after 40 weeks. However, the high percentage of accurate assessments near term is misleading due to the overrepresentation of cephalic presentations in this group, and the m e a n gestational age in this study, which was 33.6 (_+4.3) weeks. A study of women at term is needed to determine if the accuracy of Leopold's assessments is higher in this population. The percent of malpresentations assessed accurately was highest (64.3%) before 29 weeks of gestation. The overall accuracy of clinicians' assessment of fetal position was low (60.3%). However, their accuracy did increase to 80% by 41 to 42 weeks of gestation. The relationship of the fetal back to the mother was assessed correctly in more cases than was the actual fetal position. There was a lower percentage of correct assessments of both fetal presentation and position in overweight subjects. Parity did not influence the accuracy of fetal presentation assessments. These results are disappointing, but this study had many limitations. There were only 36 malpresentations in the sample and they were underrepresented near term. Additionally, the sampling technique may have seriously under-estimated clinicians' accuracy of assessing fetal presentation as the number of assessments made by clinicians was not equal in all groups. This may have skewed

the results in some groups, such as the physicians with 3 to 4 years of experience. Clinicians may have ordered sonograms in only those cases where they were unsure of their assessments and, in cases where they were certain of their assessment, felt it unnecessary to obtain confirmation with ultrasound examination. On the other hand, it is possible that clinician accuracy was even less than observed in these data. Because patients in this clinic did not have routine ultrasound examinations, it is impossible to know how many realpresentations were not identified by clinicians.
CONCLUSION

This study demonstrated that there was a significant number of errors in the assessment of fetal presentation and position by Leopold's maneuvers. Only 53% of all malpresentations were assessed correctly. There was not a consistent difference in the percentage of accurate assessments by the a m o u n t of clinician experience: Clinicians with I or less or 5 or more years of experience had higher rates of accurate assessments than those with 3 to 4 years of experience. The length of gestation did influence the accuracy of assessments, with a higher percentage of accurate assessments of both presentation and position observed near term. However, when analyzed separately, the percentage of malpresentations assessed correctly actually decreased later in pregnancy. The percentage of accurate assessments of both presentation and position was lower in overweight women. Parity did not influence the accuracy of presentation assessments.
REFERENCES

relationship of intrauterine radiation to subsequent mortality and development of leukemia in children. Am J Epidemiol 97(5):283-313, 1973. 3. Granoth G: Defects of the central nervous system in Finland, IV. Associations with diagnostic x-ray examinations. Am J Obstet Gynecol 133(2):191-194, 1979. 4. Hobbins JC, Winsberg F, Berkowitz R: Ultrasonography in Obstetrics and Gynecology, 2nd ed. Baltimore, Williams & Wilkins, 1983. 5. Williams JW: Obstetrics. New York, Appleton & Co, 1903. 6. Crede E, Leopold G: The obstetrical examination: A short guide for physicians, students of medicine, midwives, and students in midwifery, in Edgar JC (ed & transl). NY J Gynecol Obstet 2:1129, 1892. 7. Crede E, Leopold G: Text-book of obstetrics for midwives, 5th ed. Leipzig, 1892. 8. Eastman NJ: Williams obstetrics, 10th ed. New York, Appleton-CenturyCrofts, 1950. 9. Pritchard JA, MacDonald PC, Gant NF: Williams obstetrics, 17th ed. New York, Appleton-Century-Crofts, 1984. 10. Crede E, Leopold G: A short guide to the examination of lying-in women (W Wilson, transl). London, H Kimpton, 1894. 11. Beck A: Obstetrical practice, 2nd ed. Baltimore, Williams & Wilkins, 1939. 12. Davis EP: A Manual of practical obstetrics. Philadelphia, Blakiston, Son & Co, 1894. 13. Leopold G, Sporlin: Die Leitung der Regelmassigen Geburten nur durch Aussere Untersuchung. Arch Fur Gyn, 45:337, 1894. 14. Leopold G, Pinard A: De l'Exploration Externe en Obstetrique. Ann de Gyn, 10(3):310-320, 1897. 15. Troxell R: A compression maneuver for the detection of nuchal cord. Master's thesis, University of Illinois at the Medical Center, Chicago, 1980. 16. US Public Health Service: Weight by height and age for adults 1 8 - 7 4 years: United States 1971-1974. Data from National Health Survey (Series 11, N 208). Hyattsville, Office of Health, Research, Statistics and Technology, 1979.

1. Bithell JF, Stewart A: Prenatal irradiation and childhood malignancy: A review of British data from the Oxford survey. Br J Can 31(3):271-287, 1975. 2. Diamond EL, Schmerler H: The

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