Palpation is the act of using one’s hands to figure out something on or in a body. In maternity services, the practitioner routinely palpates the pregnant belly to assess the position and size of the foetus.
After the male midwife, which later became the obstetrician, infiltrated birth services and paternalized it into a male-centric, provider-centric practice, they’ve been “discovering” all kinds of things that were just normally known and carried out by midwives for centuries. Among them is the standard way to palpate a pregnant belly.
German obstetrician-gynaecologist Christian Gerhard Leopold (1846-1911) is credited with the obstetrical manoeuvre used today to palpate pregnant bellies called ‘Leopold’s Manoeuvre’.
Leopold’s Manoeuvre is a series of 4 specific actions. These 4 actions, along with an assessment of the maternal pelvic shape will help the practitioner to determine if complications will occur during delivery and whether a caesarean should be recommended. They think of it much like a crystal ball that somehow predicts the future. In the provider-centric world of maternity services, it’s another way the practitioner replaces the pregnant mother as the expert on her body and her birth and minimises the power of the birth dance where the mother and baby work together through movement to bring the baby earthside.
Manoeuvre one: Fundal Grip
The practitioner walks their hands up the sides of the uterus to the top of the uterus, called the ‘fundus’. Palpating the upper abdomen will determine if the foetus is lying longitudinal (up/down), oblique (on an angle), or transverse (side-to-side). If the baby is longitudinal, palpating the upper abdomen should determine if it’s a bum or a head.
Manoeuvre two: Umbilical Grip
Next is to determine where the foetal back is lying. By placing hands on either side of the mid-abdomen, the practitioner applies deep pressure on alternating sides to determine where the back is and where the extremities are (arms and legs).
Leopold’s Manoeuvres - public domain
Manoeuvre three: Pawlick’s Grip
This is also named after a male obstetrician-gynaecologist, Karel Pawlick (1849-1914). This step determines how much of the foetus is above the pelvic inlet. The practitioner uses their fingers and thumb to grasp the lower abdomen, just above the pubic bone (pubic symphysis) to feel how much of the foetus can be felt above the pubic bone.
Manoeuvre four: Pelvic Grip
The practitioner faces the patient’s feet and tries to locate the foetus’ brow by placing both hands on the lower abdomen and moving the fingers of both hands towards the pubis by sliding the hands over the sides of the patient’s uterus. On the side where there is the greatest resistance to the practitioner’s descending fingers is the baby’s brow. A well-flexed head, meaning the chin is tucked down towards the chest, will be on the opposite side of the foetal back. If the head is extended, that is, looking straight ahead or upwards, the back of the head is felt on the same side where the back was found. If the brow cannot be found, the head is descended into the pelvis.
With the routine overuse of ultrasound, many practitioners are losing the art of palpation. Routine multiple ultrasounds are now taking the place of non-invasive and non-risky palpation to assess foetal size (with varying degrees of accuracy), amniotic fluid volume (with varying degrees of accuracy), and position of the baby (with a great deal of accuracy). It could be that since ultrasound is very accurate at determining position, practitioners are losing confidence in their own skills.
As a Traditional Birth Attendant, I like palpating pregnant bellies. I especially like it as a grandmother (Nana). Nothing delights me more than playing with my own grandchildren inside their mother’s bellies. In fact, Nana has turned her own grandchild from breech to cephalic. It’s a simple skill that tends to make me a more useful grandmother.
In all the texts I scoured that discusses how to do Leopold’s Manoeuvre, not once was the foetus ever considered as a sentient member of the procedure. The mother’s comfort is often considered, but primarily, it’s about the practitioner doing something to the client to gather information.
I tend to see palpation through a different lens. I feel it’s more about building a relationship with the baby than anything else. After all, if I’m going to be invited to the birth, the baby should know who I am and whether I am someone they can trust to care for their mummy and therefore take care of them.
In my relationship with pregnant families, the first part of palpating a pregnant belly is to ask the mother if she would like this. She doesn’t have to submit to this. This is her choice. I’ve had clients with a history of sexual assault where this was a very threatening idea that someone would be touching their belly and never wanted it. Instead, they just told us where the baby was and what their guess was on how big the baby was. As it turns out, maternal guessing is pretty accurate and often beats the guesses of ultrasounds or experienced practitioners (1). Another client liked palpation, but could only do it sitting up with one hand over her breasts and one protecting her groin.
If the mother agrees to palpation, then I always suggest she go relieve her bladder first. There’s nothing worse than someone playing with your belly and a full bladder. It’s a recipe for leaking out a wee drip or a pent-up fart.
I have a nice couch by a sunny window that clients are invited to lie down on with as many pillows behind them as feels comfortable. I tend to sit on the couch with them nestled beside their legs.
Now here comes the most important part of palpation:
I introduce myself to the baby.
I say hello to the baby. I tell them my name and that I’m a friend of their mummy and daddy. I let them know that Nana often has cold hands.
I start very gently and talk to the baby the whole time. There are no pre-determined set of manoeuvres as this is usually led by the baby. I may find their little bum and squeal with delight! I talk about how much they’re growing. I invite them to play with me. Sometimes their little foot will poke out to start a little game with me. I’ll ask them to show me what position they’re in and if they’d be ok with us listening to their heartbeat with a fetoscope. If my hands are going to go lower on the mother’s abdomen to where a head might be nestled, I always ask permission from the mother before touching her anywhere close to her pubic bone. Likewise, if the parents want a measurement of fundal height, it’s the mother that places the end of the measuring tape on the top of her pubic bone. There’s no need for someone else to be rooting around down there. Once mum picks her spot where the tape measure starts, then that also helps to eliminate measuring errors that can come with multiple people measuring her belly and placing the tape differently.
Some babies become quite playful. And some will lie quietly, listening to me, deciding if I am friend or foe. It becomes quite easy to sense the baby’s receptivity. A baby who has taken a journey along with their mother through previous obstetric mistreatment or disrespectful prenatal visits will often lie quietly, perhaps taking in their mother’s reactions. It may take another visit to warm up to me and become more playful. I tell them that by the time they arrive, I hope we’ll be good friends.
Through gentle palpation, the baby and I are getting to know each other. The parents and I are building trust. We’re having fun! And through gentle touch, we discover where the baby is positioned at that particular moment. It’s not predictive of much else. Even persistently breech babies have turned in labour when I’ve been present. Perhaps in the presence of calm and loving family and birth attendant, the babies felt it a simple matter to rotate and come out head first.
Through gentle palpation, we can also get a sense for how much amniotic fluid is in the womb. It’s a chance to talk about hydration and salt. Parents are invited to listen to their baby’s heartbeat with a fetoscope, and depending on the position of the placenta, they may be treated to the sounds of its ‘whooshing’ as blood flows through the maternal side.
A fetoscope is non-invasive and listens to the baby’s heartbeat and the placenta
Through gentle palpation, we can invite the baby to adjust their position to make it easier on mummy. Perhaps a poking foot is feeling like it’s about to break mummy’s rib. Or little one hasn’t started the descent down into the pelvis as it gets closer to term. Having a simple conversation with the little one and explaining how they can help has shown over and over that these precious babies are sentient and love their mothers and want to participate in a loving and safe arrival.
And to conclude the palpation, I thank the baby for allowing me to play with them.
This gentle approach has brought many mothers to tears. For many of them, it’s the first time their body and their baby have been treated with reverence. In fact, I too, have often been brought to tears by the enthusiastic response of these precious babies who quickly understand that I care deeply about them.
Modern maternity services are decidedly centred around the practitioner. The manoeuvres designed to gather information help the practitioner to determine a course of action that lessens the potential for an obstetrically-determined negative outcome. However, truly client-centred and family-centred maternity care includes the baby as a fully sentient member of the family who deserves as much care, caution, respect, and dignity as every other member of the family. And that’s where we see some of the best outcomes!
Much love,
Mother Billie
©Billie Harrigan Consulting
Endnote
1. Ashrafganjooei, T., Naderi, T., Eshrati, B., & Babapoor, N. (2010). Accuracy of ultrasound, clinical and maternal estimates of birth weight in term women. EMHJ-Eastern Mediterranean Health Journal, 16 (3), 313-317, 2010.