# Obstetric Examination Nursing > Obstetric examination in nursing: four Leopold manoeuvres, symphysio-fundal height, fetal heart ranges, fifths palpable and left-tilt positioning. - Canonical URL: https://prepelephant.com/topics/allied/nursing/obstetric-examination-nursing - Exam / course: Allied Health · Subject: Nursing - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Obstetric Examination Nursing", PrepElephant, https://prepelephant.com/topics/allied/nursing/obstetric-examination-nursing ## Direct answer Four abdominal manoeuvres, a tape measure and a fetal stethoscope decide most of what obstetric examination needs: the lie, presentation, position and engagement of the fetus, the height of the fundus, and the wellbeing of the fetal heart. Leopold's sequence — fundal grip, umbilical grip, Pawlik's grip and the deep pelvic grip — is performed with an emptied bladder, warm hands and the woman supine with a left lateral tilt to keep the gravid uterus off the inferior vena cava. The symphysio-fundal height in centimetres roughly tracks weeks of gestation from about twenty weeks, the fetal heart is normally heard at 110-160 beats per minute, and engagement is judged abdominally in fifths, with two-fifths or less palpable meaning the head has entered the pelvis. Every finding is dated and documented, because the trend is the clinical signal. ## What you must remember - **Leopold's four grips:** first (fundal) identifies the pole in the fundus — breech soft and irregular, head hard, round and ballotable; second (umbilical) determines lie and side of the back; third (Pawlik's) confirms the presenting part; fourth (deep pelvic grip) assesses engagement. - **Fundal height landmarks:** about 12 weeks just above the symphysis, 20 weeks at the umbilicus, 36 weeks at the xiphisternum; after 20 weeks the symphysio-fundal height in centimetres approximates gestational age. - **Fetal heart:** normal 110-160 per minute, heard through the fetal back in cephalic presentation below the umbilicus — above it in breech; Pinard stethoscope or doppler. - **Engagement in fifths:** the Crichton method — five-fifths palpable means free, two-fifths or less means engaged; non-engagement at term in a primigravida flags possible cephalopelvic disproportion. - **Positioning:** supine with a 15-degree left tilt to prevent supine hypotensive syndrome from aortocaval compression. - **Red-flag discrepancies:** symphysio-fundal height more than 3-4 centimetres off dates suggests polyhydramnios, oligohydramnios, multiple pregnancy or growth restriction — refer for ultrasound, never reassure. - **Contraction assessment:** frequency start-to-start, duration and intensity by palpation, documented as part of the same examination. ## Working through Leopold's on a 38-week primigravida Ask her to empty her bladder, lie supine with a pillow under the right hip, and expose only what is needed — warm hands are not courtesy, since cold contracts abdominal muscles and ruins palpation. Facing her feet for the first two grips: the fundus holds a soft, broad, irregular mass — breech, so a cephalic presentation is likely. Fingers glide down the sides of the uterus: a smooth, resistant convex plane on the mother's left is the back; small mobile knobs on the right are limbs — a left-sided back, and the fetal heart will be found in the left lower quadrant, loudest through that back at 138 per minute on the Pinard. Turning to face her head: Pawlik's grip traps a hard round mass above the symphysis — the head, still movable. The deep pelvic grip finds only two-fifths of it palpable above the brim: engaged. One examination has produced lie longitudinal, presentation vertex, back left, engagement two-fifths, fundal height 36 centimetres at a dated 38 weeks — a correlation worth noting, and a growth-scan referral if the discrepancy widens on repeat. ## How examiners ask about it The classic viva asks what each grip determines, and the classic failure is swapping the second and third: the umbilical grip gives lie and back, while Pawlik's confirms only the presenting part. Indian examiners add the fifths rule — "how much head is palpable in an engaged fetus?" — two-fifths or less by the Crichton convention, and "three-fifths" costs the mark. The measurement technique is the other trap: the tape runs from the upper border of the symphysis to the fundal top palpated with the ulnar border of the hand, and after engagement the fundus drops, so fundal height alone must never be read as fetal growth. Supine examination without tilt is the last common error — both an exam and a real-world one, since the resulting hypotension cuts placental flow precisely while the fetus is being assessed. ## Frequently asked questions ### What does each of Leopold's four manoeuvres determine? The fundal grip identifies the pole in the fundus, the umbilical grip gives lie and back position, Pawlik's grip confirms the presenting part, and the deep pelvic grip assesses engagement. ### What is the normal fetal heart rate in labour? 110-160 beats per minute; rates outside this range, or decelerations relative to contractions, require immediate escalation and continuous monitoring. ### What does "two-fifths palpable" mean? By the Crichton fifths method, two-fifths or less of the head palpable above the pelvic brim indicates engagement — the widest presenting diameter has passed the brim. ### Why is a left lateral tilt used during abdominal examination? To displace the uterus off the inferior vena cava and aorta, preventing supine hypotensive syndrome that reduces placental perfusion. ### When does a symphysio-fundal height discrepancy become significant? A height differing from gestational age by more than about 3-4 centimetres after twenty weeks warrants ultrasound for growth disorders, liquor abnormalities, multiple pregnancy or wrong dates.