About three and a half years ago, I traveled Summertown, Tennessee to study at the renowned midwifery center, The Farm. The Farm Midwifery Center offers an in depth Midwifery Assistant course to those interested in deepening their knowledge of childbirth education and midwifery practice, and I couldn’t pass up the opportunity to go. This amazing place is home to Ina May Gaskin, plus other brilliant midwives, who carry on the tradition of superb midwifery care to expectant and new mothers.
The course taught us how to measure blood pressure, check heart rate, check dilation, and deepened my understanding of newborn procedures. Additionally, we were taught a hands on method called Leopold’s Maneuvers (which consists of 4 different hand positions used to measure and palpate the belly) to determine the position of the baby. While, I am NOT claiming to be an expert in these skills, they were very interesting and actually not that hard to learn. Aside from the experiential and practical portion of the course, we also had the opportunity to observe a few prenatal appointments. Although I had been a doula for five years already, and had observed how many medical professionals handle pregnant and laboring women, I was surprised by how hands on the midwifery examination is for the pregnant mother. The amount of touch utilized in these appointments was astounding as compared to the hospital examinations. Instead of palpating the belly to determine baby position and estimated fetal weight, the ultrasound machine was rolled into the room. I do not recall seeing a set of hands touch a pregnant belly.
This experience got me thinking about why the hands-on technique of determining fetal position and estimation of fetal weight were no longer being instrumented. Were these techniques put out to pasture when the ultrasound machine became so accessible? Was the art of human touch not being taught to the younger generation of care providers? (SIDE NOTE- my midwife does palpate my belly at every visit and using Leopold’s maneuver regularly and is passing this skill on to her apprentice.) I asked two OB/GYNs their thoughts on this technique.
From Dr. Gae Rodke at St. Lukes/Roosevelt in NYC
“Yes, palpation of the pregnant abdomen, like so many physical examination techniques, seems to be a dying art. When I was a resident, ultrasound techniques for evaluating fetal well-being and size were just being developed… As ultrasound proficiency became a greater part of residency training, it was seen as more “objective”/ scientific, and gained increasing favor. Never mind that a sonographic estimate of weight can be 10-15% off, depending on baby’s position, angle, and whether it is shorter or longer-legged, proportionally. (So a 4000 gram estimate–8 lb 12oz baby, could really be a 3400 gram baby–7 lb 8oz, or 4600 grams–10 lb 2oz–a huge difference.)
Palpation is not foolproof, either, but in a non-obese woman most OBs who are skilled can get within half a pound to a pound of the actual weight. However, the weight of the baby is not the only issue. The size and shape of the pelvis, the physical condition of the mother, the effectiveness of the contractions, position (of the baby and the mother), should also be taken into account.
Leopold’s maneuvers were developed to ascertain fetal position. These also have become to be perceived to be less crucial, since sonography can be used to ascertain fetal position. I do still practice them regularly, and I try to only use sonography when needed to confirm questionable exams, or when the result would significantly change my management.
Like all techniques- they are only as good as the person doing it. If these skills are not taught and practiced, then the accuracy and proficiency will be less.”
From Dr. Harry Lee at St. Lukes/Roosevelt
“Leopolds aren’t so much taught as they are self taught. As a resident I would palpate a belly of a laboring patient and take a guess and then correlate that with the birth weight. The more you do this the better you get.
There have been multiple studies done comparing Leopolds estimations of fetal weight to ultrasound estimations and they are about equally as accurate. They are all about ±15%. That leaves a lot of leeway. It’s just that every Ob and even Tom Cruise has an ultrasound machine and having a measurement seems more objective to some people and a Leopolds estimate seems more subjective.
As to positioning, that’s what the Leopolds was originally for. To determine fetal position. It is imperfect for that however. I’ve seen patients come up from the Birthing Center with an undiagnosed breech in labor. That’s why the policy on L&D (Labor and Delivery) at Roosevelt is to confirm cephalic presentation by ultrasound on everyone. That is clearly superior.”
The conclusion I have drawn after talking to OB/GYNs and reading multiple studies on this subject is that while there is definitely value in the ultrasound, the hands-on, less invasive method (if performed by an experienced practitioner), can be equally as accurate.
Skills like Leopold’s Maneuver and touching the pregnant and laboring belly are unfortunately not being passed on or practiced very much by the up and coming obstetrics practitioners. The removal of human touch is just a symptom of a bigger problem that is arising in the obstetrics community, and perhaps in our culture. Human contact, trust of instincts, personalization and consistency of care are slowly slipping away from the very human, primal experience of birth, leaving us with a very sterile, medicalized view of childbirth.
For those wishing to read more of the studies conducted questioning this very idea of the value and accuracy of the human touch compared to that of a machine, please refer to the links below.
Accuracy of Leopold maneuvers in screening for malpresentation: a prospective study.
Is it time for routine ultrasound in late pregnancy at Bhumibol Adulyadej Hospital?
A comparison of Leopold’s maneuver, McDonald’s measurement and ultrasonic estimation of fetal weight
