Evidence shows that palpation by those who know how to do it is just as accurate using Leopold’s Maneuvers vs using ultrasound late in pregnancy in estimating fetal weight. Yet, many don’t rely on palpation for fetal positioning or estimating weight possibly due to lack of skill but also due to the ease of using ultrasound for an end result. Leopold’s Maneuvers are really some of the last vestiges of palpation research for pregnancy with hospital care providers. It has allowed the continuance of touch with directions to follow that can be replicated. As midwives may we not be confined to obstetrical techniques when it comes to palpation.
Palpation or fetal positioning has typically been a goal-oriented task for midwives and many of us have prided ourselves on our ability to palpate baby in a particular position whether or not we use “Leopold’s.” However, one of the things that can be lost in this outcome-focused endeavor is an overall sense of relationship. When we touch a pregnant body, they too are a part of what we are feeling. This is a place where we can become aware of relationship.
Babies are communicating and are so smart when it comes to having “inside information.” They are traveling and occupying where they have the most space (if they are able). Many people will have judgments on baby over this space they occupy if it doesn’t correlate with where they would prefer they be! We have to be careful of how we label babies, the naughty baby or the rebel or the stubborn baby, when in reality they may just be communicating.
But are we listening? What is the baby telling us at any point in pregnancy? Are we joining in on a shaming culture when we don’t find what we expect or are we taking it as a signal to listen more deeply?
As we set our hands on the belly after we have asked or been invited into the space, how are we coming into relationship with the pregnant person, their body, and that of the baby? How are they coming into relationship with us? We start from a place of informed consent, naming if there is resistance to our cold or warm hands, naming the reactions of the mother / parent / pregnant individual to know that they are in control and can change what we are doing at any time. Is the baby in consent as well?
It is in this moment where we first touch that we set the stage for our introduction into this dyad. We also know that what we feel will probably change and reveal itself to us. As this touch becomes routine, as midwives, we may forget the first time we felt a belly and baby and was in awe of that bigger picture. May we continue to remember this miracle and respect it.
As we place our hands or become aware of the tone of the belly, we start gently with light touch and broad yet subtle movements. We are not just palpating the baby, we are feeling for the relationship. For isn’t this why so many of us got into this work? We arrive holding the space of relationship. Tone, mobility, motility, reactions, sensations, contour, ballottement, and movement of both bodies. And they too are reacting to us.
We feel this change as the pressure ebbs and flows with each breath or movement or toning contraction. We feel the movements and differentiate the firm kick from the rolling shoulder or bum or wiggle of the fingers or bump of an elbow or knee.
We feel the differences of bodies in pregnancy. The shape of the ribs, location of the pubic bone, the depth of the uterus or space available to the baby. We visualize or palpate the angle of the hips or knees or shoulder. Has one side become tighter or rolled forward compared to another. Does there seem to be bands of restriction leading from one place to another?
We look more deeply at the pulling of scars on tissues or limitations of space. How might this affect the baby’s positioning? For cesarean scars, have they been touched, cared for, loved, shamed, ignored? We may be entering a sacred space with that palpation. We may open up somatic responses and hold that space with them as best we can.
Us not being able to feel is also telling us something.
“I feel two heads!” Ok, maybe there are feet against an anterior placenta.
“I don’t feel baby.” What do you feel? Can you feel the muscle tone or fluid levels?
“Is this back I feel or is this a placenta?”
“How come baby is avoiding the center of the uterus?” Is the placenta there, the uterus twisted or could there even be a unique shape of a uterus that baby knows about?
Even as we feel twins we now have more dynamics involved. How is one baby’s body affecting the space for the other if at all? Now there are even possibly two placentas and two sacs of water. Is one easier to feel than the other? Are there fluid level or size differences?
When we cannot find the baby, what can we feel? A light posterior contour? A kick or a wiggle to the side? Can we listen to the pregnant body or baby or find them where they meet? May we not be outcome-focused but be curious in this mystery. Can we be comfortable that particular day in the art of not knowing?
And sometimes we see this as an opportunity to get to know the pregnant body and focus on that. Baby’s positioning is not completely random as we pass 30 plus weeks. Can we feel the tone and softness or the abdominal muscles or feel around the belly following the tissues to the tightness the spine? Can we feel the ability for the pregnant body to breathe and the ease or resistance of that breath? And can we sweep to feel the round ligaments that can feel like udon noodles, ribbons or not even be found at all?
Can we change how we palpate… even if it is just for a few moments in time? Bodyworkers have the ability to know a pregnant body even as they lie down on their side. The uterus falls from the center and out from under the ribs. The baby as well as the midwife has a new perspective to spatial relationship. Are there more restrictions or less? What do we feel differently than we didn’t feel before? Can we feel more with their back now that it is exposed? Can we feel restrictions underneath the armpit or next to the breast and what does it feel like to open up those fascial lines? Can we affect it with a jiggle or ever light touch?
How might the pregnant body be mirrored by the baby? If pain is present, how does this affect how the parent and baby are coming into relationship? Which came first the pain or the presentation? Yet we as birthworkers are also affecting change by even witnessing this space. We also affect the tissue by acknowledgment, validation, caring touch, jiggling, sifting, or releasing.
Something that seemed an impossible task without the technology of a fetoscope, doppler or ultrasound may change under our hands. We may feel shifts of fluids, movement within the bone itself, or the move towards organization of nervous systems.
An ultrasound becomes relied upon by providers when they need to get something “right.” It is a reproducible experience. A body balancing client seeing me for breech at 38 weeks was pregnant with her 4th baby. Her obstetrician was newly turned out and let her know that she didn’t recommend a version and wanted to schedule a cesarean birth at 39 weeks. The interesting thing was that this mother had never had her belly touched except by a doppler or ultrasound. I realized that there was no differentiation between a uterus for a first term pregnancy compared to a subsequent one where the uterus had been stretched before. This baby turned head down just with some basic bodywork because there was a lot of space. The opportunity could by chance have presented on its own as well, but it hadn’t. A picture tells one perspective and may not have the 3 dimensional depth of what is happening on the inside or even what can be felt from the surface. Baby might just need to be provided an opportunity to choose to be head down.
The remaining palpation skills in some communities is Leopold’s Maneuvers. May we hold these up. Yet for many of us, we have opportunities to not be confined by these teachings but can use them as a doorway to learning that internal relationship. We can feel beyond fetal position and continue to learn the basics of anatomy and physiology of not just the pregnant body and baby but also that reflected in ourselves as we come into relationship and move towards the restoration of basic palpation skills and awareness.
Tell, Noor; Omuso, Inara MD; Hunter, Krystal MBA; Khandelwal, Meena MD Accuracy of Leopold’s Maneuver Compared to Ultrasound in Estimating Fetal Birth Weight [12B], Obstetrics & Gynecology: May 2019 – Volume 133 – Issue – p 23S-24S doi: 10.1097/01.AOG.0000559397.09291.a3
#breechbirth #breechpregnancy #shoulderdystocia #leopoldsmaneuvers #palpatingbellies #bodyworkandbirthwork
Nicole, this literally brought me to tears. Thank you so much for putting into words what my hands are learning. Im feeling pulled between text book Leopold’s and what is expected of me to learn as a student midwife, and the instinct to connect with both mama and baby. To just “be.” To connect and communicate. A sacred space of us 3. Not rushing, but truly connecting. Doing both is the goal, I know, but you just gave me the hug of confidence not to doubt myself. It’s ok to take my time. It’s not about passing a test in the moment, it’s about connection. I need reminded of that more often, and that we are all different, seeking information that we can process, which may not be the way of someone else. We all learn and connect differently, and one is not right or wrong. Simply unique. We all have different gifts to share. I am breathing easier now, because you shared. Thank you so very much.
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Tamara, thank you so much for your heartfelt reply. The instinct also may be a doorway to learning what you are expected to learn. Maybe finding a balance and the two shall meet? I look forward to hearing more. I think the more experienced I become the more permission I give myself and others give me to “not know.”