Situation: The nurse is assigned to the labor, delivery, and postpartum units of a government hospital. During the birth of a large baby, the fetal head delivers and then retracts tightly against the perineum, and gentle downward traction does not deliver the anterior shoulder. In what order should the team carry out these actions? 1. Apply pressure just above the pubic bone toward the fetal face 2. Deliver the posterior arm 3. Call for help and note the time 4. Sharply flex the client's thighs onto her abdomen

The turtle sign indicates shoulder dystocia. The nurse first calls for help and notes the time, then positions the client in the McRoberts maneuver (sharp thigh flexion straightens the sacrum), then applies suprapubic pressure to dislodge the anterior shoulder. Internal maneuvers such as delivery of the posterior arm follow only if these first-line steps fail. Fundal pressure is never used.

Clinical situation

The description of the fetal head delivering and then retracting tightly against the perineum is the classic turtle sign. It indicates shoulder dystocia, an obstetric emergency in which the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head. Because umbilical cord compression and fetal hypoxia can occur rapidly, the priority is a systematic, team-based response that moves from least invasive external maneuvers to internal maneuvers only when needed.

Why the correct sequence is 3 → 4 → 1 → 2

The first action is to call for help and note the time. Shoulder dystocia cannot be managed effectively by one provider alone. Additional personnel are needed for maneuvers, neonatal resuscitation, and documentation. Noting the time is critical because the head-to-body delivery interval guides decision-making and is a key medicolegal and neonatal outcome variable ^[4].

The second action is McRoberts maneuver: sharply flexing the client’s thighs onto her abdomen. This position flattens the lumbar lordosis and rotates the symphysis pubis cephalad, which increases the anterior-posterior diameter of the pelvic inlet and helps free the impacted anterior shoulder ^[2][3]. It is noninvasive and can be performed quickly once help has arrived.

The third action is suprapubic pressure applied just above the pubic bone, directed toward the fetal face. This external maneuver adducts the fetal shoulders and rotates the bisacromial diameter into the wider oblique diameter of the pelvis, helping dislodge the anterior shoulder from behind the symphysis ^[1][3]. Suprapubic pressure is applied simultaneously with, not instead of, the McRoberts position.

Only if these first-line external maneuvers fail should the team move to internal maneuvers such as delivery of the posterior arm. Reaching into the posterior vagina, flexing the fetal elbow, and sweeping the posterior arm across the chest is more invasive and carries a higher risk of fetal fracture or brachial plexus injury, so it is reserved for cases unresponsive to McRoberts and suprapubic pressure ^[1][4].

Step	Maneuver	Type	Purpose
1	Call for help, note time	Team activation	Assemble team; establish time reference for hypoxia risk
2	McRoberts maneuver	External	Flatten sacrum, rotate symphysis cephalad, widen pelvic inlet
3	Suprapubic pressure	External	Adduct shoulders, rotate bisacromial diameter into oblique pelvis
4	Deliver posterior arm	Internal	Reduce bisacromial diameter by delivering one arm across chest

Watch out! Fundal pressure is contraindicated in shoulder dystocia. It pushes the fetal shoulder more firmly against the pubic symphysis and increases the risk of brachial plexus injury and uterine rupture ^[2][4].

Key point! McRoberts maneuver and suprapubic pressure are recommended as initial choices because they are less invasive, but their combined success rate is only approximately 23–40% ^[3]. Therefore, the team must be prepared to progress to internal maneuvers without delay if the shoulders do not deliver.

The sequence follows a stepwise escalation from external to internal maneuvers, with team activation and time documentation preceding any physical intervention. Retrospective data suggest that posterior arm delivery has a higher success rate than rotational maneuvers once internal maneuvers are required, but it is not the first-line choice because of its invasiveness ^[1]. The priority remains rapid, coordinated progression through maneuvers while monitoring the head-to-body interval and preparing for neonatal resuscitation ^[2][4].