What are the implications and management options for a patient presenting with a positive turtle sign in the context of Obstetrics and Gynecology (OBGYN)?

Positive Turtle Sign in Obstetrics

A positive turtle sign indicates shoulder dystocia—an obstetric emergency where the fetal head delivers but the anterior shoulder becomes impacted behind the maternal pubic symphysis, requiring immediate systematic intervention to prevent permanent brachial plexus injury, hypoxic brain damage, or fetal death.

Understanding the Clinical Presentation

The "turtle sign" describes the characteristic appearance where the fetal head delivers but then retracts tightly against the maternal perineum between contractions, resembling a turtle withdrawing into its shell. This pathognomonic finding signals that the anterior fetal shoulder is trapped behind the pubic symphysis and cannot deliver spontaneously 1.

Critical Time Constraints

• Permanent neurological injury or death can occur within 4-5 minutes of head delivery if the thorax remains undelivered, as umbilical cord compression prevents fetal oxygenation 1.
• Every intervention must be performed rapidly but deliberately, with clear communication among the obstetric team 1.

Immediate Management Algorithm

Step 1: Call for Help and Position (0-30 seconds)

• Activate the shoulder dystocia emergency protocol immediately—call for additional obstetric providers, anesthesia, pediatrics/neonatology, and additional nursing staff 1.
• Position the patient in McRoberts maneuver: hyperflexion of maternal thighs against the abdomen, which increases the relative anterior-posterior diameter of the pelvis and often resolves 40-60% of shoulder dystocia cases 1.
• Apply suprapubic pressure (NOT fundal pressure, which worsens impaction) with a CPR-hand position just above the pubic symphysis, directed laterally and posteriorly to dislodge the anterior shoulder 1.

Step 2: Internal Maneuvers (30-60 seconds if McRoberts fails)

• Perform the Rubin maneuver: insert hand posteriorly, identify the posterior aspect of the anterior (impacted) shoulder, and apply pressure to rotate the shoulder into the oblique diameter 1.
• Alternatively, perform the Woods corkscrew maneuver: apply pressure to the anterior aspect of the posterior shoulder to rotate the fetus 180 degrees 1.
• Deliver the posterior arm: reach posteriorly, identify the posterior fetal arm, sweep it across the chest, and deliver it, which reduces shoulder diameter by 2-3 cm 1.

Step 3: Advanced Maneuvers (if initial attempts fail)

• Consider the Gaskin maneuver (all-fours position) if the patient can be repositioned, which changes pelvic dimensions and may allow spontaneous delivery 1.
• Zavanelli maneuver (cephalic replacement followed by cesarean delivery) is a last-resort option when all other maneuvers fail and requires immediate surgical capability 1.

Critical Pitfalls to Avoid

• Never apply fundal pressure, as this drives the anterior shoulder further behind the pubic symphysis and dramatically increases the risk of permanent brachial plexus injury 1.
• Never perform excessive traction on the fetal head, which causes brachial plexus stretch injuries; all maneuvers should focus on rotating or dislodging the shoulder, not pulling the head 1.
• Do not delay calling for help—shoulder dystocia requires a coordinated team response, and outcomes worsen significantly when providers attempt solo management 1.
• Avoid multiple attempts at the same maneuver—if a technique fails after one proper attempt, immediately proceed to the next intervention in the algorithm 1.

Documentation Requirements

• Document the exact time of head delivery, each maneuver attempted (in sequence), time intervals between maneuvers, personnel present, and time of complete delivery 1.
• Record Apgar scores, cord blood gases, and any neonatal resuscitation required 1.
• Note any maternal complications including perineal lacerations, postpartum hemorrhage, or uterine rupture 1.

Postpartum Considerations

• Examine the neonate immediately for brachial plexus injury (Erb's palsy affecting C5-C6 or Klumpke's palsy affecting C8-T1), clavicular fracture, and humeral fracture 1.
• Monitor for postpartum hemorrhage, as shoulder dystocia increases risk of uterine atony and genital tract lacerations requiring surgical repair 1.
• Provide immediate debriefing with the patient and family, explaining what occurred and the interventions performed 1.
• Arrange pediatric follow-up for assessment of brachial plexus function, as 80-90% of injuries resolve spontaneously within 6-12 months, but some require surgical intervention 1.

Prevention in Future Pregnancies

• Document shoulder dystocia prominently in the medical record, as recurrence risk is 10-15% in subsequent pregnancies 1.
• Consider elective cesarean delivery for future pregnancies if the prior shoulder dystocia resulted in permanent injury or if estimated fetal weight exceeds 4,500 grams in diabetic mothers or 5,000 grams in non-diabetic mothers 1.