A pregnant woman in active labor has the fetal head visible, but it strongly retracts after each contraction (crowning not maintained). What is the appropriate management?

1. A

   Ritgen maneuver

2. B

   Extra help & Hyperflex both Legs

3. C

   Apply fundal pressure and push

4. D

   Immediate episiotomy

Appeared in: NORCET 10 Prelims-2026

Explanation

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• The clinical scenario describes the 'turtle sign' (fetal head retracting after delivery), which is diagnostic of shoulder dystocia, an obstetric emergency.
• The first-line management protocol for shoulder dystocia involves two simultaneous actions: calling for additional help and performing the McRoberts maneuver.
• The McRoberts maneuver consists of hyperflexing the mother's legs sharply against her abdomen. This simple external maneuver alters pelvic angles and can resolve the shoulder impaction.
• Calling for help is critical to assemble a team for further maneuvers, maternal support, and neonatal resuscitation if needed.

Why Other Options Were Wrong

• Option A: The Ritgen maneuver is used to control the delivery of the fetal head during a normal, uncomplicated birth to prevent perineal trauma. It does not address the bony impaction of the shoulder.
• Option C: Applying fundal pressure is strictly contraindicated. It can worsen the impaction of the anterior shoulder against the pubic symphysis and significantly increases the risk of fetal injury (brachial plexus, clavicle fracture) and uterine rupture.
• Option D: An episiotomy does not resolve the bony obstruction of shoulder dystocia. It only cuts soft tissue (skin and muscle) to provide more room for the clinician's hands to perform internal maneuvers. It is not a primary, first-line intervention.

Related Visual

• Visual 1: Diagram - Illustration of the 'turtle sign,' showing the fetal head retracting against the perineum after a contraction.
• Visual 2: Diagram - The McRoberts maneuver, demonstrating a provider hyperflexing the mother's legs toward her abdomen.
• Visual 3: Flowchart - The HELPERR mnemonic, showing the sequence of interventions for managing shoulder dystocia.

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Management of Shoulder Dystocia as background academic context rather than a clinical decision trigger.
• Shoulder dystocia is an unpredictable and time-sensitive obstetric emergency. Rapid recognition and a systematic, calm response are crucial to prevent severe neonatal and maternal morbidity.
• Nurses play a key role in identifying the turtle sign, immediately calling for help, and assisting with positioning for the McRoberts maneuver. Clear communication and knowledge of the HELPERR protocol are essential for all labor and delivery staff.
• What if? If the McRoberts maneuver and suprapubic pressure fail, the next steps involve internal maneuvers like delivering the posterior arm or rotational maneuvers (Wood's screw, Rubin). These are more invasive and carry higher risks of fetal injury.

How to Approach the Question

• First, identify the key clinical sign in the question stem: 'fetal head visible, but it strongly retracts after each contraction'.
• Recognize this as the 'turtle sign', which is the classic presentation of shoulder dystocia.
• Recall that shoulder dystocia is an obstetric emergency requiring immediate and specific interventions.
• Evaluate the options based on the standard management protocol for shoulder dystocia (often remembered by the HELPERR mnemonic).
• The first steps are always to call for 'Help' and perform the 'Legs' maneuver (McRoberts). Option B directly reflects these initial actions.
• Eliminate other options: Ritgen maneuver is for normal delivery, fundal pressure is contraindicated, and episiotomy is a secondary, not primary, intervention.

Concept Tested & Keywords

• Concept Tested: Management of Shoulder Dystocia
• Stem keywords: pregnant woman, active labor, fetal head visible, strongly retracts, crowning not maintained, turtle sign
• Lead-in keywords: appropriate management
• Clinical cues: Fetal head retracting after crowning is the 'turtle sign', a hallmark of shoulder dystocia.

Question ID

QvRClhZWuj4mKuJESPvmgG

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