The term “turtling syndrome” is an informal name for a severe complication during vaginal childbirth known clinically as Shoulder Dystocia. This condition occurs when the baby’s head has delivered, but the rest of the body remains trapped within the mother’s pelvis. This mechanical obstruction prevents the natural progression of labor. It is a time-sensitive, unpredictable complication that requires immediate action and can lead to serious consequences for both the infant and the mother.
Understanding the Turtling Sign
The “turtling” sign is the defining visual indicator of Shoulder Dystocia. After the baby’s head is delivered, it draws back tightly against the mother’s perineum, resembling a turtle retracting its head into its shell. This retraction happens because the baby’s anterior shoulder is mechanically lodged behind the mother’s pubic bone, preventing the descent of the chest and body. This impaction signals an obstetrical emergency where the normal forces of labor are insufficient to complete the delivery. When rotation fails, the wider shoulder-to-shoulder diameter becomes stuck. The obstruction is bony-to-bony, and the delay in delivery, often measured in minutes, is directly linked to the potential for injury.
Primary Factors Leading to Impaction
Shoulder Dystocia is caused by a size or positional mismatch between the baby and the maternal pelvis. The most significant predisposing factor is fetal macrosomia, defined as an estimated birth weight over 8 pounds, 13 ounces. Larger babies have wider shoulder diameters, making navigation through the pelvic inlet challenging.
Maternal conditions like pre-existing or gestational diabetes mellitus greatly increase the risk of macrosomia. Elevated maternal glucose stimulates the fetus to produce excess insulin, leading to disproportionate growth, particularly of the trunk and shoulders. A history of a previous delivery complicated by Shoulder Dystocia also raises the recurrence risk for subsequent pregnancies by approximately ten percent.
Other factors include maternal obesity, excessive weight gain during pregnancy, a prolonged second stage of labor, and operative vaginal deliveries using instruments like forceps or a vacuum extractor. Despite these identifiable risk factors, most cases occur unexpectedly in women who have no known predisposing conditions and deliver average-sized babies.
Immediate Risks of Impaction
The immediate risks associated with a stuck shoulder are severe due to the time-sensitive nature of the impaction. For the baby, the primary concern is birth trauma and lack of oxygen. When the chest and umbilical cord are compressed, the baby experiences hypoxia.
The stretching or pulling required to free the impacted shoulder can damage the network of nerves in the neck and shoulder, known as the brachial plexus. This Brachial Plexus Injury can result in temporary or, in rare cases, permanent paralysis or weakness in the baby’s arm (Erb’s palsy). Less commonly, the pressure or maneuvers may cause fractures of the baby’s clavicle or humerus.
The mother also faces significant complications from the intense efforts needed to resolve the obstruction. The most common maternal injuries are severe tears or lacerations of the perineum, vagina, or rectum, often extending into third or fourth-degree tears. The strain on the uterus and soft tissues also increases the risk of postpartum hemorrhage.
Steps Taken During Delivery
When the turtling sign is recognized, the delivery team initiates a standardized sequence of maneuvers to dislodge the shoulder. The first and most commonly successful intervention is the McRoberts maneuver. This involves sharply flexing the mother’s hips and bringing her knees up toward her chest, which rotates the pelvis and flattens the sacrum to create more space.
Simultaneously, an assistant often applies suprapubic pressure—firm pressure applied externally to the mother’s abdomen just above the pubic bone. This pressure is directed downward and toward the baby’s back, helping to push the anterior shoulder out from behind the pubic bone.
If these initial external maneuvers are unsuccessful, the care team moves on to internal fetal maneuvers. These involve the obstetrician inserting a hand into the vagina to manually rotate the baby’s shoulders, using techniques such as the Rubin or Woods screw maneuvers, or to deliver the baby’s posterior arm. The goal of these rotational techniques is to turn the baby’s shoulder diameter into a wider pelvic dimension. These steps are performed rapidly and systematically, with the overall time from diagnosis to delivery being tracked meticulously to minimize the risk of injury.