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Difficulty: Very hardAnte/Intra/Postpartum and Newborn Care

The Practical Nurse (PN) is assisting the Registered Nurse (RN) and a nurse-midwife during the vaginal delivery of a client at 41 weeks of gestation. After the fetal head is delivered, it immediately retracts tightly against the maternal perineum. Place the following nursing actions in the correct sequential order of priority.

  1. 1Call for immediate additional assistance and the neonatal resuscitation team.
  2. 2Lower the head of the maternal bed to a completely flat position.
  3. 3Assist the client in flexing her thighs sharply back against her abdomen.
  4. 4Apply firm, downward pressure just above the maternal symphysis pubis.
  5. 5Document the precise time the fetal head emerged and the specific maneuvers utilized.

Answer

The correct sequence is to first call for help, then flatten the bed, assist with the McRoberts maneuver, apply suprapubic pressure, and finally document the event.
When a fetal head retracts against the perineum (the 'turtle sign'), it strongly indicates shoulder dystocia. The nurse must first call for immediate assistance as this is an emergency beyond the scope of a single practitioner. Next, the bed is flattened to prepare for the McRoberts maneuver (hyperflexing the maternal legs), which is the first-line physical intervention. If that fails, suprapubic pressure is applied to manually dislodge the shoulder. Documentation is completed concurrently or immediately following the maneuvers to ensure an accurate timeline of the prolonged delivery.

Step-by-Step Solution

1
Call for immediate additional assistance.
Additional healthcare personnel arrive to assist with the obstetric emergency.
The 'turtle sign' indicates shoulder dystocia, a severe emergency requiring multiple staff members for maternal maneuvers and potential immediate newborn resuscitation.
2
Lower the head of the bed to a flat position.
The client is positioned supine and flat on the delivery bed.
A flat position is biomechanically required to properly perform the subsequent McRoberts maneuver.
3
Assist with flexing the client's thighs sharply against her abdomen.
The maternal pelvis tilts, widening the pelvic outlet.
This is the McRoberts maneuver, the primary non-invasive technique to resolve shoulder dystocia.
4
Apply firm, downward pressure above the symphysis pubis.
The anterior fetal shoulder is manually pushed downward.
Suprapubic pressure helps collapse the fetal shoulder, allowing it to pass under the maternal pubic symphysis.
5
Document the timing and maneuvers.
An accurate medical and legal record is created in the client's chart.
Precise documentation of the head emergence time and the exact sequence of maneuvers is required for postpartum and neonatal care planning.

Key Concept

Management of shoulder dystocia
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Topics

Ante/Intra/Postpartum and Newborn Care

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