In the recent study evaluating outcomes after instituting a shoulder dystocia protocol that included 5 components, the authors describe a “reduced frequency of brachial plexus palsy when a shoulder dystocia occurred.” I have several questions for the authors:

• 1
  

  After institution of the protocol, did the institutional cesarean rate change?

  
  
• 2
  

  Did the protocol include the use of downward traction?

  
  
• 3
  

  Given the stable shoulder dystocia rate for the 3 study periods, to what do the authors ascribe the decreased brachial plexus palsy rates after institution of the protocol?

If the brachial plexus injuries were related to the shoulder dystocia event and not traction by the provider, would the authors have expected the brachial plexus palsy rate to have remained stable?