In the June issue of the American Journal of Obstetrics & Gynecology , Cheedalla et al examined the association between maternal body mass index (BMI) and neonatal adverse outcomes and compared the frequency and type of maneuvers used to resolve shoulder dystocia by maternal prepregnancy BMI. This is a vastly understudied problem, making it a valuable contribution to the existing body of research. We congratulate the authors on their contribution to the literature on shoulder dystocia, and we are interested in learning more about the study and seeking clarification on a few points.

First, the study used prepregnancy BMI rather than delivery admission BMI. We are interested in the rationale for this decision, as gestational weight gain can be a factor for adverse outcomes at delivery. Second, birthing position and estimated fetal weight were not provided in the article. These factors could influence delivery management. Therefore, we would like to know if these data are available. Finally, the order of maneuvers used to resolve shoulder dystocia was not applied consistently. This was surprising, given that current clinical guidelines recommend performing first-line maneuvers (McRoberts and suprapubic pressure) before moving toward second-line maneuvers (Rubin, Woods screw, delivery of the posterior arm, etc.). Hence, the lack of consistent application of maneuvers is concerning, as it may have led to provider bias in escalating care (ie, internal maneuvers) more rapidly in women with a BMI of ≥35.0 kg/m ². Do the authors believe that this inconsistent application of maneuvers may have skewed the results of the study?

In conclusion, we applaud the authors for their pioneering research into the association between BMI and shoulder dystocia management. We are eager to hear from the authors to continue this discourse and promote the understanding of clinical management of shoulder dystocia in patients with a BMI of >35.0 kg/m ².

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