We appreciate the engagement with our article and thank the authors for their thoughtful questions regarding our study. Our study assessed maternal prepregnancy body mass index (BMI) and neonatal adverse outcomes after shoulder dystocia. In addition, we assessed the frequency and types of maneuvers based on maternal prepregnancy BMI.
We used maternal prepregnancy BMI in this study rather than maternal BMI at the time of delivery to provide context for prepregnancy counseling for maternal obesity. Higher prepregnancy BMI is a potentially modifiable risk factor for shoulder dystocia with prepregnancy counseling, whereas BMI at the time of delivery may not be as actionable because of the recommendation to gain weight during pregnancy, regardless of prepregnancy BMI. Although increased gestational weight gain in pregnancy has been associated with increased risk of shoulder dystocia, it is unknown whether increased gestational weight gain is associated with adverse neonatal outcomes in the setting of shoulder dystocia. This would be an excellent next step for future research.
Unfortunately, the birthing position was not recorded in the electronic medical record. We also did not collect information on the estimated fetal weight of study participants, as this too is not consistently recorded in the medical record. Moreover, we believe that fetal/infant weight is likely within the causal pathway. Thus, the fetal/infant weight would not be appropriate to adjust for in our analyses.
In line with the guidelines, it is standard in our clinical practice to manage shoulder dystocia with the McRoberts maneuver and/or suprapubic pressure as the initial maneuvers. In our study, the frequencies of the use of the McRoberts maneuver and suprapubic pressure were 96.0% and 90.2%, respectively. Given the retrospective design of the study, we do not know why these frequencies are not higher. In response to the questions raised by the letter authors, we assessed the use of these maneuvers based on maternal BMI to evaluate for potential provider bias based on BMI. The McRoberts maneuver was performed in 95.5% of patients with a BMI of <30.0 kg/m 2, 96.9% of those with a BMI 30.0 to 34.9 kg/m 2, and 97.3% of those with a BMI of ≥35.0 kg/m 2 ( P =.56). Similarly, there were no differences in the use of suprapubic pressure in the groups: 89.7% for patients with a BMI of <30.0 kg/m 2, 89.4% for those with a BMI of 30.0 to 34.9 kg/m 2, and 93.6% for those with a BMI of ≥35.0 kg/m 2 ( P =.42). As the lower-than-expected frequency of these maneuvers does not differ by BMI group, it does not seem to be related to provider bias in the selection of initial maneuvers.
The authors report no conflict of interest.
References
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