We would like to thank Dr Jelsema for his interest in our article as well as the questions he has asked. During time periods A, B, and C of the study, the cesarean rates were 27.1%, 28.2%, and 29%, respectively. This change in the point estimate was not statistically significant ( P = .12). Even if statistical significance had been reached, we do not believe this would explain a decrease in the frequency of brachial plexus palsy documented given the denominator for the frequency was “per shoulder dystocia,” and that the frequency of shoulder dystocia per delivery did not change over time. The protocol itself was focused upon the team response to the shoulder dystocia and did not convey specific maneuvers, or order of maneuvers, that should be employed in the management of the shoulder dystocia. Thus, providers’ judgment was relied upon to determine what maneuvers and traction were employed.

The last 2 questions are more difficult to answer, as they are speculative as opposed to factual. We do not believe we can know, from the study itself, what exact factor is responsible for the reduction in brachial plexus palsy. However, we do not believe it is due to providers changing their approach to traction, as that change was not part of the protocol. Indeed, we believe this study highlights that it is unlikely that there is one “provider” who is responsible for each and every obstetric outcome, particularly in a setting as emergent as shoulder dystocia and for an outcome with as many potential etiologies as brachial plexus palsy. Instead, the importance of a team approach, which includes contributions from physicians, midwives, nurses, patients, and their families, is emphasized as a potential factor in ameliorating the consequences of this obstetric emergency.