to the editor: I applaud Dr. Morrison's effort to provide a complete review of common peripartum emergencies in her recent article.¹ The breadth of the topic is certainly daunting, and her review of the applicable literature is well done.

I feel, however, that one omission in regard to the management of shoulder dystocia should be mentioned. Evidence in the medical literature indicates that a technique called the “all-fours” maneuver is a reasonable option to include in the treatment algorithm of this obstetric emergency.²

The all-fours maneuver has been reported, both anecdotally and in the midwifery literature, to be effective in resolving shoulder dystocia.³ The success of the maneuver depends on the patient's ability to roll over into the “hands and knees” position. As mentioned in Dr. Morrison's article, shoulder dystocia occurs when the anterior fetal shoulder becomes wedged behind the mother's symphysis pubis and cannot be easily reduced. The all-fours maneuver takes advantage of the laxity of the sacroiliac joint at term, which may result in an increase of 1 to 2 cm in the sagittal diameter of the pelvic outlet.⁴ The dorsal lithotomy position restricts this posterior movement of the sacrum. The all-fours maneuver eases the delivery of the posterior fetal shoulder.

This procedure has recently been included in the curriculum for the American Academy of Family Physician's course “Advanced Life Support in Obstetrics (ALSO)” as the additional “R” in the HELPERR mnemonic.⁵ Although the all-fours maneuver is not the standard of care, it is an alternative to the Zavanelli maneuver or the delivery of the infant's posterior arm in the dorsal lithotomy position.

to the editor: I would like to commend Dr. Morrison for her article on common peripartum emergencies.¹ She provides a thorough and logical discussion of some of the obstetric emergencies most frequently encountered during the peripartum period.

After reviewing the section on postpartum hemorrhage, however, I must mention some additional points from the American College of Obstetrics and Gynecology (ACOG) Educational Bulletin on postpartum hemorrhage.² This bulletin was not referenced in Dr. Morrison's article.

Although Dr. Morrison correctly describes the use of the prostaglandin derivative carboprost, or 15-methyl prostaglandin F_2a, it should be noted that it is contraindicated in patients with “. . . active cardiac, pulmonary, renal, or hepatic disease.”² The bulletin also recommends the use of another prostaglandin derivative, dinoprostone, or prostaglandin E₂, for postpartum hemorrhage. Although carboprost is preferred over dinoprostone because of the latter drug's potential to cause vasodilatation and hypotension, use of dinoprostone should be considered in patients for whom carboprost is contraindicated for the aforementioned medical conditions. Dinoprostone causes essentially the same side effects as carboprost (vomiting, diarrhea, nausea, fever, headache, chills or shivering), and it is administered as a 20-mg rectal dose once every two hours.

in reply: I would like to thank Drs. Weigand and Butler for pointing out useful additional techniques for handling peripartum emergencies—namely dinoprostone for postpartum hemorrhage and the all-fours maneuver for shoulder dystocia. Certainly, clinicians may find these options useful in certain situations. Given the space and reference constraints in American Family Physician, I had to omit many such helpful points. I am pleased that these tips have now been included through these letters from our colleagues. Like Dr. Weigand, I also recommend the “Advanced Life Support in Obstetrics” course from the AAFP as a wonderful resource for anyone who wishes to explore these topics in more depth.