Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: The Reverse Løvset Maneuver For SD
Date: December 3, 2025
Host: Dr. Chapa

Overview

In this episode, Dr. Chapa brings his trademark energy and practical insight to the topic of the Reverse Løvset Maneuver for shoulder dystocia, newly featured in the November 2025 AJOG Surgeon's Corner. He delves into its origins, proper technique, clinical indications, comparisons to other maneuvers (especially posterior arm delivery), and nuances that every clinician should know. This episode is tailored for learners and practitioners seeking both clarity and confidence with shoulder dystocia interventions—with Dr. Chapa’s signature mix of clinical rigor and laid-back humor.

Key Discussion Points & Insights

Historical and Clinical Context

• Norwegian Origins
  • Dr. Chapa recounts his experiences in Norway and ties it to Dr. Jørgen Løvset, the maneuver's originator in the 1940s.

    “This is the Løvset maneuver. Løvset maneuver for shoulder dystocia. Now, it's actually called the reverse Løvset maneuver because the original Løvset maneuver is how we do a breech delivery… The reverse Løvset maneuver is just the opposite and not used in breech, it's used for shoulder dystocia…”
    [02:16]

• Shoulder Dystocia Basics:
  • Highlights the need to anticipate shoulder dystocia for every delivery due to its unpredictability.
  • Stresses a stepwise, combination approach using established maneuvers as the first line.

What is the Reverse Løvset Maneuver?

• Original vs. Reverse:

  • Original Løvset: Used for breech delivery, rotation of the baby’s ventrum (belly) upward to deliver the nuchal arms.
  • Reverse Løvset: For shoulder dystocia; rotation of the baby’s ventrum toward the floor to free the anterior shoulder from under the pubic symphysis.

    “The reverse Løvset is just the opposite where we take the baby and we make the chest go down... It's one of the rotational mechanisms for shoulder dystocia.”
    [03:06]

• Not New!

  • Although recently featured in the AJOG, Dr. Chapa notes the technique has been around since the 1940s.

    “Reverse Løvset has been around since the 1940s… As if somebody has discovered a new continent. Well, continent was there all the time.”
    [04:29]

Stepwise Management & Success Rates

• Recommended Order of Maneuvers:

  1. Suprapubic Pressure (Rubin 1) + McRoberts Maneuver
  2. Posterior Arm Extraction
     • Posterior arm usually offers the highest success rates. However, hand size and birth canal space can make this challenging.
  3. Rotational Maneuvers (Reverse Løvset, Woods, etc.)

• Evidence on Effectiveness:

  • Posterior arm delivery: ~86% success (literature and systematic reviews)
  • Rotational maneuvers (incl. Reverse Løvset): ~60–70% success

    “Rotational maneuvers have a success rate of around 60 to 70%. You’re like, that's pretty good. Totally. I’ll take it. 60 to 70% is good. …However… posterior arm is best… around 86%.”
    [27:40]

• Risks:

  • Rotational maneuvers have a lower rate of brachial plexus injury compared to posterior arm delivery (approx. 4% vs up to 20%).

    “With posterior arm delivery… you can also get brachial plexus injury as you pull. …almost like a Klumpke's kind of palsy that has been reported as high as 20%. …Rotational maneuvers… around 4%.”
    [28:40]

Practical Technique: How To Do the Reverse Løvset Maneuver

• Hand Choice:

  • Use the hand corresponding to the side of the baby's back in the maternal vagina
    • If baby’s back is on mom’s left–use right hand (counterclockwise rotation)
      If baby’s back is on mom’s right–use left hand (clockwise rotation)

• Grip:

  • Index and middle finger on the baby’s posterior axillary fat pad—not deep in the axilla (for neurovascular safety); thumb resting on the baby’s back.

• Rotation:

  • Rotate the baby’s torso (not just arm/axilla) to bring the belly down (ventrum towards the floor), freeing the anterior shoulder.

  “It's a focus on the posterior shoulder without actually messing with the axilla, the armpit itself, because we don't want to mess the neurovascular bundles under there.”
  [16:19] “All we want to do is do a rotation to bring the stomach facing down. And as it does that, it releases the shoulder.”
  [21:22]

• Force Application:

  • Use the whole upper body for the rotation, not just fingers or wrist—stabilize the wrist and move as a unit for better control.

    “The reverse Løvset maneuver also uses our forces transmitted to the child, not to the axilla, but to the upper torso. Short of it is don't put your fingers in the axilla, grab the posterior fat pad, stabilize your wrist and using your entire body, move with that rotation.”
    [26:36]

• Simulation/Practice:

  • Strongly encourages practice on simulation models for muscle memory.

Comparisons and Pearls

• Key Hierarchy (Success and Risks):

  • Posterior arm delivery > rotational maneuvers > McRoberts/suprapubic pressure alone (for success)
  • BUT: Posterior arm delivery carries a higher risk of brachial plexus injury if done forcefully.
  • Rotational maneuvers, especially those avoiding deep axillary instrumentation, are less traumatic for the neurovascular structures.

• Other Approaches Mentioned:

  • Posterior axillary sling technique (with suction tubing/catheter)—effective but risks neurovascular injury.
  • Lobster claw/pincer grasp (for direct extraction)—historically described, but be mindful of axilla trauma.

Notable Quotes & Memorable Moments

• On clinical humility and preparedness:

  “Every delivery should be a shoulder dystocia anticipated and proven otherwise, because the majority don’t have risk factors.”
  [04:53]

• On the real-life practicality of techniques:

  “People have already done this…without even knowing what it was called. Like, man, I don’t know, I grabbed that shoulder and I kind of moved it around, rotated it counterclockwise…and like, that’s a reverse Løvset!”
  [27:19]

• On anatomical reality and humor:

  “That’s one of the advantages of having small hands. When you’re 5’2”, 5’3”, you can put your hand into the vagina… But if you’ve got ginormous monster hands, God bless you, I feel sorry for your gloves…but nonetheless, it’s hard to get monster hands into the vagina.”
  [14:21]

• Encouragement to know multiple techniques:

  “You pick and choose. The lesson here, boys and girls, is that nothing is free. Posterior arm delivery likely works. However, you also have a higher risk of brachial plexus injury if you pull too hard. So don’t pull too hard. So rotational maneuvers have a place.”
  [29:27]

Key Timestamps

• [02:16] — Introduction to Løvset and Reverse Løvset Origin/History
• [03:06] — Defining the classic versus reverse maneuver
• [04:29] — Noting the maneuver is not new, despite AJOG coverage
• [04:53] — Best initial maneuvers per data (Rubin 1 & McRoberts)
• [07:11] — Discussion on real-world success rates and hierarchy
• [12:03] — Surgical challenges: hand size, risk of episiotomy, need for alternatives
• [16:19] — Technique walkthrough: focus on posterior shoulder, grip nuance
• [21:22] — Step-by-step for right/left hand depending on fetal position
• [26:36] — How to apply whole-body force for effective rotation
• [27:40] — Success rates for different maneuvers
• [28:40] — Brachial plexus risk discussion
• [29:27] — Final thoughts on the place for multiple techniques

Take-Home Messages

• Reverse Løvset is a valuable, often underused tool—but not new.
• Master posterior arm delivery, but know your alternatives for complex cases.
• Technique matters: grip the posterior axillary fold, not the axilla; use the hand corresponding to fetal position and rotate belly down using your body, not just fingers.
• Each tool has risks and benefits—posterior arm for higher success, rotational maneuvers for less brachial plexus trauma.
• Practice on simulation and keep up to date with literature—every delivery could be a shoulder dystocia.

“Podcast family, as always, we’re thankful for you. …We have covered something from November of 2025, even though we’re doing this on December 3, 2025… Now that we’ve done all that, let’s take it home.”
— Dr. Chapa [31:54]