A (7:11)

However.

A (7:13)

Does this actually work? Well, you got to go back to other data sets because that's actually describing the procedure itself. But when you actually take a look at the data, while I'm all for knowing as much tools as possible and you should practice this, you should practice a reversal of sit maneuver on a simulation, a bony pelvis model, a little baby doll like we all have, well, should have in labor and deliveries where we try to practice maneuvers, at least we do to try to not only to teach nurses, medical students, residents, fellows, whatever, but also for muscle memory that helps build your muscle memory. But we're gonna talk about this. What is the percent success of this compared to percent success of something like posterior arm delivery? Okay, so we're gonna get into these because these are very well published. Again, posterior arm delivery seems to have the best chance of success together with suprapubic pressure, which is revived one along with Mick Roberts maneuver. Those are the best. And we're going to give you the percentage of what this looks like. It is pretty high. And to be honest, I mean, the reverse lofts, that maneuver done correctly should work, but it doesn't seem to be as high spoiler as posterior arm delivery. But again, I'm all for all four, and we all should be four. Anything that helps us beat this issue. So in this episode, we're going to cover the November 2025, which is this month, Sturgeon's corner from the Gray Journal that talks about the reverse lofts. It maneuver from Norway coming for you. No way. Norway. Knock, knock. It's America and we're gonna punch you in the face. All right, maybe we're not gonna punch you in the face, but I am very USA friendly. I love my country and. And when I saw this thing, I'm like, oh, love to maneuver. Yeah, Norway. I remember that great friends still have friends in Trondheim and in Oslo. But I'm not eating that damn soup. That soup was horrible. All right, I think I've set it up enough. I think I'm in trouble now with Norwegians. God bless you, Norwegians. Thank you for the fish. Thank you for the soup. All right, let's get out of here. We'll be right back.

A (9:46)

This is Dr. Chapa's obgyn no spin podcast.

A (10:16)

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A (11:01)

Me and Vincent would have been satisfied with some freeze dried taste. His choice, right? Podcast family, you never have to settle for anything in life. Nor should you. And that includes your cup of coffee. We're super thankful still for our partnership with the Strong Coffee Company that is striving to reach our natural greatness. Strong coffee company with 20% discount code unique to our podcast family found in our show notes. Again, go to our show notes for a 20% discount whatever you buy through the Strong Coffee Company and kick up your cup of coffee a notch. Again, thankful for the strong Coffee Company 20 discount with the link in our show notes.

A (11:47)

Oh, this place is adorable. Damn it. Where are you guys? We're you. I'm in Norway. Norway? You're in Sweden. Damn it.

A (12:03)

Oh my goodness. I couldn't resist. 2021 Super bowl commercial. Will Ferrell for GM. Not a sponsor, but that's just awesome. Oh, this place is so quaint. It's actually Sweden. Anyway, I'll just say yes. Thank you Norway. Phenomenal people. I don't know how you put up with the cold. My goodness, it's brutal. Brutal. But it does relate to what we're talking about, of course, because Norwegian obstetrician Dr. Luvsett, to be most accurate, it was Jurgen Lufsett in the 1940s described this issue of baby rotation mainly to release the nuchal arms at breech, now being adopted, to bring the baby belly down, ventrum down, to rotate the impacted anterior shoulder away from the pubic symphysis. Okay, so nothing new. We're going to briefly talk about this. I'm going to walk you through this, but I want to focus on why this is an issue. Number one, post your arm delivery, you got to know how to do it. Number two, sometimes if the baby is extremely large and there's just not enough room into the vagina, even with sometimes, you know, doing the an episiotomy which doesn't release the impaction. But sometimes you need that that room to get your hand in there, which is just a great way to get a 4th degree Oasis tear, which is terrible in and of itself. So I try not even to do an episiotomy. If they tear, they tear. And I can try. My hands are pretty small. 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, reach the antecubital fossa, flex, bring the hand through the chest, grab the baby's hand and then sweep across the chest to bring the arm out. And that works. That totally works. With high percentage. We're talking about high 80s. I'll give you that percentage here in a minute. But it does work in combination with suprapubic in the appropriate direction and McRoberts. But sometimes it's hard to do that. That's why there's been a variety of approaches, and there's been this new spotlight, this new attention towards that posterior axilla. Look, if it's too hard to wedge it and corkscrew it, move it either clockwise or counterclockwise. Rubens woods on all these different rotational maneuvers, which are absolutely fine. Absolutely fine, but sometimes they're hard to do. Well, why don't we try to grab that posterior shoulder? We can see that specifically around the axilla and try to mobilize that. That's why there's things like the posterior axillary sling maneuver, using either a suction tubing or a less flexible urinary catheter. Doesn't have a lot of give to try to wench it. Honestly, wench the posterior axilla out. The problem is that there's some valuable stuff in that axilla. There's neurovascular bundles. You got worry about that. You got to worry about burn injury with a rubber catheter. That's been described as a case report. So you got to be careful. There's also things that have been described as a lobster claw approach, where you get one hand and using your index finger and your thumb and then your index finger of your other hand, and you basically make a pincer grasp with two hands around the posterior shoulder and use that as a winch with traction applied just on the axilla, but not within the axilla itself. That's also a thing that's been described as a way to mobilize a shoulder. That was back in the early 2000s. That was the Mentekalu procedure, the Mentekollu procedure to try to tiger grasp or lobster grasp. I don't know why I said tiger grasp. Lobster grasp that posterior shoulder and rotate. So attention has been on the posterior axilla. That's my point. There's a tension on the posterior axilla. So whether it's a sling, whether it's the Montegulu kind of clasp maneuver to try to pull it straight out or as a rotation, these are things that are possible. The posterior axilla may be where it's at. If everything else fails, this is where the reverse love.

A (16:06)

Oh, my gosh, I've totally lost my issue here. The reverse Lovestedt maneuver, the reverse love step maneuver comes into play. Okay, now I'm going to explain this. So for our practical purposes, as you're driving, okay, just look, don't take your eyes on the road. You got your right hand in front of you and your left hand, right hand, left hand. We're going to make this super easy because this Surgeon's Corner article From November of 2025 goes through this and it's not complicated. And the take home message is this. 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. Okay? Not a lot of tissue in the little baby's axilla, little baby's underarm, little armpit there. So we try to protect that. Now, I understand you gotta do what you gotta do to get that arm out. That's why there's like, shoot, I wanna put a pincer grip on that joker and pull that thing straight out so then I can do the posterior arm. And that's fine. You do have to do what you have to do. But if it's better to keep your fingers or instruments away from the axilla itself, then it would be better. That's the thought process, okay? And that's where the reverse loves that maneuver comes in. Now, before I get into that, just very quickly, I want to remind everybody of a wonderful publication that we reviewed last year. Because in March of 2024, in again, the same journal, the Gray Journal, that's the American Journal of obgyn, under expert reviews, there was, quote, a critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia. End quote. And we covered this on this show and it goes over. You know, there's a wrong way to do McRoberts or, you know, people are pushing on the foot and pushing it up. Well, that's a great way to get sciatic nerve injury. And it doesn't do what you want to do. You want to bring the buttocks up a little bit so that the symphysis rotates back away from the pubic symphysis itself. And so there's an appropriate way to do McRoberts, which is a hand just supporting just right by the popliteal area and pushing that part of the leg up, not by the feet and. But push, putting the hand just by the poppiteal fossa on the leg itself, on the back of the thigh and then pushing that up while you maintain the leg horizontal that helps push the pubic symphysis back and rotate the sacrum to flatten it. Never push on the feet upwards. Right. That's a great way again to get either peroneal. I'm sorry, femoral or sacral nerve injury. And in this publication, as it goes through the different types of success, it states very clearly the success rate of posterior arm delivery is greater than rotational methods, which is greater than McRoberts and suprapubic pressure alone. Okay, so in this hierarchy of what's gonna work, go for the posterior arm. So I just have to be. I just wanna be very clear here, both for academic, scientific and practical reasons, that that's. I typically go for the arm, but again, I have small hands. 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. And I get that one of my former associates has got giant sausage fingers, and I'm like, bro, how? And so that, hey, there's an advantage to having small hands. Okay. In this regard. So I get that. If you can't get your hand in there. Yes. While you can make room in the posterior compartment within the peas, that's going to destroy her anal sphincter area, which is also traumatic. So as we try to minimize the traumatic and the morbid issues, maybe try to concentrate on the posterior shoulder. So all I'm saying is there is a role for this. Although the best seems to be. Not my opinion, even back in this expert review From March of 24, the best seems to be go for the posterior arm. And since Suprapubic pressure and McRoberts are your first line, it's inherent. You would think that those would be already being done, and they should be being done as this arm is being delivered. So having said that, and just wanted to clarify that, that it seemed to be the best right now based on the data. But this love set maneuver does have a place. All right, so back to our discussion. You have your right hand and your left hand. Right, Left. Right. Left. Surprise. Right. You have a right hand and a left hand. And which hand to use depends on where the baby's back is in the maternal vagina. So our right hand is, of course, on the side of mom's left. On the mom's left. So if the baby's back. Here we go. Very easy, guys. If the baby's back is on mom's left, you're going to use your right hand because your fingers are Going to be right in the back of the axilla. Not in the axilla. Right in the back of that posterior axilla in what's called the posterior axillary fold. Now, if you're saying, well, what is that? The easiest I can tell you is, hey, have you ever seen a woman who's got a little larger bmi? I'm not being mean, it just as it is. And that little part of the fatty part of the skin that doesn't right fit in the bra, that's the posterior axillary fat pad. Even babies have it. That's all right. I love you. There's nothing wrong with it. It's okay. That's how God made you. So that's what you're trying to grab, that little piece of skin that's called the posterior axillary fat. That's where your two fingers, index finger and middle finger are gonna go as your thumb, okay, kind of rests on the baby's back. So you're not grabbing this like a lobster claw. It's the fingers are right there with your hand, with your thumb just kind of resting on the baby's back. Now, the idea is now put this in your, in your mental image here. If the baby's back is on mom's left, that means it's looking towards the right. Got that? Towards mom's right. So if the baby's back is up on maternal left, that means the baby's looking to the right. We're trying to get here, guys. Remember, we're trying to get the baby to be belly down. So in this case, our hand is now going to grab. The force is going to be on that posterior shoulder on that posterior back on the torso of the baby. And what we're going to do is we're going to rotate counterclockwise. Okay, Counterclockwise. In other words, we are now going to pronate. Our hand should be pronated. So when we're done with this, our hand, the palm should be facing down as we move the baby to that 180 degrees. Okay, so I know it sounds kind of weird. Let me just say that again quickly. If the baby's back is on mom's left, that means it's looking to the right. We're going to grab our right hand, put it in the posterior axillary fat pad, and we're going to rotate counterclockwise so that the baby rotates stomach or ventrum down. Now if the baby's back, let's flip it, okay? So everybody take a pause. Let's Flip it. If the baby's back is on mom's right, so we're using our left hand because the hand, we have to use the hand where the baby's back is again, finger and middle finger, index finger and middle finger are going to be on the baby's fat pad with the thumb just resting on it. And then we're going to rotate. Now, now follow me here. Okay, so the baby's back is towards mom's right, so it's looking to the left. And so we're going to rotate. We want the baby to be down. So we're now going to rotate clockwise. We're going to bring that shoulder where our hand is and we're going to rotate clockwise. We're going to move it upwards like on the face of a clock so that now the baby's anterior shoulder now rotates away from that pubic symphysis and the stomach's to the down. Okay, so very quickly, because it sounds complicated, it's not. If baby's back is on mom's left, we're going to use our right hand. And we want the baby's stomach area to be facing down. So go counterclockwise while not putting pressure on the axilla itself in the underarm. The pressure should be transmitted in the torso of the child. Okay. Now if the baby's back is on mom's right, in other words, it's looking towards mom's left. We're gonna use our left hand. We can put our fingers in back of that posterior fat pad. And we're gonna now bring that shoulder up, if you will. We're gonna go clockwise. We're gonna rotate the stomach down. So remember, loftset always means something to do with rotating and where that stomach is pointing on a breach, whether it's vaginal breach or a C section, you do loft set to bring the abdomen to the side and up to rotate the to release the nuchal arms. That's lofset. The reverse is rather than it pointing up, we want the stomach to point down. So the take home message is very simple. Three take home messages here for reverse love set. Know where the posterior shoulder is? Spoiler it's posterior. Know which side the baby's back is. So if the baby's back is on the left, we're using our right hand. And if it's on mom's right, we're going to use our left hand. And it's very simple. With two fingers on that fat pad with a thumb resting on the back as well. Without grasping or pinching the axilla. All we want to do is do a rotation to bring the stomach facing down. And as it does that, it releases the shoulder. That's pretty it, that's pretty much it. Now the, the. And I get that most people who do this, even in videos that I've seen, you end up kind of grasping or gripping the posterior axilla at some degree. But your fingers shouldn't be within the armpit. So that's fine. If you want to make like a shoulder, like a little cup, like a little shoulder girdle and to rotate it that way, that's. That's perfectly fine. The idea is not to put your fingers inside the armpit like a posterior sling would. Okay, so again, just a different way to try to protect the neurovascular bundle. All in an attempt to rotate or corkscrew the child belly down, Belly down. And that dislodges or frees the anterior shoulder. Okay, so I'm going to read you the description very quickly and then I want to give you some quick statistics on what works. And this is high, this is over, you know, 60% and. But the posterior arm delivery is closer to like high 80s percent. Okay, but you got to do what you got to do. So let me read you this quick little synopsis. Insert the hand palm facing the fetal back at the 6 o' clock position, so posterior along the fetal back until reaching the posterior axilla. Gripping the posterior axillary fold with index and middle fingers in a hook like grip, avoiding the axillary fossa. Don't get the armpit, then rotate using the clinician's upper body away.

A (26:36)

To bring the baby in a rotational maneuver, belly down. So what that means using the rotator's body means if my hand is collapsing a certain way and I'm going to go counterclockwise, I don't want to just move my hand. I want to stabilize my wrist and move my entire body so the entire force of my now upper torso is moving. Okay, so this isn't just your hand moving. This should be your hand is still solid with your other hand grabbing your wrist and you're rotating away. So the reverse lofts it 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. So if you're going to move counterclockwise, your body now think about put your hand in front of you right, Kinda like a handshake. And if you're gonna be rotating counterclockwise, your body, your head should be tilted towards your left. Does that make sense? Like a little robot. You rotate that way. On the other hand, if you're using your left hand, and again, put it, as in a handshake position, and you're gonna rotate counterclockwise, your head and body together with your hand should be moving that shoulder. As your body kind of rotates and moves towards your right, your whole kind of body transmit that force to rotate that shoulder out. This is fine. And people have already done this. They do 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 reversal offset. Like, look, I don't know what you call it, but I move the posterior shoulder away. Fine. Take home message. Know where the posterior shoulder is, Know which hand you're going to use. Did I say know which side the posterior shoulder is? Yeah, that's right. I mean, if, sorry, which way the baby's back is to the baby's right or left, that's going to dictate which hand to use. And then stabilize your wrist and then rotate. Rotate either clockwise or counterclockwise for your last pearl, which is bringing the baby belly down. Podcast family. It's very quick. I just wanted to give you some quick awareness of what's out there. And I know we've covered this briefly as we talked about shoulder to strosh in the past, but this is now more mechanistic and more practical. Just to let you know what's out in print, because this was out this month, we're doing this still within the first week of. Of December. And this was just in November. Sorry, did I say that this was this month? Sorry, guys. It's just as point of reference, it is December 3rd. My goodness, it is December 3rd, 2025, when we're recording this. And. And I'm still in November. So this was out November 2025. All right, so I'm three days late. For heaven's sakes. Geez. They're all run together. They all run together. So this was November of 2025, and we're recording this on December 3rd, 2025. Okay, so does this work? Yeah, for sure. I mean, 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. Rotate that shoulder away. However, here it is, guys, and we're going to be done. The reason that the gray journal said that posterior arm is best is because posterior arm is either to get alone or with McRoberts and Rubin. One, which is suprapubic pressure, seems to work at the highest, around 86%. Okay, so, yes, they both work, and my answer is no. As many things as possible. Know as many things as possible to get that kid delivered safely. Okay? If you don't know how to do this, practice on the sim. The other reason why rotational methods seem to be favored is because you're gonna have less risk of br. Brachial plexus injury compared to posterior arm delivery. Let me give you this whoppy number, and then we're going to end this here. If you do a rotation because you keep the axilla intact, unless you put your fingers in the axilla, then your chance of having a brachial plexus injury just by the maneuvers themselves is around 4%. That's based on the data that was BJOG. Okay? However, with posterior arm delivery, usually because of that pull traction. Now, remember this. Now, the posterior arm, we're not talking about brachial plexus on the anterior, that's Erb's stretch injury. But on the posterior arm, you can also get brachial plexus injury as you pull. Almost like a clumpy's kind of palsy that has been reported as high as 20%. So 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. Rotational maneuvers have a place. And this is one of them because you have less risk of brachial plexus injury. Wow. Seems like that was a lot of info for just one simple procedure. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. We have covered something from November of 2025, even though we're doing this on December 3, 2025, because I misspoke earlier. Now that I think we've done all that, Michael, my goodness, I don't know what happened with this one.

A (31:54)

This is let's get this out, wrap it up, and call it a day podcast family. Now that we've done all that, let's take it home.

A (32:25)

This has been Dr. Chapa Zobe Gyn no Spin podcast.

A (32:32)

Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin podcast.

A (32:48)

Sam.