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J Reprod Med. 1998 May;43(5):439-43.

All-fours maneuver for reducing shoulder dystocia during labor.

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Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN 37232-2519, USA.



To report on a large amount of clinical experience with shoulder dystocia managed primarily with the all-fours maneuver.


The all-fours maneuver consists of moving the laboring patient to her hands and knees. Eighty-two consecutive cases of shoulder dystocia managed with this technique were reported to a registry through January 1996.


The incidence of shoulder dystocia was 1.8%, and half of the newborns weighed > or = 4,000 g. Sixty-eight women (83%) delivered without the need for any additional maneuvers. The mean diagnosis-to-delivery interval was 2.3 +/- 1.0 (SD) minutes (range, 1-6). No maternal or perinatal mortality occurred. Morbidity was noted in only four deliveries: a single case of postpartum hemorrhage that did not require transfusion (maternal morbidity, 1.2%), one infant with a fractured humerus and three with low Apgar scores (neonatal morbidity, 4.9%). All morbidity occurred in cases with a birth weight > 4,500 g (P = .0009).


The all-fours maneuver appears to be a rapid, safe and effective technique for reducing shoulder dystocia in laboring women.

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