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delivery or when the HBDI is more than 1 minute, as recommended by Spong et al.,3 who have shown in their prospective study on 250 vaginal deliveries that 60 sec represented the mean + 2SDs of the HBDI. We agree with Spong et al. that 1 minute is a reasonable cut-off point, and by adopting this criterion, we would avoid over-diagnosis on the one hand and missing the diagnosis on the other; moreover, our statistics can also be compared with international figures. We also believe that setting a time limit would avoid delay in the diagnosis and improve perinatal outcome, as HBDI also has a strong impact on neonatal outcome. 4 We agree that the common practice is to start with McRoberts' manoeuvre, as performed in 97% of our cohort. 2 The experience and judgment of the accoucheur at that juncture could have influenced the choice of manoeuvre, as posterior arm delivery was performed as the primary manoeuvre in one of 205 cases and as the secondary manoeuvre in 22 of 147 cases, and the experience of the accoucheur is certainly an important factor affecting the success and complication rate of different manoeuvres. However, as it was a retrospective review, it is difficult to take experience into account. j References

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