What is the best delivery intervention for a woman with a fetus in an anterior occipital position, at station +1, after 20 minutes of active pushing with no caput or moulding?

Management of Delivery with Fetus in Anterior Occipital Position at Station +1 After 20 Minutes of Pushing

Vacuum-assisted delivery (option C) is the most appropriate intervention for a woman with a fetus in anterior occipital position at station +1 after 20 minutes of active pushing with no caput or moulding.

Assessment of the Current Situation

The scenario presents a woman in the second stage of labor with:

• 20 minutes of active pushing
• Fetal head at station +1 (engaged in the pelvis)
• Anterior occipital position (favorable position)
• No caput or moulding (suggesting no significant obstruction)

Rationale for Vacuum Assistance

Why Vacuum is Preferred:

• The fetus is in an anterior occipital position, which is optimal for vacuum application
• Station +1 indicates the head is well descended in the pelvis, making vacuum application feasible
• Absence of caput or moulding suggests no significant obstruction to delivery
• After 20 minutes of pushing without progress, assistance is warranted but the situation is not yet an emergency

Comparison of Options:

1. Forceps (Option A):

   • While forceps can be effective, they are associated with higher rates of maternal trauma compared to vacuum
   • Forceps should be reserved for situations requiring more traction or rotational force
   • The use of a single forceps as a lever for disimpaction is considered dangerous 1

2. Fundal Pressure (Option B):

   • Fundal pressure is not recommended in any obstetric scenario
   • It can increase the risk of uterine rupture, placental abruption, and fetal injury
   • The American College of Obstetricians and Gynecologists explicitly recommends avoiding fundal pressure 2

3. Vacuum (Option C):

   • Appropriate for anterior positions with adequate station
   • Associated with lower rates of maternal trauma compared to forceps
   • Effective for assisting delivery when maternal pushing efforts need augmentation
   • Suitable for this specific clinical scenario with favorable fetal position

4. Expectant Management (Option D):

   • While 20 minutes of pushing is not excessive for a nulliparous woman, lack of progress with good maternal effort warrants intervention
   • Prolonged second stage increases risks of maternal exhaustion and fetal distress
   • With the fetus at +1 station in anterior position, assisted delivery is appropriate rather than continued waiting

Technical Considerations for Vacuum Application

• Ensure proper placement of the vacuum cup over the flexion point (approximately 3 cm anterior to the posterior fontanelle)
• Apply suction gradually according to manufacturer's recommendations
• Pull in coordination with maternal contractions and pushing efforts
• Direct traction should follow the pelvic curve (initially downward, then horizontally, and finally upward)
• Abandon the procedure if:
  • No descent after 3 pulls
  • The cup detaches 3 times
  • Procedure exceeds 15-20 minutes

Cautions and Contraindications

• Ensure no contraindications to vacuum use exist (preterm delivery <34 weeks, fetal bleeding disorders, etc.)
• Be prepared to abandon vacuum and proceed to cesarean delivery if unsuccessful
• Document all maneuvers, indications, and fetal/maternal outcomes thoroughly

Important Considerations

• Persistent occiput posterior positions are associated with prolonged second stage and increased operative delivery rates 3, but this patient has an anterior position which is favorable
• Vacuum extraction is appropriate for anterior positions at station +1 with adequate maternal pelvis
• The absence of molding suggests the fetal head has not been subjected to significant compression in the birth canal 4, making vacuum assistance a reasonable option

By choosing vacuum assistance in this scenario, you are providing timely intervention to facilitate delivery while minimizing maternal and fetal risks compared to the other options presented.