From the Guidelines
Cesarean section is the preferred choice over operative vaginal delivery in a protracted second stage of labor when there is suspicion of cephalopelvic disproportion (CPD) or other factors that signal concern, such as maternal diabetes, obesity, pelvic shape and size, fetal macrosomia, malposition, malpresentation, asynclitism, and excess molding, as indicated by the most recent evidence 1. When considering the choice between operative vaginal delivery and cesarean section in a protracted second stage of labor, several key factors must be taken into account, including:
- Maternal and fetal conditions
- Provider expertise
- Specific clinical circumstances
- Estimated fetal weight, with cesarean delivery being indicated for estimated fetal weights more than 4,500 g in the presence of a prolonged second stage of labor or arrest of descent, as suggested by earlier guidelines 1 For operative vaginal delivery to be considered, the following conditions must be met:
- The cervix must be fully dilated
- The fetal head engaged (station +2 or lower)
- The exact fetal position known
- Adequate anesthesia available
- An experienced operator present However, cesarean section is a more prudent and safer choice if evidence of CPD is found or cannot be ruled out with a reasonable degree of certainty, as it reduces the risks of damage to the mother and fetus 1. The decision should be made collaboratively with the patient after discussing the risks and benefits of each approach, considering factors such as:
- Maternal preferences
- Pelvic adequacy
- Prior obstetric history Before either intervention, oxytocin augmentation and other measures to progress labor, such as maternal position changes, adequate hydration, and rest, should be considered if contractions are inadequate. Ultimately, the choice between operative vaginal delivery and cesarean section requires careful clinical judgment, prioritizing the safety and well-being of both the mother and the fetus.
From the Research
Indications for Operative Vaginal Delivery and Cesarean Section
The decision between operative vaginal delivery and cesarean section (C-section) in a protracted second stage of labor depends on several factors, including:
- Maternal and fetal characteristics that impact the duration of the second stage of labor 2
- The presence of complications such as fetal asphyxia, arrest of the head in the same plane of the pelvis, ineffective uterine contractions, and malpositions 3
- The need for expedited birth due to non-reassuring fetal heart tones or other concerns 4, 5
Factors Influencing the Decision
The following factors may influence the decision between operative vaginal delivery and C-section:
- The duration of the second stage of labor, with guidelines recommending allowing 2-3 hours for nulliparous women and 1-2 hours for multiparous women 4, 6
- The presence of epidural analgesia, which may affect labor progress and increase the risk of malpositions 6
- The skill and experience of the birth attendant in performing operative vaginal deliveries 4, 5
- The individual assessment of the woman and her fetus, taking into account potential risks and benefits of each option 6
Operative Vaginal Delivery Options
Operative vaginal delivery options include:
- Forceps delivery, which may be indicated for fetal asphyxia, arrest of the head, and ineffective uterine contractions 3
- Vacuum-assisted vaginal delivery, which may be associated with increased risk of neonatal cephalohematoma 5
- The use of a second instrument if the first one fails, which may be associated with worse outcomes 5