What is the most appropriate management for a pregnant woman in labor with a fully dilated cervix, fetal head engaged at +2 station, minimal variability, late decelerations, and maternal exhaustion after prolonged pushing?

Operative Vaginal Delivery is the Most Appropriate Management

In this clinical scenario with a fully dilated cervix, fetal head at +2 station, and Category III fetal heart rate tracing (minimal variability with late decelerations), operative vaginal delivery should be performed immediately to expedite delivery and avoid the increased maternal and neonatal morbidity associated with second-stage cesarean section. 1

Why Operative Vaginal Delivery (Option B) is Correct

Fetal Distress Requires Immediate Delivery

• Late decelerations with minimal variability represent Category III fetal heart rate tracing indicating fetal compromise that requires immediate delivery. 1
• The fetal head is engaged at +2 station, which is sufficiently low for safe operative vaginal delivery. 2
• The cervix is fully dilated, meeting the essential prerequisite for operative vaginal delivery. 2

Maternal Exhaustion Supports Operative Intervention

• Maternal exhaustion after prolonged pushing is a recognized indication for operative vaginal delivery when the station is appropriate. 2
• Continuing to push (Option C) would delay delivery in the setting of fetal distress and is contraindicated. 1

Second-Stage Cesarean Section Has Higher Morbidity

• Cesarean delivery in the second stage of labor carries greater maternal morbidity than operative vaginal delivery, including increased risk of uterine incision extensions, hemorrhage requiring transfusion, and infection. 3
• The likelihood of morbidity for both mother and baby associated with cesarean delivery increases with advancing labor and is greater than with operative vaginal delivery at full dilation. 1

Why Other Options Are Incorrect

Option A (Cesarean Section) - Unnecessarily High Risk

• Cesarean section at +2 station with full dilation exposes the patient to risks of impacted fetal head, including uterine incision extensions, vascular injury, and increased blood loss. 3
• The "pull" methods required for impacted fetal head (reverse breech extraction, Patwardhan method) carry risks of femoral and humeral fractures in the neonate. 3
• Operative vaginal delivery achieves the same goal (immediate delivery) with lower maternal morbidity. 1

Option C (Reassessing After 1 Hour) - Dangerous Delay

• Delaying delivery for one hour in the presence of Category III fetal heart rate tracing (late decelerations with minimal variability) risks permanent neurologic injury or fetal death. 1
• Fetal distress requires immediate intervention, not observation. 2

Option D (Oxytocin) - Wrong Clinical Context

• Oxytocin is indicated for active phase protraction disorder or arrest of labor, not for maternal exhaustion with fetal distress at full dilation. 4, 5
• The patient is fully dilated and the head is engaged—this is not a labor dystocia requiring augmentation. 4
• Oxytocin would delay delivery in a situation requiring immediate intervention for fetal compromise. 5

Technical Considerations for Operative Vaginal Delivery

Instrument Selection

• Both forceps and vacuum are acceptable options, though forceps achieve vaginal birth with the primary instrument more reliably (risk ratio 0.58,95% CI 0.39-0.88). 1
• The choice should be based on operator skill and clinical circumstances. 2

Prerequisites Must Be Met

• Cervix must be fully dilated (confirmed in this case). 2
• Station must be at least +2 cm or lower (confirmed at +2 station). 2, 6
• Adequate clinical experience and appropriate training of the operator are essential. 2

Common Pitfall to Avoid

• Do not proceed to cesarean section without considering operative vaginal delivery when the station is appropriate and the cervix is fully dilated, as this unnecessarily increases maternal morbidity. 1
• Failure to achieve delivery with the chosen instrument in a reasonable time should prompt abandonment and consideration of cesarean section. 2