What is the recommended management for a 38-year-old woman at 33 weeks gestation with a category 2 cardiotocography (CTG) in the second stage of labor, with the fetal head palpable in the vagina?

Operative Vaginal Delivery with Forceps or Ventouse

With the fetal head palpable in the vagina during the second stage of labor and a Category 2 CTG, proceed with operative vaginal delivery using either forceps or ventouse, as this represents the safest and most expeditious route to delivery that minimizes maternal and neonatal morbidity compared to cesarean section at full dilation.

Clinical Context and Decision-Making

This scenario describes a patient in the second stage of labor with:

• Fetal head visible/palpable in the vagina (indicating low station, likely +2 or below)
• Category 2 CTG (non-reassuring but not immediately ominous)
• Need for expedited delivery to prevent progression to Category 3 and potential fetal compromise

The key clinical question is whether to proceed with operative vaginal delivery versus cesarean section.

Why Operative Vaginal Delivery is Preferred

Avoiding Second-Stage Cesarean Complications

Cesarean section at full dilation with a deeply engaged fetal head carries substantially higher maternal morbidity:

• Impacted fetal head complicates up to 10% of emergency cesarean deliveries and is particularly problematic when performed in the second stage 1
• Maternal complications include unintentional uterine incision extensions (increased 2.3-10 times), hemorrhage (increased by 149.5-444 ml), bladder and ureteric injuries, and prolonged operative time 1, 2
• Technical difficulty arises from lack of space between the fetal head and maternal pubic symphysis, making it difficult to deliver the head through the uterine incision 1
• Neonatal complications include increased NICU admission rates and potential birth trauma from difficult extraction maneuvers 3

Advantages of Operative Vaginal Delivery

• Direct access to the fetal head when already low in the pelvis
• Avoids the technical complications of impacted fetal head at cesarean
• Shorter procedure time compared to cesarean with impacted head
• Lower maternal morbidity when performed appropriately with proper training 4

Forceps vs. Ventouse Selection

Both instruments are acceptable options when the head is palpable in the vagina:

• Forceps may provide more controlled traction and are preferred when rapid delivery is needed
• Ventouse may be gentler on maternal tissues but requires more time for application and may have higher failure rates
• Proper training in application techniques is essential to minimize nerve injury risk, particularly facial nerve paralysis with forceps 4
• Avoid using a single forceps blade as a lever, as this increases facial nerve injury risk 4

When Cesarean Section Becomes Necessary

If operative vaginal delivery fails or is contraindicated, cesarean section must be performed with specific techniques to manage the impacted head:

• Manual vaginal disimpaction (vaginal push method) or reverse breech extraction are the primary techniques 1, 2
• Reverse breech extraction has shown advantages including decreased uterine incision extensions (2.3-10 times less), reduced operative time (6.5-33 minutes shorter), and less blood loss (149.5-444 ml less) compared to abdominovaginal delivery 2
• Uterine tocolysis should be administered to relax the uterus and facilitate disimpaction 1
• Attempting delivery during contractions exacerbates difficulty and should be avoided 5

Why Fetal Scalp Sampling is Not the Answer

Fetal scalp sampling is not appropriate management in this scenario because:

• Category 2 CTG already indicates need for expedited delivery
• The patient is in the second stage with the head visible—this is the time for delivery, not further assessment
• Scalp sampling would only delay necessary intervention without changing management

Critical Pitfalls to Avoid

• Do not delay delivery for further monitoring when the head is already low and CTG is Category 2
• Do not proceed to cesarean section as first-line when operative vaginal delivery is feasible, given the substantially higher morbidity of second-stage cesarean 1, 3
• Ensure proper training and experience with the chosen instrument before attempting operative delivery 4
• Have a backup plan ready if operative vaginal delivery fails, including personnel experienced in managing impacted fetal head at cesarean 1