What is the best action for a pregnant woman at 33 weeks gestational age with a categorical (Cat) 2 fetal heart rate and the fetal head palpable in the vagina, with all other parameters being normal?

Immediate Assisted Vaginal Delivery (Forceps or Vacuum)

Given that the fetal head is already palpable in the vagina at 33 weeks with a Category 2 fetal heart rate tracing, immediate assisted vaginal delivery with forceps or vacuum extraction is the best action to expedite delivery and optimize outcomes for both mother and baby. 1

Clinical Reasoning

Why Not Cesarean Section?

• The fetal head is already descended into the vagina, making cesarean delivery technically more difficult and potentially dangerous 2
• At full dilation with low station, vaginal delivery should be attempted unless there are specific obstetric contraindications 2
• Cesarean section with an impacted fetal head carries serious maternal risks including hemorrhage, organ injury, and neonatal complications such as skull fractures and brain hemorrhage 2

Why Assisted Vaginal Delivery is Appropriate

• Category 2 fetal heart rate patterns require intervention but not necessarily immediate cesarean delivery 2
• When the cervix is fully dilated and the fetal head is at an appropriately low station (which "felt in the vagina" clearly indicates), immediate assisted vaginal delivery should be considered 2
• The American College of Obstetricians and Gynecologists recommends expedited delivery via operative vaginal delivery or cesarean section for abnormal FHR tracings, with the choice depending on clinical circumstances 3

Management Algorithm

Immediate Actions:

• Perform intrauterine resuscitation measures simultaneously while preparing for delivery 2, 3:
  • Change maternal position to left lateral to relieve aortocaval compression 3
  • Administer oxygen at 10 L/min by facemask 3
  • Assess maternal vital signs 2
  • Perform vaginal examination to confirm station and rule out cord prolapse 2, 3
  • Discontinue oxytocin if being administered 2

Delivery Decision:

• If the head is truly palpable in the vagina (station +2 or lower), proceed with forceps or vacuum extraction 1
• This allows for the fastest delivery time while avoiding the complications of cesarean section with a deeply engaged head 2

Critical Considerations at 33 Weeks

• The fetus is preterm but viable (viability begins at 24-26 weeks) 4
• Category 2 tracings represent an indeterminate pattern that may indicate evolving fetal compromise 2
• Time is critical - prolonged Category 2 patterns can deteriorate to Category 3 (abnormal) 2

Why Not Fetal Sampling?

• Fetal scalp pH sampling is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery 2
• With the head already in the vagina and a Category 2 tracing, the priority is expedited delivery, not further testing 2

Common Pitfalls to Avoid

• Do not transport to the operating room if immediate vaginal delivery is feasible - this wastes precious time 2
• Do not attempt cesarean section with a deeply engaged head without first considering vaginal delivery - this significantly increases maternal and neonatal morbidity 2
• Do not delay for additional monitoring when the clinical picture indicates need for expedited delivery 2, 3