What is the most appropriate action for a pregnant woman in labor with fetal distress, indicated by late decelerations and minimal variability, who is exhausted after continued pushing with the baby engaged at 2+?

Operative Vaginal Delivery is Most Appropriate

Given fetal distress (late decelerations with minimal variability) in an exhausted mother with the baby engaged at 2+ station, operative vaginal delivery (forceps or vacuum) is the most appropriate immediate intervention to expedite delivery and prevent further fetal compromise. 1

Rationale for Operative Vaginal Delivery

The clinical scenario presents Category II-III fetal heart rate abnormalities requiring expedited delivery:

• Late decelerations with minimal variability indicate possible fetal hypoxia or acidemia requiring discontinuation of oxytocin (if in use) and expedited delivery via operative vaginal or cesarean delivery 1

• Station 2+ indicates the fetal head is adequately descended (2 cm below the ischial spines), making operative vaginal delivery technically feasible and safer than cesarean section at this stage 2

• 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 2

• The "pull" methods required for impacted fetal head during second-stage cesarean (reverse breech extraction or Patwardhan method) carry risks of femoral and humeral fractures in the neonate 2

Why Other Options Are Inappropriate

Option C (Reassessing after 1 hour) is Dangerous

• Delaying delivery with persistent late decelerations and minimal variability risks progressive fetal acidemia 1, 3
• The absence of normal variability with late decelerations suggests physiologic compensations are being overwhelmed by asphyxia severity 3
• Category III patterns (absent variability with recurrent late decelerations) require expedited delivery, not observation 1

Option D (Oxytocin) is Contraindicated

• Oxytocin is not indicated for maternal exhaustion with fetal distress at full dilation but rather for active phase protraction disorder or arrest of labor 2
• With evidence of fetal compromise (late decelerations), oxytocin should be discontinued, not initiated 1
• Continuing oxytocin with abnormal fetal heart rate patterns risks worsening uteroplacental insufficiency 1

Option A (Cesarean Section) is Less Optimal Than Operative Vaginal Delivery

• While cesarean section is acceptable, operative vaginal delivery at 2+ station has lower maternal morbidity than second-stage cesarean 2
• Cesarean should be reserved for failed operative vaginal delivery or when operative delivery is not feasible 1, 4

Critical Implementation Points

Before proceeding with operative vaginal delivery:

• Ensure adequate anesthesia for the exhausted mother 4
• Confirm station is truly 2+ through serial suprapubic palpation of the fetal skull base (not just molding) 5
• Verify no evidence of cephalopelvic disproportion through complete cephalopelvimetric assessment 6, 5
• The operator must have adequate clinical experience and appropriate training 4

During the procedure:

• Failure to achieve delivery in a reasonable time should prompt abandonment and conversion to cesarean section 4
• Either vacuum or forceps may be used based on operator experience, as neither is clearly safer or more effective 4
• Routine episiotomy is not necessary 4

Common Pitfall to Avoid

Do not confuse molding with true descent - use serial suprapubic palpation of the base of the fetal skull to confirm actual descent rather than relying solely on vaginal examination 5