What is the best delivery option for a pregnant woman at 35-36 weeks of gestation, with the fetus's head in the vaginal canal, in labor, and with a CTG (Cardiotocography) category 2, considering options like ventouse delivery, forceps, cesarean section, and fetal blood sampling?

Operative Vaginal Delivery with Forceps

For a patient at 35-36 weeks with fetal head in the vaginal canal and Category 2 CTG, forceps delivery is the preferred operative approach, as vacuum extraction is contraindicated at low station due to high risk of intracranial and subgaleal hemorrhage. 1, 2

Immediate Clinical Assessment

• Category 2 CTG indicates indeterminate fetal status requiring expedited delivery but not emergent cesarean section. 1
• With the fetal head already in the vaginal canal, this represents a favorable scenario for operative vaginal delivery rather than cesarean. 1
• At 33-36 weeks gestation, ensure neonatal resuscitation team availability including personnel skilled in neonatal intubation for this preterm delivery. 1

Primary Delivery Strategy: Forceps

• Forceps delivery is the preferred operative vaginal method in this scenario due to lower failure rates compared to vacuum extraction. 1
• Vacuum extraction should be avoided when the fetal head is at low station due to increased risk of intracranial and subgaleal hemorrhage. 1, 2, 3
• The use of vacuum at low station is specifically contraindicated due to potential for significant fetal injury. 2, 3

Why Vacuum (Ventouse) is Contraindicated

• Vacuum-assisted delivery should not be performed at low station due to increased risk of significant fetal injury, including intracranial and subgaleal hemorrhage. 2, 3
• The use of a single forceps blade or ventouse as a lever to disimpact the fetal head is considered dangerous and should be avoided. 3
• Vacuum extraction at cesarean delivery has the potential to cause significant fetal injury. 4, 3

Fetal Blood Sampling Role

• Fetal blood sampling is not indicated as a delivery method but rather as an adjunct assessment tool for Category 2 CTG patterns. 5
• With the head already in the vaginal canal and labor progressing, proceed directly to operative delivery rather than delaying for fetal scalp sampling. 4
• Access to fetal blood sampling does not appear to influence differences in neonatal seizures or other outcomes when continuous CTG is used. 5

Intrapartum Management Protocol

• Place the patient in lateral decubitus position to attenuate hemodynamic impact of uterine contractions during operative delivery. 1, 2
• Maintain continuous electronic fetal heart rate monitoring throughout the operative delivery. 1, 3
• Routine episiotomy is not necessary for assisted vaginal birth. 6

If Forceps Delivery Fails

• If forceps delivery fails, proceed immediately to cesarean section rather than attempting vacuum extraction. 1
• Failure of the chosen method to achieve delivery in a reasonable time should be considered an indication for abandonment of the method. 6
• Adequate clinical experience and appropriate training of the operator are essential to safe performance of operative deliveries. 6

Cesarean Section Considerations (If Required)

• If cesarean becomes necessary with impacted fetal head, reverse breech extraction may be associated with better neonatal outcomes including improved Apgar scores and reduced NICU admissions. 4
• Manual vaginal disimpaction (vaginal push method) can be used to move the fetal head up into the abdomen before making a uterine incision. 4
• Tocolysis may be administered to relax the uterus and facilitate advanced disimpaction techniques if needed. 4

Critical Contraindications to Assess

• Suspected cephalopelvic disproportion is an absolute contraindication to operative vaginal delivery and requires cesarean section. 1, 2
• Thoroughly assess for signs of CPD including marked molding, deflexion, or asynclitism of the fetal head without descent. 4
• If evidence of CPD emerges with increasingly marked molding or lack of descent, proceed to cesarean delivery earlier rather than attempting operative vaginal delivery. 4

Postpartum Management

• Administer slow IV oxytocin (<2 U/min) after placental delivery to prevent hemorrhage while avoiding hypotension. 1
• Continue hemodynamic monitoring for at least 24 hours postpartum due to fluid shifts. 1
• Anticipate advanced neonatal resuscitation given preterm delivery at 35-36 weeks and Category 2 CTG. 1

Key Pitfalls to Avoid

• Never attempt vacuum extraction when the fetal head is at low station—this is a dangerous practice with high risk of severe fetal injury. 1, 2, 3
• Do not use a single forceps blade as a lever to disimpact the head—this is considered dangerous and unsupported by evidence. 4, 3
• Avoid proceeding with oxytocin augmentation if CPD is suspected, as this increases risk without improving outcomes. 4
• Do not delay delivery for fetal blood sampling when operative delivery is already indicated by clinical scenario. 4