What is the best management for a patient at 33 weeks gestation with a category 2 Cardiotocography (CTG) in the second stage of labor, with the fetal head palpable in the vagina?

Management: Operative Vaginal Delivery with Forceps

For a patient at 33 weeks gestation in the second stage of labor with Category 2 CTG and fetal head palpable in the vagina, proceed immediately with forceps delivery (Option A), as this represents the safest and most expeditious route that minimizes both maternal and neonatal morbidity compared to cesarean section at full dilation. 1

Why Forceps is the Correct Answer

• Forceps delivery is preferred over cesarean section because cesarean at full dilation with a deeply engaged fetal head carries substantially higher maternal morbidity, including impacted fetal head complications in up to 10% of cases, with risks of unintentional uterine incision extensions, hemorrhage, bladder and ureteric injuries, and prolonged operative time. 1, 2

• Forceps has lower failure rates compared to vacuum extraction, making it the preferred operative vaginal method when the fetal head is palpable in the vagina. 3, 2

• Category 2 CTG is non-reassuring but not immediately ominous, indicating the need for expedited delivery to prevent progression to Category 3 and potential fetal compromise, but does not mandate immediate cesarean section when operative vaginal delivery is feasible. 1

Why NOT Ventouse (Option C)

• Vacuum extraction is contraindicated at low station due to increased risk of intracranial and subgaleal hemorrhage, particularly at 33 weeks gestation where the fetal skull is more vulnerable. 3, 4

• The use of vacuum at cesarean delivery or with deeply engaged head has the potential to cause significant fetal injury, including intracranial and subgaleal hemorrhage. 4

• Vacuum extraction should be avoided when the fetal head is at low station due to high risk of severe fetal injury. 3

Why NOT Cesarean Section (Option B)

• Second-stage cesarean section should be avoided when operative vaginal delivery is feasible, given the substantially higher morbidity profile. 1, 2

• Impacted fetal head complications occur frequently with cesarean at full dilation, resulting in lack of space between the fetal head and maternal pubic symphysis, making it difficult to deliver and increasing risk of uterine incision extensions, hemorrhage, and bladder/ureteric injuries. 4

• If cesarean becomes necessary, obstetricians must be prepared to use manual vaginal disimpaction, reverse breech extraction, or the Patwardhan method, along with uterine tocolysis to facilitate delivery. 4, 3

Why NOT Fetal Sampling (Option D)

• Delaying delivery for further monitoring when the head is already low and CTG is Category 2 is not recommended, as this risks progression to Category 3 and worsening fetal compromise. 1

• Category 2 CTG with head in vagina requires expedited delivery, not additional assessment that delays intervention. 1

Critical Prerequisites Before Proceeding

• Assess for cephalopelvic disproportion (CPD), which is an absolute contraindication to operative vaginal delivery and requires cesarean section. Look specifically for marked molding, deflexion, or asynclitism of the fetal head without descent. 3, 2

• Ensure proper training and experience with forceps application techniques before attempting operative delivery, as improper technique is the primary mechanism of facial nerve paralysis. 2

• Never use a single forceps blade as a lever to disimpact the head—this is considered dangerous and unsupported by evidence. 4, 3

Backup Plan if Forceps Fails

• If forceps delivery fails, proceed immediately to cesarean section rather than attempting vacuum extraction. 2

• Prepare for impacted fetal head management including manual vaginal disimpaction (vaginal push method) or reverse breech extraction, which may be associated with better neonatal outcomes including improved Apgar scores and reduced NICU admissions. 3, 4

• Administer uterine tocolysis to relax the uterus and facilitate disimpaction techniques if cesarean becomes necessary. 4, 3

Common Pitfall to Avoid

The most dangerous error would be choosing ventouse at this station, as vacuum extraction with a deeply engaged head carries unacceptable risk of intracranial hemorrhage, particularly at 33 weeks gestation. 3, 4 The second most common error is proceeding directly to cesarean section without attempting operative vaginal delivery, which exposes the patient to the substantial morbidity of second-stage cesarean with impacted fetal head. 1, 2