Management: Operative Vaginal Delivery with Forceps
For a patient at 35 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
Operative vaginal delivery is strongly preferred over cesarean section in this clinical scenario 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 uterine incision extensions, hemorrhage, and bladder/ureteric injuries. 1, 2
Forceps specifically is preferred over ventouse (vacuum) because vacuum extraction is contraindicated when the fetal head is at low station due to significantly increased risk of intracranial and subgaleal hemorrhage. 3, 4
The use of a single forceps blade or ventouse as a lever to disimpact the fetal head is considered dangerous and explicitly not recommended. 4, 3
Forceps delivery has lower failure rates compared to vacuum extraction, making it the preferred operative vaginal method when the fetal head is palpable in the vagina. 2, 5
Why Other Options Are Incorrect
Option B (Cesarean Section) - Incorrect
Proceeding directly to cesarean section when operative vaginal delivery is feasible is not recommended, given the substantially higher morbidity of second-stage cesarean. 1
The technical complications of impacted fetal head at cesarean include unintentional uterine incision extensions, hemorrhage, bladder and ureteric injuries, and prolonged operative time. 1
Option C (Ventouse/Vacuum) - Contraindicated
Vacuum-assisted delivery should not be performed at low station due to increased risk of significant fetal injury, including intracranial and subgaleal hemorrhage. 3, 4
The use of vacuum at cesarean delivery has the potential to cause significant fetal injury. 4
Option D (Fetal Sampling) - Inappropriate Delay
Delaying delivery for further monitoring when the head is already low and CTG is Category 2 is not recommended. 1
Category 2 CTG is non-reassuring and requires expedited delivery to prevent progression to Category 3 and potential fetal compromise. 1
Clinical Rationale for Urgency
A patient in the second stage of labor with fetal head visible/palpable in the vagina and Category 2 CTG requires expedited delivery to prevent progression to Category 3 and potential fetal compromise. 1
Continuous CTG is associated with reduced rates of neonatal seizures (RR 0.50,95% CI 0.31 to 0.80), though it increases cesarean section rates (RR 1.63,95% CI 1.29 to 2.07). 6
Critical 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. 3, 4
Do not use a single forceps blade as a lever to disimpact the head—this is considered dangerous and unsupported by evidence. 3, 4
Ensure proper training and experience with forceps before attempting operative delivery, as this is crucial to minimize nerve injury risk, particularly facial nerve paralysis. 1, 2
Have a backup plan ready if operative vaginal delivery fails, including personnel experienced in managing impacted fetal head at cesarean. 1
Prerequisites Before Proceeding
Thoroughly assess for cephalopelvic disproportion (CPD), which is an absolute contraindication to operative vaginal delivery and requires cesarean section. 3, 4
Look for signs of CPD including marked molding, deflexion, or asynclitism of the fetal head without descent. 3, 4
Ensure adequate clinical experience and appropriate training of the operator, as hospital credentialing boards should grant privileges only to appropriately trained individuals. 7