What is the best course of action for a pregnant woman at 33 weeks gestation (Ga) with a Category 2 Cardiotocography (CTG) and the fetal head palpable in the vagina, where all other parameters are normal?

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Operative Vaginal Delivery (Forceps or Ventouse) is the Best Action

For a pregnant woman at 33 weeks gestation with a Category 2 CTG and fetal head palpable in the vagina, operative vaginal delivery with forceps or ventouse is the most appropriate management, as this represents the second stage of labor requiring expedited delivery while avoiding the substantially higher maternal morbidity associated with cesarean section at full dilation with a deeply engaged fetal head. 1

Clinical Reasoning and Decision Algorithm

Why This is Second Stage Labor, Not Preterm Labor Management

  • The fetal head being palpable in the vagina indicates the patient is in the second stage of labor with full cervical dilation and descent of the presenting part, regardless of gestational age 1
  • This clinical scenario requires immediate delivery decisions based on labor stage, not expectant preterm management 1

Why Category 2 CTG Requires Expedited Delivery

  • Category 2 CTG tracings are indeterminate and non-reassuring, requiring close monitoring and potential intervention to prevent progression to Category 3 fetal compromise 2, 1
  • When the fetal head is already low in the pelvis with a Category 2 CTG, expedited delivery is indicated rather than continued observation 1
  • The American College of Obstetricians and Gynecologists emphasizes that delaying delivery for further monitoring when the head is already low and CTG is Category 2 increases risk without benefit 1

Why Operative Vaginal Delivery is Superior to Cesarean Section

  • Cesarean section 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 2, 1
    • Unintentional uterine incision extensions 2
    • Hemorrhage 2
    • Bladder and ureteric injuries 2
    • Prolonged operative time 2

  • Operative vaginal delivery avoids these technical complications while achieving expedited delivery 1

  • The American College of Obstetricians and Gynecologists recommends proceeding with operative vaginal delivery as the safest and most expeditious route that minimizes maternal and neonatal morbidity compared to cesarean section at full dilation 1

Instrument Selection: Forceps vs. Ventouse

  • Both forceps and ventouse are acceptable options when the head is palpable in the vagina 1
  • Forceps advantages: More controlled traction, lower failure rates, preferred at low station 1, 3
  • Ventouse advantages: Gentler on maternal tissues, but requires more time for application and has higher failure rates 1
  • The choice depends on operator experience and specific clinical circumstances, but proper training in application techniques is essential to minimize nerve injury risk 1

Expected CTG Changes During Operative Delivery

  • After instrument application, 90% of CTG traces show abnormal features, including:

    • Tachycardia (40-44% of cases) 3
    • Variable decelerations (39-44% of cases) 3
    • Late decelerations (27-35% of cases) 3
    • Saltatory patterns (15-35% of cases) 3
    • Prolonged decelerations (11-14% of cases) 3

  • These CTG abnormalities during operative delivery are expected and do not indicate poor outcomes when delivery is accomplished expeditiously 3

  • Despite these transient CTG changes, perinatal outcomes remain good with mean Apgar scores of 8-9 and umbilical cord pH >7.20 3

Critical Management Considerations at 33 Weeks

  • Administer antenatal corticosteroids if not previously given, as delivery is anticipated before 33 6/7 weeks 2, 4, 5
  • Administer intrapartum magnesium sulfate for fetal neuroprotection, as gestational age is <32 weeks 2
  • Have neonatal resuscitation team present at delivery given prematurity 2

Why Other Options Are Incorrect

Option A (Cesarean Section) - INCORRECT

  • Proceeding to cesarean section as first-line when operative vaginal delivery is feasible is not recommended given the substantially higher morbidity of second-stage cesarean 1
  • Cesarean section should only be performed if operative vaginal delivery fails or is contraindicated 1

Option D (Fetal Sampling) - INCORRECT

  • Fetal scalp pH sampling is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery 2
  • When the head is palpable in the vagina with Category 2 CTG, the appropriate action is expedited delivery, not further assessment 1
  • Delaying for additional testing when delivery is already indicated increases risk without benefit 1

Backup Plan if Operative Delivery Fails

  • If operative vaginal delivery fails, cesarean section must be performed with specific techniques to manage the impacted head 2, 1:
    • Manual vaginal disimpaction (vaginal push method) 2
    • Reverse breech extraction 2
    • Uterine tocolysis to relax the uterus and facilitate disimpaction 2
    • Avoid attempting delivery during contractions, which exacerbates difficulty 2

Common Pitfalls to Avoid

  • Do not proceed directly to cesarean section without considering operative vaginal delivery when the head is low and conditions are favorable 1
  • Do not delay delivery for further CTG monitoring or fetal sampling when expedited delivery is already indicated 1
  • Ensure proper training and experience with the chosen instrument before attempting operative delivery 1
  • Have personnel experienced in managing impacted fetal head available if cesarean becomes necessary 1

References

1
Guideline

Operative Vaginal Delivery with Forceps or Ventouse

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Fetal heart rate changes observed on the CTG trace during instrumental vaginal delivery.

The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 2019

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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