A 33‑week gestation woman in labor with a type‑2 (moderately abnormal) deceleration on cardiotocography, fetal head at +2 station, severe obstetric hemorrhage and hypotension (BP 90/60), should the emergency management be operative vaginal delivery with forceps, vacuum extraction, or cesarean section?

Emergency Management: Immediate Cesarean Section

In a 33-week gestation woman with severe hemorrhage, hypotension (90/60), and Category 2 decelerations, cesarean section is the definitive management regardless of fetal station, as maternal hemodynamic instability from severe bleeding is an absolute contraindication to operative vaginal delivery. 1, 2

Why Cesarean Section is Mandatory

Maternal hemodynamic compromise from severe hemorrhage overrides all other considerations. The clinical scenario presents a dual emergency:

• Severe obstetric hemorrhage with hypotension (90/60) represents maternal hemodynamic instability that makes operative vaginal delivery unsafe, as it requires maternal pushing effort and time for instrument application that this patient cannot tolerate 3
• Category 2 decelerations at 33 weeks indicate fetal compromise requiring expedited delivery, but the maternal condition dictates the safest route 3
• The +2 station would normally favor forceps delivery in a stable patient, but maternal hemorrhagic shock takes absolute priority 1, 2

Critical Contraindications to Operative Vaginal Delivery

Operative vaginal delivery (forceps or vacuum) requires maternal hemodynamic stability to allow time for:

• Proper instrument application and positioning 1, 2
• Maternal expulsive efforts during contractions 4
• Controlled traction technique 5

This patient cannot provide any of these due to hemorrhagic shock. 1, 3

Specific Management Algorithm

Immediate Actions (Simultaneous):

• Activate massive transfusion protocol and prepare for emergency cesarean section 3
• Place patient in left lateral decubitus position to optimize venous return and cardiac output during transport to operating room 3
• Administer rapid IV crystalloid resuscitation while preparing blood products 3
• Ensure neonatal resuscitation team is present for 33-week preterm delivery 3

Intraoperative Considerations:

• Anticipate impacted fetal head at +2 station requiring manual vaginal disimpaction or reverse breech extraction technique 1, 2
• Administer uterine tocolysis to relax the uterus and facilitate fetal head disimpaction if needed 2
• Use slow IV oxytocin (<2 U/min) after placental delivery to prevent further hemorrhage while avoiding worsening hypotension 3

Why Forceps/Vacuum Are Contraindicated Here

While the American College of Obstetricians and Gynecologists recommends forceps as preferred operative vaginal delivery at +2 station under normal circumstances 1, 2, severe hemorrhage with hypotension creates absolute contraindications:

• Forceps delivery requires 5-10 minutes for proper application, positioning, and controlled traction—time this bleeding patient does not have 5, 4
• Vacuum extraction is already contraindicated at preterm gestation (33 weeks) due to increased risk of intracranial and subgaleal hemorrhage 1, 3
• Maternal pushing effort is required for successful operative vaginal delivery, which is impossible in a hypotensive, hemorrhaging patient 4

Common Pitfalls to Avoid

• Never attempt operative vaginal delivery in a hemodynamically unstable patient—the time required for instrument application and delivery will worsen maternal shock 1, 2
• Do not delay for further resuscitation—proceed immediately to cesarean section while resuscitating simultaneously 3
• Prepare for impacted head complications at cesarean given the +2 station, including having experienced personnel available for disimpaction techniques 1, 2
• Avoid rapid oxytocin bolus postpartum in this hypotensive patient—use slow infusion (<2 U/min) to prevent cardiovascular collapse 3

The correct answer is C - Cesarean Section.