In a stable 35‑36 weeks + 1‑day pregnant woman in active labor with a low fetal head and a Category 2 cardiotocogram, what is the appropriate step‑wise management (fetal scalp blood sampling, operative vaginal delivery, or emergency cesarean section)?

Management of Category 2 CTG with Low Fetal Head at 35-36 Weeks

In a vitally stable woman at 35-36 weeks with active labor, low fetal head, and Category 2 CTG, proceed with assisted vaginal delivery (ventouse or forceps) if the head is at the perineum and delivery is imminent; otherwise, perform continuous fetal monitoring and prepare for emergency cesarean delivery if the CTG pattern worsens or fails to improve.

Immediate Assessment and Monitoring

• Continuous electronic fetal heart rate monitoring is mandatory in this clinical scenario given the Category 2 CTG pattern, which indicates indeterminate fetal status requiring heightened surveillance 1
• The patient's vital stability and low fetal head position (in vaginal canal) suggest vaginal delivery remains feasible, which is the preferred mode when maternal status allows 1
• At 35-36 weeks gestation, the fetus is late preterm and does not require tocolysis or corticosteroids at this stage if delivery is imminent 2

Decision Algorithm for Mode of Delivery

If Fetal Head is at Perineum (Station +2 or Lower):

• Proceed with operative vaginal delivery using low forceps or vacuum extraction to expedite delivery and minimize maternal pushing effort, which reduces hemodynamic stress 1
• The uterine contractions should descend the fetal head without maternal pushing to avoid unwanted Valsalva maneuver effects 1
• Assisted delivery is appropriate when the head is low and delivery can be accomplished safely and quickly 1

If Fetal Head is Higher (Above +2 Station):

• Fetal scalp blood sampling is NOT recommended as a routine intervention in this scenario - the evidence does not support its use to guide delivery decisions when Category 2 CTG is present with concerning clinical context 3
• Allow labor to progress with close monitoring if the CTG pattern remains Category 2 without progression to Category 3 4
• Prepare for emergency cesarean delivery if any of the following occur:
  • CTG deteriorates to Category 3 pattern
  • Maternal condition changes
  • Labor arrest occurs (defined as no cervical change for minimum 4 hours with adequate contractions or 6 hours with inadequate contractions at ≥6 cm dilation) 3

Anesthesia and Hemodynamic Management

• Lumbar epidural analgesia is recommended because it reduces pain-related sympathetic activity, reduces the urge to push, and provides immediate anesthesia if cesarean delivery becomes necessary 1
• Place the woman in lateral decubitus position to attenuate hemodynamic impact of uterine contractions and optimize uteroplacental perfusion 1
• Monitor systemic arterial pressure and maternal heart rate continuously, as epidural anesthesia may cause hypotension 1

Critical Pitfalls to Avoid

• Do not attempt mid-cavity operative vaginal delivery with Category 2 CTG at this gestational age - the risk of fetal injury outweighs potential benefits when the head is not at the perineum 1
• Avoid prolonged expectant management with persistent Category 2 CTG - while some Category 2 patterns are benign, the combination of preterm gestation (35-36 weeks) and concerning fetal heart rate pattern warrants expedited delivery planning 5
• Do not perform routine amniotomy if membranes are intact and labor is progressing, as this commits to delivery within a timeframe without proven benefit in this scenario 3
• Cesarean delivery should not be performed prematurely for arrest unless strict criteria are met (minimum 4-6 hours of arrest with adequate management), but fetal compromise overrides these timing considerations 3

Preterm Considerations at 35-36 Weeks

• At this gestational age, vaginal delivery remains the goal if labor progresses and fetal status permits, as neonatal risks are relatively low and cesarean delivery increases maternal morbidity 1, 2
• The rate of fetal compromise requiring cesarean delivery increases with advancing gestational age and nulliparity, but maternal stability and low fetal head favor vaginal approach 5
• Multidisciplinary team coordination between obstetricians and anesthesiologists is essential for optimal management at this gestational age 1