In a 33‑week pregnant woman in labor with a type II deceleration on cardiotocography, fetal head at +2 station, severe maternal hemorrhage and hypotension, what is the appropriate immediate management: forceps, vacuum extraction, or cesarean section?

Immediate Cesarean Section is Required

In this clinical scenario of severe maternal hemorrhage with hypotension at 33 weeks gestation, cesarean section (C) is the definitive management to save both maternal and fetal life, despite the fetal head being at +2 station. 1

Critical Decision-Making Framework

Maternal Instability Overrides All Other Considerations

• Cesarean section is specifically recommended for maternal or fetal instability, and this patient meets criteria with severe bleeding causing hypotension (90/60 mmHg) 1
• Hemorrhagic shock in obstetrics represents inadequate organ perfusion with insufficient oxygen delivery to tissues, and once established becomes irreversible even with volume correction 2
• The physiologic reserve of pregnancy has been exceeded when hypotension develops, signifying abrupt and dangerous blood loss 3

Why Operative Vaginal Delivery is Contraindicated Here

While the fetal head at +2 station would normally favor forceps delivery for Category 2 decelerations 4, 5, the presence of severe maternal hemorrhage with hemodynamic instability fundamentally changes the clinical picture:

• Operative vaginal delivery requires time for proper positioning, anesthesia consideration, and controlled traction - time this unstable patient does not have 6, 7
• Forceps delivery, though preferred over vacuum at +2 station, carries higher risk of maternal pelvic floor trauma and additional bleeding 7
• The source of severe bleeding must be identified and controlled immediately, which cannot be accomplished during operative vaginal delivery 2

Specific Contraindications to Forceps (Option A)

• Maternal hemodynamic instability from hemorrhage makes the prolonged second stage required for forceps application dangerous 3
• Additional maternal pelvic floor trauma from forceps increases bleeding risk in an already hemorrhaging patient 7
• Failure to control the bleeding source takes priority over route of delivery 2

Specific Contraindications to Vacuum (Option B)

• Vacuum extraction is absolutely contraindicated at low station (+2) due to high risk of fetal intracranial and subgaleal hemorrhage 4, 5, 8
• Vacuum has higher failure rates than forceps, and failed operative vaginal delivery would further delay definitive management 4, 6
• At 33 weeks gestation (preterm), the fetal skull is more vulnerable to vacuum-related injury 4

Immediate Management Protocol

Pre-Cesarean Resuscitation (Simultaneous with Preparation)

• Initiate aggressive volume resuscitation with crystalloid and blood products to restore tissue perfusion 2
• Place patient in lateral decubitus position to improve venous return and cardiac output 4, 5
• Monitor for hypothermia development, which substantially increases morbidity and mortality in hemorrhagic shock 2

Cesarean Section Execution

• Delivery should occur within 5 minutes in life-threatening maternal complications 1
• Ensure neonatal resuscitation team is present for this 33-week preterm delivery with Category 2 tracing 4
• Identify and control the bleeding source immediately upon delivery 2

Critical Pitfall to Avoid

Do not attempt operative vaginal delivery in a hemodynamically unstable patient - the time required for proper technique and the additional maternal trauma will worsen outcomes. The multiple organ dysfunction syndrome that follows established hemorrhagic shock is often irreversible 2. Most deaths from obstetric hemorrhage are preventable with immediate, organized intervention 3.

Post-Delivery Management

• Administer slow IV oxytocin (<2 U/min) after placental delivery to prevent further hemorrhage while avoiding additional hypotension 4
• Continue hemodynamic monitoring for at least 24 hours due to postpartum fluid shifts 4, 5
• Maintain normothermia throughout the perioperative period 2