In a 33‑week‑gestation pregnant woman who is hemodynamically stable, in active labor with the fetal head low in the vaginal canal and a Category 2 cardiotocography (CTG) trace, should we attempt operative vaginal delivery (forceps or vacuum) versus immediate cesarean section, and is fetal scalp blood sampling indicated?

Operative Vaginal Delivery Management at 33 Weeks with Category 2 CTG

Attempt forceps delivery immediately as the preferred operative vaginal approach, given the fetal head is already low in the vaginal canal—this offers the best balance of maternal and neonatal outcomes while avoiding the significantly higher risks of cesarean section at this advanced stage of labor. 1, 2

Critical Initial Assessment

Before proceeding with any delivery method, you must rapidly exclude cephalopelvic disproportion (CPD), which occurs in 40-50% of labor arrest cases and represents an absolute contraindication to operative vaginal delivery 3. Perform immediate digital examination assessing for:

• Marked molding, deflexion, or asynclitism without descent (these signal CPD and mandate cesarean) 3
• Fetal head station confirmation (already stated as low in vaginal canal, favorable for forceps) 1
• Presence of caput versus true descent via suprapubic palpation of skull base 3

If any evidence of CPD exists or cannot be ruled out with reasonable certainty, proceed directly to cesarean section—the risks of attempting vaginal delivery are too great 3.

Primary Delivery Strategy: Forceps (NOT Vacuum)

Forceps delivery is your first-line operative approach because:

• Vacuum extraction is contraindicated at low station due to significantly increased risk of intracranial and subgaleal hemorrhage 3, 1, 2
• Forceps have lower failure rates compared to vacuum in this clinical scenario 1, 2
• The fetal head position in the vaginal canal makes this favorable for forceps rather than cesarean 1

Intrapartum Management During Forceps Attempt

• Position patient in lateral decubitus to attenuate hemodynamic impact of contractions 1, 2
• Maintain continuous electronic fetal monitoring throughout the procedure 1, 2
• Ensure neonatal resuscitation team is present with personnel skilled in neonatal intubation for this 33-week preterm delivery 1

Fetal Blood Sampling: NOT Indicated

Fetal scalp blood sampling is not indicated in this scenario because:

• Category 2 CTG requires expedited delivery, not further testing 1
• The fetal head is already low in the vaginal canal, making immediate delivery the priority rather than additional monitoring
• Time spent on fetal blood sampling delays definitive management when operative delivery is already indicated

If Forceps Delivery Fails

Proceed immediately to cesarean section—do NOT attempt vacuum extraction as a second-line operative approach 1, 2. The use of vacuum at cesarean delivery carries high risk of fetal intracranial and subgaleal hemorrhage 3, 1.

Cesarean Technique for Impacted Head

If cesarean becomes necessary with the head now impacted low:

• Manual vaginal disimpaction (vaginal push method) can move the fetal head up into the abdomen before uterine incision 2
• Reverse breech extraction may be associated with better neonatal outcomes including improved Apgar scores and reduced NICU admissions 2
• Never use a single forceps blade or vacuum abdominally to assist delivery—this is dangerous and unsupported by evidence 3, 2

Critical Pitfalls to Avoid

• Do not attempt vacuum extraction with fetal head at low station—this is a dangerous practice with high risk of severe fetal injury including intracranial hemorrhage 3, 1, 2
• Do not use a single forceps blade as a lever to disimpact the head—considered dangerous 3, 2
• Do not proceed with operative vaginal delivery if CPD cannot be excluded—40-50% of arrest cases have CPD, and attempting vaginal delivery risks catastrophic maternal and fetal injury 3
• Do not delay for fetal blood sampling—Category 2 CTG with head in canal requires expedited delivery 1

Postpartum Management

• Administer slow IV oxytocin (<2 U/min) after placental delivery to prevent hemorrhage while avoiding hypotension 1, 2
• Continue hemodynamic monitoring for at least 24 hours postpartum due to fluid shifts 1, 2
• Anticipate advanced neonatal resuscitation given preterm delivery at 33 weeks and Category 2 CTG 1

Why NOT Immediate Cesarean?

While cesarean is definitive, with the fetal head already low in the vaginal canal and maternal hemodynamic stability confirmed, forceps delivery offers:

• Lower maternal morbidity compared to cesarean with impacted fetal head 2
• Avoidance of complications associated with delivering an impacted head through abdominal incision 3
• Faster delivery time when the head is already favorably positioned 1

The key distinction is that maternal hemodynamic stability allows time for a controlled forceps attempt, whereas instability would mandate immediate cesarean regardless of fetal head position 4.