In a 36‑week pregnant woman in active labour with a type‑2 (moderate, non‑reassuring) cardiotocograph deceleration and the fetal head at +2 station, what is the appropriate management?

Management of Category II Fetal Heart Rate Tracing at +2 Station

In a 36-week pregnant woman in active labor with Category II (type 2) decelerations and the fetal head at +2 station, the appropriate management is operative vaginal delivery with forceps or ventouse, provided immediate intrauterine resuscitation measures are attempted first and cephalopelvic disproportion is excluded. 1

Immediate Intrauterine Resuscitation

Before proceeding to delivery, perform the following resuscitative measures:

• Discontinue oxytocin immediately if it is running, as this is the priority intervention for Category II tracings with recurrent decelerations indicating uteroplacental insufficiency 2
• Change maternal position to left lateral to relieve potential cord compression and improve uteroplacental blood flow 2
• Administer supplemental oxygen at 6-10 L/min via face mask to improve fetal oxygenation 2
• Perform vaginal examination to assess for rapid descent, cord prolapse, or other complications 2
• Administer intravenous fluid bolus and assess maternal vital signs 1

Decision Algorithm for Mode of Delivery

At +2 station, the fetal head is well-descended into the pelvis, making operative vaginal delivery the preferred approach over cesarean section for several critical reasons:

Why Operative Vaginal Delivery is Preferred

• Station +2 is ideal for operative vaginal delivery, as the fetal head has descended sufficiently to allow safe application of forceps or vacuum 3
• Category II tracings require expedited delivery but do not mandate immediate cesarean section like Category III tracings 1, 4
• Cesarean section at +2 station carries significantly higher maternal morbidity including increased blood loss, uterine extension, bladder injury, and difficult fetal extraction compared to operative vaginal delivery 3

Contraindications to Operative Vaginal Delivery

Operative vaginal delivery should not be attempted if:

• Maternal hemodynamic instability is present (e.g., active hemorrhage with hypotension), which would mandate immediate cesarean section 5
• Cephalopelvic disproportion is suspected or confirmed based on excessive molding, deflexion, asynclitism without descent, or failed descent despite adequate contractions 1, 6
• The tracing deteriorates to Category III (absent baseline variability with recurrent late/variable decelerations or bradycardia), requiring immediate delivery 1, 2

Fetal Scalp Sampling is Not Indicated

• Fetal scalp sampling is not appropriate in this clinical scenario because the patient requires expedited delivery given the Category II tracing at +2 station, not further diagnostic testing 1
• Scalp sampling may be considered for indeterminate tracings earlier in labor when there is time for additional assessment, but at +2 station with decelerations, the focus should be on delivery 7

Monitoring During Operative Vaginal Delivery

• Expect transient CTG abnormalities during instrument application, including tachycardia (40-44%), variable decelerations (39-45%), late decelerations (27-35%), and saltatory patterns (15-35%), which are common mechanical effects and do not predict poor neonatal outcome if delivery is accomplished promptly 3
• Continuous fetal monitoring should be maintained throughout the procedure 3

When to Convert to Cesarean Section

Proceed to cesarean section if:

• Operative vaginal delivery fails after appropriate trial (typically one or two pulls with proper technique) 1
• The tracing deteriorates to Category III during attempts at operative delivery 2
• Maternal instability develops during the procedure 5
• Evidence of cephalopelvic disproportion emerges during attempted operative delivery 1

Common Pitfalls to Avoid

• Do not proceed directly to cesarean section without attempting intrauterine resuscitation measures first, as many Category II tracings will improve with simple interventions 2, 4
• Do not delay delivery for prolonged observation once intrauterine resuscitation has been attempted; if the tracing remains non-reassuring after 1-2 hours or deteriorates, proceed with delivery 4
• Do not attempt operative vaginal delivery if you lack experience with the chosen instrument or if prerequisites (adequate anesthesia, empty bladder, known position, adequate station) are not met 3