In a 36‑week pregnant woman in labor with a late deceleration on cardiotocography and the fetal head at station +2, what is the appropriate management?

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Management: Proceed with Forceps Delivery

In a 36-week pregnant woman in active labor with Category 2 (Type 2) decelerations on CTG and fetal head at +2 station, forceps delivery is the recommended management approach. 1, 2

Why Forceps is the Correct Choice

Operative vaginal delivery with forceps is preferred over cesarean section at this stage because the fetal head is already deeply engaged (+2 station), and cesarean delivery at full dilation with an impacted fetal head carries substantially higher maternal morbidity—including impacted head complications in up to 10% of cases, unintentional uterine extensions, hemorrhage, and bladder/ureteric injuries. 1

Key Decision Points:

  • Category 2 CTG is non-reassuring but not immediately ominous, indicating need for expedited (not emergent) delivery to prevent progression to Category 3 fetal compromise 1, 3

  • Station +2 represents a favorable scenario where the fetal head is palpable low in the vagina, making operative vaginal delivery the safest and most expeditious route that minimizes both maternal and neonatal morbidity 1

  • Forceps has lower failure rates compared to vacuum extraction and is the preferred instrument in this clinical scenario 2, 4

Why NOT Ventouse (Vacuum)?

Vacuum extraction is explicitly contraindicated when the fetal head is at low station (+2) due to markedly increased risk of intracranial and subgaleal hemorrhage in the neonate. 2, 3

  • The American College of Obstetricians and Gynecologists specifically warns against vacuum use at low station due to potential for significant fetal injury 3

  • Vacuum extraction has higher failure rates than forceps, which would delay definitive delivery in a Category 2 CTG scenario 5

Why NOT Cesarean Section?

Cesarean section should be reserved for failed operative vaginal delivery or when cephalopelvic disproportion is suspected, not as first-line management when the head is already low in the pelvis 1, 2

  • Second-stage cesarean with impacted fetal head has substantially higher maternal morbidity than forceps delivery 1

  • Technical complications include difficult extraction, extended operative time, and increased blood loss 1

Why NOT Fetal Scalp Sampling?

Fetal scalp sampling would cause unnecessary delay when expedited delivery is already indicated by the combination of Category 2 CTG and favorable station for operative delivery 1

  • The clinical scenario already warrants intervention—further testing would not change management and risks progression to Category 3 1, 3

  • With the head at +2 station, the safest approach is to proceed directly with operative delivery rather than continue monitoring 1

Critical Pre-Delivery Assessment

Before proceeding with forceps, you must exclude cephalopelvic disproportion (CPD), which is an absolute contraindication to operative vaginal delivery: 3

  • Assess for marked molding, deflexion, or asynclitism of the fetal head without descent 3

  • Use suprapubic palpation to differentiate caput from true fetal descent 3

  • If CPD is suspected (present in 40-50% of labor arrest cases), proceed immediately to cesarean section 3

Intrapartum Management Protocol

  • Place patient in lateral decubitus position to attenuate hemodynamic impact of uterine contractions 6, 2

  • Maintain continuous electronic fetal heart rate monitoring throughout the operative delivery 6, 2

  • Ensure proper forceps application technique to minimize risk of facial nerve paralysis 1

  • Have backup plan ready: if forceps delivery fails, proceed immediately to cesarean section rather than attempting vacuum 3

Post-Delivery Care

  • Administer slow IV oxytocin (<2 U/min) after placental delivery to prevent hemorrhage while avoiding hypotension 6, 2

  • Continue hemodynamic monitoring for at least 24 hours postpartum due to fluid shifts 6, 2

  • Ensure neonatal resuscitation team is present given preterm delivery at 36 weeks and Category 2 CTG 3

Common Pitfalls to Avoid

  • Never use a single forceps blade as a lever—this is considered dangerous and explicitly not recommended 1, 2

  • Never attempt vacuum extraction at low station—this carries high risk of severe fetal intracranial injury 2, 3

  • Do not delay delivery for further monitoring when the head is already low and CTG is Category 2 1

  • Do not proceed to cesarean as first-line when operative vaginal delivery is feasible, given the substantially higher morbidity of second-stage cesarean 1

References

1
Guideline

Operative Vaginal Delivery with Forceps or Ventouse

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Operative Vaginal Delivery with Forceps

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Management of Preterm Labor at 33 Weeks

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Operative vaginal delivery.

Obstetrics and gynecology, 2010

5
Research

Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians.

European journal of obstetrics, gynecology, and reproductive biology, 2011

6
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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