During a prolonged second stage, a nulliparous woman who has been pushing for 3 hours with regional analgesia has no descent. Fetal head is at +2 station, direct occiput anterior. CTG is Category II. What is the MOST appropriate operative decision?
- A Non-rotational outlet forceps (e.g., Wrigley's forceps)
- B Kielland's rotational forceps from +2 station
- C Ventouse (vacuum) delivery is contraindicated at +2 station
- D Trial of instrumental delivery in theatre with immediate recourse to caesarean if unsuccessful ✓
Explanation
A 'trial of instrumental delivery' is recommended when there is uncertainty about success of vaginal delivery — specifically at stations above +3, with significant asynclitism, or with a Category II/III CTG. The head at +2 with no descent after 3 hours of pushing despite regional anaesthesia (which alone warrants up to 4 hours in nulliparas) raises concern. RCOG guidelines stipulate that any operative vaginal delivery where there is doubt about success should be conducted as a 'trial' in theatre with everything ready for immediate caesarean delivery. Kielland's at +2 with a primigravid uterus and Category II CTG is a high-risk setting requiring trial conditions, not a straightforward outlet procedure.
Reference: Williams Obstetrics, 26th ed.
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Written and medically reviewed by the StethoPrep medical team.