A 28-year-old primigravida at term is in the second stage of labor. After 2 hours of pushing with adequate contractions and epidural analgesia, the fetal head is at +2 station in occipitoanterior position. Fetal heart rate is reassuring. Regarding the indications and contraindications for vacuum extraction in this scenario, all of the following are correct EXCEPT:

Explanation

## Indications and Contraindications for Vacuum Extraction ### Clinical Scenario Analysis The patient has: - Prolonged second stage (2 hours in primigravida; normal limit ~3 hours) - Adequate contractions and analgesia - Fetal head at +2 station, OA position - Reassuring fetal heart rate - No signs of cephalopelvic disproportion **Key Point:** Vacuum extraction is indicated for prolonged second stage with reassuring fetal status and no contraindications. This patient is a candidate. ### Contraindications to Vacuum Extraction #### Absolute Contraindications | Contraindication | Reason | |---|---| | **Prematurity <34 weeks** | Immature fetal skull; increased risk of intracranial hemorrhage, cephalohematoma | | **Suspected fetal bleeding disorder** | Hemophilia, alloimmunization with hydrops; scalp trauma may cause severe hemorrhage | | **Face or brow presentation** | Incompatible with cup placement; risk of orbital/facial trauma | | **Suspected osteogenesis imperfecta** | Fragile bones; high risk of fracture | #### Relative Contraindications | Contraindication | Rationale | |---|---| | **Suspected macrosomia** | Increased risk of failed delivery; not absolute — depends on maternal pelvis and descent | | **Caput succedaneum present** | Difficult cup placement; increased risk of detachment | | **Scalp abrasion/sampling** | Relative caution; not absolute contraindication | | **Operator inexperience** | Increased risk of failed delivery and fetal trauma | **High-Yield:** Previous fetal scalp sampling (FBS) or scalp electrode placement is a **relative contraindication** — not absolute. The scalp site may be tender or have minor abrasion, but vacuum can still be safely applied if the operator is experienced and the clinical indication is strong. Absolute contraindications are few and involve structural/hematologic incompatibility. ### Why Each Statement Is Correct or Incorrect **Statement 1 (Correct):** Prolonged second stage with reassuring fetal heart rate is a classic indication for operative vaginal delivery. ACOG supports this approach. **Statement 2 (Correct):** Suspected fetal macrosomia is a **relative** contraindication. Vacuum delivery carries higher risk of failure and maternal/fetal trauma in macrosomic infants, but it is not absolutely contraindicated if clinical judgment supports it. **Statement 3 (INCORRECT):** Previous scalp sampling is a **relative**, not absolute, contraindication. The scalp may be slightly tender or have minor abrasion, but vacuum extraction can proceed safely with experienced operator. Absolute contraindications are rare and involve conditions incompatible with safe operative delivery (prematurity <34 weeks, suspected bleeding disorder, face presentation). **Statement 4 (Correct):** Prematurity <34 weeks is an absolute contraindication. The fetal skull is insufficiently ossified, and scalp trauma from cup traction carries unacceptable risk of intracranial hemorrhage and subdural hematoma. **Mnemonic for Absolute Contraindications to Vacuum:** **FOBS** - **F**ace/brow presentation - **O**steogenesis imperfecta - **B**leeding disorder (suspected) - **S**evere prematurity (<34 weeks)