Antepartum haemorrhage — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response, in this order: ^[1][2]

• "This is a major antepartum haemorrhage and my working diagnosis is placental abruption, because the pain preceded the bleeding, the loss is dark, and she has two risk factors — smoking and hypertension."
• "I would call for help immediately: consultant obstetrician, anaesthetist, midwifery coordinator, and I would alert the blood bank and the neonatal team for a possible birth at 34 weeks."
• "In parallel: left lateral tilt, two large-bore cannulae, bloods including a coagulation profile with fibrinogen and a crossmatch, warmed fluids then blood, catheter and hourly urine output, and continuous CTG."
• "I would palpate for tone and tenderness, mark her fundal height with the time next to it, and I would not perform a digital vaginal examination until I know where the placenta is."^[1][2]

Examiner is listening for: parallel action, a named working diagnosis with the reasoning, the specific bloods, and the vaginal-examination rule stated unprompted. ^[1]

Probe 1 — "Her pulse is 118 with a blood pressure of 132/86. Are you reassured?"

• "No. Her shock index is 118 divided by 132, which is 0.89, and that is already abnormal in someone whose booking blood pressure was 148/94 — a reading of 132/86 may represent a substantial fall from her own baseline."^[2]
• "In abruption the visible loss underestimates the true loss because blood is trapped behind the placenta and within the myometrium. I would treat the physiology and the uterus, not the pad."^[2]
• "I would recheck her observations every 5 minutes and mark the fundal height so I can detect a rising uterus."^[2]

Probe 2 — "The ultrasound reports a normally sited fundal placenta and no retroplacental collection. Does that change your diagnosis?"

• "No. Ultrasound has low sensitivity for abruption, so a normal scan does not exclude it. The scan has done its most important job, which is to tell me this is not a praevia, so a speculum examination is now safe."^[3][1]
• "Abruption stays a clinical diagnosis, supported by the pain, the uterine tone and tenderness, the CTG and the coagulation profile."^[3][2]

Probe 3 — "Here are her blood results. Interpret them for me."

The results the examiner hands you: haemoglobin 104 g/L, platelets 118 x 10 to the ninth per litre, fibrinogen 2.6 g/L, prothrombin time and APTT normal.^[4][7]

• "The fibrinogen is the number that worries me. In late pregnancy fibrinogen normally runs about 4 to 6 g/L, so 2.6 g/L is a substantial fall even though the laboratory may flag it as normal, and an early fall in fibrinogen predicts progression to severe haemorrhage."^[4][7]
• "Prothrombin time and APTT move later than fibrinogen, so a normal clotting screen does not reassure me. I would repeat the set within 30 to 60 minutes, alert the blood bank, and be ready to give cryoprecipitate or fibrinogen concentrate to keep the fibrinogen at or above 2 g/L."^[4][7]

Probe 4 — "The CTG shows frequent low-amplitude uterine activity with poor relaxation, a baseline that has risen from 140 to 165 bpm, and reducing variability. What now?"

• "That is the fetal heart rate signature of a progressing abruption, and fetal heart rate patterns track the extent of separation. This trace plus a clinically suspected abruption means birth now."^[8][2]
• "I would proceed to category 1 caesarean section, continue resuscitation on the way, and tell the anaesthetist that her coagulation profile is falling so a general anaesthetic is likely to be safer than a spinal."^[7][4]
• "Steroids: betamethasone 11.4 mg IM would be given on the way past if there is time, but I would not delay the birth for it, and at 34+1 weeks I would not give magnesium sulphate for neuroprotection under the Australian and New Zealand threshold."^[6]

Probe 5 — "She is RhD negative. What do you do about that, and when?"

• "Rh D immunoglobulin 625 IU intramuscularly in Australia and New Zealand, as soon as possible and within 72 hours, and I do not wait for the laboratory to give it."^[5]
• "I would also send a maternal sample for fetomaternal haemorrhage quantification — Kleihauer as the screen, flow cytometry as the more accurate confirmation — because abruption is a classic cause of a large fetomaternal bleed and she may need a calculated top-up dose."^[5]

Probe 6 — "She is frightened and asking whether the baby will be all right. Her partner is in the room."

This is a scored domain, not a courtesy. Demonstrate it out loud. ^[1]

• Move to her eye level, use her name, and be plain: "You are bleeding from behind the placenta. That is serious for you and for the baby, and the safest thing is to deliver now by caesarean. There is a whole team here and a paediatric team will be with the baby."
• Be honest without forecasting: "At 34 weeks babies usually do well, but they often need help with breathing and a stay in the nursery. I cannot promise you an outcome, and I will keep telling you what is happening as we go."
• Include the partner, allocate a midwife to stay with them, avoid jargon, and commit to a debrief afterwards.^[1]

Probe 7 — "What are you watching for after the birth?"

• "Postpartum haemorrhage, because abruption predisposes to atony and to coagulopathy. I would give prophylactic uterotonics, keep the coagulation profile going, and have a balloon and compression sutures available."^[2][7]
• "Then acute kidney injury with hourly urine output, ongoing coagulopathy, thromboprophylaxis reassessed once haemostasis is secure, blood pressure follow-up given her hypertension, smoking cessation support, and a debrief with a plan for the next pregnancy including recurrence risk."^[7][2]