Birth injuries — structured oral station (12 minutes)

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

Model response — say it in this order: ^[1][2]

• "This is suspected subgaleal haemorrhage. Boggy diffuse swelling that crosses suture lines and extends behind the ears, with tachycardia, prolonged capillary refill and pallor, in an infant born by a difficult vacuum with two cup detachments. I would call the neonatal registrar now."
• "ABC, two large-bore cannulae or umbilical venous access, bloods including FBC, coagulation and crossmatch early, fluid bolus 10 mL per kilogram of isotonic crystalloid repeated to perfusion."
• "I would start RANZCOG C-Obs 28 high-tier surveillance — heart rate and respiratory rate every 30 to 60 minutes, head circumference and scalp measurement every 1 to 2 hours, serial haematocrit every 2 to 4 hours, low threshold to image."
• "I would activate neonatal retrieval to a tertiary centre early."^[1]

Examiner is listening for: the diagnosis, the parallel resuscitation, the C-Obs 28 surveillance named and tiered, and the early-retrieval decision. ^[1]

Probe 1 — "How do you distinguish subgaleal from cephalohaematoma?"

• "The single bedside discriminator is suture-crossing. Cephalohaematoma is subperiosteal and bound by suture lines — it does not cross them. Subgaleal is subaponeurotic, between the galea aponeurotica and the periosteum, and crosses all sutures. Cephalohaematoma rarely causes systemic compromise; subgaleal can exsanguinate a term neonate over hours."^[1][3]
• "Caput succedaneum is subcutaneous oedema, crosses sutures, but resolves in hours and does not cause systemic compromise."^[5]

Probe 2 — "His initial haemoglobin is 165. How do you interpret this?"

• "The early haemoglobin in acute neonatal haemorrhage is misleading because equilibration has not yet occurred. The first number may be near the pre-bleed value even when significant loss has occurred. I would manage on physiology — tachycardia, prolonged capillary refill, pallor, progressive swelling — and the trend of serial haematocrit, not on the first number."^[1][2]

Probe 3 — "What is the surveillance framework you are using?"

• "RANZCOG C-Obs 28 — Prevention, Detection and Management of Subgaleal Haemorrhage in Neonates. Surveillance intensity is set at low, intermediate, or high according to the perceived risk, which depends on both the birth circumstances (instrumental, with cup detachments, off-axis traction, prolonged application, sequential instruments) and the condition of the neonate (any sign of scalp swelling, pallor, tachycardia). This infant is high tier."^[1]
• "The minimum monitoring on the high tier: heart rate and respiratory rate every 30 to 60 minutes, head circumference and scalp measurement every 1 to 2 hours, serial haematocrit every 2 to 4 hours, and a low threshold to involve the neonatal team and to image. The high-tier infant stays under continuous observation for at least the first 6 to 24 hours."^[1][2]

Probe 4 — "The parents are frightened. The father asks if his son is going to die."

This is a scored communication domain. Demonstrate it out loud: ^[1]

• Move to their eye level, use the baby's name, brief plainly: "Your son had a difficult birth and we are concerned that some blood has collected under the skin of his scalp. We have a whole team here. We are giving him fluids and have blood on standby. We are watching him very closely and we will keep telling you what is happening."^[1]
• Acknowledge fear directly: "I know this is frightening. We are treating him aggressively. The lights over his cot are warming him; the nurses are checking him every half hour; the paediatric team is here. I will come back and update you as soon as there is news."
• Commit to a debrief afterwards and to a named person for their questions.

Probe 5 — "What documentation will you complete?"

• "The indication, the instrument and cup size and placement, the number of tractions and cup detachments, the duration of application, any off-axis traction, the fetal condition at birth, the Apgars, the cord gases, the neonatal examination, and the surveillance plan I have instituted. The named decision-maker at each step. A complete contemporaneous record is the registrar's defence if the case is later reviewed."^[4]