Caesarean birth — structured oral station (12 minutes)

Probe 1 — "Take consent for her planned caesarean. What do you tell her?"

Demonstrate the conversation out loud. This is a scored communication domain, not a list. ^[2][3]

• Why: "Your baby is bottom-first. The Term Breech Trial randomised over 2000 women and found serious problems for the baby in 1.6 per cent with a planned caesarean compared with 5.0 per cent with a planned vaginal breech birth, with no difference in serious problems for the mother."^[2]
• Common risks: infection, bleeding, pain, slower recovery, and a longer stay than a vaginal birth.^[4]
• Serious risks: injury to the bladder, ureter or bowel; the need for a blood transfusion; rarely a hysterectomy; and blood clots.^[7]
• Future pregnancies — the part candidates omit: "Each caesarean makes the next one harder. The risk of the placenta lying low and growing into the scar rises steeply — with a low placenta it goes from about 3 per cent after one caesarean to 40 per cent after three."^[3]
• Alternatives: external cephalic version if she is still eligible, or a planned vaginal breech birth with an experienced team, and what each involves.^[2]
• Timing: at 39 weeks or later unless there is a reason to deliver earlier, with a plan for what to do if she labours first.^[4]
• Check her understanding by asking her to tell you back what she has decided and why.^[4]

If she asks about steroids: "Corticosteroids before a planned caesarean at term probably reduce admission to the neonatal unit for breathing problems, but the certainty of the evidence is low for the specific respiratory conditions, so we discuss it rather than give it routinely."^[9]

Probe 2 — "You are now called to a cord prolapse at 6 cm with a bradycardia of 70. Categorise and act."

• "This is category 1 — an immediate threat to the life of the fetus. The audited decision-to-delivery standard is 30 minutes."^[1]
• "While moving: elevate the presenting part off the cord manually or fill the bladder, position her knee-to-chest or in exaggerated Sims, stop any oxytocin, consider tocolysis, give oxygen if indicated, and get intravenous access."^[1]
• "In theatre: left lateral tilt or manual displacement, weight-based cefazolin before skin incision, and the anaesthetist decides between a rapid spinal and a general anaesthetic based on how fast we truly need to be."^[4]
• "The 30 minutes is an audit standard, not a physiological cliff. I would not force a general anaesthetic on a woman who could have a spinal in the same time frame."^[1]

Probe 3 — "Talk me through the operation."

• Transverse skin incision two to three finger-breadths above the symphysis; Joel-Cohen entry has less febrile morbidity, less pain and analgesic use, less blood loss, and shorter operating time and hospital stay than Pfannenstiel.^[6]
• Open the sheath, separate the recti, enter the peritoneum high and bluntly, form a bladder flap only if it helps.^[5]
• Small low transverse hysterotomy with blunt cephalad-caudad expansion to reduce unintended extension.^[5]
• Deliver the head with flexion and elevation plus fundal pressure; delay cord clamping if the baby is well.^[4]
• Uterotonic, controlled cord traction for the placenta, then continuous uterine closure; inspect both angles.^[5][7]
• Do not close the peritoneum routinely; close the sheath; close fat if 2 cm or deeper; subcuticular skin closure.^[5]

Examiner probe: "Single or double layer?" — "CORONIS randomised 15,935 women across five technique pairs, including single versus double layer, and found no statistically significant difference in the primary composite for any pair. I close in two layers where a future pregnancy is planned, but I would not claim the trial evidence proves it."^[5]

Probe 4 — "You extend the incision laterally and there is brisk bleeding at the angle. What now?"

• "Do not place a deep blind suture — the ureter passes beneath the uterine artery about 1.5 to 2 cm lateral to the cervix and this is exactly where it is injured."^[7]
• "Apply pressure, get better exposure and light, ask for a second assistant, and consider extending the hysterotomy to see the apex of the tear. Identify the apex, then suture from beyond it under direct vision, keeping medial."^[7]
• "Mobilise the bladder downward if it is in the way, check ureteric peristalsis, and involve a senior colleague or urology if I cannot see what I am suturing."^[7]
• Quote the incidence to show calibration: bladder injury about 267 per 100,000 caesareans and ureteric injury about 9 per 100,000, with surgeon inexperience the leading risk factor.^[7]

Probe 5 — "How do you get her home well?"

• Analgesia: scheduled multimodal — paracetamol 1 g IV intraoperatively then 650 mg orally every 6 hours, ketorolac 30 mg IV every 6 hours for four doses then ibuprofen 600 mg orally every 6 hours, with short-acting opioids for breakthrough only.^[8]
• Catheter out immediately after a scheduled caesarean; oral fluids straight away and solid food within 2 hours; chewing gum to speed bowel recovery; mobilisation from about 4 hours.^[8]
• Thromboprophylaxis: mechanical for all until she is walking, chemoprophylaxis where risk factors are present.^[8]
• Additional antibiotic doses only for obesity without preoperative azithromycin, an operation lasting 4 hours or more, blood loss over 1500 mL, or intra-amniotic infection.^[8]
• Discharge and counselling: 24 to 48 hours in the low-risk woman with neonatal follow-up arranged, wound and infection safety net, an interpregnancy interval of 18 to 23 months, contraception discussed before the operation, and the mode-of-birth conversation for next time.^[8][3]