Caesarean birth on maternal request — structured oral station (12 minutes)

Opening prompt — "Take me through how you would handle this consultation."

Model response — perform the conversation, do not summarise it: ^[1][8]

• "Before I answer her question, I would ask what is behind it. I'd sit down, give her time, and say: 'Before we talk about the operation, can you tell me what's worrying you about labour?' Then I'd stop talking."
• "I would screen deliberately for fear of childbirth — whether it started before this pregnancy, or after something that happened before — and for previous birth trauma, sexual violence, and family violence. I'd ask how many children she hopes to have, because that changes the whole risk balance."
• "I would not answer the caesarean question on the first visit. I'd offer what might make the request unnecessary — continuity of carer, a named midwife, a written birth plan, a debrief of any previous birth, perinatal mental health referral — and I'd book her back."^[1][9]

Examiner is listening for: the opening question, the deliberate screening, the deferral to a second visit, and the offer of structured support before any decision.^[1][9]

Probe 1 — "She has primary tokophobia. What is that, and what does it change?"

• "Tokophobia is an unreasoning dread of childbirth. Hofberg and Brockington described primary tokophobia dating from before any pregnancy, secondary tokophobia after a traumatic birth, and tokophobia as a symptom of depression. She has the primary form."^[8]
• "It changes the consultation because it is treatable. In the randomised trial of intervention for fear of childbirth, 62% of the women who originally requested caesarean chose vaginal birth after therapy. I would refer her to perinatal mental health and offer structured support — and I would not make the support conditional on withdrawing the request."^[9]

Probe 2 — "She returns at 30 weeks and still wants the caesarean. Give me the benefit-and-harm conversation."

Give both columns in absolute terms, then state the certainty: ^[5][1]

• "On the harms side, the first caesarean is a decision about every future pregnancy. Accreta risk rises with each caesarean — with praevia, from about 3% at the first to 40% at the third and 61% at the fourth. Future uterine rupture, peripartum hysterectomy, praevia and adhesions all rise. This pregnancy she faces more wound infection, endometritis, haemorrhage and thromboembolism."^[3][5]
• "On the benefits side, planned caesarean appears to reduce long-term stress urinary incontinence by about 8% absolute — adjusted odds ratio 1.85 for vaginal birth — and reduces pelvic organ prolapse surgery and anal sphincter injury, the latter especially relative to assisted vaginal birth."^[7][5]
• "And I would say out loud that RANZCOG grades the certainty behind every one of those outcomes as very low, because the cohorts cannot cleanly separate true request from other elective indications. Honest uncertainty is part of the consent."^[1]

Probe 3 — "How does this end, under RANZCOG C-Obs 39?"

• "C-Obs 39 gives me exactly two endings. After a full discussion over more than one visit, if she still requests caesarean birth, I may agree to perform it, or I may refer her to a second obstetrician for further discussion. There is no third ending."^[1]
• "If I have a conscientious objection, I may decline to perform it myself — but I must not leave her without a pathway. I refer promptly, to a named colleague, early enough that she still has choices, and I document that referral. Conscientious objection is permitted; abandonment is not."^[1][2]
• "If I agree, the date is 39+0 or later, cross-referenced to C-Obs 23, unless there is a written clinical reason — and the vaginal-birth-after-caesarean conversation is booked for the postnatal period, not left to the next pregnancy."^[1]

Probe 4 — "She is frightened and tearful during the conversation. How do you handle that?"

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

• Move to her eye level, use her name, slow down. "It is completely reasonable to feel frightened, and I'm glad you told me. We have time, and there are people who can help with exactly this."
• Acknowledge the fear without minimising it, and do not use the fear to pressure her either way — neither "you must try vaginal" nor "of course you can have a caesarean" while she is distressed.
• Offer a named referral (perinatal mental health), a second longer visit, and continuity of carer. Commit to following up.^[8][9]

Probe 5 — "What would you write in the notes?"

• "The reason for the request, what I screened for and the result, what I offered (continuity, mental health referral, debrief), the numbers I quoted and in which direction, that I stated the very low certainty, the decision aid used, the decision and who made it, and — if a date was set — that it is at or after 39 weeks with a documented rationale."
• "If I declined, I'd record the conscientious objection, the named referral, and the timeline. An undocumented conversation is the failure most likely to generate a complaint."^[1]