Intrapartum care with existing medical conditions — structured oral station (12 minutes)

Opening prompt — "Walk me through how you would manage her labour."

Model response — start with the plan, then the specifics: ^[4]

• "First I would find and read her written intrapartum plan, agreed antenatally by obstetrics, cardiology and anaesthesia. The whole of safe care for a class III lesion depends on that plan being in the notes and followed."
• "She is mWHO class III — severe aortic stenosis is a fixed-output lesion. The default is planned vaginal birth in a centre with cardiology and intensive care, because ROPAC found planned caesarean was not beneficial for most cardiac women."^[5][4]
• "My plan: left lateral position, continuous pulse oximetry and strict fluid balance, an early slow epidural to blunt the catecholamine surge, an assisted second stage to shorten bearing down, and oxytocin slow and dilute for the third stage — never ergometrine, because it causes an acute afterload rise and can precipitate pulmonary oedema."^[4]

Probe 1 — "Why avoid ergometrine, and what do you use instead?"

• "Ergometrine causes acute systemic vasoconstriction. In a fixed-output lesion that cannot raise its cardiac output, the afterload rise backs up into the lungs and causes pulmonary oedema. It is contraindicated in cardiac disease and hypertension."
• "Instead I use oxytocin for the third stage, given slowly and dilute — a rapid bolus also causes hypotension and tachycardia, which she will not tolerate. I would have a low threshold for an actively managed third stage given her risk."^[4]

Probe 2 — "A second woman on the suite has type 1 diabetes. What is your intrapartum glucose plan?"

• "Tight capillary glucose control, monitored hourly through labour, with an insulin and dextrose infusion if it drifts. The standard target range is around 4 to 7 mmol per litre, the level achieved in the randomised comparison of intrapartum regimens. A rotating-fluids regimen is a reasonable alternative and was comparable to an insulin drip."^[7]
• "The key moment is birth: insulin requirements fall off a cliff as the placental insulinase is delivered, so I halve the infusion immediately and transition her back towards her prepregnancy regimen. I would also put a neonatal hypoglycaemia alert on the baby."^[6]

Probe 3 — "A third woman is on therapeutic enoxaparin for a recent PE and wants an epidural. How do you counsel her?"

• "For therapeutic-dose low-molecular-weight heparin, the ASRA guidance requires a 24-hour interval before any neuraxial procedure, and the next dose waits 4 hours after catheter removal. Prophylactic-dose is 12 hours — the difference matters."^[10]
• "If she is in labour sooner than the window allows, I would discuss options with the anaesthetist — a carefully titrated approach, or a general anaesthetic if a caesarean becomes necessary. I would not compromise the window to expedite the block."
• "The reassurance is that a systematic review found no case of obstetric spinal epidural haematoma when the timing rules are kept — which is exactly why we keep them rather than assume them away."^[8][10]

Probe 4 — "A fourth woman with epilepsy has a tonic-clonic seizure at 7 cm. What now?"

Say the sequence out loud, then defend the differential: ^[11]

• "Airway, left lateral, call for help, time the seizure. For ongoing seizure I would give intravenous lorazepam 4 mg, repeated once after 10 minutes."
• "Then I rule out eclampsia — check the blood pressure, the reflexes, the urinalysis. If eclampsia is possible I give magnesium sulphate; it is safer to treat first and clarify the diagnosis afterwards."
• "I would continue her antiseizure medication — never stop it because she is nil by mouth — and arrange one-to-one care. A seizure in labour is eclampsia until proven otherwise, but a woman with epilepsy is allowed to have epilepsy."^[11]

Probe 5 — "She is anxious about what happens after the birth."

Communication is scored — demonstrate the conversation: ^[4]

• Move to her eye level, use her name: "You have done the hard part. We will keep a close eye on you for the next few days, because the period after birth is when the heart is under the most strain as fluid moves around."
• Explain the surveillance plan plainly: high-dependency for 72 hours, daily review, and a clear point of contact. Reassure about breastfeeding where the lesion allows it.
• Commit to a debrief and to pre-pregnancy counselling with her cardiologist before she thinks about another pregnancy.^[4]