Normal puerperium and postnatal care — structured oral station (12 minutes)

Opening prompt — "She says she does not feel right. What do you do?"

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

• "A woman who feels dreadful with a normal early-warning score is a woman I examine, not reassure. The single most repeated error in maternal death enquiries is attributing new symptoms to normal recovery."
• "I would take a full set of observations including respiratory rate — the vital sign most often not recorded and most predictive of deterioration — and do a focused review: breasts, uterus, bladder, bowels, lochia, wound, legs, mood, and medication and contraception."^[3]
• "I would specifically ask about heavy or restarted bleeding, fever, breathlessness, calf swelling, a severe headache, and any thoughts of harm to herself or the baby — the postnatal red flags."^[1]

Examiner is listening for: the refusal-to-reassure principle, respiratory rate, and the structured review rather than a guess at a diagnosis. ^[3]

Probe 1 — "Her uterus is firm and lochia is normal. Her respiratory rate is 22. What does that mean to you?"

• "A respiratory rate over 20 in a postnatal woman is one of the four findings that should stop the ward round. A composite score can look acceptable while one parameter is frankly abnormal. I would escalate — repeat the observations, examine the chest and calves, send a lactate and consider sepsis or thromboembolism before reassuring her."^[3]

Probe 2 — "She is now well, and you are planning her discharge. Describe the postnatal contact schedule she will receive."

• "NICE NG194: a face-to-face midwife visit within 36 hours of transfer of care; a community contact between 7 and 14 days; and a general practitioner maternal review at 6 to 8 weeks covering mood, continence, contraception, feeding and chronic-disease follow-up."^[1]
• "WHO complements this with contacts at 24 hours, 48 to 72 hours, 7 to 14 days and around 6 weeks, framed as a continuum. ACOG's fourth-trimester model adds a contact within 3 weeks and a comprehensive visit by 12 weeks."^[1][2]

Probe 3 — "She wants the combined pill. When can she start it?"

• "She can start combined hormonal contraception from 21 days postpartum if she has no venous thromboembolism risk factors, because postpartum VTE risk falls but does not return to baseline by then. If she had VTE risk factors — obesity, caesarean, preeclampsia, immobility, smoking, transfusion — it should wait until 6 weeks."^[4]
• "Progestogen-only methods are safe at any time after birth, including immediately, and are the better default while she is establishing feeding. An intrauterine device goes in within 48 hours or after 4 weeks, never in between, because of perforation risk."^[4]

Probe 4 — "On day 7 she texts the community midwife: she is tearful all the time and cannot sleep. How do you respond?"

This is a scored domain — demonstrate the mood assessment out loud: ^[5]

• "Tearfulness that has not settled by day 10, or is worsening, is no longer maternity blues — it is a different diagnosis until I have assessed it. I would see her, ask directly about mood, bonding, sleep, appetite and any thoughts of self-harm or harm to the baby, and use a validated tool such as the Edinburgh Postnatal Depression Scale."
• "If there is any hint of perplexity, rapid fluctuation, or insomnia without tiredness, I am thinking postpartum psychosis — a same-day psychiatric emergency, not a routine review."^[5]
• "I would give her a clear safety-net and a named contact, and book follow-up — detection without a pathway is not care."