Nutrition, supplementation and exercise — structured oral station (12 minutes)

Opening prompt — "She is at 9 weeks and takes nothing. What do you start?"

Model response — say it in this order: ^[1][3]

• "Ideally folate and iodine would have started before conception, but I will start both now. Folic acid 400 micrograms daily, and iodine 150 micrograms daily, continued through the pregnancy and breastfeeding."
• "Because she is vegan I would add vitamin B12 — vegan diets are B12-deficient and untreated deficiency can cause neurological sequelae in the breastfed infant — and check a full blood count, ferritin and vitamin D, supplementing iron and vitamin D if she is deficient."
• "I would also ask about her medications — in particular whether she is on an antiepileptic, has diabetes, a previous neural tube defect, or a BMI of 30 or more, any of which would push the folate dose to 5 mg."^[1][2][3]

Examiner is listening for: the two universal supplements (folate, iodine) with doses, the vegan-specific additions, and the high-risk folate check. ^[1][6]

Probe 1 — "She is vegan. Why does that change your plan?"

• "Vegan diets are usually adequate in folate but deficient in vitamin B12, iron, zinc and often vitamin D. So I add B12, screen iron and vitamin D, and supplement to target. I would also advise against any high-dose vitamin A (retinol) supplement — it is teratogenic."^[6]

Probe 2 — "Set her weight-gain target."

• "Her BMI is 21, which is normal weight. The IOM range for a normal-weight woman is 11.5 to 16 kg total, or about 0.42 kg per week in the second and third trimester. I would set that as her target and revisit it."^[5]

Probe 3 — "What exercise do you advise, and what would you tell her to avoid?"

• "I would encourage regular exercise — RANZCOG C-Obs 62 and ACOG both say women without contraindications should exercise, and there is no evidence it is harmful. The prescription is most days, at least 30 minutes moderate at a time, 150 to 300 minutes a week, plus strengthening twice weekly."
• "I would tell her to avoid exercise flat on her back after the first trimester, avoid overheating, and avoid contact sports or activities with a fall risk. A rating of perceived exertion of 12 to 14, or the talk test, keeps the intensity right."^[4]

Probe 4 — "She drinks six cups of tea and a coffee. What do you say?"

• "That is around 250 to 300 mg of caffeine a day, which is above the limit. I would advise keeping caffeine under 200 mg a day — ACOG Committee Opinion 462. Moderate intake under 200 mg does not appear to be a major contributor to miscarriage or preterm birth; higher intake is associated with miscarriage — Weng reported an adjusted hazard ratio of 2.23 for 200 mg a day or more."
• "Practically: cut to about one coffee or two to three cups of tea. And I would advise complete abstinence from alcohol, since no safe threshold has been established."^[6]

Probe 5 — "She is worried exercise will harm the baby. How do you respond?"

Communication is a scored domain — demonstrate it out loud: ^[4]

• "I would reassure her clearly and warmly: in an uncomplicated pregnancy, exercise is safe and beneficial — it lowers the risk of gestational diabetes, helps with weight, mood and recovery — and there is no evidence it harms the baby. I would invite her to start gently if she is not used to it and build up. I would check for contraindications first and document the plan together."^[4]