Perimortem caesarean birth — structured oral station (12 minutes)

Opening prompt — "What do you want to do?"

Model response — commit immediately: ^[6][7]

• "She arrested at 11:48 and it is now 11:51, so we are three minutes in with no output. Her fundus is above the umbilicus. I am going to perform a resuscitative hysterotomy — a perimortem caesarean — here in the resuscitation bay, starting now, aiming to deliver by five minutes from the arrest."^[1][6]
• "I need: a scalpel, the perimortem caesarean pack if you have one, and someone to keep displacing the uterus to her left until the baby is out. Do not stop compressions and do not move her."^[7][9]
• "Please call the neonatal team to a separate resuscitaire, and have uterotonics and blood ready — the field will be dry until she gets a circulation back, and then it will bleed."^[7][5]
• "This is a maternal resuscitation manoeuvre. I am doing it for her."^[4][6]

Examiner is listening for: an immediate, unhedged decision with a stated time, the phrase "for maternal benefit", and refusal to move the patient. ^[6][4]

Probe 1 — "You do not know her exact gestation. Does that change anything?"

• "No. Gestational age is often unknown or unreliable in an arrest, so the bedside decision tool is fundal height. A fundus at or above the umbilicus means the uterus is large enough to compress the great vessels, and three finger-breadths above the umbilicus clearly meets that."^[6][7]
• "Below the umbilicus, standard adult resuscitation applies unmodified and the procedure has no role."^[7][6]

Probe 2 — "Justify the procedure physiologically."

• "Four mechanisms. First, relief of aortocaval compression: the gravid uterus flattens the inferior vena cava against the spine, and chest compressions already deliver only a fraction of normal cardiac output."^[1][6]
• "Second, redistribution: the term uterus takes a large share of cardiac output, and emptying it returns that flow to her brain and heart."^[2][4]
• "Third, ventilation: reduced intra-abdominal pressure un-splints the diaphragm and improves compliance, which matters because pregnancy shortens the safe apnoea time."^[7][9]
• "Fourth, the fetus: fetal oxygen delivery stops with the maternal circulation, so neonatal outcome tracks the arrest-to-delivery interval — but that is the secondary benefit, not the indication."^[3][8]

Probe 3 — "Talk me through the operation."

• "No anaesthetic — she is in cardiac arrest and has no cerebral perfusion. I would state aloud that if she regains circulation and shows awareness, the anaesthetist gives anaesthesia at that point."^[7][9]
• "No consent, no formal skin preparation, no drapes if they cost time. A splash of antiseptic if it is already in someone's hand."^[7][6]
• "Midline vertical skin incision from just below the umbilicus to the pubic symphysis — fastest access, least retraction, least anatomy to negotiate. Through fascia and peritoneum in as few passes as I can, extending bluntly where it is safe."^[4][7]
• "Vertical or low transverse hysterotomy, started with the scalpel and extended with scissors or fingers, protecting the fetus. Deliver the fetus, then the placenta, and hand the baby straight to the neonatal team."^[7][6]
• "Pack the uterus and abdomen. Compressions, ventilation, rhythm checks, drugs and defibrillation never stop, and uterine displacement continues until the baby is out."^[6][7]

Probe 4 — "How good is the evidence for the four-minute rule?"

This probe rewards intellectual honesty. Do not oversell it. ^[3][4]

• "It is expert consensus, not trial evidence. Katz, Dotters and Droegemueller proposed it in 1986 after reviewing the historical case literature, reasoning from aortocaval compression physiology. There has never been a randomised trial and there never will be one."^[1][3]
• "What supports it: Katz's 2005 follow-up of 38 cases, in which delivery preceded the return of maternal pulse and blood pressure in 12 of 18 cases with documented haemodynamics, and no mother deteriorated because of the operation."^[2]
• "Einav's 2012 review of 94 cases found maternal survival to discharge of 54.3%, most with good cerebral performance, benefit to the mother in about a third of cases and harm in none, with delivery within 10 minutes associated with better maternal outcome."^[3]
• "The strongest human data are from CAPS: median collapse-to-delivery of 3 minutes in survivors against 12 minutes in those who died — an observational association, not proof."^[5]
• "Rose and Benson argued for renaming it resuscitative hysterotomy and abandoning a rigid cut-off, precisely so that nobody uses '4 minutes have passed' as a reason not to operate."^[4]

Probe 5 — "You are now at nine minutes and nobody has cut. Is it too late?"

• "No, and this is the question I most want to answer clearly. The four-minute target exists to drive urgency, not to define futility."^[4][3]
• "Survival with good neurological outcome is documented well beyond it. The systematic review of out-of-hospital arrest reported a woman surviving with normal neurological function after a 29-minute collapse-to-hysterotomy interval, and a neonate surviving at 47 minutes."^[8]
• "Across the published literature the operation has not been shown to worsen maternal condition. So late is better than never — I would do it now."^[2][3]

Probe 6 — "The emergency consultant says you cannot operate without consent. Respond."

Respect and communication are scored. Disagree without conflict. ^[7][6]

• "I understand the concern, and I want to be clear: she lacks capacity in cardiac arrest, so this is emergency treatment in her best interests and consent is neither required nor obtainable."^[7]
• "It is standard of care in the RCOG guideline, the American Heart Association statement and the European Resuscitation Council guidance. The medico-legal risk runs the other way: an arrested woman at 34 weeks who is not delivered has been denied a recommended resuscitation intervention."^[7][6]
• "I will document the time of arrest, the time of incision, the time of delivery, who was present and my reasoning, and I will speak to the family myself."^[9][5]

Probe 7 — "You deliver at five minutes and thirty seconds. Two minutes later she has a pulse. What happens next?"

• "Two things happen at once. She will start bleeding — the field was dry only because there was no circulation. I want uterotonics, the massive haemorrhage protocol, blood in the room, and I will pack and control the uterus."^[7][5]
• "And she may now need anaesthesia and analgesia — the anaesthetist takes that immediately."^[9][7]
• "Then theatre for definitive haemostasis and formal closure once she is stable enough to move, followed by intensive care with targeted temperature management, treatment of the underlying cause, and neuroprognostication deferred to at least 72 hours."^[7][6]
• "The baby goes to the neonatal team for assessment for hypoxic-ischaemic encephalopathy and consideration of cooling."^[8][9]

Probe 8 — "Her partner arrives. Nobody has spoken to him. What do you say?"

• Hand over clinical leadership, then go yourself with a named support person, sit down and use her name.
• "I am the obstetrician who has been looking after Amy. Her heart stopped in the waiting room. To help her heart work, we had to deliver your baby here in the emergency department. Your baby is with the baby doctors now. Amy's heart has restarted and she is very unwell — she is going to intensive care."
• Warn before you inform, pause after each piece, avoid jargon, and check understanding.
• Be honest about uncertainty and do not promise an outcome. Offer to take him to see the baby, and commit to returning with news.
• Afterwards: a structured debrief for the family, a separate debrief for the team, an incident review, and psychological support for the emergency department staff who witnessed it.^[9][5][7]