Placental abruption with intrauterine fetal death — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response, in this order: ^[1][3]

• "This is a severe placental abruption with an intrauterine fetal death, and I must assume she is coagulopathic until proven otherwise."
• "I would call for help now: consultant obstetrician, consultant anaesthetist, midwifery coordinator, and activate the massive obstetric haemorrhage protocol with the blood bank."
• "In parallel: left lateral tilt, two large-bore cannulae, warmed fluids then blood, catheter with hourly urine output, active warming, and bloods on the first draw including a coagulation profile with fibrinogen and a crossmatch of four units."
• "I would examine her abdomen for tone and tenderness, mark the fundal height with the time next to it, and I would not perform a digital vaginal examination until I know the placental site."^[1][3]

Examiner is listening for: the coagulopathy assumption stated up front, parallel action, and the specific bloods including fibrinogen. ^[4]

Probe 1 — "There is barely any blood on the pad. Does that reassure you?"

The examiner tells you the total revealed loss is about 150 mL.^[1]

• "No. Her shock index is 130 divided by 96, which is 1.35, and she has a rigid tender uterus. In abruption the blood is trapped behind the placenta and within the myometrium, so the visible loss badly understates the true loss."^[1][2]
• "The concealed group is roughly one in five and is the group that presents in shock with a nearly clean pad, and it is the group with coagulopathy and fetal death — which she already has."^[1]

Probe 2 — "Do you want an ultrasound to confirm the abruption?"

• "I already have the ultrasound finding that matters, which is the absent fetal heartbeat. I would not delay resuscitation for a scan to confirm abruption, because sonography has low sensitivity and a normal scan does not exclude it."^[5]
• "Abruption is a clinical diagnosis. My confirmatory information will come from the uterus, the physiology and the coagulation profile."^[5][2]

Probe 3 — "Here are her results. What do they mean and what do you do?"

The results the examiner hands you: fibrinogen 0.9 g/L, platelets 62 x 10 to the ninth per litre, prothrombin time prolonged, haemoglobin 74 g/L.^[3][4]

• "This is overt obstetric disseminated intravascular coagulation. Fibrinogen falls first and fastest in this setting, and 0.9 g/L against a term range of roughly 4 to 6 g/L is profound."^[3][4]
• "I would give cryoprecipitate or fibrinogen concentrate immediately, with red cells and fresh frozen plasma per the massive haemorrhage protocol, platelets, calcium replacement and active warming."^[3]
• "My targets are fibrinogen at or above 2 g/L, platelets above 50 x 10 to the ninth per litre, normal ionised calcium and normothermia, with the coagulation set repeated every 30 to 60 minutes."^[3][4]
• "If viscoelastic testing is available I would use it, because a low FIBTEM A5 tells me to give fibrinogen now rather than in forty minutes."^[3]

Probe 4 — "The baby has died. How is she going to give birth?"

• "Vaginal birth is my default, once the coagulopathy is being corrected and provided she remains haemodynamically manageable. The uterus in abruption is usually hypertonic and contracting, labour is often rapid, and a caesarean in a coagulopathic woman adds a large bleeding surgical wound to an already bleeding uterus."^[1][3]
• "I would perform amniotomy where feasible and use oxytocin as required, with continuous maternal monitoring and ongoing product replacement."^[1]
• "I would reserve caesarean for maternal instability that will not correct with resuscitation, mechanical obstruction, or another obstetric indication."^[2]

Probe 5 — "She is in severe pain and asks for an epidural."

• "Not while she is coagulopathic. With a fibrinogen of 0.9 g/L and platelets of 62 x 10 to the ninth per litre, neuraxial blockade carries an unacceptable risk of spinal or epidural haematoma."^[3]
• "I would offer intravenous opioid analgesia, patient-controlled where available, and explain plainly why I cannot offer an epidural yet and what would have to change for that to become safe."^[3]
• "If she needs a caesarean before the coagulopathy corrects, that is a general anaesthetic."^[3]

Probe 6 — "Tell her that her baby has died."

This is scored. Demonstrate it out loud rather than describing it. ^[1]

• Sit down, at her eye level, with a midwife present. Use her name and her baby's name if she has one.
• Warning shot then plain words, no euphemism: "I am so sorry. I have very sad news. The scan shows that your baby's heart has stopped beating. Your baby has died."
• Stop talking. Allow silence. Do not fill it with medicine.
• Then the essentials only: "You are also bleeding heavily and that is dangerous for you, so we need to keep treating that now. I will explain everything again as many times as you need."
• Ask who she wants with her, offer to call them, and allocate a named midwife to stay.
• Commit to a follow-up conversation about why this happened, including the placental examination and a bereavement pathway.^[1]

Probe 7 — "She mentions the fall happened during an argument with her partner."

• Recognise this as a disclosure and respond without alarm or judgement: "Thank you for telling me. Nothing about this is your fault."^[8]
• Ask directly and privately, with the partner out of the room and using a professional interpreter rather than a family member if needed: "Are you safe at home? Has anyone hurt you?"^[8]
• Explain the limits of confidentiality, involve the social work team, document factually in her notes rather than in a shared record the partner can see, and follow local mandatory reporting requirements where children are involved.^[8]
• Trauma is an established precipitant of abruption, and intimate partner violence in pregnancy is under-recognised, so the enquiry is clinical, not optional.^[8]

Probe 8 — "At caesarean, if you had needed one, the uterus is mottled purple. What is it and what do you do?"

• "A Couvelaire uterus, or uteroplacental apoplexy — blood tracking between the myometrial fibres to the serosa."^[6]
• "It is a marker of severity, not an indication for hysterectomy. Most contract normally. I would give uterotonics, assess tone directly, correct the coagulopathy, and reserve hysterectomy for uncontrollable bleeding after the full ladder has failed."^[6][1]

Probe 9 — "What will you tell her about the next pregnancy?"

• "Recurrence risk after one abruption is substantially increased compared with the background risk, and it rises further after two, although it remains well below half."^[7]
• "Next time she needs early booking with an obstetric-led plan, aspirin if she has coexisting preeclampsia risk factors, growth surveillance, and support for smoking cessation and safety at home — the modifiable risk factors are the ones we can act on."^[7][8]
• "I would also arrange placental histopathology and a perinatal mortality review, and see her myself at a named follow-up appointment."^[1]