Post-term pregnancy — structured oral station (12 minutes)

Opening prompt — "How would you answer her question?"

Model response — lead with shared decision-making, then the risk: ^[1][4]

• "This is a post-term counselling conversation, not a single answer. I would begin by confirming her gestational age is correct — the first-trimester dating scan is reassuring — and then discuss the risks and the options so she can make an informed choice."
• "The risk I would explain is that stillbirth rises with gestation: it is roughly 0.11 per 1000 at 37 weeks and climbs to about 3.18 per 1000 at 42 weeks, with one extra stillbirth for every 1449 pregnancies that continue from 40 to 41 weeks. The absolute risk is small but the relative rise is large, and it steepens after 40 weeks."^[1]
• "I would offer her a membrane sweep today, which reduces the chance of needing a formal induction, and lay out two paths: induction from 41 weeks, or expectant management with surveillance and a review date."^[4]

Probe 1 — "What is the evidence that induction helps?"

• "The Gülmezoglu 2012 Cochrane review — 22 trials, 9383 women — found that a policy of induction at or beyond term reduced perinatal death with a relative risk of 0.31, a number needed to treat of 410, and importantly it did not increase caesarean; caesarean was actually lower, RR 0.89."^[2]
• "Meconium aspiration syndrome was also halved. There was no significant difference in NICU admission."^[2]
• "This is the evidence base for offering induction at or beyond 41 weeks, and it overturns the old teaching that induction increases caesarean."^[2]

Probe 2 — "What about inducing her now, at 41+3 — or even earlier, at 39 weeks?"

• "ARRIVE asked whether we should induce low-risk nulliparas at 39 weeks. It found a lower caesarean rate, 18.6% versus 22.2%, and a primary composite that narrowly met threshold, 4.3% versus 5.4%."^[3]
• "But I would not impose 39-week induction routinely. The critiques are important: the cohort was motivated, low-risk and US-based with intensive surveillance of the expectant arm, the threshold was narrow, and routine rollout risks medicalising low-risk pregnancy and straining induction capacity."^[5]
• "For this woman at 41+3, induction now is well-supported by the Cochrane data. For a 39-week offer I would counsel and let her decide — it is a reasonable option, not a default."^[3][5]

Probe 3 — "She listens, and says she would prefer to wait. How do you respond?"

This is a scored communication and respect domain. Demonstrate it out loud: ^[4]

• "I would respect her decision. She is capable and now informed. I would move to her eye level, acknowledge her preference, and make sure she understands the surveillance plan and the safety-net."
• "I would offer enhanced surveillance — at least twice-weekly CTG and ultrasound for amniotic fluid volume from 42 weeks — and I would be honest that surveillance lowers but does not eliminate the stillbirth risk."^[1]
• "I would give her explicit advice to attend immediately if her baby's movements reduce, because that is the single most important safety-net."
• "And I would set a documented ceiling — delivery is strongly advised by 42+0 — with a review date, and I would record the whole discussion and her decision in her notes."^[4]

Probe 4 — "A colleague says the CTG reassures him that waiting is safe. What do you think?"

• "I would disagree politely. A reassuring CTG today does not guarantee a living fetus next week. Post-dates surveillance has a high false-positive rate and has not been shown, in isolation, to prevent all post-term stillbirths."
• "The honest position is that surveillance reduces but does not abolish the risk — which is exactly why delivery by 42 weeks, not indefinite monitoring, remains the recommendation."^[1]

Probe 5 — "How would you summarise your approach at the close of the consultation?"

• "Confirm the gestation, offer the sweep, present absolute numbers, support an informed choice, and — whatever she chooses — document the decision, set a surveillance schedule and ceiling if she waits, and safety-net on fetal movements. The post-term consultation is graded on risk literacy and shared decision-making, and I would make sure both are visible."^[1][4]