Preterm labour and birth — structured oral station (12 minutes)

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

Model response — say it in this order: ^[1][2]

• "This is threatened preterm labour at 26+2 weeks in a hospital that cannot look after this baby. My first three questions are: is she really in labour, is there a reason she must deliver now, and can I get her to a tertiary unit before the birth."
• "While I take the history I would ask the midwife to put in a cannula and take FBC, CRP, group and hold, an MSU and a high vaginal swab, and to confirm the dating scan gestation."
• "I would exclude chorioamnionitis and abruption clinically — temperature, pulse, uterine tenderness, liquor colour and smell, bleeding. Both are absent here, and that is what allows me to consider tocolysis."
• "I would give betamethasone 11.4 mg intramuscularly now and start magnesium sulfate 4 g intravenously over 20 to 30 minutes then 1 g per hour, and I would ring the tertiary unit and the retrieval service while the drugs are being drawn up."^[1][3][4]

Examiner is listening for: parallel action, exclusion before tocolysis, real doses, and transfer named in the first answer rather than as an afterthought. ^[7]

Probe 1 — "Why are you giving magnesium sulfate? What will you tell her it does?"

• "It is for fetal neuroprotection, not tocolysis. The Cochrane review of six trials and nearly 6000 women found it reduces cerebral palsy at up to 2 years with a risk ratio of 0.71 and a number needed to treat of about 60, and reduces death or cerebral palsy with a risk ratio of 0.87."^[3]
• "I would tell her: 'This medicine is for the baby's brain. It lowers the chance of cerebral palsy. It will make you feel hot and flushed and a bit sick — that is expected, and we will stay with you.'"^[3]
• "I would chart hourly respiratory rate, deep tendon reflexes, conscious state and urine output, and I would have calcium gluconate 1 g intravenously available as the antidote."^[3][2]

Probe 2 — "She is contracting every 3 minutes. Do you tocolyse, and with what?"

• "Yes, because there is something specific to buy: the corticosteroid course and the 2-hour transfer. Nifedipine immediate-release 20 mg orally, repeated once after 30 minutes if she is still contracting, then 20 mg every 6 to 8 hours for a maximum of 48 hours. Atosiban is my alternative if she becomes hypotensive."^[5][2]
• "I would not tocolyse if there were chorioamnionitis, significant abruption, non-reassuring fetal status, advanced labour, fetal death, a lethal anomaly, or severe preeclampsia."^[1][2]
• "I would be honest about what tocolysis achieves. The network meta-analysis of 122 trials shows every class delays birth by 48 hours and 7 days, but no class on its own improves neonatal mortality. The benefit is entirely in what I do with the time."^[5]
• If pushed on nifedipine plus magnesium: "Both lower blood pressure, so I would monitor her pressure closely and reduce or stop the nifedipine if she becomes symptomatic."^[5][3]

Probe 3 — "The tertiary unit says they have no cot. What now?"

• "I would escalate rather than accept. I would ask my consultant to speak to the tertiary consultant, and I would ask the state retrieval or perinatal emergency service to find a bed anywhere with neonatal intensive care, including interstate if that is what it takes."^[7]
• "In parallel I would prepare to deliver here: neonatal team briefed and in the room, resuscitaire checked, thermal care ready, and the neonatal retrieval team activated so they are travelling toward us, not summoned after the birth."^[7][2]
• "Place of birth is one of the strongest determinants of survival at this gestation, so this is a phone call worth being unpopular over."^[7]

Probe 4 — "Her partner asks: 'Is our baby going to live?'"

This is a scored domain, not a courtesy. Demonstrate it out loud. ^[7]

• Sit down, eye level, no drape between you: "I am not going to give you a number that pretends to be certain. What I can tell you is that at 26 weeks most babies born in a specialist unit survive, and that survival and long-term outcome improve with every day we can safely gain and with being born in the right hospital."
• Name the plan in plain words: "So we are doing three things. A steroid injection for the baby's lungs. A drip for the baby's brain. And we are trying to get you to a hospital with an intensive care nursery."
• Check understanding, invite questions, and commit to a neonatologist conversation: "The baby doctors will come and talk with you before anything happens, and they will be at the birth."
• Acknowledge the fear explicitly rather than reassuring it away, and offer support for the partner as well as the woman.^[7][1]

Probe 5 — "She settles. Twenty-four hours later she is not contracting. What do you do?"

• "Stop the tocolytic at 48 hours — there is no role for maintenance tocolysis. Complete the corticosteroid course. Stop the magnesium once birth is no longer expected within 24 hours, and restart it if labour returns."^[5][3]
• "Reassess: cervical length, symptoms, infection screen results, and whether she should stay in the tertiary unit or return home with a clear escalation plan. A short cervix with a high fibronectin keeps her close."^[8]
• "Plan the rest of the pregnancy and the next one: preterm birth clinic, growth surveillance, smoking cessation if relevant, and a documented plan for what happens if she represents."^[8][6]