Puerperal sepsis and endometritis — structured oral station (12 minutes)

Opening prompt — "What do you do from the doorway?"

Model response: ^[1]

• "This is puerperal sepsis with organ dysfunction — tachycardia, tachypnoea and hypotension — not just a fever. I would call for help: senior obstetrician, anaesthetist, midwifery coordinator, and escalate to intensive care early."
• "I would deliver the first-hour bundle: oxygen to target saturations, blood cultures, intravenous broad-spectrum antibiotics within the hour, intravenous fluids, serum lactate, and urine output measurement."^[2]
• "Each hour of delay to antibiotics carries an odds ratio of about 1.04 for in-hospital mortality, and never receiving antibiotics carried an adjusted odds ratio of 22.7 for death — so I give the antibiotic, I do not plan it."^[3]

Examiner is listening for: the organ-dysfunction framing, the six bundle elements, and the antibiotic given within the hour. ^[2]

Probe 1 — "What antibiotics, specifically?"

• "The Cochrane benchmark for postpartum endometritis is clindamycin plus gentamicin, with once-daily gentamicin at least as effective as thrice-daily; a broad alternative is ampicillin plus gentamicin with metronidazole. I would give broad cover of aerobes, anaerobes and streptococci empirically and narrow on culture."^[4]
• "Her pain is out of proportion to her wound, with vomiting and an offensive lochia — I am worried about invasive group A streptococcal disease. In suspected GAS or toxic shock I add clindamycin to the beta-lactam for its antitoxin effect: it suppresses exotoxin production by inhibiting protein synthesis, independent of the kill."^[5]

Probe 2 — "She is not improving on day 2. What are you thinking?"

• "I re-think the source, not just the drug. No antibiotic drains an abscess. I would image for a pelvic or wound collection and drain it — image-guided where possible, surgically where unavailable."^[2]
• "I would also reconsider: resistant organism, retained products needing evacuation once she is stabilised, septic pelvic thrombophlebitis producing persistent fever in an otherwise improving woman, or a non-infective diagnosis such as pulmonary embolism. If retained products is the source, resuscitate and antibiotic first, then evacuate — never the reverse."^[4]

Probe 3 — "Her four-year-old at home has a sore throat. Does that change anything?"

• "It reinforces invasive group A streptococcal disease — household transmission from a child with a sore throat is the classic exposure history. I would notify public health, assess household contacts, and assess the baby for infection."^[5]
• "The systematic review of 1160 cases found endometritis in 45.9%, bacteraemia in 49.0%, puerperal sepsis in 28.2% progressing to toxic shock in about a third, and an overall case fatality of 2.0%. The organism is uncommon but it is the one that kills."^[5]

Probe 4 — "She is terrified and her partner is at the bedside."

Communication is a scored domain: ^[2]

• Move to her eye level, use her name, and say plainly: "You have an infection after the birth, and it is making you more unwell than we would like. We have a team here. We are giving you antibiotics and fluids through a drip, and we are looking for the source. I will keep telling you what is happening."
• Allocate a staff member to support the partner, avoid jargon, and commit to a debrief afterwards. Silence at the bedside while the medicine is perfect still costs marks.^[2]