Recovery after operative birth — structured oral station (12 minutes)

Opening prompt — "Take me through her post-caesarean management."

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

• "She had a category 2 caesarean under spinal with intrathecal morphine, BMI 47, blood loss 600 mL — high-risk for surgical site infection, VTE, and poor recovery. I would run the enhanced recovery after caesarean bundle with attention to dose adjustment for her weight."
• "Day 0: free fluids within 2 hours, catheter out within 6 to 12 hours once the block resolves, first mobilisation within 12 hours with assistance, scheduled paracetamol 1 g qid plus diclofenac 50 mg tds, with tramadol 50 mg every 4 h prn for breakthrough."
• "Thromboprophylaxis is weight-banded: enoxaparin 60 mg SC daily for BMI 50 to 70 — she is at 47, so 40 mg daily is appropriate; first dose at least 4 hours after the spinal block was placed. Duration 10 days."
• "Neuraxial morphine monitoring: respiratory rate and sedation score hourly for 24 hours, with naloxone available — per the SOAP consensus statement."^[5]

Examiner is listening for: bundle element with a dose, weight-banding recognition, neuraxial interval, and monitoring.^[2]

Probe 1 — "Her antibiotic was given before skin incision. Why does that matter?"

• "The Sullivan randomised trial and the Mackeen Cochrane review demonstrated that cefazolin given before skin incision approximately halves surgical site infection compared with administration at cord clamping. The standard dose is cefazolin 2 g IV, increased to 3 g if body weight exceeds 120 kg."^[4]
• "For this woman at BMI 47, weight likely exceeds 120 kg, so she should have received 3 g. I would check the dose given and document it."

Probe 2 — "It is now 18 hours after surgery and her respiratory rate is 10. What do you do?"

• "This is a red flag for delayed neuraxial opioid-induced ventilatory depression, which peaks at 6 to 12 and again at 12 to 24 hours after intrathecal morphine."^[5]
• "I would call the anaesthetist immediately, give naloxone 100 to 200 micrograms IV titrated to respiratory rate, and move to continuous monitoring. I would stop any additional opioid, review the multimodal regimen, and ensure naloxone is at the bedside until she is fully alert with a respiratory rate above 12."

Probe 3 — "Her pain on movement is 7 out of 10 despite scheduled paracetamol and diclofenac. What is your reading?"

• "Uncontrolled pain on day 1 predicts a longer stay, persistent opioid use, and a poorer recovery-quality score — it is a red flag, not a complaint."^[2]
• "I would rule out a surgical complication first: examine the wound and uterus, consider a wound haematoma or early endometritis, check the haemoglobin if there is any concern about concealed bleeding."
• "If the examination is reassuring, I would add regional adjuncts — transversus abdominis plane block if available — escalate opioid rescue to oral morphine 5 to 10 mg every 4 hours, and involve the acute pain service. I would set a clear analgesia review at 6 hours and a discharge only when pain is controlled on oral agents."

Probe 4 — "She is keen to breastfeed. Will any of your drugs interfere?"

• "Paracetamol and diclofenac are safe in breastfeeding at standard doses. Tramadol is safe in single doses. Codeine is contraindicated because of the ultra-rapid CYP2D6 metaboliser risk to the neonate — this is the classic trap."^[2]
• "Intrathecal morphine transfers minimally into breast milk at these doses; the benefit of effective analgesia outweighs the small exposure."

Probe 5 — "She wants to go home on day 2. What do you say?"

• "Discharge at 48 hours is appropriate if she meets every discharge criterion: afebrile for over 24 hours, pain controlled on oral analgesia, mobilising independently, voiding spontaneously, passing flatus, wound clean and dry, lochia normal."
• "And the safety criteria: thromboprophylaxis prescribed with her taught to self-inject, contraception plan documented, neonatal plan in place, follow-up booked, safety-net advice explained, and adequate social supports at home."
• "With a BMI of 47 I would also arrange a wound review in the community at day 5 to 7 because of her elevated surgical site infection risk."^[2]

Probe 6 — "Three weeks later she presents to ED with calf pain and dyspnoea. What happened?"

• "This is the VTE risk that persisted beyond her discharge. Despite appropriate 10-day thromboprophylaxis, she remained at elevated risk for several weeks."
• "Management: oxygen, empirical enoxaparin 1 mg/kg SC while awaiting imaging, Wells score, and CT pulmonary angiography — the modality of choice. D-dimer is unhelpful postnatally. If she is haemodynamically unstable, consider thrombolysis."^[2]