Retained placenta and manual removal — structured oral station (12 minutes)

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

Model response — say it in this order: ^[1][17]

• "This woman has an undelivered placenta at 35 minutes with 500 mL of ongoing blood loss. Bleeding overrides the clock — I am managing this as a postpartum haemorrhage with tissue as the cause."
• "I would call for help: consultant obstetrician, anaesthetist, midwifery coordinator. Two large-bore cannulae, bloods including fibrinogen and group and hold. Oxytocin 10 IU IM with an infusion, tranexamic acid 1 g IV over 10 minutes, catheterise, keep a running tally, and transfer to theatre now."^[1][17]

Examiner is listening for: the bleeding-override rule spoken out loud, parallel resuscitation, and a clear destination of theatre. ^[1]

Probe 1 — "The consultant asks whether you would try umbilical vein oxytocin first. What is the evidence?"

• "The Release trial — Lancet 2010, 577 women — randomised retained placenta to 50 IU oxytocin in saline versus placebo via the umbilical vein. Manual removal was needed in 61.3% versus 62.1%, relative risk 0.98. No effect."^[2]
• "I would not delay theatre for it. It is reasonable to try in a stable, non-bleeding woman because it is cheap and simple, but it is not a substitute for manual removal — and this woman is bleeding."^[2]

Probe 2 — "What about sublingual nitroglycerin to relax a constriction ring?"

• "The GOT-IT trial — PLoS Med 2019, 1107 women — gave 800 micrograms sublingual nitroglycerin versus placebo. Manual removal at 15 minutes was 93.3% versus 92.0%, odds ratio 1.01, no difference, and the nitroglycerin group had more palpitations — 9.8% versus 4.0%. The authors concluded it should not be used."^[6]
• "Adequate anaesthesia — a spinal or general — relaxes a ring far more reliably. Nitroglycerin is an adjunct at most, not a replacement for theatre."^[6]

Probe 3 — "Describe how you perform manual removal, and the one step that matters most."

• "In theatre: consent, regional or general anaesthesia, catheterise, lithotomy, uterotonics ready. One hand follows the cord through the cervix in a cone; the other hand holds the fundus externally to prevent pushing the uterus away or inverting it. Find the placental edge, develop the cleavage plane with the ulnar border of the hand in a sweeping motion, deliver the placenta whole, check it is complete, give a uterotonic and inspect the tract."^[1][8]
• "The step that matters most: if there is no plane, the cord tears, or bleeding becomes torrential — I stop. I leave the placenta in situ, call the most senior obstetrician and anaesthetist, and manage as suspected accreta. This woman has had a previous caesarean, so accreta is on my list. Continuing when there is no plane is how a survivable situation becomes a four-litre haemorrhage and a hysterectomy."^[18][1]

Probe 4 — "She is frightened and asks why she has to go to theatre. Her partner is with her."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name: "The placenta hasn't come out and you're bleeding a little more than we'd like. We need to take you to theatre to remove it safely, with proper pain relief. The team is here and I will explain everything as we go."
• Acknowledge the fear and the separation from her baby; allocate a staff member to support the partner; commit to a debrief afterwards.^[1]

Probe 5 — "What about antibiotics at manual removal?"

• "The honest answer is the evidence is thin. The 2024 Cochrane review found only four retrospective cohorts and could not draw firm conclusions. RANZCOG C-Gen 17 says there is insufficient evidence for or against prophylaxis, and leaves it to clinical judgement. Most units give a single broad-spectrum dose, and I would, but I would say the evidence is thin rather than strong."^[8]