Secondary postpartum haemorrhage — structured oral station (12 minutes)

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

Model response: ^[1]

• "This is secondary postpartum haemorrhage in a woman with the strongest risk factor — a previous primary PPH. The two commonest causes are retained products and endometritis, and in most women they coexist."
• "I would assess her observations and shock index — she may already be anaemic, so the same loss hits a smaller reserve. I would take bloods including FBC, group and hold, coagulation and CRP, start antibiotics covering aerobes and anaerobes, and examine her: speculum to quantify bleeding and look for tissue at the os, and bimanual for uterine size and tenderness."^[1]

Examiner is listening for: coexistence of the two common causes, antibiotics before theatre, and tissue-at-os removal with sponge forceps. ^[1]

Probe 1 — "Ultrasound shows an echogenic stripe of 9 mm. Do you take her to theatre?"

• "An echogenic stripe is frequently clot and decidua, not retained tissue. The finding I am looking for is an echogenic mass with colour Doppler flow. Even then, ultrasound is a rule-in test with a poor rule-out — in a modern cohort a 7 mm threshold gave a positive predictive value of about 75% and a negative predictive value of only about 50%."^[3]
• "So I would not operate on a stripe. I would treat her medically first — antibiotics and a uterotonic — because around 82% of women succeed without surgery, and retained products on ultrasound is the strongest predictor of failure."^[2]

Probe 2 — "She fails medical management and you consent her for evacuation. What do you tell her?"

• "I would name uterine perforation — in the classic series three of 132 women perforated, one needing hysterectomy — and Asherman syndrome, intrauterine adhesions that affect future fertility. I would also tell her that only a minority of evacuated women, about 37%, actually have retained tissue confirmed, so the operation is not always diagnostic."^[1]
• "Operatively I want a senior operator, ultrasound guidance, suction rather than sharp curettage, oxytocin and antibiotic cover — the infected two-week uterus is soft and thin, and that is where perforations happen."^[1]

Probe 3 — "She bleeds torrentially in theatre and the cavity looks empty. What are you thinking?"

• "Uterine artery pseudoaneurysm, until proven otherwise. It is a pressurised arterial lesion held in by clot — a curette will open it. I would stop, resuscitate, get Doppler on the table, and call interventional radiology for embolisation, which is effective and fertility-sparing."^[5]
• "If she has had two negative evacuations and is still bleeding, I would send a serum hCG before any third instrumentation — gestational trophoblastic neoplasia after a term birth is rare and missed precisely because nobody sends the hCG."^[5]

Probe 4 — "She is frightened and asks why this keeps happening."

Communication is a scored domain: ^[1]

• Move to her eye level, name the situation plainly: "You have had heavy bleeding after this birth. It is usually caused by a small piece of placenta that did not come away, with some infection. We are giving you antibiotics and, if needed, a small procedure to remove it. Most women get better with medicine alone. I will keep telling you what is happening."
• Acknowledge fear, commit to a follow-up plan, and ensure she is not sent home with unresolved bleeding — repeated presentations treated as new episodes is a systems failure, not her uterus.^[1]