Trauma in pregnancy — structured oral station (12 minutes)

Opening prompt — "Take me through your immediate management of this woman."

Model response — say it in this order: ^[1][4]

• "First I tilt her — 15 to 30 degrees left lateral tilt on the spinal board, or manual left uterine displacement, because she is over 20 weeks and the gravid uterus is compressing her inferior vena cava and aorta. That is the first modification."
• "I run the primary survey: airway with cervical spine control, pre-oxygenating and anticipating a difficult pregnant airway; breathing with high-flow oxygen; circulation with two large-bore cannulae and bloods including group and antibody screen and crossmatch."
• "Her heart rate of 116 with a narrowed pulse pressure is compensated shock — pregnancy lets her lose up to 1.5 L before her blood pressure drops. I activate the massive transfusion protocol early."
• "I treat her aggressively — maternal stabilisation is fetal resuscitation."^[1][4]

Examiner is listening for: tilt first, the modified primary survey, the masked-shock reasoning, mother-first. ^[4][10]

Probe 1 — "Her oxygen saturation is falling and her respiratory rate is 28. What is happening and what do you do?"

• "Pregnancy reduces functional residual capacity and raises oxygen consumption, so she desaturates fast. I pre-oxygenate fully and intubate early with a rapid-sequence induction and a smaller cuffed tube — the pregnant airway is oedematous, friable and anterior, and she is a full-stomach aspiration risk."
• "I have an experienced operator and a difficult-airway plan, including videolaryngoscopy if available."^[4]

Probe 2 — "She is stabilised. Describe your secondary survey and fetal assessment."

• "Obstetric abdomen: symphysis-fundal height, tenderness, tone, contractions, fetal lie and presentation, vaginal bleeding; speculum only after placenta praevia is excluded by ultrasound."
• "Continuous CTG from arrival for at least 4 hours, extended to 24 hours if any uterine activity, bleeding or abnormal trace — frequent contractions are the earliest sign of abruption."
• "Bedside FAST/eFAST ultrasound for free intraperitoneal fluid; proceed to contrast-enhanced CT where clinically indicated. Pregnancy is NOT a contraindication to indicated imaging."
• "FBC, coagulation with fibrinogen, crossmatch, U&E, LFTs, lactate; Kleihauer-Betke if she is RhD-negative."^[2][10]

Probe 3 — "Six hours later she develops uterine tenderness, frequent contractions and fresh bleeding. What is the diagnosis and what do you do?"

• "This is a placental abruption — uterine tenderness, frequent contractions and bleeding after trauma is classic, even when the original mechanism seemed minor."
• "I resuscitate: two large-bore cannulae, FBC, coagulation with fibrinogen (falls first in obstetric DIC), crossmatch 4 units, U&E; correct coagulopathy with fibrinogen replacement; keep her warm."
• "Continuous CTG. Plan delivery if maternal or fetal compromise, established labour, or uncontrolled coagulopathy. Vaginal birth is acceptable if both are stable; caesarean for fetal or maternal compromise."
• "Activate the major haemorrhage protocol and involve senior obstetric, anaesthetic and neonatal teams."^[2][9]

Probe 4 — "She suddenly collapses in pulseless electrical activity. Describe your resuscitation and the role of perimortem caesarean."

• "I call the cardiac arrest team, start high-quality CPR with her in left lateral tilt or with manual left uterine displacement — the gravid uterus impairs venous return in the supine position."
• "I address the reversible causes using the obstetric-modified 4 Hs and 4 Ts, including reversing magnesium toxicity with calcium gluconate if she is on magnesium."
• "I make the decision for perimortem caesarean within 4 minutes of the arrest and start the incision at that mark — she is at 30 weeks, well above the 20-week threshold. Emptying the uterus improves venous return and the effectiveness of chest compressions, so it is performed for her survival as much as the fetus's."
• "I continue resuscitation throughout and after delivery."^[1][3][4]

Probe 5 — "She recovers and is admitted. Her partner has been loud and has tried to answer every question on her behalf. What do you do?"

This is a scored communication and safeguarding domain. Demonstrate it out loud: ^[11][13]

• "I would ensure I speak to the woman alone, with the partner absent, and screen her for intimate partner violence using a validated tool such as HITS or HARK. IPV is a leading mechanism of trauma in pregnancy and is under-recognised."
• "If the screen is positive, I would conduct a structured safety assessment, involve social work, develop a documented safety plan, and offer referral to specialist IPV services. I would not discharge her to an unsafe environment."
• "I would make a mandatory report where legislation requires it, and consider child-protection notification if other children are at risk."
• "I would document the screen, the plan, and the actions."^[11][13]

Probe 6 — "She is RhD-negative. What is the role of the Kleihauer-Betke test?"

• "Trauma can cause fetomaternal haemorrhage — fetal red cells crossing into the maternal circulation — which sensitises the RhD-negative mother and can cause significant fetal anaemia."
• "I send a Kleihauer-Betke (or flow cytometry) to quantify the bleed, give standard prophylactic anti-D within 72 hours, and give additional anti-D if the fetomaternal bleed exceeds the volume covered by the standard dose."^[2][9]