Uterine rupture and scar dehiscence — structured oral station (12 minutes)

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

Model response — commit immediately: [1][4]

• "This is a uterine rupture until proven otherwise. Scarred uterus, oxytocin running, new pain through a working epidural, maternal tachycardia and a sustained fetal bradycardia — that is the picture."
• "First action: stop the oxytocin. Then declare the emergency and activate the massive obstetric haemorrhage protocol."
• "Call by name: obstetric consultant, anaesthetist, theatre coordinator, neonatal team, blood bank. Scribe and timekeeper. We are going to theatre now for a laparotomy."
• "Resuscitate on the way: high-flow oxygen, two large-bore cannulae, full blood count, coagulation with fibrinogen, crossmatch four to six units, urea and electrolytes, calcium and lactate, and tranexamic acid 1 g intravenously over 10 minutes."[1][5]

Examiner is listening for: the diagnosis named first, the oxytocin stopped first, and no diagnostic detour before theatre. [4]

Probe 1 — "The anaesthetist wants to top up her epidural for the pain. What do you say?"

• "No. Pain that breaks through a working epidural in a woman with a uterine scar is a red flag, not a top-up indication — it is deep visceral and peritoneal pain that a labour block does not cover."[3]
• "In the Dutch prospective national study, women whose rupture ended badly had more warning symptoms than those who did not: abdominal pain with an odds ratio of 3.34 and cardiotocograph abnormalities with an odds ratio of 9.94, and those signs were most often present 20 to 60 minutes before birth. Masking them is how we lose the hour we still have."[3]
• "I would ask her instead to prepare for a general anaesthetic and a major haemorrhage."[1]

Probe 2 — "You cannot get an ultrasound machine for four minutes. Do you wait?"

• "No. A normal scan never excludes rupture, and the laparotomy is the investigation. I would only use ultrasound if it were already at the bedside and delayed nothing — free intraperitoneal fluid or a fetus outside the cavity would be confirmatory, not permissive."[1]
• "The time argument is decisive: in the Norwegian national cohort of complete ruptures, time to delivery under 20 minutes gave the fewest intrapartum and infant deaths at 9.9%, and over 30 minutes versus under 20 minutes carried an odds ratio of 16.7 for death."[4]

Probe 3 — "At laparotomy the baby is in the abdomen. The defect runs from the old scar out to the left, there is bleeding from the uterine vessels, the loss is well over two litres and the fibrinogen has collapsed. What do you do?"

• "Deliver the baby and hand it over. Control the bleeding edges with clamps or compression, get a second experienced pair of hands scrubbed, and define the defect: size, site and every extension — lateral to the vessels, down to the cervix, forward to the bladder."[1][5]
• "Then I would make the decision out loud with my consultant: this is a hysterectomy. She is unstable, the defect extends laterally into the uterine vessels, and with a fibrinogen of 1.0 g/L further reconstruction will not outrun the coagulopathy."[5][6]
• "Temporising while we prepare: bilateral uterine artery ligation, internal iliac ligation if skilled help is present, pelvic packing, cell salvage. Transfuse to fibrinogen at or above 2 g/L and platelets above 50 x 10 to the 9 per litre, replace calcium, warm her actively."[5]
• "I would check the bladder and the ureters before and after, because a lateral lower-segment extension puts both at risk."[1]

Probe 4 — "When would you have repaired instead?"

• "Stable haemodynamics, a correctable coagulopathy, clean approximable edges confined to the lower segment, no extension into the cervix, broad ligament, uterine vessels or bladder, and a woman who wants future fertility. Then debride, secure the angles first, close in two layers with a delayed-absorbable suture and re-inspect."[1][6]
• "And I would be honest about the comparative evidence: in a nationwide study of 644 ruptures, 44.6% had repair and 55.4% hysterectomy, but the hysterectomy group was older, more comorbid and more often had impaired consciousness — so the outcome difference is confounded by indication, not proof that repair is better."[6]

Probe 5 — "Her uterus was preserved. She asks whether she can have another baby."

• "Yes, and the honest answer depends on where the rupture was. In the largest series of pregnancies after a previous complete rupture — 72 maternities — there were 3 new complete ruptures, 4.2%, and 6 uneventful partial ruptures."[7]
• "All three complete ruptures were preterm and in scars outside the lower segment. The recurrence rate was 0% where the previous rupture had been in the lower segment and 8.6% where it had been outside it. Hers was in the lower segment, which is the more favourable group."[7]
• "The plan is a planned caesarean before labour, in a unit with immediate theatre and blood, with a consultant present and clear instructions to come in early with any pain or bleeding."[1][7]
• "The hardest part is timing. In that series, corrected perinatal mortality was 1.3%, but 36.1% of babies were born before 37 weeks and most of that prematurity was iatrogenic — driven by our anxiety as much as hers. I would name that trade-off explicitly rather than pretend earlier is automatically safer."[7]

Probe 6 — "The partner asks how this was allowed to happen. He was told a VBAC was safe."

This is scored under rapport, respect and communication. Answer him, do not defend yourself. [1][8]

• Sit down, at eye level, and answer the question he actually asked: "The scar in her womb gave way during labour. That is a recognised risk of labouring after a caesarean — it is uncommon, but it is real, and it happened to her."
• Be specific without hiding behind numbers: "For a woman in her situation the risk was in the order of half a percent to one percent, and it is higher when labour is induced or augmented, as hers was. That should have been discussed and I will check what she was told and make sure you both have it in writing."[8]
• "Nothing about the way she was cared for tonight was unusual until she developed pain, and from that point we moved as fast as we can move."
• Commit to formal open disclosure, a written summary and a consultant follow-up appointment, and say when it will happen.[3]