– not confirmed by fetal pH sampling
– fetal scalp blood pH < 7.1
– decision to Caesarean section intervals more than 60 minutes
●
Ruptured uterus
●
Failed forceps
●
Failed vacuum extraction
●
Combined forceps and vacuum extraction
166
RISK MANAGEMENT
●
Third- and fourth-degree tears
●
Intrapartum blood transfusion
●
Haemorrhage – intrapartum or postpartum
●
Retained placenta, retained placental tissue
●
Hb < 8.0 g or fall of 3 g
●
Wound breakdown – perineal or Caesarean section
●
Return to theatre
●
Maternal admission to ICU
●
Unexpected maternal pyrexia
●
Trauma to other internal organs
●
Fetal outcomes
●
Apgar score < 5 at 5 minutes
●
Unexpected admission to SCBU
●
Cord blood pH < 7.00
●
Undiagnosed fetal anomaly
●
Perinatal sepsis
●
Fetal trauma
●
Failed epidural
●
Failed to receive pain relief
●
Dural tap
●
Dural headache
●
Conversion to GA
●
Staffing problems
●
Failed to respond to bleep/unable to contact
●
Transfer problems
0
1
2
3
4
Global score
0
1
2
3
4
Totaclass="underline"
/20
167
This page intentionally left blank
Circuit C, Station 8
Twin pregnancy
Candidate’s instructions
Mrs Jarvis, gravida 2, para 1, books into the antenatal clinic under the care of your consultant. She has had a detailed scan at 20 weeks, which shows that she is expecting twins. She is thrilled about the situation and wants to discuss with you what to expect during the rest of the pregnancy and the possibility of a home birth.
YOU WILL BE MARKED ON YOUR ABILITY TO DISCUSS THE RISKS OF A TWIN PREGNANCY, AND THE PLAN FOR DELIVERY
You have 14 minutes.
169
CIRCUIT C
Examiner’s instructions
Say to the candidate: ‘Take me through what you would do in this situation.’
Prompt
‘Would you like any other information?’
Information available
●
32-year-old teacher, Caucasian
●
Normal pregnancy to date
●
Normal obstetric history – SVD 3.4 kg
●
PMSH normal, no medication and no allergies
●
Detailed scan suggest monozygotic twins with two amniotic sacs, otherwise no abnormality
●
Blood tests – O, Rh-positive, Hb 11.0 g
●
Rest of tests negative
170
TWIN PREGNANCY
Mark sheet
Asks for other information without prompt
0
1
Explanation of monozygosity
●
Needs to pick up on the monozygosity and its higher risk for the fetuses 0
1
Maternal risks
0
1
2
3
Fetal risks
●
Needs to cover minor symptoms due to size of uterus as well as the other risks of discordancy, acute polyhydramnios and twin-to-twin transfusion, hyper-tension, diabetes, premature labour
●
Risks to the babies of premature labour, RDS, hypothermia, hypoglycaemia, jaundice, infection etc.
●
Problems if very preterm
0
1
2
3
Intrapartum care
0
1
2
3
4
Postpartum care
0
1
2
Dealing with home delivery situation
0
1
2
Global score
0
1
2
3
4
Totaclass="underline"
/20
171
This page intentionally left blank
Circuit C, Station 9
Molar pregnancy – counselling
Candidate’s instructions
The patient you are about to see is Mrs Astride, who is 43 years old. She had an evacuation of uterus for what was thought to be a delayed miscarriage about 4
weeks ago. The histology has come back showing a complete hydatidiform mole.
She was under your consultant’s care 3 years ago when she had a Caesarean section for IUGR and PET; a live male infant was delivered at term. She is very concerned about having another child to provide a sibling for her son.
She is unaware of the histology report. You are asked to break the news to her and its implications. You are asked to discuss her further management.
MARKS WILL BE AWARDED FOR:
●
Explanation of the diagnosis
●
Implications and further management
You have 14 minutes.
173
CIRCUIT C
Role-player’s instructions
You are a 43-year-old social worker called Mrs Brenda Astride. You have one child who was delivered by Caesarean section 3 years ago because of blood pressure problems. He was a little on the small side and weighed 2.5 kg at term.
You are anxious to provide a brother or sister for him and so further fertility is very important to you.
You have recently had a miscarriage and have an inkling that all was not quite right. The doctor will break the news to you. You want to know why this happened.
Is there anything that you did to cause this, or anything you could have done to prevent it? What are the risks of it happening again and is there any chance of a further pregnancy? Would it be worth going for IVF?
174
MOLAR PREGNANCY – COUNSELLING
Mark sheet
●
Acknowledges pregnancy loss/bereavement aspect
●
Allows patient time to ask questions
0
1
2
●
Explains diagnosis
●
Explains the diagnosis of molar pregnancy correctly – 90 per cent have dupli-cation of haploid sperm XX and rest dispermic XY; female nuclear DNA is inactivated
●
Avoids jargon
0
1
2
3
4
●
Implications and further management
●
Further management needs to be discussed
●
Registration with trophoblastic service
●
Chest X-ray
●
Beta-HCG levels, urinary and length of follow-up
●
Length of follow-up, and contraceptive advice
0
1
2
3
4
5
Implications for future fertility
●
85 per cent have subsequent normal pregnancy
●
2 per cent risk of second mole, 20 per cent risk of third mole
●
Background risk of age re. pregnancy loss
●
May want to consider ovum donation
0
1
2
3
4
5
Global score
0
1
2
3
4
Total score:
/20
175
Circuit C, Station 10
Results interpretation
Candidate’s instructions
At this station you will be given a number of scenarios with the relevant results.
MARKS WILL BE AWARDED FOR DISCUSSING THE FOLLOWING WITH
THE EXAMINER:
●
Any further information you would like from the patient
●
The results, giving an explanation
●
The options for further management