Consultant Obstetrics & Gynecology oral assessment prep

Knowledge: This is a category three or pathological trace with absent variability and recurrent late decelerations in a woman on oxytocin, and the combination with thick meconium means I should assume significant fetal compromise and plan to deliver within minutes rather than continuing to observe.

Management: While preparing to deliver I would institute intrauterine resuscitation: stop the oxytocin, position her in the left lateral, give a fluid bolus if she is hypotensive, treat hypotension with a vasopressor with my anaesthetist, and consider acute tocolysis with terbutaline 250 micrograms subcutaneously if there is uterine hypertonus. I would call for the neonatal team, the anaesthetist and a second midwife, and inform theatre.

Ethics and communication: Taking over from the resident must be done in a way that is safe for the patient and preserves the trainee: I would step in decisively and explain to the woman who I am and what I am recommending, but I would avoid criticising the resident in front of her, and I would debrief privately afterwards to teach rather than blame.

Reference: NICE NG229, Fetal Monitoring in Labour (2022); RCOG Green-top Guideline No. 26, Assisted Vaginal Birth (2020); ACOG Practice Bulletin No. 219, Operative Vaginal Birth (2020)

Knowledge: This is severe and arguably critical ovarian hyperstimulation syndrome. She has all the high-risk features: polycystic ovary syndrome, a very high oocyte yield, and a fresh transfer, which means that if she has conceived the syndrome will be prolonged and worsened by endogenous hCG, giving a late-onset picture at around day eight to ten.

Management: I would admit her, ideally to a high-dependency setting, with hourly urine output via catheter, daily weight and abdominal girth, and serial haematocrit, electrolytes, creatinine, liver function, albumin and coagulation. Fluid management is judicious intravenous crystalloid to restore intravascular volume with human albumin as a colloid when she is hypoalbuminaemic and oliguric, avoiding diuretics until she is intravascularly replete because they will worsen haemoconcentration and thrombotic risk.

Ethics and communication: Severe hyperstimulation after a fresh transfer in a woman with polycystic ovaries and 29 oocytes raises a legitimate question about whether the risk was adequately mitigated, and I would address that honestly rather than defensively, even though the treating unit may be a private clinic with a commercial interest in the cycle.

Reference: RCOG Green-top Guideline No. 5, The Management of Ovarian Hyperstimulation Syndrome (2016); ESHRE Guideline on Ovarian Stimulation for IVF/ICSI (2019, updated 2023)

Knowledge: Clinically this is advanced, probably stage IIIC or IV, high-grade serous ovarian carcinoma, and the two management questions are whether she should have primary debulking surgery or neoadjuvant chemotherapy with interval debulking, and what her fitness and disease distribution allow.

Management: I would arrange discussion at the gynaecological oncology multidisciplinary meeting with review of the CT, cytology and CA-125, assess her performance status, nutritional state and comorbidity, drain the pleural effusion if symptomatic and send it for cytology as it affects staging, and consider a diagnostic laparoscopy with a scoring system such as the Fagotti score to judge resectability.

Ethics and communication: I would meet the family respectfully, acknowledge their motive, and not confront them as adversaries, because a hostile first meeting makes everything harder. I would explain that I cannot promise to withhold the diagnosis from their mother, because it is her information, but that I can promise something else that is genuinely reassuring: I will not force information on her.

Reference: ESMO-ESGO Consensus Conference Recommendations on Ovarian Cancer (2019); NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer (2024); Baile et al., SPIKES: A Six-Step Protocol for Delivering Bad News, The Oncologist (2000)

Knowledge: The presenting request is contraception but the clinical problem is safeguarding. A 15-year-old in a sexual relationship with a 29-year-old, with secrecy imposed by the older partner, meets the recognised markers of child sexual exploitation and grooming: a significant age gap, a position of trust or family access, isolation from adults, and instruction to conceal, so this is not a consensual relationship between peers regardless of how she describes it.

Management: I would see her in a private room with a female chaperone, take a careful and non-judgemental history without repeated or forensic-style questioning, since detailed evidential interviewing is the role of the trained child protection team, and record her account in her own words.

Ethics and communication: The single most important thing is that I never promise confidentiality I cannot keep. Early in the consultation I would say that what she tells me is private, but that if I learn that she or another child is being harmed I have a legal duty to share that with people whose job is to protect her, and that I will tell her before I do it and explain exactly who I am telling and why.

Reference: WHO, Responding to Children and Adolescents Who Have Been Sexually Abused: Clinical Guidelines (2017); FSRH Clinical Guideline, Contraception for Young People Aged Under 25 (2019, amended 2023); UAE Federal Law No. 3 of 2016 on Child Rights (Wadeema Law), mandatory reporting duties