Obstetrics and gynaecology asks its registrars to hold conversations that few other specialties do: with a woman who has just lost her baby, with a couple whose emergency caesarean was delayed, with a woman who refuses a treatment you believe her baby needs. Selection panels test these directly, with an assessor playing the woman and staying in role. This guide covers the scenarios that recur and how to handle each.
What the panel is listening for
Honesty without brutality. Silence allowed. Plain words. The woman's decision respected even when you disagree. The partner included. And a registrar who stays in the room.
The stillbirth
A woman has just had a stillbirth at 38 weeks. Begin the conversation with her and her partner.
There is no good way to do this and the panel knows it. SPIKES gives the shape. Sit down. Find out what they understand. A warning shot: "I am so sorry, I have something very hard to tell you." Then the truth in plain words, without euphemism: the baby has died. Then silence, for as long as they need. Do not fill it with explanations.
When they are ready, answer their questions honestly, including "why" with "we do not know yet, and we will try to find out". Explain what happens next: the birth, which they may not have thought about, the time with the baby, the choices about seeing and holding, the investigations that may explain it, the support available. Do not rush any of it. Say that you will be there and who else will be. Document, and return.
The probe: she asks whether it was her fault; he becomes angry; she asks for a caesarean. Each has an honest, gentle answer: almost never anyone's fault, and the investigations will help; anger is grief and you stay; vaginal birth is usually safer for her and you will talk it through.
The woman who wants a caesarean
A woman at 39 weeks wants a caesarean without a medical indication. Explore the reasons, which are often fear, a previous bad experience, or something she has read. Address the fear first. Give the evidence plainly: the risks and benefits of caesarean and vaginal birth for her and for future pregnancies. Offer what might help: a birth plan, an epidural, a meeting with the anaesthetist, a tour of the unit. If she still wants a caesarean after an informed discussion, say that her choice is respected and that you would involve the consultant and follow the hospital's policy on maternal request. The answer that fails is the one that argues.
The woman who refuses induction
Explore the reasons. Give the evidence for the recommendation and the risks of declining, plainly and without pressure. Offer alternatives and monitoring. Respect the decision, document the discussion, and keep the door open with a plan to review. Say that you would involve the consultant and that a woman with capacity has the right to decline.
The refused caesarean
A woman with capacity refuses a caesarean you believe is needed for the baby's safety. This is the hardest version of refusal, and the law is clear: a woman with capacity may decline treatment even if the baby is at risk. Confirm capacity, explore the reasons, explain the risks as clearly as you can, involve the consultant immediately and the anaesthetist and the paediatrician, offer alternatives, document, and respect the decision. Say that you would stay with her and support her whatever she decides.
The angry couple
A couple are angry about a delay in their emergency caesarean. Acknowledge first and genuinely. Listen to the whole complaint. Explain what happened without defending or blaming. Say what will happen now and what you will do about the delay: the incident report, the review, the consultant's conversation with them. Offer the complaints process. If the delay caused harm, open disclosure applies.
The miscarriage at the first scan
The warning shot, the truth, the silence, then the options for management explained without pressure, the acknowledgement that this is a loss however early, and the follow up.
Family violence
A woman discloses family violence in an antenatal visit. Believe her, ask about her safety and the children's, know the hospital's pathway and the social worker, and do not act beyond what she wants unless a child is at risk. Document carefully and know where the record can be seen.
Preparing
Practise each conversation aloud with someone who stays in role and pushes back. Record the stillbirth one; most registrars find they talk too much. Learn your state's law on capacity and refusal, maternal request caesarean policy, and the family violence pathway. These scenarios are where the panel finds out who you are.