History Taking · Intermediate · O&G

Postpartum Fever and Heavy Bleeding

Practise this PLAB 2 history taking station on Puerperal Sepsis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on the gynaecology ward. Mrs Joanne Coleman, a 36-year-old woman, was discharged from hospital three days post-vaginal delivery. She has presented to the emergency department with fever, abdominal pain, and heavy vaginal bleeding. Please take a focused history regarding her labour, delivery, and postpartum period, assess the severity of current symptoms, and discuss your initial management plan for suspected puerperal sepsis and endometritis.

Background notes: PMH: Generally healthy

What this station tests

  • Puerperal sepsis triad: fever, offensive lochia, uterine tenderness
  • Sepsis Six within 1 hour: blood cultures, IV antibiotics, fluids, lactate, urine output, oxygen
  • USS to exclude retained products of conception: commonest cause of postpartum endometritis
  • Breastfeeding can continue on most IV antibiotics: important reassurance for the mother
  • Risk factors: prolonged labour, PROM, instrumental delivery, manual removal of placenta

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Postpartum fever is puerperal sepsis until proven otherwise. Maternal sepsis remains a leading cause of maternal death in the UK. Mrs Coleman is 36, day 5 post-vaginal delivery, readmitted with fever, heavy bleeding, and offensive lochia. Open with: 'Mrs Coleman, I can see you are quite unwell. Tell me what has happened since you went home, and I am going to start treating you while we talk.'

Core approach

Recognise the sepsis presentation. Fever (38.5C), tachycardia, offensive lochia (foul-smelling discharge), heavy vaginal bleeding, uterine tenderness on palpation, feeling generally unwell. This triad of fever, offensive lochia, and uterine tenderness is postpartum endometritis/puerperal sepsis.

Risk factors: prolonged labour, prolonged rupture of membranes (ask), instrumental delivery, manual removal of placenta, retained products of conception. Ask about her delivery details.

Assess severity using the Sepsis Six pathway. NEWS score. Lactate. Blood cultures before antibiotics. Is she haemodynamically stable? Any signs of severe sepsis (hypotension, confusion, oliguria)?

She is worried about her baby (at home with her husband). She feels guilty about being readmitted. Address breastfeeding: she can continue breastfeeding on most IV antibiotics used for puerperal sepsis.

Closing and safety netting

Immediate management: Sepsis Six within 1 hour. Blood cultures, IV antibiotics (broad-spectrum, typically IV co-amoxiclav plus metronidazole or piperacillin-tazobactam per local protocol), IV fluids, lactate, urine output monitoring, high-flow oxygen if needed. USS to exclude retained products (commonest cause of postpartum endometritis). If retained products: surgical evacuation.

Reassure about breastfeeding: most IV antibiotics used are safe during breastfeeding. Arrange for the baby to visit or for her to express milk. Safety net: she is admitted with monitoring. Follow-up with obstetric team.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for puerperal sepsis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Sepsis recognised. Delivery risk factors obtained. Severity assessed (NEWS, lactate). USS planned for retained products.

Costs marks: Not recognising sepsis. Not asking about delivery. Not assessing severity.

Domain 2 (Primary focus)

Scores well: Sepsis Six initiated. Broad-spectrum IV antibiotics. USS for retained products. Breastfeeding advice. Monitoring plan.

Costs marks: Delayed antibiotics. No USS. Not addressing breastfeeding.

Domain 3 (Throughout)

Scores well: Addressing guilt about readmission. Reassuring about breastfeeding. Arranging baby visits. Explaining the treatment plan.

Costs marks: Not addressing baby concern. Not reassuring about breastfeeding.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not treating as sepsis: postpartum fever with offensive lochia is an emergency, not a routine infection
  2. Not performing USS for retained products: this is the commonest treatable cause
  3. Not addressing breastfeeding: the mother's primary concern alongside her own health

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the puerperal sepsis history in this PLAB 2 station?

Postpartum fever is puerperal sepsis until proven otherwise. Maternal sepsis remains a leading cause of maternal death in the UK. Mrs Coleman is 36, day 5 post-vaginal delivery, readmitted with fever, heavy bleeding, and offensive lochia.

What are examiners marking in this puerperal sepsis station?

Marks are won for: Sepsis recognised. Delivery risk factors obtained. Severity assessed (NEWS, lactate). USS planned for retained products. Marks are lost for: Not recognising sepsis. Not asking about delivery. Not assessing severity.

What is the most common mistake candidates make in this puerperal sepsis station?

Not treating as sepsis: postpartum fever with offensive lochia is an emergency, not a routine infection.

How do I prepare for this station if I have not managed puerperal sepsis in clinical practice?

Structure beats experience here. Focus on sepsis Six within 1 hour: blood cultures, IV antibiotics, fluids, lactate, urine output, oxygen. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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