Antenatally diagnosed fetal conditions: paediatric planning — branching viva

Station opening

Examiner: "The fetal echocardiogram confirms hypoplastic left heart syndrome with a normal karyotype. What is your planning role?" [1]

Strong candidate (must-hit)

• Confirms the diagnosis and judges it time-critical and ductal-dependent; the paediatrician's role is to translate the diagnosis into a postnatal plan — place, time and capability of delivery. [1] [2]
• Plans a cardiac-centre delivery with prostaglandin E1 ready from birth, and the staged surgical strategy with neurodevelopmental follow-up. [1] [19]

Weak candidate

• "That is cardiology; I will see the baby on the ward after surgery." [1]
• Memorises a prostaglandin dose but cannot say why timing matters or who briefs the team. [19]

Branch A — Why ductal-dependence drives everything

Examiner: "Why does this lesion become dangerous at birth, and why does that dictate where the baby is delivered?" [1]

Strong

• The systemic circulation depends on the ductus arteriosus; the duct closes within hours of birth in response to the rising oxygen, so without prostaglandin the circulation collapses. Antenatal diagnosis exists so delivery is planned at a cardiac-capable centre with prostaglandin running before closure. [1] [19]

Weak

• "It is a heart problem, so the baby needs a cardiologist eventually." [1]

Branch B — The resuscitation error in a different baby

Examiner: "A different fetus has a left congenital diaphragmatic hernia. The on-call team mask-ventilates at birth and the baby deteriorates. What went wrong?" [7]

Strong

• Mask ventilation inflates the intrathoracic stomach-bowel and worsens lung compression; the correct approach is early intubation with a gastric tube for decompression and gentle ventilation in a tertiary NICU that can manage pulmonary hypertension. The mechanism is pulmonary hypoplasia plus persistent pulmonary hypertension. [7]

Weak

• "They should have given more oxygen." [7]

Branch C — The EXIT scenario

Examiner: "Now a fetus has a large cervical lymphatic malformation predicted to obstruct the airway. What is the plan?" [2]

Strong

• Consider an EXIT procedure: secure the airway on placental support before cord division, with a coordinated obstetric, anaesthetic, airway and neonatal team briefed in advance. Planning is everything; the airway cannot wait for improvisation. [2]

Weak

• "Deliver normally and intubate if needed afterwards." [2]

Branch D — Gastroschisis versus omphalocele

Examiner: "How would you plan differently for gastroschisis and omphalocele?" [9]

Strong

• Gastroschisis is typically right-sided, has no covering sac and a normal cord, and is usually isolated; the plan is bowel protection, warmth, nil by mouth and surgical-team readiness. Omphalocele is midline, covered by a sac, and carries chromosomal and cardiac associations that widen the work-up; the two must never be planned identically. [9] [18]

Weak

• "They are both abdominal wall defects, so the plan is the same." [9] [18]

Branch E — The loop after birth

Examiner: "The baby is delivered and stabilised. As the paediatrician, what closes the loop?" [20]

Strong

• Coordinates developmental surveillance and the medical home: neurodevelopmental follow-up, growth and feeding, disease-specific reviews, a named owner and a safety-net. The loop does not close at discharge. [20]

Weak

• "Hand over to the surgeons and discharge when stable." [20]
• Offering a single prognostic narrative that ignores residual uncertainty and family values. [2]