EHPLE Midwifery cheat sheet

Naegele's rule: estimated due date = first day of last menstrual period + 280 days (9 months + 7 days); adjust for cycle length by adding (cycle length − 28) days.

Fundal height in centimetres approximates gestational age in weeks from 20-36 weeks; a single measurement 3 cm or more below gestational age warrants ultrasound assessment for growth restriction or oligohydramnios.

Fetal heart rate is audible with a hand-held Doppler from about 10-12 weeks and with a Pinard stethoscope from about 20 weeks; normal baseline is 110-160 beats per minute.

Routine antenatal schedule commonly includes booking visit by 10 weeks, then visits at roughly 16, 25, 28, 31, 34, 36, 38 and 40 weeks, with increased frequency if risk factors are present.

Physiological changes of pregnancy: plasma volume rises 40-50% by 32 weeks, cardiac output rises 30-50%, haemoglobin falls by dilution (physiological anaemia), and blood pressure normally falls in the second trimester.

Hyperemesis gravidarum is diagnosed by persistent vomiting plus weight loss over 5%, dehydration and electrolyte disturbance; ketonuria and hypokalaemia are common and admission for intravenous fluids and antiemetics is indicated.

Dating ultrasound at 11-14 weeks (crown-rump length) is the most accurate method for estimating gestational age; first-trimester crown-rump length predicts dates within about 5-7 days.

Screening for gestational diabetes with a 75 g oral glucose tolerance test is offered at 24-28 weeks; thresholds commonly used are fasting 5.1 mmol/L, 1-hour 10.0 mmol/L, 2-hour 8.5 mmol/L.

Rhesus-negative unsensitised women receive anti-D immunoglobulin at around 28 weeks and within 72 hours of delivery of a Rh-positive baby, plus after any potentially sensitising event such as amniocentesis or antepartum haemorrhage.

First stage of labour: regular painful contractions with progressive cervical dilatation; active first stage is defined as dilatation from 5 cm to 10 cm, with slower progress than 0.5 cm per hour over 4 hours prompting reassessment.

Second stage: full dilatation to birth of the baby; passive second stage lasts until the woman feels an urge to push, active second stage until birth; nulliparous active second stage typically lasts up to 2 hours, parous up to 1 hour.

Third stage: birth of the baby to expulsion of the placenta; active management uses a prophylactic uterotonic (commonly 10 IU oxytocin intramuscularly), controlled cord traction and uterine tone assessment.

Cardiotocography baseline classification: normal 110-160 bpm, bradycardia below 110, tachycardia above 160; variability normal 5-25 bpm, reduced below 5, increased above 25 for over 25 minutes.

Decelerations: early decelerations mirror contractions and are benign head compression; variable decelerations indicate cord compression; late decelerations begin after the contraction peak and suggest uteroplacental insufficiency.

Sinusoidal pattern is a smooth undulating baseline of 5-15 bpm without accelerations, associated with fetal anaemia; it requires urgent escalation and further investigation.

A prolonged deceleration lasts more than 3 minutes; a deceleration lasting more than 15 minutes is classified as a baseline change and mandates emergency review.

Partogram use: plot cervical dilatation, descent, contractions, fetal heart rate and maternal observations; alert line and action line guide transfer or intervention decisions.

Uterine hyperstimulation with oxytocin (more than 5 contractions in 10 minutes averaged over 30 minutes) requires stopping or reducing the infusion, left lateral position and consideration of tocolysis.

Involution of the uterus: fundus is palpable at the umbilicus immediately after birth, descends about 1 cm per day, and is no longer abdominally palpable by 10-14 days.

Lochia: rubra (red) days 1-4, serosa (pink-brown) days 4-10, alba (white-yellow) up to 4-6 weeks; offensive odour, fever or return to rubra suggests infection or retained products.

Primary postpartum haemorrhage is blood loss of 500 mL or more within 24 hours of birth (1000 mL or more after caesarean); secondary PPH occurs from 24 hours to 12 weeks.

Secondary postpartum haemorrhage is most often caused by retained placental tissue or endometritis; ultrasound and antibiotics with possible surgical evacuation are the usual pathway.

Breastfeeding initiation within the first hour and frequent feeding (8-12 times in 24 hours) support establishment of supply; colostrum is produced in small volumes and is sufficient for a term newborn.

Milk 'coming in' occurs around 48-72 hours postpartum under the influence of falling progesterone and rising prolactin; engorgement peaks around days 3-5.

Mastitis presents with a tender red breast, fever above 38.5 C and flu-like symptoms; continued effective milk removal plus appropriate antibiotics (commonly flucloxacillin) is recommended, and feeding from the affected breast may continue.

Postpartum haemorrhage resuscitation follows a structured approach: call for help, assess airway, breathing and circulation, uterine massage, uterotonics (oxytocin, ergometrine, carboprost, misoprostol), tranexamic acid 1 g intravenously within 3 hours of birth, and fluid or blood replacement.

Thromboembolism risk is highest in the first 6 weeks postpartum; a woman with unilateral leg swelling, chest pain or breathlessness needs urgent assessment for deep vein thrombosis or pulmonary embolism.

Apgar score is assessed at 1 and 5 minutes across five components (appearance, pulse, grimace, activity, respiration), each scored 0-2; it is a measure of condition and response to resuscitation, not a predictor of outcome.

Normal newborn observations: respiratory rate 30-60 breaths per minute, heart rate 100-160 bpm awake, axillary temperature 36.5-37.5 C, and capillary refill under 3 seconds.

Newborn resuscitation sequence: dry and stimulate, assess tone, breathing and heart rate, open the airway with a neutral position, give five inflation breaths if not breathing, then ventilate at 30-60 breaths per minute if heart rate remains below 100.

Chest compressions in the newborn are indicated when heart rate is below 60 bpm despite effective ventilation; use a 3:1 compression-to-ventilation ratio at 120 events per minute.

Newborn physiological jaundice appears after 24 hours, peaks around days 3-5 and resolves by 14 days; jaundice within the first 24 hours is always pathological and needs urgent investigation.

Bilirubin thresholds for phototherapy and exchange transfusion are plotted against gestational age and hours of life; risk factors include prematurity, haemolysis, sepsis and exclusive breastfeeding with inadequate intake.

Newborn bloodspot screening is taken on day 5 (acceptable from day 5 to day 8) and covers conditions including congenital hypothyroidism, phenylketonuria, cystic fibrosis, sickle cell disease and medium-chain acyl-CoA dehydrogenase deficiency.

Vitamin K is offered to all newborns: a single intramuscular dose of 1 mg for term babies, or an oral regimen of three doses, to prevent vitamin K deficiency bleeding.

Newborn examination includes checking red reflex, hips for developmental dysplasia (Ortolani and Barlow manoeuvres), palate, spine, anus, pulses and femoral arteries, and counting digits.

Pre-eclampsia: new hypertension (140/90 mmHg or above) after 20 weeks plus proteinuria or other maternal organ dysfunction; severe features include blood pressure 160/110 or above, symptoms and abnormal liver or renal results.

Magnesium sulfate is the treatment of choice for eclampsia and severe pre-eclampsia; monitor respiratory rate, deep tendon reflexes and urine output, with calcium gluconate as the antidote for toxicity.

Antepartum haemorrhage: placenta praevia causes painless bright-red bleeding; placental abruption causes painful bleeding with a tense uterus and may be concealed, so estimated loss can underestimate true loss.

Vasa praevia presents with painless bleeding at membrane rupture with immediate fetal compromise; fetal blood loss is small in volume but catastrophic, and immediate caesarean birth is required.

Shoulder dystocia: call for help, perform McRoberts manoeuvre with suprapubic pressure, then consider internal manoeuvres (Wood's screw, Rubin II) and delivery of the posterior arm; never apply fundal pressure.

Cord prolapse: recognise from visible cord or sudden fetal bradycardia after membrane rupture, call for emergency help, elevate the presenting part, position the woman knee-chest or Trendelenburg and prepare for immediate birth.

Preterm labour before 34 weeks: antenatal corticosteroids (betamethasone) accelerate fetal lung maturity, magnesium sulfate provides neuroprotection before 32 weeks, and tocolysis buys time for steroids and transfer.

Gestational diabetes is managed with diet and exercise first, then metformin or insulin if targets are not met; targets are commonly fasting below 5.3 mmol/L and 1-hour postprandial below 7.8 mmol/L.

Uterine rupture is suggested by sudden severe abdominal pain, loss of contraction pattern, fetal heart rate abnormality and vaginal bleeding; it requires immediate laparotomy and delivery.

Oxytocin is used for induction and augmentation of labour and for prevention of postpartum haemorrhage; it is a high-alert medicine requiring controlled infusion rates and continuous fetal monitoring during use.

Ergometrine is contraindicated in hypertension and pre-eclampsia because it causes vasoconstriction; it is also avoided in heart disease and should not be given before delivery of the baby.

Carboprost (prostaglandin F2-alpha) is contraindicated in asthma; misoprostol is used for postpartum haemorrhage where other uterotonics are unavailable or ineffective.

Tranexamic acid 1 g intravenously is given within 3 hours of birth for postpartum haemorrhage and is not a substitute for uterotonics or surgical measures.

Anti-D immunoglobulin dose is guided by the size of fetomaternal haemorrhage, assessed with a Kleihauer test; a standard antenatal dose of 1500 IU covers most routine indications.

Magnesium sulfate toxicity presents with loss of deep tendon reflexes, respiratory depression and oliguria; calcium gluconate 10% is the antidote and should be immediately available.

Drugs contraindicated or avoided in breastfeeding include codeine (CYP2D6 ultrarapid metaboliser risk in the infant) and combined hormonal contraception in the first 6 weeks postpartum for women at risk of venous thromboembolism.

Pharmacokinetics change in pregnancy: increased plasma volume and hepatic clearance lower plasma concentrations of some drugs, while gastric emptying is delayed; dose adjustment may be required.

Prescribing in midwifery requires checking the British National Formulary or equivalent, confirming allergies, gestation and breastfeeding status, and recording the indication and any counselling given.

Valid consent requires capacity, sufficient information and voluntariness; a competent pregnant woman may refuse any intervention, including caesarean birth, even if the fetus may be harmed.

The Mental Capacity Act framework presumes capacity, supports decision-making, and requires best-interests decisions where capacity is lacking; advance decisions to refuse treatment are legally binding if valid and applicable.

Confidentiality may be broken only with consent, where required by law, or in the public interest to prevent serious harm; share information on a need-to-know basis and record the rationale.

Safeguarding: follow local safeguarding procedures, document objectively, and refer to children's social care where there are concerns about domestic abuse, substance misuse, or risk to the unborn or newborn baby.

Female genital mutilation is a criminal offence in the UK; mandatory reporting duties apply to regulated professionals when FGM is identified in a girl under 18.

Notifiable incidents include maternal death, serious incident requiring investigation, and certain infections; the midwife must report through the local risk management and incident reporting system.

Duty of candour requires openness with women and families when something has gone wrong, including an apology, explanation of what happened and what will be done to prevent recurrence.

Professional regulation requires practising within the scope of competence, maintaining a portfolio of continuing professional development, and escalating when a situation exceeds competence.

Folic acid 400 micrograms daily is recommended from 3 months before conception until 12 weeks of pregnancy; higher doses (5 mg) are used for women with diabetes, obesity, epilepsy medication or a previous neural tube defect.

Vitamin D supplementation of 10 micrograms daily is recommended for pregnant and breastfeeding women; the UK Healthy Start scheme provides vouchers for eligible families.

Alcohol: no safe level of alcohol consumption in pregnancy is established, so abstinence is advised; smoking cessation support should be offered at every antenatal contact.

Contraception after birth: progestogen-only methods can be started immediately postpartum; combined hormonal contraception is generally deferred until 6 weeks postpartum in breastfeeding women and in those at risk of venous thromboembolism.

Lactational amenorrhoea method is effective only if all three criteria are met: exclusively breastfeeding, amenorrhoea, and less than 6 months postpartum.

Emergency contraception: levonorgestrel 1.5 mg is licensed up to 72 hours, ulipristal acetate 30 mg up to 120 hours, and a copper intrauterine device can be inserted up to 5 days after unprotected sex as the most effective option.

Cervical screening is offered from age 25 to 64 in the UK; during pregnancy a screening test can be performed but colposcopy is usually deferred until after birth unless cancer is suspected.

Sexual health: offer testing for chlamydia, gonorrhoea, HIV, syphilis and hepatitis B in pregnancy; untreated infection is associated with preterm birth, ophthalmia neonatorum and congenital infection.

Perinatal mental health: use validated tools such as the Edinburgh Postnatal Depression Scale; ask about mental health at booking and again at 4-6 weeks postpartum, and refer promptly when concerns arise.