Midwifery Exam: Antepartum Care

Antepartum Care tests whether you can build and then adjust a pregnancy dateline: dating, routine surveillance, risk-based screening, and counseling about results. Items cluster around timing - which test belongs at which gestational age - and around the next action after an abnormal value.

Establishing the dateline

• Crown–rump length at 7 0/7–13 6/7 weeks is the most accurate dating parameter (about ±5–7 days); a first-trimester scan outranks later head circumference and biparietal diameter when they disagree.
• ACOG's schedule for an uncomplicated pregnancy: every 4 weeks to 28 weeks, every 2 weeks to 36 weeks, then weekly until birth.
• From 28 weeks, teach fetal movement awareness; formal daily kick counts are not required for all pregnancies.

Routine screening and its windows

• First visit: CBC, blood type and antibody screen, rubella and varicella immunity, syphilis, HIV, hepatitis B, urinalysis, and chlamydia/gonorrhea when indicated.
• From about 10 weeks: cell-free DNA is a screening test, not diagnostic; chorionic villus sampling 10–13 weeks; amniocentesis at 15 weeks or later.
• 18 0/7–22 0/7 weeks: anatomy survey.
• 24–28 weeks: gestational diabetes screening - two-step 50 g glucose challenge (threshold 130–140 mg/dL), then a 100 g 3-hour test read with Carpenter–Coustan values (95/180/155/140 mg/dL).
• 27–36 weeks: Tdap every pregnancy; influenza vaccine in season.
• 28 weeks: 300 mcg Rh(D) immune globulin if Rh-negative and unsensitized.
• 36 0/7–37 6/7 weeks: group B streptococcus culture.
• 81 mg aspirin daily, started 12–16 weeks, for a high-risk preeclampsia profile.

Worked example

A 29-year-old G2P1001 is Rh-negative with a negative antibody screen at 24 weeks and returns at 28 weeks. The action is to give 300 mcg RhIg now - not to repeat the antibody screen and wait. Reasoning: antenatal prophylaxis covers the third trimester, when fetomaternal hemorrhage risk climbs; after birth, a second dose is indicated within 72 hours if the newborn is Rh-positive, and a weak-D result never justifies withholding prophylaxis.

Traps

• Ordering RhIg when the antibody screen is positive; immunoglobulin does not reverse sensitization.
• Using a 75 g one-step test and then applying Carpenter–Coustan thresholds, which belong to the 100 g test.
• Treating a positive cell-free DNA or quad screen as diagnostic.
• Missing that Tdap is repeated in every pregnancy, not once per lifetime.
• Screening everyone for GDM at 16 weeks instead of reserving early testing for people with risk factors.

Intrapartum Care

Intrapartum Care tests your ability to read labor progress against modern definitions and to interpret fetal heart tracings into an action. Two frameworks carry most of the marks: the ACOG/SMFM labor-arrest definitions and the 2008 NICHD three-tier fetal heart rate system.

Labor progress

• Latent phase extends to 6 cm and may be prolonged, especially in nulliparas; active phase begins at 6 cm.
• Active-phase arrest: cervix at least 6 cm, ruptured membranes, and no cervical change after 4 hours of adequate contractions or 6 hours of inadequate contractions.
• Second-stage limits: nullipara 3 hours (4 with epidural), multipara 2 hours (3 with epidural).

Fetal heart rate interpretation

• Describe baseline rate, variability, accelerations, and decelerations before assigning a category.
• Category I: baseline 110–160, moderate variability, accelerations, no late or variable decelerations - no intervention.
• Category III: absent variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern - expeditious delivery.
• Recurrent variable decelerations: maternal repositioning, intravenous fluid, amnioinfusion, and evaluation for cord prolapse.
• Recurrent late decelerations: reposition, fluid bolus, stop oxytocin, and give terbutaline for tachysystole (more than 5 contractions in 10 minutes averaged over 30 minutes). Routine oxygen for Category II tracings is no longer recommended.

Worked example

A laboring patient on oxytocin has six contractions in 10 minutes with late decelerations after each, moderate variability preserved. Reasoning: this is tachysystole with recurrent late decelerations, a Category II tracing with a clear iatrogenic cause. Stop the oxytocin, place her left lateral, give a 500–1000 mL crystalloid bolus, and give terbutaline 250 mcg subcutaneously if the pattern persists. Resume oxytocin only at a lower rate once the tracing is reassuring; absent improvement, move to Category III management.

Traps

• Calling variable decelerations late; the timing relative to the contraction, not the depth, defines the type.
• Treating a Category I tracing with unnecessary intervention.
• Using oxygen as a reflex for every Category II tracing.
• Pushing before full dilation in a nullipara because the patient feels pressure.
• Quoting older 4 cm active-phase and 2-hour second-stage rules.

Postpartum Care

Postpartum Care tests the first hour after birth - where most maternal deaths are preventable - and the six weeks that follow. Expect quantitative blood loss, staged uterotonics, postpartum hypertension, and the visit schedule.

Postpartum hemorrhage

• Measure cumulative blood loss; 1000 mL or any loss with hemodynamic instability defines hemorrhage.
• Stepwise response: uterine massage, empty the bladder, inspect for lacerations and retained placenta, then uterotonics.
• Oxytocin 10 IU IM, or 10–40 IU in 500–1000 mL crystalloid.
• Methylergonovine 0.2 mg IM every 2–4 hours - contraindicated in hypertension and preeclampsia.
• Carboprost 250 mcg IM every 15 minutes, maximum 2 mg - contraindicated in asthma.
• Misoprostol 600–1000 mcg sublingual or rectally when injectables are unavailable or fail.
• Tranexamic acid 1 g IV within 3 hours of birth, repeatable once after 30 minutes.

Postpartum hypertension

• Blood pressure of 140/90 or higher after 20 weeks through 6 weeks postpartum needs evaluation; 160/110 or higher is an emergency treated with magnesium sulfate plus labetalol or nifedipine.
• Late postpartum preeclampsia and eclampsia can present after discharge, often with headache or visual change.

Follow-up and prevention

• ACOG recommends contact within 3 weeks and a comprehensive visit by 12 weeks.
• Screen for depression with the Edinburgh Postnatal Depression Scale; discuss contraception.
• Give MMR or varicella vaccine postpartum if nonimmune; complete RhIg within 72 hours if indicated; repeat a glucose tolerance test 4–12 weeks after gestational diabetes.

Worked example

Thirty minutes after a spontaneous vaginal birth the fundus is boggy, blood loss is 700 mL and rising, and the patient is normotensive. Reasoning: start uterine massage and oxytocin 10 IU IM, empty the bladder, and inspect the genital tract. If bleeding continues, methylergonovine 0.2 mg IM is appropriate because she is normotensive; add tranexamic acid now rather than after 3 hours, when its benefit falls away.

Traps

• Giving methylergonovine to a patient with preeclampsia.
• Giving carboprost to a patient with asthma.
• Estimating blood loss visually instead of weighing.
• Discharging a patient with a blood pressure of 155/105 without a plan.

Newborn Care

Newborn Care tests the first hours and days of transition: resuscitation readiness, prophylactic care, screening windows, and the common metabolic problems that appear before discharge.

Transition and immediate care

• Dry, warm, stimulate, and assess; delayed cord clamping of at least 30–60 seconds applies to term and preterm infants who do not need immediate resuscitation.
• Apgar scoring covers heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 minutes. It documents status - it never drives resuscitation, which begins on the basis of respirations, heart rate, and tone.

Prophylaxis and screening

• Vitamin K 0.5–1 mg IM within the first hour to prevent vitamin K deficiency bleeding.
• Erythromycin 0.5% ophthalmic ointment to both eyes for gonococcal prophylaxis.
• Hepatitis B vaccine within 24 hours of birth.
• Newborn bloodspot screening at 24–48 hours, after feeding; hearing screen; pulse oximetry screening for critical congenital heart disease after 24 hours.

Common problems

• Hypoglycemia: screen at-risk infants (infant of a diabetic mother, large or small for gestational age, preterm, late preterm) before feeds. Values below 40 mg/dL in the first 4 hours, or below 45 mg/dL thereafter, prompt feeding and a recheck in 30–60 minutes; symptomatic or very low values need intravenous dextrose.
• Jaundice within the first 24 hours is always pathologic. Plot total bilirubin against age in hours and treat by threshold; check a direct fraction when jaundice persists.
• Group B streptococcus prophylaxis: penicillin G 5 million units IV, then 2.5–3 million units every 4 hours until birth; cefazolin for non-anaphylactic penicillin allergy.

Worked example

A term infant of a diabetic mother has a heel-stick glucose of 32 mg/dL at 2 hours of age, is alert, and feeds well. Reasoning: this is asymptomatic hypoglycemia in a at-risk infant. Feed and recheck in 30–60 minutes rather than starting intravenous dextrose immediately; reserve IV therapy for symptomatic infants, values under 25 mg/dL, or persistent failure of feeding to raise glucose.

Traps

• Using the Apgar score to decide whether to resuscitate.
• Withholding vitamin K pending parental consent discussion that never happens.
• Ignoring a bilirubin drawn at 18 hours because the value looks low.
• Deferring pulse oximetry screening to the outpatient visit.

Gynecologic and Reproductive Health

This domain tests well-woman prevention and the office problems that fill a midwifery panel: cervical and breast screening intervals, sexually transmitted infection testing, contraception selection against the medical eligibility criteria, and abnormal bleeding.

Screening intervals

• Cervical cancer screening starts at 21. Ages 21–29: cytology every 3 years. Ages 30–65: co-testing every 5 years or cytology every 3 years. Stop at 65 after adequate prior negative screening.
• Management follows risk, not reflex colposcopy: ASC-US with negative HPV returns in 3 years; HPV-positive results escalate.
• Breast screening: the USPSTF recommends biennial mammography from 40 to 74; ACOG recommends starting at 40 with annual or biennial intervals through shared decision-making. Know both and say which you are citing.
• Chlamydia and gonorrhea annually for sexually active people 24 and younger, and for older people with risk factors; HIV screening at least once from 15 to 65; syphilis according to risk.
• Bone density testing at 65, or earlier with risk factors.

Contraception

• Long-acting reversible methods are first-line for adolescents and nulliparas.
• Combined hormonal contraception is contraindicated with migraine with aura, smoking at 35 or older, a history of venous thromboembolism, breast cancer, and uncontrolled hypertension.

Abnormal uterine bleeding

• Use PALM-COEIN: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified.
• Any postmenopausal bleeding warrants endometrial sampling.

Worked example

A 33-year-old has ASC-US cytology with a negative HPV test. Reasoning: this combination carries low immediate risk, so repeat co-testing in 3 years is correct. Colposcopy would be overtreatment, and returning in 1 year reflects older algorithms superseded by risk-based management.

Traps

• Performing cervical cytology on someone under 21.
• Treating asymptomatic bacterial vaginosis found incidentally.
• Missing endometrial biopsy in postmenopausal bleeding.
• Prescribing combined pills to a patient with migraine with aura.

Primary Care

Primary Care tests the general medical care a midwife provides across the lifespan and, especially, how common conditions change in pregnancy. The recurring question is which drug or threshold is safe before, during, and after pregnancy.

Chronic disease

• Chronic hypertension in pregnancy is defined as 140/90 or higher. Stop ACE inhibitors and angiotensin receptor blockers before conception; use labetalol or nifedipine.
• Asthma: continue inhaled corticosteroids. Uncontrolled asthma harms the pregnancy more than the medication does; treat exacerbations aggressively.
• Diabetes: aim for an A1c below 6.5% before conception; folic acid 400 mcg daily, or 4 mg with a prior neural tube defect.

Common infections

• Urinary tract infection: cephalexin or amoxicillin are usual first-line choices in pregnancy. Nitrofurantoin is avoided at term and in G6PD deficiency. Pyelonephritis needs admission and intravenous therapy.
• Bacterial vaginosis: metronidazole 500 mg twice daily for 7 days.
• Avoid fluoroquinolones, doxycycline, and high-dose fluconazole in pregnancy.

Mental health and prevention

• Screen with the Edinburgh Postnatal Depression Scale or PHQ-9; untreated perinatal depression carries substantial risk, and sertraline is a common first choice in lactation.
• Vaccinate: influenza in season, Tdap each pregnancy, and RSV vaccine at 32–36 weeks in the seasonal window.
• Screen for intimate partner violence at intervals, privately.

Worked example

A patient at 38 weeks reports dysuria and frequency, and urine culture grows E. coli susceptible to nitrofurantoin. Reasoning: nitrofurantoin is avoided near term because of hemolytic anemia risk in the newborn, so treat with cephalexin guided by susceptibility, and obtain a test of cure. Asymptomatic bacteriuria in pregnancy is still treated, because it progresses to pyelonephritis.

Traps

• Continuing an ACE inhibitor into pregnancy.
• Dismissing asymptomatic bacteriuria as contamination in pregnancy.
• Stopping an SSRI abruptly at conception.
• Missing hypertension because you only act at 140/90 in the nonpregnant patient when the office threshold is 130/80.

Professional Practice and Health Systems

Professional Practice and Health Systems tests judgment outside the clinical algorithm: scope of practice, consultation and transfer, patient safety bundles, equity, documentation, and evidence appraisal. Items often present a clinically reasonable action that is professionally wrong - or a correct clinical action that is documented or communicated badly.

Scope, consultation, and transfer

• Know the difference between consultation (a colleague's opinion, with the midwife retaining management), collaboration (shared care), and transfer (care moves to another clinician).
• Scope is set by state law and institutional policy, not by comfort. Working outside it, even successfully, is a practice failure.
• Transfer decisions are made on trajectory, not on certainty: a Category III tracing, hemorrhage unresponsive to two uterotonics, or a patient at 34 weeks in preterm labor at a birth center all warrant transfer before deterioration.

Safety bundles and quality

• The AIM bundles standardize obstetric hemorrhage, severe hypertension, and sepsis response with checklists, quantification of blood loss, and read-back communication.
• Debriefs and event reporting are quality tools, not admissions of fault.

Equity and communication

• Use professional interpreters, not family members. Screen for implicit bias in pain assessment and offer of analgesia.
• Shared decision-making requires stating options, risks, benefits, and uncertainty, then documenting the patient's choice - including refusal.

Worked example

At a freestanding birth center, a patient at 8 cm develops a prolonged deceleration lasting 6 minutes. Reasoning: this is a Category III tracing. Call 911 or the collaborating hospital, start intrauterine resuscitation in transit, give a structured SBAR report - situation, background, assessment, recommendation - and document times, the tracing, and the receiving clinician. Waiting for spontaneous recovery consumes the window that made transfer worthwhile.

Traps

• Documenting a conversation after the fact as if it occurred earlier.
• Obtaining consent from a relative for a competent adult.
• Treating a safety debrief as a disciplinary hearing.
• Citing a guideline without naming the body or year, which makes the chart entry unchallengeable and unverifiable.