Midwifery Licensing cheat sheet

Estimated date of delivery by Naegele's rule: first day of last menstrual period minus 3 months plus 7 days; confirm with first-trimester ultrasound, which is most accurate for dating (crown-rump length up to 13+6 weeks).

A pregnancy is post-term at 42+0 weeks; late-term is 41+0 to 41+6; term is 37+0 to 41+6; preterm is before 37+0; early term 37+0 to 38+6; full term 39+0 to 40+6.

Physiologic anemia of pregnancy: plasma volume rises about 40-50% versus red cell mass about 20-30%, so hemoglobin below 11.0 g/dL in first trimester or below 10.5 g/dL in second/third trimester defines anemia.

Screening schedule: 1-hour 50-g glucose challenge at 24-28 weeks; cell-free DNA or combined first-trimester screen from 10 weeks; anatomy scan at 18-22 weeks; group B streptococcus culture at 36+0 to 37+6 weeks.

RhD-negative unsensitized patients receive anti-D immune globulin at 28 weeks and within 72 hours of delivery of an RhD-positive infant, plus after abortion, ectopic, amniocentesis, or antepartum bleeding.

Blood pressure thresholds: chronic hypertension precedes 20 weeks or persists past 12 weeks postpartum; gestational hypertension arises after 20 weeks without proteinuria or organ dysfunction; preeclampsia adds proteinuria or maternal organ/uteroplacental dysfunction.

Fetal heart rate baseline is 110-160 beats per minute; accelerations are at least 15 bpm for 15 seconds (10 bpm for 10 seconds before 32 weeks); a reactive nonstress test has two such accelerations within 20 minutes.

Quickening is typically felt at 18-20 weeks in nulliparas and 16-18 weeks in multiparas; fundal height in centimeters approximates gestational age in weeks from 20 to 36 weeks, within plus or minus 2 cm.

Prenatal visit cadence for uncomplicated pregnancy: every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, then weekly until delivery.

First stage: latent phase is cervical dilation to 5 cm with acceptable duration up to 20 hours in nulliparas and 14 hours in multiparas; active phase begins at 5 cm and normally dilates at least 1 cm per hour.

Second stage: diagnosis at complete dilation; typical duration limits are about 3 hours nullipara and 2 hours multipara without epidural, adding roughly 1 hour with epidural; arrest is no descent or no rotation after 2 hours of pushing.

Uterine tachysystole is more than 5 contractions in 10 minutes averaged over 30 minutes; management includes maternal repositioning, oxygen if hypoxemic, and reducing or stopping oxytocin.

Oxytocin induction protocols start at low dose (1-2 mU/min) with titration every 30-40 minutes; monitor contraction frequency and fetal heart rate, and use tachysystole or nonreassuring tracings as stop rules.

Category III fetal heart rate tracing includes absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern; it requires immediate evaluation and intrauterine resuscitation.

Intrauterine resuscitation bundle: stop oxytocin, reposition to left lateral, intravenous fluid bolus, correct hypotension, administer oxygen for hypoxemia, and consider tocolysis for tachysystole.

Active management of third-stage labor: prophylactic uterotonic within 1 minute of birth, controlled cord traction, and uterine massage; assess blood loss quantitatively because visual estimation underestimates loss.

Postpartum hemorrhage is cumulative blood loss of at least 1000 mL or loss with signs of hypovolemia within 24 hours of birth; uterine atony accounts for about 70-80% of cases.

Shoulder dystocia maneuvers in sequence: call for help, McRoberts positioning, suprapubic pressure, internal rotation, then delivery of the posterior arm; episiotomy alone does not relieve the bony impaction.

Apgar scoring at 1 and 5 minutes assigns 0-2 points each for appearance, pulse, grimace, activity, and respiration; scores of 7-10 are generally reassuring and the score does not guide resuscitation.

Newborn vital norms: heart rate 110-160 bpm when awake, respiratory rate 30-60 breaths per minute, axillary temperature 36.5-37.5 degrees Celsius; sustained tachypnea above 60 warrants evaluation.

Physiologic newborn weight loss is up to about 7-10% of birth weight in the first days, with regain to birth weight by 10-14 days; formula or expressed milk volumes rise from about 15-30 mL per feed in the first day.

Delayed cord clamping for at least 30-60 seconds in vigorous term infants increases iron stores; for preterm infants it reduces intraventricular hemorrhage and transfusion needs.

Newborn screening blood spot is collected after 24 hours and ideally at 48-72 hours of age; hearing screening and pulse oximetry screening for critical congenital heart disease occur before discharge.

Postpartum hemorrhage risk persists into the first 24 hours (primary) and from 24 hours to 12 weeks (secondary); secondary causes include retained products, endometritis, and pseudoaneurysm.

Postpartum depression screening uses the Edinburgh Postnatal Depression Scale at the initial postpartum visit; a score of 10 or more prompts further assessment, and 13 or more suggests likely depression.

Uterine involution: fundus is at the umbilicus immediately after birth, descends about 1 cm per day, and is typically nonpalpable abdominally by 2 weeks postpartum.

Lochia progresses from rubra (days 1-3), to serosa (days 4-10), to alba (after about 10 days); foul odor or return to rubra suggests infection or retained tissue.

Cervical cancer screening: begin at 21 years; ages 21-29 cytology every 3 years; ages 30-65 cytology every 3 years, co-testing every 5 years, or primary HPV testing every 5 years; stop after 65 with adequate prior negative screening.

Mammography: average-risk screening typically begins at 40-50 years with biennial intervals through at least 74 years; individual risk factors and shared decision-making modify start and stop ages.

Contraceptive effectiveness by typical use: implant and intrauterine devices above 99%, injectable about 94%, pill about 93%, male condom about 87%, withdrawal about 78%.

Emergency contraception: copper intrauterine device is most effective up to 5 days; ulipristal acetate is effective up to 120 hours; levonorgestrel is effective up to 72 hours and less effective with higher body weight.

Menopause is defined retrospectively after 12 months of amenorrhea; perimenopause averages about 4 years and vasomotor symptoms typically last a median of 7 years.

Osteoporosis screening with dual-energy x-ray absorptiometry begins at 65 years for all women, or earlier at 50-64 with risk factors; a T-score of -2.5 or lower defines osteoporosis.

Bacterial vaginosis: Amsel criteria require 3 of 4 (homogeneous discharge, clue cells, pH above 4.5, positive whiff test); first-line treatment is oral metronidazole, topical metronidazole, or clindamycin.

Human papillomavirus vaccination is recommended at 11-12 years, catch-up through 26 years, and shared decision-making at 27-45 years; two doses if started before 15 years, three doses if later.

Informed consent requires disclosure of diagnosis, proposed intervention, material risks and benefits, alternatives including no treatment, and the patient's voluntary agreement; it is a process, not a signature.

Mandatory reporting duties typically cover suspected child abuse or neglect, and in many jurisdictions elder or dependent-adult abuse; reporting obligations generally override confidentiality for these categories.

Scope of practice is defined by state statute and board rules and includes supervision or collaborative agreement requirements, prescriptive authority, and hospital privileging; exceeding it is a licensure risk.

Confidentiality exceptions include patient authorization, statutory reporting, imminent serious harm to self or others, and court order; disclose only the minimum necessary information.

Documentation standards: record date and time, objective findings, clinical reasoning, informed consent discussion, and patient response; late entries are labeled as additions and never altered retroactively.

Impaired practice and impairment concerns are reported to the licensing board or a designated peer review body; most states offer alternative-to-discipline programs for substance use disorders.

A patient may refuse any intervention if decisionally capable, including in pregnancy; document capacity assessment and the discussion of risks, and continue to provide all other care.

Delegation is permitted only for tasks within the delegate's training and the delegator's scope; the licensed clinician retains accountability for assessment, planning, and evaluation.

First-line antihypertensives in pregnancy: labetalol, nifedipine, and methyldopa; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.

Magnesium sulfate for seizure prophylaxis in preeclampsia: 4-6 g loading dose over 15-20 minutes, then 1-2 g per hour; monitor deep tendon reflexes, respiratory rate, and urine output, with calcium gluconate as antidote.

Oxytocin high-alert handling: dilute per protocol, use an infusion pump, and titrate to contraction pattern; excessive infusion causes tachysystole, water intoxication, and hyponatremia.

Betamethasone 12 mg intramuscularly every 24 hours for two doses (or dexamethasone 6 mg every 12 hours for four doses) between 24 and 34 weeks reduces neonatal respiratory distress syndrome and intraventricular hemorrhage.

Teratogen avoidance: isotretinoin, warfarin, methotrexate, valproate, and angiotensin-converting enzyme inhibitors carry major fetal risk; verify pregnancy status and contraception before prescribing known teratogens.

Pharmacokinetic changes in pregnancy include increased plasma volume and glomerular filtration, hepatic CYP2D6 induction, and delayed gastric emptying; drug levels of some anticonvulsants and antidepressants fall.

Combined hormonal contraception is avoided with migraine with aura, smoking at 35 years or older, uncontrolled hypertension, prior venous thromboembolism, and known thrombogenic mutations.

Prescriptive authority for advanced practice clinicians requires a Drug Enforcement Administration registration for controlled substances, state licensure, and compliance with prescription drug monitoring program queries.

Evidence hierarchy from strongest to weakest: systematic reviews and meta-analyses of randomized trials, randomized controlled trials, cohort studies, case-control studies, case series, expert opinion.

Relative risk compares incidence between exposed and unexposed groups; attributable risk is incidence in exposed minus incidence in unexposed; number needed to treat equals 1 divided by absolute risk reduction.

Sensitivity is true positives divided by all with disease; specificity is true negatives divided by all without disease; positive predictive value depends on prevalence and equals true positives divided by all positive tests.

A 95% confidence interval excluding the null value (1 for ratios, 0 for differences) corresponds to statistical significance at the 0.05 level; statistical significance does not establish clinical importance.

Randomized controlled trials reduce selection bias through randomization and allocation concealment; blinding reduces performance and detection bias; intention-to-treat analysis preserves randomization.

Quality improvement uses plan-do-study-act cycles with measurable aims, process and outcome measures, and run charts or statistical process control to distinguish common from special-cause variation.

Evidence-based practice integrates the best available research, clinician expertise, and patient values; appraisal tools include GRADE for certainty and the Cochrane risk-of-bias tool.

Institutional review board approval and informed consent are required before human-subjects research; vulnerable populations such as pregnant people and neonates require additional protections and justification.

Estimated date of delivery by Naegele's rule: first day of last menstrual period minus 3 months plus 7 days; confirm with first-trimester ultrasound, which is most accurate for dating (crown-rump length up to 13+6 weeks).

A pregnancy is post-term at 42+0 weeks; late-term is 41+0 to 41+6; term is 37+0 to 41+6; preterm is before 37+0; early term 37+0 to 38+6; full term 39+0 to 40+6.

Physiologic anemia of pregnancy: plasma volume rises about 40-50% versus red cell mass about 20-30%, so hemoglobin below 11.0 g/dL in first trimester or below 10.5 g/dL in second/third trimester defines anemia.

Screening schedule: 1-hour 50-g glucose challenge at 24-28 weeks; cell-free DNA or combined first-trimester screen from 10 weeks; anatomy scan at 18-22 weeks; group B streptococcus culture at 36+0 to 37+6 weeks.

RhD-negative unsensitized patients receive anti-D immune globulin at 28 weeks and within 72 hours of delivery of an RhD-positive infant, plus after abortion, ectopic, amniocentesis, or antepartum bleeding.

Blood pressure thresholds: chronic hypertension precedes 20 weeks or persists past 12 weeks postpartum; gestational hypertension arises after 20 weeks without proteinuria or organ dysfunction; preeclampsia adds proteinuria or maternal organ/uteroplacental dysfunction.

Fetal heart rate baseline is 110-160 beats per minute; accelerations are at least 15 bpm for 15 seconds (10 bpm for 10 seconds before 32 weeks); a reactive nonstress test has two such accelerations within 20 minutes.

Quickening is typically felt at 18-20 weeks in nulliparas and 16-18 weeks in multiparas; fundal height in centimeters approximates gestational age in weeks from 20 to 36 weeks, within plus or minus 2 cm.

Prenatal visit cadence for uncomplicated pregnancy: every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, then weekly until delivery.

First stage: latent phase is cervical dilation to 5 cm with acceptable duration up to 20 hours in nulliparas and 14 hours in multiparas; active phase begins at 5 cm and normally dilates at least 1 cm per hour.

Second stage: diagnosis at complete dilation; typical duration limits are about 3 hours nullipara and 2 hours multipara without epidural, adding roughly 1 hour with epidural; arrest is no descent or no rotation after 2 hours of pushing.

Uterine tachysystole is more than 5 contractions in 10 minutes averaged over 30 minutes; management includes maternal repositioning, oxygen if hypoxemic, and reducing or stopping oxytocin.

Oxytocin induction protocols start at low dose (1-2 mU/min) with titration every 30-40 minutes; monitor contraction frequency and fetal heart rate, and use tachysystole or nonreassuring tracings as stop rules.

Category III fetal heart rate tracing includes absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern; it requires immediate evaluation and intrauterine resuscitation.

Intrauterine resuscitation bundle: stop oxytocin, reposition to left lateral, intravenous fluid bolus, correct hypotension, administer oxygen for hypoxemia, and consider tocolysis for tachysystole.

Active management of third-stage labor: prophylactic uterotonic within 1 minute of birth, controlled cord traction, and uterine massage; assess blood loss quantitatively because visual estimation underestimates loss.

Postpartum hemorrhage is cumulative blood loss of at least 1000 mL or loss with signs of hypovolemia within 24 hours of birth; uterine atony accounts for about 70-80% of cases.

Shoulder dystocia maneuvers in sequence: call for help, McRoberts positioning, suprapubic pressure, internal rotation, then delivery of the posterior arm; episiotomy alone does not relieve the bony impaction.

Apgar scoring at 1 and 5 minutes assigns 0-2 points each for appearance, pulse, grimace, activity, and respiration; scores of 7-10 are generally reassuring and the score does not guide resuscitation.

Newborn vital norms: heart rate 110-160 bpm when awake, respiratory rate 30-60 breaths per minute, axillary temperature 36.5-37.5 degrees Celsius; sustained tachypnea above 60 warrants evaluation.

Physiologic newborn weight loss is up to about 7-10% of birth weight in the first days, with regain to birth weight by 10-14 days; formula or expressed milk volumes rise from about 15-30 mL per feed in the first day.

Delayed cord clamping for at least 30-60 seconds in vigorous term infants increases iron stores; for preterm infants it reduces intraventricular hemorrhage and transfusion needs.

Newborn screening blood spot is collected after 24 hours and ideally at 48-72 hours of age; hearing screening and pulse oximetry screening for critical congenital heart disease occur before discharge.

Postpartum hemorrhage risk persists into the first 24 hours (primary) and from 24 hours to 12 weeks (secondary); secondary causes include retained products, endometritis, and pseudoaneurysm.

Postpartum depression screening uses the Edinburgh Postnatal Depression Scale at the initial postpartum visit; a score of 10 or more prompts further assessment, and 13 or more suggests likely depression.

Uterine involution: fundus is at the umbilicus immediately after birth, descends about 1 cm per day, and is typically nonpalpable abdominally by 2 weeks postpartum.

Lochia progresses from rubra (days 1-3), to serosa (days 4-10), to alba (after about 10 days); foul odor or return to rubra suggests infection or retained tissue.

Cervical cancer screening: begin at 21 years; ages 21-29 cytology every 3 years; ages 30-65 cytology every 3 years, co-testing every 5 years, or primary HPV testing every 5 years; stop after 65 with adequate prior negative screening.

Mammography: average-risk screening typically begins at 40-50 years with biennial intervals through at least 74 years; individual risk factors and shared decision-making modify start and stop ages.

Contraceptive effectiveness by typical use: implant and intrauterine devices above 99%, injectable about 94%, pill about 93%, male condom about 87%, withdrawal about 78%.

Emergency contraception: copper intrauterine device is most effective up to 5 days; ulipristal acetate is effective up to 120 hours; levonorgestrel is effective up to 72 hours and less effective with higher body weight.

Menopause is defined retrospectively after 12 months of amenorrhea; perimenopause averages about 4 years and vasomotor symptoms typically last a median of 7 years.

Osteoporosis screening with dual-energy x-ray absorptiometry begins at 65 years for all women, or earlier at 50-64 with risk factors; a T-score of -2.5 or lower defines osteoporosis.

Bacterial vaginosis: Amsel criteria require 3 of 4 (homogeneous discharge, clue cells, pH above 4.5, positive whiff test); first-line treatment is oral metronidazole, topical metronidazole, or clindamycin.

Human papillomavirus vaccination is recommended at 11-12 years, catch-up through 26 years, and shared decision-making at 27-45 years; two doses if started before 15 years, three doses if later.

Informed consent requires disclosure of diagnosis, proposed intervention, material risks and benefits, alternatives including no treatment, and the patient's voluntary agreement; it is a process, not a signature.

Mandatory reporting duties typically cover suspected child abuse or neglect, and in many jurisdictions elder or dependent-adult abuse; reporting obligations generally override confidentiality for these categories.

Scope of practice is defined by state statute and board rules and includes supervision or collaborative agreement requirements, prescriptive authority, and hospital privileging; exceeding it is a licensure risk.

Confidentiality exceptions include patient authorization, statutory reporting, imminent serious harm to self or others, and court order; disclose only the minimum necessary information.

Documentation standards: record date and time, objective findings, clinical reasoning, informed consent discussion, and patient response; late entries are labeled as additions and never altered retroactively.

Impaired practice and impairment concerns are reported to the licensing board or a designated peer review body; most states offer alternative-to-discipline programs for substance use disorders.

A patient may refuse any intervention if decisionally capable, including in pregnancy; document capacity assessment and the discussion of risks, and continue to provide all other care.

Delegation is permitted only for tasks within the delegate's training and the delegator's scope; the licensed clinician retains accountability for assessment, planning, and evaluation.

First-line antihypertensives in pregnancy: labetalol, nifedipine, and methyldopa; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.

Magnesium sulfate for seizure prophylaxis in preeclampsia: 4-6 g loading dose over 15-20 minutes, then 1-2 g per hour; monitor deep tendon reflexes, respiratory rate, and urine output, with calcium gluconate as antidote.

Oxytocin high-alert handling: dilute per protocol, use an infusion pump, and titrate to contraction pattern; excessive infusion causes tachysystole, water intoxication, and hyponatremia.

Betamethasone 12 mg intramuscularly every 24 hours for two doses (or dexamethasone 6 mg every 12 hours for four doses) between 24 and 34 weeks reduces neonatal respiratory distress syndrome and intraventricular hemorrhage.

Teratogen avoidance: isotretinoin, warfarin, methotrexate, valproate, and angiotensin-converting enzyme inhibitors carry major fetal risk; verify pregnancy status and contraception before prescribing known teratogens.

Pharmacokinetic changes in pregnancy include increased plasma volume and glomerular filtration, hepatic CYP2D6 induction, and delayed gastric emptying; drug levels of some anticonvulsants and antidepressants fall.

Combined hormonal contraception is avoided with migraine with aura, smoking at 35 years or older, uncontrolled hypertension, prior venous thromboembolism, and known thrombogenic mutations.

Prescriptive authority for advanced practice clinicians requires a Drug Enforcement Administration registration for controlled substances, state licensure, and compliance with prescription drug monitoring program queries.

Evidence hierarchy from strongest to weakest: systematic reviews and meta-analyses of randomized trials, randomized controlled trials, cohort studies, case-control studies, case series, expert opinion.

Relative risk compares incidence between exposed and unexposed groups; attributable risk is incidence in exposed minus incidence in unexposed; number needed to treat equals 1 divided by absolute risk reduction.

Sensitivity is true positives divided by all with disease; specificity is true negatives divided by all without disease; positive predictive value depends on prevalence and equals true positives divided by all positive tests.

A 95% confidence interval excluding the null value (1 for ratios, 0 for differences) corresponds to statistical significance at the 0.05 level; statistical significance does not establish clinical importance.

Randomized controlled trials reduce selection bias through randomization and allocation concealment; blinding reduces performance and detection bias; intention-to-treat analysis preserves randomization.

Quality improvement uses plan-do-study-act cycles with measurable aims, process and outcome measures, and run charts or statistical process control to distinguish common from special-cause variation.

Evidence-based practice integrates the best available research, clinician expertise, and patient values; appraisal tools include GRADE for certainty and the Cochrane risk-of-bias tool.

Institutional review board approval and informed consent are required before human-subjects research; vulnerable populations such as pregnant people and neonates require additional protections and justification.