Cambodia Midwifery Exit Exam cheat sheet

WHO 2016 ANC model: 8 contacts - first before 12 weeks, then 20, 26, 30, 34, 36, 38 and 40 weeks; the earlier 4-visit FANC schedule is superseded.

Estimated date of delivery by Naegele's rule: first day of last menstrual period + 7 days − 3 months + 1 year (280 days / 40 weeks).

First-visit bundle: confirm pregnancy and gestational age, calculate BMI, measure blood pressure, test urine for protein, test haemoglobin, determine blood group and Rh, screen for syphilis and HIV, and give iron-folic acid.

Iron-folic acid: 60 mg elemental iron plus 400 µg folic acid daily; continue 3 months postpartum. In Cambodia, deworming with mebendazole 500 mg is given after the first trimester in endemic areas.

Tetanus-diphtheria toxoid: 2 doses in the first pregnancy with 4 weeks between doses, then 1 dose in each subsequent pregnancy (or according to national schedule) to achieve 5 protected doses.

Danger signs to teach every woman: vaginal bleeding, severe headache with blurred vision, fever, draining of fluid, reduced fetal movement, convulsions, severe abdominal pain, and difficulty breathing.

Gestational age assessment: symphysio-fundal height in cm approximates weeks from 20–36 weeks (±2 cm); ultrasound before 24 weeks is the most accurate dating method and is preferred when available.

Routine supplements and nutrition counselling: calcium, iron-folate, and counselling on a diversified diet, plus avoidance of alcohol and tobacco. In malaria-endemic provinces, intermittent preventive treatment may apply.

Definitions: latent first stage = regular contractions with cervical dilatation <5 cm; active first stage = ≥5 cm dilatation with regular contractions; second stage = full dilatation to birth of the baby.

WHO Labour Care Guide (2020) replaced the 1 cm/hour alert line: plot dilatation, descent, contractions, fetal heart rate, and maternal BP/pulse every 30 minutes in active labour; act if progress crosses the LCG reference thresholds.

Partograph rules: in active labour, cervical dilatation <1 cm/hour over 4 hours, or descent not progressing, indicates the need for reassessment and referral - not prolonged observation.

Fetal heart rate: auscultate for 1 minute every 30 minutes in the first stage and every 5 minutes in the second stage; normal 110–160 bpm. Decelerations with contraction recovery are reassuring; late or persistent decelerations are not.

Active management of the third stage (AMTS): intramuscular oxytocin 10 IU within 1 minute of birth, controlled cord traction, and uterine massage - reduces postpartum haemorrhage.

Do not perform routine episiotomy, routine amniotomy, or routine enema; allow a companion of choice and free position in labour, and encourage oral fluids and light diet in low-risk labour.

Second-stage pushing: support spontaneous pushing with contractions; do not apply fundal pressure. Perineal support and warm compresses reduce severe perineal trauma.

Immediate newborn care at birth: dry thoroughly, assess breathing, skin-to-skin contact within 1 minute, and delay cord clamping for 1–3 minutes while initiating breastfeeding within the first hour.

Postpartum haemorrhage definition: blood loss ≥500 mL after vaginal birth or ≥1000 mL after caesarean, or any blood loss causing haemodynamic instability; uterine atony accounts for about 70–80% of cases.

Check maternal vital signs at least every 15 minutes for the first 2 hours, then every 4 hours for 24 hours; assess uterine tone, lochia, and perineal wound at each check.

Breastfeeding: exclusive breastfeeding for 6 months, on demand, at least 8–12 times per 24 hours; correct latch with the baby's mouth wide and chin to the breast.

Newborn danger signs: not feeding well, convulsions, fast breathing (≥60/min), severe chest indrawing, fever ≥37.5 °C or hypothermia <36.5 °C, jaundice in the first 24 hours, and pus or bleeding from the umbilicus - refer immediately.

Newborn weight: expect up to 10% loss in the first week, regained by day 10–14. Weight <2500 g = low birth weight; <1500 g = very low birth weight, requiring referral to a facility with neonatal care.

Kangaroo mother care: continuous skin-to-skin contact, exclusive breastfeeding, and early discharge with follow-up - the standard for stable low-birth-weight babies.

Postpartum visits: within 24 hours, day 3, between days 7–14, and at 6 weeks; screen for postpartum depression, anaemia, and family planning needs at each visit.

Vitamin K 1 mg intramuscularly to every newborn within 1 hour of birth prevents haemorrhagic disease of the newborn.

Eclampsia: give magnesium sulphate 4 g IV plus 10 g IM (Pritchard regimen), then 5 g IM every 4 hours for 24 hours; monitor respiratory rate ≥16/min, patellar reflex present, and urine output ≥30 mL/hour before each dose.

Antepartum haemorrhage: never perform a vaginal examination before excluding placenta praevia by ultrasound; if praevia is suspected, refer without vaginal examination.

Shoulder dystocia: call for help, McRoberts position (hyperflexed hips), suprapubic pressure, then internal rotational manoeuvres; never apply fundal pressure or pull the head.

Cord prolapse: call for help, elevate the presenting part with a gloved hand, position the woman knee-chest or Trendelenburg, and arrange immediate caesarean section.

Postpartum haemorrhage sequence: massage the uterus, give oxytocin 10 IU IM, empty the bladder, give tranexamic acid 1 g IV within 3 hours of birth, then misoprostol 800 µg sublingually; refer if bleeding continues.

Referral decision rule: refer when the facility cannot provide the needed intervention (caesarean, blood transfusion, neonatal intensive care) or when the woman is unstable despite initial treatment.

Referral communication: use SBAR (Situation, Background, Assessment, Recommendation) and send a referral note with gestational age, vital signs, treatments given, and time of last dose.

Pre-eclampsia with severe features: BP ≥160/110 mmHg plus symptoms or lab abnormalities; give antihypertensives (e.g. hydralazine 5 mg IV or nifedipine 10 mg orally) and magnesium sulphate, then refer for delivery.

Newborn resuscitation sequence: warm, dry, stimulate, position the head, clear the airway if needed, then give positive pressure ventilation with a self-inflating bag and mask at 40–60 breaths/min.

Use room air (21% oxygen) initially for term babies; reserve oxygen for babies who remain cyanotic or fail to improve after effective ventilation.

Chest compressions: 3 compressions to 1 breath (90 compressions and 30 breaths per minute), two-thumb technique, started if heart rate <60/min after 60 seconds of effective ventilation.

Apnoea or gasping at birth is an indication to start positive pressure ventilation immediately; do not wait for a heart rate measurement.

Hypoglycaemia in the newborn: blood glucose <2.5 mmol/L (45 mg/dL); treat with early feeding or expressed breast milk, and refer if symptomatic or persistent.

Neonatal sepsis signs: poor feeding, lethargy, temperature instability, respiratory distress, and jaundice; refer urgently for antibiotics - do not wait for culture results.

Neonatal jaundice: any jaundice in the first 24 hours, jaundice of the palms and soles, or jaundice with poor feeding requires urgent referral for bilirubin measurement and phototherapy.

Newborn resuscitation equipment check before every birth: bag-mask of appropriate size, suction, warm towels, radiant warmer, and a person trained in resuscitation present at every delivery.

Postpartum family planning timing: lactational amenorrhoea method is effective only if the woman is fully breastfeeding, amenorrhoeic, and the baby is under 6 months; otherwise start a method before discharge.

Progestogen-only methods (implants, DMPA, progestogen-only pills) can be started immediately postpartum, including during breastfeeding; combined hormonal methods are delayed until 6 weeks postpartum in breastfeeding women.

Emergency contraception: levonorgestrel 1.5 mg orally within 72 hours, or copper IUD within 5 days of unprotected intercourse; the IUD is the most effective option.

Safe abortion: WHO recommends vacuum aspiration or medical abortion with mifepristone plus misoprostol; abortion is lawful in Cambodia when performed by a trained provider within the legal gestational limit.

Post-abortion care: assess for complications (haemorrhage, infection, incomplete abortion), provide antibiotics and contraception counselling, and refer for uterine evacuation if retained products are suspected.

Cervical cancer screening: HPV testing is preferred over cytology where available; screening starts at age 30 in most national programmes, with follow-up intervals of 5–10 years for HPV-negative results.

Antenatal syphilis screening: test all pregnant women at the first visit; treat with benzathine penicillin G 2.4 million units IM, and treat the partner to prevent reinfection.

Contraceptive effectiveness: implant and IUD >99%, injectable ~94%, pill ~91% with typical use, condom ~87% with typical use - use these figures when counselling on method choice.

WHO 5 Moments for Hand Hygiene: before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.

Hand hygiene duration: alcohol-based rub 20–30 seconds; soap and water 40–60 seconds. Use soap and water when hands are visibly soiled or after exposure to spore-forming organisms such as Clostridioides difficile.

Sterile gloves are required for vaginal examination, delivery, and any procedure breaching mucosa; clean gloves are used for non-sterile contact such as changing linen.

Sharps safety: never recap needles by hand; place used sharps immediately in a puncture-resistant container filled to no more than three-quarters capacity.

Post-exposure prophylaxis for HIV: start antiretrovirals as soon as possible, ideally within 2 hours and no later than 72 hours after exposure, and continue for 28 days.

Single-use items (syringes, needles, gloves, cord clamps) must never be reused; sterilise reusable instruments by autoclave at 121 °C for 15 minutes or 134 °C for 3 minutes.

Waste segregation: infectious waste (blood-soaked dressings, placenta) in yellow bags, sharps in puncture-proof containers, and general waste in black bags; never mix categories.

Clean birth practices: clean hands, clean perineum, clean surface, clean cord-cutting instrument, and clean cord tie - each reduces neonatal sepsis and maternal infection.

PMTCT cascade: test all pregnant women for HIV at the first ANC visit, start lifelong antiretroviral therapy (ART) immediately if positive, and re-test in late pregnancy or at delivery in high-prevalence settings.

Option B+: all HIV-positive pregnant and breastfeeding women receive lifelong ART regardless of CD4 count; this is the WHO-recommended approach and the one used in Cambodia.

Infant prophylaxis: HIV-exposed infants receive nevirapine (or zidovudine plus nevirapine) from birth for 6 weeks; extended prophylaxis is used for high-risk infants.

Infant feeding for HIV-positive mothers: exclusive breastfeeding for 6 months with maternal ART adherence, because the risk of mixed feeding is higher than exclusive breastfeeding.

HIV testing of the infant: early infant diagnosis by DNA PCR at 6 weeks of age (or at the earliest opportunity), with repeat testing after weaning and a final antibody test at 18 months.

Syphilis and gonorrhoea in pregnancy: screen and treat with benzathine penicillin for syphilis and ceftriaxone for gonorrhoea; treat partners simultaneously to prevent reinfection.

Hepatitis B: screen all pregnant women; give the birth-dose vaccine to all newborns within 24 hours, and give hepatitis B immunoglobulin to babies of HBsAg-positive mothers where available.

Universal precautions apply to every client regardless of known HIV status; never assume a negative status from appearance or history alone.

Informed consent requires three elements: capacity, adequate information (risks, benefits, alternatives), and voluntary decision; document the discussion and the woman's decision.

Confidentiality: health information may be disclosed only with the patient's consent, when required by law (e.g. notifiable disease reporting), or to prevent serious harm; disclose the minimum necessary information.

Midwifery scope in Cambodia: midwives provide antenatal, intrapartum, postpartum, newborn, and family planning care; procedures such as caesarean section and instrument-assisted birth are outside the midwife's scope and require referral.

Duty of care and referral: a midwife who cannot provide the needed care must arrange timely referral and not abandon the woman; failure to refer is a recognised breach of professional duty.

Mandatory reporting: suspected child abuse, sexual assault, and some communicable diseases must be reported under Cambodian law; know the local reporting pathway.

Respectful maternity care: prohibit physical abuse, non-consented procedures, discrimination, and abandonment; these constitute mistreatment and violate professional ethics.

Documentation: record objectively, contemporaneously, and legibly; the health record is a legal document and may be used in legal proceedings.

Conflict of interest and conscientious objection: a midwife may decline a procedure on moral grounds only if she refers the woman to another provider without delay and without judgment.

Cambodia's health system has three tiers: health centres (catchment ~10,000 people), referral hospitals at district level, and national hospitals; the health equity fund covers costs for poor households.

Referral pathway: health centre → district referral hospital → provincial/national hospital; the midwife at the health centre is the first point of contact for pregnancy and birth.

Community health education principles: use plain language, teach back, and locally appropriate materials; involve family decision-makers and community health volunteers.

Health behaviour change models: the transtheoretical model (pre-contemplation, contemplation, preparation, action, maintenance) and the health belief model (perceived susceptibility, severity, benefits, barriers, cues to action) guide counselling.

Antenatal education content: birth preparedness and complication readiness - saving money, identifying a birth companion, arranging transport, and knowing danger signs.

Immunisation schedule in Cambodia: BCG and hepatitis B at birth, then pentavalent, OPV, and measles according to the national schedule; the midwife records and reports doses.

Maternal death review: every maternal death should be notified and reviewed to identify avoidable factors; the review is confidential and non-punitive.

Health management information system: record ANC visits, deliveries, referrals, and family planning acceptors accurately; data drive supply ordering and programme monitoring.