Kuwait MOH Midwife cheat sheet

Naegele rule: estimated due date = first day of last menstrual period + 280 days (9 months + 7 days); confirm with early ultrasound crown-rump length when dates are uncertain or cycles are irregular.

Recommended schedule (WHO 2016 focused antenatal care): 8 contacts - first before 12 weeks, then 20, 26, 30, 34, 36, 38 and 40 weeks; Kuwait practice commonly uses monthly visits to 28 weeks, fortnightly to 36, then weekly.

Gravida = total number of pregnancies including current; para = births at or beyond 22–24 weeks (viability threshold varies; Kuwait commonly uses 24 weeks). Multiple pregnancy counts as one pregnancy but each infant counts in para.

Normal ranges: systolic 90–140 mmHg, diastolic 60–90 mmHg; haemoglobin ≥11 g/dL in first and third trimester, ≥10.5 g/dL in second; fasting glucose <5.1 mmol/L on 75 g OGTT.

Fetal heart rate 110–160 bpm is normal; use intermittent auscultation with Pinard or Doppler for at least 60 seconds after a contraction in low-risk labour.

Routine first-visit tests: blood group and RhD, antibody screen, full blood count, rubella IgG, syphilis/HIV/HBsAg screening, urinalysis, and dating ultrasound; RhD-negative unsensitised women receive anti-D prophylaxis at 28 weeks and within 72 hours of birth.

Fundal height from 24 weeks should track within 2 cm of gestational weeks in centimetres; a static or deviating measurement triggers growth ultrasound.

Folic acid 400 micrograms daily from preconception to 12 weeks; 5 mg daily if previous neural tube defect, diabetes, obesity (BMI >30), or antiepileptic use.

Danger signs requiring immediate referral: vaginal bleeding, severe headache with visual disturbance, epigastric pain, reduced fetal movements, rupture of membranes, fever, or severe abdominal pain.

Latent first stage: regular contractions with cervical change up to 5 cm dilation; active first stage: 5 cm to full dilation, with cervical change of about 1 cm per hour as a reference - slower progress prompts reassessment, not automatic intervention.

Second stage: full dilation to birth; nulliparous typical duration up to 3 hours (longer with epidural), multiparous up to 2 hours; passive descent before active pushing is acceptable.

Third stage: birth to expulsion of placenta; active management = prophylactic uterotonic (10 IU oxytocin IM), controlled cord traction, and uterine assessment; expected within 30 minutes.

Partograph: plot cervical dilation, descent, contractions, fetal heart rate, membranes, and maternal observations; action line crossing (4 hours after alert line) indicates need for obstetric review.

Cardiotocography categories: baseline 110–160 bpm, variability 5–25 bpm, accelerations, no decelerations = normal; late or variable decelerations with reduced variability = abnormal, escalate immediately.

Position and mobility in labour reduce duration and caesarean rates; continuous support (doula or midwife) improves outcomes and should be offered.

Delayed cord clamping for at least 1 minute (or 30–60 seconds if resuscitation needed) improves neonatal iron stores; dry and stimulate the newborn on the maternal abdomen.

Perineal care: warm compress and hands-on or hands-poised support during crowning; mediolateral episiotomy only for fetal compromise or imminent severe tear; suture with continuous technique.

Do not perform routine amniotomy, routine enema, or routine shaving; these are not evidence-based in low-risk labour.

First hour: skin-to-skin contact and initiation of breastfeeding within 1 hour; observe uterine tone, lochia, and blood loss every 15 minutes for the first hour, then per unit protocol.

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

BUBBLE-HE assessment: Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy/perineum, Homans sign, Emotional status.

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

Newborn APGAR at 1 and 5 minutes: Appearance, Pulse, Grimace, Activity, Respiration; score 0–3 indicates need for immediate resuscitation; APGAR does not guide resuscitation decisions.

Newborn thermoregulation: aim axillary temperature 36.5–37.5 °C; dry, cover, hat, and skin-to-skin; hypothermia signs include lethargy, poor feeding, and cool extremities.

Newborn weight loss up to 10% in the first week is normal; regain birth weight by 10–14 days; jaundice appearing within 24 hours is always pathological.

Postnatal visits: within 24 hours of birth, day 3–5 (feeding and jaundice check), and at 6 weeks; screen for postpartum depression and ask directly about mood and safety.

Vitamin K 1 mg IM to every newborn at birth prevents haemorrhagic disease of the newborn.

Pre-eclampsia: hypertension ≥140/90 mmHg after 20 weeks plus proteinuria or maternal organ dysfunction; severe features = ≥160/110 mmHg, platelets <100, liver enzymes doubled, creatinine rise, pulmonary oedema, or neurological symptoms; treatment is magnesium sulfate and delivery.

Magnesium sulfate regimen: 4 g IV loading over 20 minutes, then 1 g/hour; monitor respiratory rate ≥12/min, reflexes present, urine output ≥30 mL/hour; antidote calcium gluconate 1 g IV.

Gestational diabetes: 75 g OGTT at 24–28 weeks; targets fasting <5.3 mmol/L, 1-hour <7.8, 2-hour <6.7 mmol/L; insulin is first-line pharmacotherapy when diet fails.

Placenta praevia: painless bright red bleeding in later pregnancy; avoid digital vaginal examination; confirm by ultrasound; caesarean birth usually required.

Placental abruption: painful bleeding with a tense uterus, often with fetal compromise; concealed bleeding may underestimate loss; resuscitate and deliver urgently.

Preterm labour: before 34 weeks give antenatal corticosteroids (betamethasone 12 mg IM ×2, 24 hours apart) and magnesium sulfate for neuroprotection before 32 weeks; tocolysis buys time for steroids and transfer.

Shoulder dystocia: McRoberts manoeuvre plus suprapubic pressure first, then internal rotation, posterior arm delivery, and all-fours; never apply fundal pressure or excessive traction.

Cord prolapse: call for help, elevate the presenting part manually or fill the bladder, position knee-chest or Trendelenburg, and prepare for immediate caesarean.

Puerperal sepsis: fever ≥38 °C with uterine tenderness and offensive lochia; start broad-spectrum antibiotics within 1 hour and obtain cultures.

Maternal collapse: call the resuscitation team, start BLS with left lateral tilt or manual uterine displacement after 20 weeks, and prepare for perimortem caesarean within 4–5 minutes if no return of circulation.

Postpartum haemorrhage bundle: call for help, rub up the uterus, empty the bladder, give oxytocin 10 IU IM (or 5 IU slow IV), then carboprost 250 micrograms IM every 15 minutes (max 2 mg), misoprostol 800 micrograms sublingually, tranexamic acid 1 g IV within 3 hours, and escalate to balloon or surgery.

Contraindications: carboprost is contraindicated in asthma; ergometrine is contraindicated in hypertension and pre-eclampsia.

Anaphylaxis: adrenaline 0.5 mg IM (1:1000) into the anterolateral thigh, repeat every 5 minutes; position supine with legs raised; oxygen and IV fluids.

Eclamptic seizure: protect from injury, left lateral position, airway support, magnesium sulfate 4 g IV loading, do not force oral airway or restrain; deliver after stabilisation.

Neonatal resuscitation sequence: warm, dry, stimulate, position airway; if apnoeic or heart rate <100, give positive pressure ventilation at 40–60 breaths/min; chest compressions if heart rate <60 after effective ventilation; 3:1 compression-to-ventilation ratio.

Umbilical cord prolapse and shoulder dystocia are time-critical; document times of recognition, manoeuvres used, and personnel present.

Massive transfusion: activate major haemorrhage protocol, give blood products in balanced ratio, keep the woman warm, and monitor for coagulopathy with fibrinogen and calcium.

Newborn assessment at birth: breathing effort, heart rate (auscultate or cord pulse), tone, colour, and response to stimulation; heart rate is the most sensitive indicator for resuscitation decisions.

Initial steps take up to 60 seconds: provide warmth, dry, stimulate, clear secretions only if obstructing, and reposition the head to a neutral sniffing position.

Positive pressure ventilation with a self-inflating bag and 21–30% oxygen; use a T-piece resuscitator if available; rate 40–60 per minute with visible chest rise.

Chest compressions: two-thumb encircling technique over the lower third of the sternum, depth one-third of chest diameter, with 3:1 ratio and 90 compressions plus 30 breaths per minute.

Endotracheal epinephrine dose for neonates: 0.5–1 mL/kg of 1:10,000 (0.01–0.03 mg/kg) IV/IO; never give undiluted 1:1000 intravenously.

Hypoglycaemia in the newborn: blood glucose <2.6 mmol/L; feed if asymptomatic and recheck; IV dextrose 10% 2 mL/kg bolus if symptomatic or persistent.

Newborn sepsis signs: temperature instability, respiratory distress, poor feeding, lethargy, jaundice, and abdominal distension; obtain blood cultures before antibiotics when possible.

Kangaroo mother care for low birth weight infants reduces mortality; initiate as soon as the infant is stable, with exclusive breastfeeding support.

The five rights: right patient, right drug, right dose, right route, right time; add documentation and reason as local best practice.

Oxytocin high-alert handling: always via infusion pump, double-check concentration and rate, and titrate to contraction frequency (maximum 4–5 contractions in 10 minutes); stop for fetal heart rate abnormalities or hyperstimulation.

Anti-D immunoglobulin: 500–1500 IU (50–100 micrograms) at 28 weeks and within 72 hours of delivery for RhD-negative unsensitised women; dose adjusted for fetomaternal haemorrhage.

Magnesium sulfate toxicity: monitor patency of reflexes, respiratory rate, and urine output; stop infusion and give calcium gluconate 1 g IV if depression occurs.

Tranexamic acid 1 g IV over 10 minutes within 3 hours of postpartum haemorrhage onset reduces death from bleeding; do not delay administration.

Uterotonics: oxytocin (first-line), ergometrine (contraindicated in hypertension), carboprost (contraindicated in asthma), misoprostol (avoid in women with prior caesarean due to rupture risk).

Medication reconciliation at admission and discharge; document allergies, and report adverse drug reactions through the national pharmacovigilance system.

Breastfeeding and drugs: most drugs pass into milk in small amounts; check compatibility, time doses after feeds, and avoid codeine and radioactive iodine.

WHO five moments of hand hygiene: before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.

Alcohol-based hand rub for visibly clean hands; soap and water when hands are visibly soiled or after contact with Clostridioides difficile or norovirus.

Standard precautions apply to all women: gloves for body fluid contact, eye protection for splashes, and safe sharps disposal in puncture-resistant containers.

Group B streptococcus: offer intrapartum antibiotic prophylaxis (penicillin G or ampicillin) for colonised women, previous GBS-affected infant, or unknown status with risk factors such as fever ≥38 °C or rupture >18 hours.

Surgical safety checklist for caesarean: confirm identity, procedure, consent, allergies, and instrument/needle counts before closure.

Incident reporting: report all medication errors, near misses, falls, and retained swabs through the hospital incident system; a no-blame culture supports learning.

Clinical audit cycle: define standards, collect data, compare, implement change, and re-audit; use maternity indicators such as caesarean rate, perineal tear rate, and postpartum haemorrhage rate.

Needlestick injury: wash with soap and water, do not squeeze, report immediately, and start post-exposure prophylaxis assessment within hours.

Scope of practice: the midwife provides care for normal pregnancy, birth, and the puerperium, and refers deviations to an obstetrician; practising outside scope is a professional and legal risk.

Informed consent: explain procedure, benefits, risks, alternatives, and the right to refuse; document the discussion and the woman's decision in the record.

Confidentiality: disclose information only with consent or when legally required; share only the minimum necessary with the care team.

Documentation: contemporaneous, factual, signed, dated, and timed entries; never alter records retrospectively without a clear, signed correction.

Kuwait MOH registration and licensure: midwives must hold valid licensure from the Ministry of Health and comply with Kuwaiti nursing and midwifery regulations and continuing education requirements.

Mandatory reporting: suspected child abuse, domestic violence, and communicable diseases must be reported per Kuwaiti law and hospital policy.

Advocacy and autonomy: support the woman's choices, including birth preferences, and provide interpreter services when language is a barrier.

Professional accountability: maintain competence, participate in continuing professional development, and follow evidence-based guidelines and institutional protocols.

Exclusive breastfeeding for the first 6 months, then complementary feeding with continued breastfeeding to 2 years or beyond, as recommended by WHO and UNICEF.

Breastfeeding positions: cradle, cross-cradle, football, and side-lying; signs of good attachment are a wide-open mouth, chin to breast, and more areola visible above than below.

Milk supply is driven by frequent effective removal; feed 8–12 times per 24 hours on demand, and avoid pacifiers and formula supplementation unless medically indicated.

LATCH tool scores latch, audible swallowing, nipple type, comfort, and hold; use it to identify and correct feeding problems.

Postpartum contraception: lactational amenorrhoea method is effective only if amenorrhoea, exclusive breastfeeding, and <6 months postpartum; progestogen-only methods can start immediately after birth.

Combined hormonal contraception is avoided in the first 6 weeks postpartum in breastfeeding women and in women with hypertension, smoking over 35 years, or migraine with aura.

Counselling on danger signs in the newborn: poor feeding, lethargy, fever, fast breathing, jaundice, and convulsions require immediate care.

Health promotion: folic acid, iron and vitamin D supplementation, avoidance of alcohol and tobacco, and screening for gestational diabetes and hypertension.

Exclusive breastfeeding for 6 months; continue to 2 years with complementary foods; on-demand feeding 8–12 times per 24 hours supports supply.

Good attachment: wide mouth, chin touching breast, lips flanged, more areola visible above than below, and audible swallowing.

Lactational amenorrhoea method: effective only with exclusive breastfeeding, amenorrhoea, and under 6 months postpartum.

Progestogen-only pill or implant can be started immediately postpartum; combined hormonal methods are avoided in the first 6 weeks in breastfeeding women.

Counselling must cover effectiveness, side effects, return to fertility, and protection against sexually transmitted infections.

Newborn danger signs: poor feeding, lethargy, fever ≥38 °C, fast breathing, jaundice, and convulsions require urgent referral.

Vitamin D 400 IU daily for exclusively breastfed infants; iron supplementation from 4–6 months if risk factors.

Health promotion includes folic acid, avoiding alcohol and tobacco, and screening for gestational diabetes and hypertension.

Exclusive breastfeeding for 6 months; continue to 2 years with complementary feeding; feed on demand 8–12 times per 24 hours.

Signs of good attachment: wide-open mouth, chin to breast, flanged lips, more areola above than below, audible swallowing.

Lactational amenorrhoea method requires exclusive breastfeeding, amenorrhoea, and <6 months postpartum.

Progestogen-only methods can start immediately postpartum; combined hormonal contraception is avoided in the first 6 weeks when breastfeeding.

Contraceptive counselling covers effectiveness, side effects, return to fertility, and STI protection.

Newborn danger signs: poor feeding, lethargy, fever, fast breathing, jaundice, and convulsions need urgent referral.

Vitamin D 400 IU daily for exclusively breastfed infants; iron supplementation from 4–6 months if at risk.

Health promotion includes folic acid, avoiding alcohol and tobacco, and screening for gestational diabetes and hypertension.