NZ Midwifery Registration cheat sheet

Normal pregnancy: cardiac output rises 30–50% by 28–32 weeks; plasma volume increases ~40–50% versus red cell mass ~20–30%, producing physiological haemodilution (Hb nadir ~105–110 g/L).

Uterine blood flow reaches ~500–750 mL/min at term; placental perfusion is pressure-dependent, so maternal hypotension (e.g. supine position, regional anaesthesia) directly reduces fetal oxygen supply.

First stage of labour: cervical dilatation with effacement; second stage: full dilatation to birth; third stage: birth of baby to expulsion of placenta and membranes.

Oxytocin (from posterior pituitary) drives uterine contractions; Ferguson reflex is a positive feedback loop: cervical/vaginal stretch increases oxytocin release.

Human placental lactogen and progesterone contribute to insulin resistance in pregnancy; screening for gestational diabetes typically occurs at 24–28 weeks.

Fetal circulation shunts: ductus venosus (umbilical vein to IVC), foramen ovale (RA to LA), ductus arteriosus (pulmonary artery to aorta); functional closure occurs after birth with lung inflation and oxygen rise.

Postpartum haemorrhage physiology: uterine atony is the most common cause; a contracted uterus mechanically occludes spiral arteries at the placental site.

Pre-eclampsia pathophysiology: abnormal trophoblast invasion → reduced spiral artery remodelling → placental ischaemia → release of anti-angiogenic factors → endothelial dysfunction, hypertension and proteinuria.

NZ antenatal schedule: first visit before 10 weeks; then visits at approximately 12, 16, 20, 24, 28, 32, 36, 38, 40 and 41 weeks, with increased frequency if risk factors are present.

Initial assessment includes: medical, obstetric, family and psychosocial history; blood pressure; BMI; urinalysis; blood group and antibodies; FBC; rubella immunity; syphilis, HIV and hepatitis B serology; and screening for diabetes.

First-trimester combined screening (nuchal translucency ultrasound plus maternal serum) is performed between 11+2 and 13+6 weeks; second-trimester maternal serum screening is performed from 14+2 to 20 weeks.

Anatomy ultrasound is offered at 18–20 weeks to assess fetal anatomy, placental location and amniotic fluid volume.

Group B streptococcus: NZ does not use universal culture screening; risk-based intrapartum antibiotic prophylaxis is offered when risk factors are present (e.g. previous GBS disease, preterm labour, prolonged rupture of membranes, maternal fever).

Anti-D immunoglobulin is offered to RhD-negative women who are non-sensitised: routine prophylaxis in the third trimester (commonly around 28 weeks) and within 72 hours of birth of an RhD-positive baby, plus after potentially sensitising events.

Risk identification includes pre-eclampsia warning signs (headache, visual disturbance, epigastric pain, sudden swelling), decreased fetal movements, vaginal bleeding, and hypertensive disorders; these require urgent assessment and referral.

Gestational diabetes screening (75 g OGTT) is offered to women with risk factors, commonly at 24–28 weeks, and earlier testing if risk is high.

Latent first stage: painful regular contractions with progressive cervical change, typically up to 4–5 cm dilatation; active first stage: from 4–5 cm to full dilatation, with expected dilatation of ~0.5–1 cm/hour in nulliparous women.

Fetal heart monitoring: intermittent auscultation is recommended for low-risk labour, typically every 15–30 minutes in the first stage and every 5 minutes (or after each contraction) in the second stage.

Cardiotocography (CTG) interpretation uses baseline rate (normal 110–160 bpm), variability (normal 5–25 bpm), accelerations and decelerations; categories guide response: normal, suspicious, or abnormal requiring escalation.

Partogram use: plot cervical dilatation, descent, contractions, maternal observations and fetal heart rate against time; failure to progress or a prolonged labour requires review and consideration of referral.

Second stage: in nulliparous women, birth is expected within about 3 hours (with or without epidural), and in multiparous women within about 2 hours; prolonged second stage requires assessment and possible transfer.

Active management of the third stage (oxytocin, controlled cord traction, uterine assessment) reduces postpartum haemorrhage compared with expectant management.

Immediate newborn care: dry and stimulate, assess breathing and tone, delay cord clamping for at least 1 minute if the baby is well, maintain warmth (skin-to-skin), and support early breastfeeding within the first hour.

Newborn resuscitation follows a stepwise approach: warmth, positioning, drying, stimulation; if not breathing, positive pressure ventilation with air; chest compressions if heart rate remains below 60 bpm despite effective ventilation.

Postnatal observations: maternal vital signs, uterine involution, lochia, perineal wound, bladder function and blood loss; newborn feeding, output, weight, temperature, jaundice and general wellbeing.

Lochia progression: rubra (days 1–4), serosa (days 4–10), alba (after ~10 days); offensive odour, large clots or heavy bleeding suggest infection or secondary postpartum haemorrhage and require review.

Breastfeeding: colostrum in the first days; mature milk typically 'comes in' around days 2–5; effective attachment (wide gape, chin to breast, asymmetric latch) and frequent feeding (8–12 times per 24 hours) support supply.

Newborn weight loss: up to ~7–10% of birth weight in the first week is common; regain to birth weight is expected by about 10–14 days; greater loss or failure to regain requires assessment.

Newborn jaundice: assess timing, extent and feeding; jaundice in the first 24 hours is always pathological and requires urgent review; breastfed jaundice after the first week is common and usually benign but requires monitoring.

Postnatal mental health: screen for depression and anxiety (e.g. Edinburgh Postnatal Depression Scale); urgent referral if there are thoughts of self-harm or harm to the baby, or signs of postpartum psychosis.

Contraception and sexual health: discuss options at postnatal visits, including LARC, progestogen-only methods compatible with breastfeeding, and the lactational amenorrhoea method criteria.

Transition to parenting: support parental confidence, infant cues, safe sleep (baby on back, in own bed, smoke-free), and referral to Well Child/Tamariki Ora services and community support.

Informed choice requires: disclosure of material risks and benefits, discussion of alternatives (including doing nothing), checking understanding, and documenting the woman's decision.

Consent must be voluntary, informed and given by a competent person; it can be withdrawn at any time, and must be obtained before procedures such as CTG, vaginal examination, induction or episiotomy.

Woman-centred care: the woman is the decision-maker; the midwife provides evidence-based information, respects her values and preferences, and supports her choices within safe practice.

Cultural safety: the midwife examines their own biases and power, recognises the impact of colonisation and racism on health, and adapts practice to the cultural needs of the woman and whānau.

Te Tiriti o Waitangi principles in health: partnership, participation and protection (and, in contemporary frameworks, equity, active protection, options and partnership) guide midwifery practice.

Whānau-centred practice: include whānau in care planning as the woman wishes; use correct pronunciation of names, mihi, and appropriate tikanga (e.g. regarding the whenua/placenta, karakia, and tapu around the head).

Interpreters and cultural support: use qualified interpreters rather than family members for consent discussions; provide written information in the woman's preferred language where possible.

Documentation of partnership: record the woman's expressed preferences, the information given, questions asked, and the agreed plan, so that continuity of informed choice is visible across the episode of care.

The Health Practitioners Competence Assurance Act 2003 provides the regulatory framework; the Midwifery Council of New Zealand sets the scope of practice, competencies, and recertification requirements.

Scope of practice: the midwife works in partnership with the woman, providing care during pregnancy, labour, birth and the postnatal period, including emergency measures and referral/consultation as required.

The midwife is accountable for their own practice and must work within their competence; they must consult, refer or transfer care when the woman's or baby's condition is outside their scope.

Documentation must be contemporaneous, accurate, legible and attributable: date, time, signature, and clear record of assessments, advice given, decisions made and the woman's response.

Privacy and information: the Health Information Privacy Code 2020 governs collection, use and disclosure of health information; share only with consent or where legally required.

Mandatory reporting: the midwife must report concerns about a health practitioner's competence or conduct to the relevant authority; child protection concerns are reported to Oranga Tamariki.

Codes and standards: the Midwifery Council's Code of Conduct and Standards of Practice, and the International Confederation of Midwives' code of ethics, set expectations for professional behaviour.

Professional boundaries and self-care: recognise impairment (fatigue, illness, substance use), seek support, and maintain competence through continuing education and reflective practice.

Postpartum haemorrhage: after birth, assess tone, tissue, trauma and thrombin; give uterotonics (oxytocin first-line), bimanual uterine massage, IV fluids, and escalate for transfer if bleeding continues.

Shoulder dystocia: call for help, use McRoberts' manoeuvre and suprapubic pressure first; consider internal rotational manoeuvres, and document the time of head-to-body interval and manoeuvres used.

Cord prolapse: recognise (sudden fetal bradycardia or variable decelerations after rupture of membranes), call for help, relieve cord compression (knee-chest or Trendelenburg, elevate presenting part), and prepare for immediate birth/transfer.

Fetal compromise: persistent abnormal CTG features (e.g. prolonged deceleration, absent variability with decelerations, sinusoidal pattern) require urgent review, intrauterine resuscitation (left lateral, IV fluids, stop oxytocin) and escalation.

Pre-eclampsia/eclampsia: severe hypertension requires urgent antihypertensive treatment; magnesium sulphate is the treatment for eclampsia and for seizure prophylaxis in severe pre-eclampsia, with transfer to a tertiary unit.

Neonatal emergencies: meconium-stained liquor requires paediatric support at birth; suspected sepsis, respiratory distress or hypoglycaemia require urgent paediatric review and transfer as indicated.

Referral and consultation pathways: the midwife consults with an obstetrician or paediatrician when risk factors arise, transfers care when the condition exceeds midwifery scope, and continues to provide midwifery support.

Emergency preparedness: know the local transfer plan, neonatal resuscitation equipment, and the process for activating ambulance or helicopter transfer; debrief after critical events for the woman, whānau and team.