1995 JOB ANALYSIS OF THE ROLE OF DIRECT-ENTRY MIDWIVES Conducted for the North American Registry of Midwives (NARM) by Schroeder Measurement Technologies, Inc., written by Kate Windom and Pansy Houghton, Ph.D., and adapted for publication by Sharon Wells, M.S., CPM.
INTRODUCTION
The first step in the development of a legally defensible certification examination is the delineation of the role that is to be certified. Performing a job analysis or role delineation and using the resulting data to develop an examination outline or test specification helps to insure that certification candidates are tested on the knowledge, skills, and abilities that are relevant to the role for which they are being certified.
This report describes the 1995 Job Analysis and Test Specification development process for the North American Registry of Midwives (NARM), direct-entry, entry-level midwifery program resulting in the credential, the Certified Professional Midwife (CPM). The goal and achievement of the NARM 1995 Job Analysis Survey was the creation of a mechanism that describes the Midwifery Model of Care as it is practiced by a diverse range of midwives in the United States.
SURVEY DESIGN
The model used to perform the job analysis for NARM certification was the development and distribution of a survey to practicing midwives throughout the United States. Respondents were asked to rate the criticality of tasks associated with the role of the direct-entry midwife. This survey was ground-breaking because it was the first survey to reflect the actual scope of midwifery as practiced in the United States by ensuring that all of the following midwifery practice profiles were represented among the respondents:
1) Diverse practice settings: Midwives practice in a variety of settings, including hospitals, birth centers and homes.
2) Multiple educational routes of entry: Midwives learn their profession through multiple educational routes, including self-study, apprenticeship, and midwifery and nurse-midwifery educational programs.
3) Differences in legal status: The legal status of midwives varies from state to state. These differences influence who is practicing midwifery, how those midwives received their training, the supervision of midwives, and the legal jurisdiction governing practice.
All of these differences are reflected in the design, distribution and results of the NARM job analysis survey. A singular characteristic of this survey was its focus on direct-entry (non-nurse) midwives who specialize in attending births outside of hospitals.
The survey offered respondents a detailed and comprehensive list of tasks that might be considered the components of competent entry-level practice. This very lengthy list originated as the result of an earlier Skills/Task Analysis conducted by NARM in 1992 and was expanded by experienced midwives from across the U.S. who volunteered for the task.
Each respondent was asked to rate the criticality of each task for responsible entry-level midwifery practice. Each respondent was also asked to look at the criticality of tasks and their relation to the laws governing practice in individual jurisdictions. This facilitated evaluation of the relationship between scope of practice (what midwives are allowed to do) and the tasks that midwives believe to be critical to competent practice.
See Appendix A for a description of the Task Criticality Rating system used in the NARM Job Analysis Survey.
BACKGROUND INFORMATION
Before the NARM delineation of the role of direct-entry midwives, The American College of Nurse Midwives performed a limited study of the role, surveying the opinions of nurse-midwives on the nursing tasks that should be included in the role of direct-entry midwives. This data was shared with the Inter-organizational Work Group (IWG) which was sponsored by the Carnegie Foundation Education. The IWG's purpose was to facilitate communication between the two major midwifery organizations the American College of Nurse-Midwives (ACNM) and the Midwives' Alliance of North America (MANA), with the goal of promoting midwifery in the United States. The IWG provided a grant to fund a 1992 Skills/Task Analysis based on MANA's Core Competencies for midwifery practice and carried out by NARM. The list of midwifery skills that was generated from the 1992 Skills/Task Analysis was the foundation for the first draft of the 1995 Job Analysis Survey list.
DEVELOPMENT OF THE 1995 JOB ANALYSIS SURVEY
Subject matter experts (SMEs) were recruited to assist with the survey design. These SMEs constituted a demographically representational panel, with expertise demonstrated across a variety of practice settings, education backgrounds and types of professional practice. The SMEs reviewed the minimum experience requirements established for certification of a direct-entry midwife as a Certified Professional Midwife (CPM), as well as the first draft of the 1995 Job Analysis Survey list. This allowed the SMEs to review all of the tasks that might be associated with the role. In addition, SMEs were asked to identify skills that might be illegal in some jurisdictions.
An important component in the survey design was an attempt to delineate the alternative (non-allopathic) modalities that represent competent midwifery practice. This was a daunting task, since there are many such modalities; including all relevant alternative practices that the SMEs could identify that would have resulted in an unwieldy survey of well over 1,000 items. Therefore, the strategy of choice was to lump these alternatives into the general category "uses non-allopathic treatments" for each section of the survey.
A similar design concern was raised over the use of allopathic treatments, or the "medical model." Midwives in states with less restrictive practice laws may have wide access to medical technology and may be allowed to perform procedures that might be illegal to perform in other jurisdictions. The method of measuring the importance of competence in technological healthcare skills was accomplished by asking respondents to rate the criticality of the use of specific instruments and equipment, the administration of oxygen, the administration of pharmacologic agents and procedures, the performance of lab work and routine gynecological cultures.
A draft survey was developed from the list generated by the SMEs and mailed to
34 midwives who were familiar with the CPM certification program. These midwives were asked to complete the survey, rating each task according to its criticality to competent practice, and to return it with comments and suggestions for any changes they thought were necessary. The final version of the survey was then produced. The final NARM survey contained 795 criticality ratings, 224 legality ratings, and a highly detailed demographic questionnaire. The survey took between 3 and 8 hours to complete.
SAMPLING METHODOLOGY
A critical aspect contributing to the value of a survey is the assurance that the respondent group is sufficiently random. In an attempt to include the widest possible survey sample, surveys were sent out to the entire identifiable body of direct-entry midwives, a sampling of Certified Nurse Midwives (making up 30% of the survey recipients) practicing in the United States. The names and addresses of these self-identified midwives were compiled primarily from mailing lists from the Midwives' Alliance of North America (MANA), Christian Midwives Coalition and the subscribers to Midwifery Today (a quarterly periodical). Midwives listed in the NARM Registry who were not MANA members or subscribers to Midwifery Today were added to the mailing list. As noted above, the survey mailing list was representative of midwives practicing in all demographic areas of the United States—urban, rural and suburban, and all professional settings—hospital, birthing center and home.
Initially, surveys were mailed to 3,078 names. Each name was assigned a code number. This number was placed on the postage-paid return envelope included in the survey, enabling the testing company to monitor who had or had not responded. Once a completed survey was sent in, it was separated from the envelope to ensure the respondent's anonymity.
Duplicates, undeliverable mail and midwives who did not wish to participate, but who notified the testing company, were eliminated. A final survey distribution figure of 2,869 was recalculated. The response rate calculation was based upon 817 surveys, resulting in a response rate of 28.5%. This is the largest number of responses to a midwifery job analysis ever obtained in the United States.
ANALYSIS OF THE DEMOGRAPHIC INFORMATION
Because of the diversity among midwives, it is difficult to describe a "typical midwife." A review of the demographic data on survey respondents yields a composite profile of a white, English speaking (with Spanish as a second language) female between the ages of 35-54, who is currently practicing and has practiced between 6-15 years. The composite respondent has from 2-6 years of college (Community College through Masters Degree) unrelated to midwifery, has served as a preceptor/mentor, engages in organized continuing education and participates in peer review.
The majority of respondents received their midwifery training through self study, apprenticeship, or attendance at a midwifery school. They are either licensed, certified or registered to practice in their jurisdiction. Client home birth was the overwhelming practice locale, followed by hospital and free standing birth centers. Many midwives reported practicing in multiple locations and more than one demographic setting. Services are provided predominately in rural locations, followed closely by services provided in urban areas, and in suburban areas.
DATA OVERVIEW
It is encouraging to note that there was a very high degree of homogeneity in the data, with the majority of the tasks classified within the Very Important to Extremely Important range. This homogeneity supports the fact that despite respondent diversity, the survey provided an accurate profile of the important tasks associated with the role.
As a balance to this homogeneity, there were 130 tasks out of 795 that were judged to fall within the Moderate, Of Little Importance or Outside the Scope of Practice ranges. These finding give us confidence that the survey describes a full complement of tasks associated with the role, and that the respondents provided the needed criticality differentiation to those tasks.
One representation of the precision of the survey was the standard deviation calculation for each response. This calculation represents the dispersion of the responses about the mean. For our survey the range was represented by values between 0-5, with 5 representing a large dispersion, and 0 an indication that respondents were in perfect agreement. A review of the standard deviations indicates that all fell in the range of less-than-1 to less-than-2, showing little variability among the respondent's rating of the criticality. This lack of variability, and stability in standard deviation values, gives us confidence that our response data is truly representative of midwifery practice.
Of the 224 tasks for which respondents were asked to provide legal status information, only 33 (15%) were said to be illegal by 50% or more of the respondents. There is a direct correlation between the items judged to be illegal and the assignments of low task importance ratings.
CONTENT AREAS
The tasks fell into the seven content areas listed in the chart below. This division is now reflected in the written examination specifications; a more detailed description of the Written Test Specifications is included in Appendix B.
Written Examination
| I. Midwifery Counseling, Education and Communication | 5%/17 |
| II. General Healthcare Skills | 5%/17 |
| III. Maternal Health Assessment | 10%/35 |
| IV. Prenatal | 25%/88 |
| V. Labor, Birth and Immediate Postpartum | 35%/123 |
| VI. Postpartum | 15%/54 |
| VII. Well-Baby | 5%/16 |
TOTAL: 100% - 350 Items on Examination
ADDENDUM TO THE 1995 JOB ANALYSIS
As part of the tasks associated with the finalization of the test specifications for the NARM Written Examination and Skills Assessment Examination, a focus group of Subject Matter Experts (SMEs) was brought together to review the complete listing of the 665 tasks that were found by survey respondents to be of significant importance to be part of the certification testing process. The SMEs were asked to examine each of the tasks to identify those that should be tested by psychomotor skills demonstration (Skills Assessment) versus those that could be tested via the written examination. The focus group did minor editing, re-ordering or deleting of duplications and redundancies to make the content outline more reflective of the data.
Two separate groups of SMEs were formed to oversee the development of Form D of the NARM Written Examination and the NARM Skills Assessment, both of which are based on the results of the 1995 NARM Job Analysis Survey.
CONCLUSION
By including the diverse universe of self-identified midwives, NARM ensured that the response data would be representative of the role as practiced. The translation of the response data into the examination specifications helps to provide legal defensibility in terms of the job relevance of the NARM Certified Professional Midwife (CPM) Program. Job relevance is one of the critical issues involved with the validity of a certification process.
NARM expresses its thanks to the 817 survey respondents to this survey for their willingness to commit significant time and effort to help specify the critical components of the Midwifery Model of Care.
A copy of the 1995 Job Analysis of the Role of Direct-Entry Midwives may be purchased from the North American Registry of Midwives, PO Box 672169, Chugiak, AK 99567or by calling 1-888-842-4784.
APPENDIX A
TASK CRITICALITY RATING SYSTEM
For each task on the survey, respondents were asked to judge the importance of each task to the criticality of competent practice on a scale of 1 to 5. Respondents were reminded that they were not to judge criticality according to time spent performing the task, or the frequency of the task performance. The importance ratings were described in the following manner;
(1) Extremely Important: Performance of this task is absolutely critical to the health and safety of the mother/child or midwife. All competent midwives must be able to perform this task.
(2) Very Important: Performance of this task is very important. Most competent midwives need to be able to perform this task.
(3) Moderately Important: Performance of this task is moderately important. Some competent midwives should be able to perform this task.
(4) Of Little or No Importance: Performance of this task is not critical, or is unrelated to competent practice. Few, if any, midwives need to be able to perform this task.
(5) Outside the Scope of Practice: Entry-level midwives do not perform this task. Performance of this task jeopardizes the health and safety of the mother/child or midwife.
I. Midwifery Counseling, Education and Communication: (5% of Exam - 17 Examination Items)
A. Provides interactive support and counseling and/or referral services to the mother regarding her relationships with her significant others and other healthcare providersII. General Healthcare Skills: (5% of Exam - 17 Examination Items)B. Provides education, support, counseling and/or referral for the possibility of less-than-optimal pregnancy outcomes
C. Provides education and counseling based on maternal health/reproductive family history and on-going risk assessment
D. Facilitates the mother's decision of where to give birth by exploring and explaining:
1. the advantages and the risks of different birth sitesE. Educates the mother and her family/support unit to share responsibility for optimal pregnancy outcome
2. the requirements of the birth site
3. how to prepare, equip and supply the birth siteF. Educates the mother concerning the natural physical and emotional processes of pregnancy, labor, birth and postpartum
G. Applies the principles of informed consent and client confidentiality
H. Provides individualized care
I. Advocates for the mother during pregnancy, birth and postpartum
J. Provides education, counseling and/or referral to other health care professionals, services, agencies for:
1. genetic counseling for at-risk mothers
2. abuse issues: including, emotional, physical and sexual
3. prenatal testing
4. diet, nutrition and supplements
5. effects of smoking, drugs and alcohol use
6. situations requiring an immediate call to the midwife
7. sexually transmitted diseases
8. complications
9. environmental risk factors
10. newborn care including normal/abnormal newborn activity, responses, vital signs, appearance, behavior, etc.
11. postpartum care concerning complications and self-care
12. contraception
13. female reproductive anatomy and physiology
14. monthly breast self examination techniques
15. implications for the nursing mother
16. the practice of Kegel exercises
A. Demonstrates the application of OSHA regulations as they relate to midwifery workplaceIII. Maternal Health Assessment: (10% of Exam - 35 Examination Items)B. Uses alternate healthcare practices (non-allopathic treatments) and modalities
1. herbsC. Refers to alternate healthcare practitioners for non-allopathic treatments
2. hydrotherapy (baths, compresses, showers, etc.)D. Treats for shock by:
1. recognizing the signs and symptoms of shock, or impending shockE. Recommends the use of vitamin and mineral supplements including:
2. assessing the cause of shock
3. administering oral isotonic/electrolyte solutions1. Prenatal Multi-VitaminF. Understands the how to administer/monitor the administration of the following pharmacological (prescriptive) agents:
2. Vitamin C
3. Vitamin E
4. Folic Acid
5. B-Complex
6. B-6
7. B-12
8. Iron
9. Calcium
10. Magnesium1. lidocaineG. Refers for performance of ultrasounds
2. medical oxygen
3. methergine
4. prescriptive ophthalmic prophylaxis ointment (e.g., erythromycin)
5. Pitocin®
6. RhoGamH. Refers for performance of biophysical profile
I. Understands how to use instruments and equipment including:
1. Amni-hook® / Ammnicot®J. Evaluate laboratory and medical records from other practitioners
2. bag and mask resuscitator
3. bulb syringe
4. Delee® (tube/mouth suction device)
5. hemostats
6. infant air-way
7. lancets
8. nitrazine paper
9. scissors (all kinds)
10. suturing equipment
11. urinary catheter
12. vacutainer/blood collection tube
13. vaginal culture equipmentK. Obtains assistance evaluating laboratory and medical records for other practitioners
A. Obtains and maintains records of health, reproductive and family medical history1. identifying information/demographics
2. personal history, including religion, occupation, education, marital status, economic status, changes in health or behavior and woman's evaluation of her health and nutrition
3. potential exposure to environmental toxins
4. medical condition
5. surgical history
6. reproductive history including:a) menstrual history7. family medical history
b) gynecologic history
c) sexual history
d) childbearing history
e) contraceptive practice
f) history of STDs
g) history of behavior posing risk for STD exposure
8. psychosocial history
9. history of abuse
10. mental health history
11. relationship with significant other
B. Performs a physical examination, including assessment of:IV. Prenatal: (25% of Exam - 88 Examination Items)1. general appearance/skin condition
2. baseline weight and height
3. vital signs HEENT (Head, eyes, ears, nose and throat) including:a) hair and scalp4. breast condition, by examination
b) eyes: pupils, whites, conjunctiva
c) the thyroid by palpation
d) enlarged lymph glands of neck, chest and under arms
e) the mouth, teeth, mucus membrane, and tonguea) evaluates mother's knowledge of self-breast examination techniques5. torso, extremities for bruising, abrasions, moles, unusual growths
6. baseline reflexes
7. heart and lungs
8. the abdomen, by palpation and observation for scars
9. kidney pain (CVAT)
10. the spine
11. pelvic landmarks
12. pelvic measurements
13. the condition of the cervix (by speculum)a) performs a Papanicolaou (Pap) test14. the size of the uterus and ovaries (by bimanual exam)
b) obtains gynecological cultures
15. the condition of the vulva, vagina, cervix, perineum and anus
A. Assess results of routine prenatal physical exams including ongoing assessment of:1. maternal psycho-social, emotional health and well-beingB. Records results of the examination in the prenatal records
2. maternal health by tracking variations and change in:a) color of mucus membranes3. nutritional patterns
b) general reflexes
c) elimination/urination patterns
d) sleep patterns
e) patterns of sexuality
f) movement, gait and energy levels
4. hemoglobin and hematocrit
5. glucose levels
6. breast condition/implications for breastfeeding
7. vaginal discharge/odor
8. signs of abuse (maternal substance abuse or emotional /sexual abuse of the mother(
9. estimated due date based upon:a) date of mother's last menstrual period10. assessment of fetal growth and well-being
b) last normal menstrual period
c) length of cycles
d) changes in mucus condition or ovulation history
e) date of positive pregnancy test
f) date of implantation bleeding/cramping/pelvic congestion
g) changes in the cervix
h) changes in the uterus
i) auscultation of fetal heart
j) date mother reported quickening
k) measurement of fundal height
l) calendar date of conception/unprotected intercourse
m) size of uterus (by bimanual examination)a) auscultation of fetal heart
b) correlation of weeks gestation to fundal height
c) fetal activity and responsiveness to stimulation
d) palpation of fetal body partsC. Provides prenatal education and counseling for:
1. nutritional, and non-allopathic dietary supplement supportD. Recognizes and responds to potential prenatal complications by:
2. common complaints of pregnancy:a) sleep difficulties
b) nausea
c) preparation of the perineum
d) fatigue
e) inflammation of the sciatic nerve
f) breast tenderness
g) skin itchiness
h) vaginal yeast infections
i) symptoms of anemia
j) indigestion/heartburn/constipation
k) varicose veins
l) physical activities for labor preparation (e.g., movement and exercise)
m) sexual changes
n) emotional changes
o) fluid retention1. identifying pregnancy-induced hypertensionE. Establishes and follows emergency contingency plans for mother and/or newborn
2. assessing, educating and counseling for pregnancy-induced hypertension with:a) nutritional/hydration assessment3. identifying and consulting, collaborating or referring or:
b) administration of calcium/magnesium supplement
c) stress assessment and management
d) non-allopathic remedies
e) monitoring for signs and symptoms of increased severity
f) assessment of drug abuse
g) increased frequency of maternal assessmenta) preeclampsia4. identifying breech presentations
b) gestational diabetes
c) urinary tract infection
d) fetus small for gestational age
e) fetal inner-uterine growth retardation
f) thrombophlebitis
g) oligohydramnios
h) polyhydramnios
5. turning breech presentation with:a) alternative positions (tilt board, exercises)6. identifying multiple gestation pregnancies
b) non-allopathic methods
7. identifying and dealing with pre-term labor with:a) referral8. assessing and evaluating a post-date pregnancy by monitoring/assessing:
b) consultation and/or treatment including:i. increase of fluids
ii. non-allopathic remedies
iii. discussion of the mother's fears - emotional support
iv. food to be eaten at least every two hours
v. the consumption of an alcoholic beverage
vi. evaluation of urinary tract infection
vii. evaluation of other maternal infection
viii. bed rest
ix. pelvic rest (including no sexual intercourse)
x. no breast stimulation (including nursing previous baby)a) the need for consultation9. treating a post-date pregnancy by:
b) fetal movement, growth, and heart tone variability
c) estimated due date calculation
d) previous birth patterns
e) amniotic fluid volume
f) maternal tracking of fetal movement
g) referral for ultrasound referral for non-stress test
h) referral for contraction stress test
i) referral and collaboration for biophysical profilea) stimulating the onset of labor by encouraging:10. identifying and referring tubal pregnancyi. sexual/nipple stimulation
ii. assessment of emotional blockage and/or fears
iii. stripping the membranes
iv. cervical massage
v. castor oil induction
vi. non-allopathic therapies
vii. physical activity
11. identifying and referring ectopic pregnancy
12. identifying and referring placental abruption
13. identifying placenta previa by assessing for:a) painless bleeding14. identifying premature rupture of the membranes
b) identification by ultrasound results
15. managing premature rupture of the membranes in a full-term pregnancy by:a) monitoring fetal heart tones and movement16. consulting and referring premature rupture of the membranes in pre-term labor
b) monitoring vital signs for signs of infection
c) encouraging increased fluid intake
d) inducing labor consulting after 24 hours without labor progression
V. Labor, Birth and Immediate Postpartum (355 of Exam - 123 Examination items)
A. Facilitates maternal relaxation and provides comfort measure throughout labor by administering/encouraging:1. massageB. Evaluates and supports a laboring mother during the first stage of labor by assessing:
2. hydrotherapy (compresses, baths, showers)
3. warmth for physical and emotional comfort (e.g., compresses, moist warm towels, heating pads, hot water bottles, friction heat)
4. communication in a calming tone of voice, using kind and encouraging words
5. the use of music and/or silence
6. continued mobility throughout labor
7. response for pain with:a) differentiation between normal and abnormal pain
b) validation of the woman's experience/fears
c) counter-pressure on back
d) relaxation/breathing techniques
e) non-allopathic treatments
f) position changes1. maternal physical and emotional condition based upon assessment of:C. Demonstrates the ability to evaluate and support a laboring mother during the second stage of labor by:a) vital signs2. anterior/swollen lip by administering/supporting
b) food and fluid intake/output
c) dipstick urinalysis for ketones
d) status of membranes
e) uterine contractions for frequency, duration and intensity with a basic intrapartum examination
f) fetal heart tones
g) fetal lie, presentation, position and descent with:i. visual observationh) effacement, dilation of cervix and station of the presenting part, maternal dehydration and/or vomiting by administering:
ii. abdominal palpation
iii. vaginal examination(1) fluids by mouth
(2) ice chips
(3) oral herbal/homeopathic remedies
(4) deep immersion in warm watera) position change3. posterior, asynclitic position by encouraging and/or supporting:
b) light pressure or massage to cervical lip
c) warm bath
d) pushing the lip over the baby's head while the mother pushes
e) deep breathing and relaxation between contractions
f) non-allopathic treatmentsa) the mother's choice of position4. pendulous belly inhibiting descent by:
b) the use of various laboring positions such as:i. on side, with top leg up, bottom leg backc) physical activities (pelvic rocking, stair climbing, walking, etc.)
ii. on hands and knees
iii. knee/chest
iv. mother pulling up lower segment of uterus during contraction, while on hands and knees
v. standing, leaning forward with legs spread and knees bent (mother supported)
d) non-allopathic treatments
e) ice applied to back
f) rest or relaxationa) positioning semi-reclining on back5. labor progress by providing:
b) assisting the positioning of the uterus over the pelvisa) psychological support measures
b) nutritional support
c) non-allopathic treatments
d) physical activity
e) position change
f) perineal massage
g) rest
h) nipple stimulation1. waiting for the natural urge to pushD. Demonstrates the ability to recognize and respond to labor and birth complications such as:
2. encouraging aggressive pushing in emergency situations
3. allowing the mother to choose the birthing position
4. recommending position change as needed
5. massaging the perineum
6. supporting the perineum
7. encouraging the mother to touch the newborn during crowning
8. assisting in normal spontaneous vaginal birth with hand maneuvers (Ritgen maneuver) to assist delivery
9. providing an appropriate atmosphere for the moment of emergence
10. documenting labor and birth1. abnormal fetal hear tones and patterns by:E. Assesses the condition of, and provides care for the newborn by:a) providing additional oxygen2. cord prolapse by:
b) changing maternal position
c) facilitating quick delivery if birth is imminent
d) evaluating for consultation and referral
e) evaluating for transporta) changing maternal position to:3. variations in presentation such as:i. knee-chestb) activating emergency medical services/medical backup plan
ii. Trendelenburg
c) applying counter-pressure to the presenting part
d) placing cord back into vagina
e) keeping the presenting cord warm, moist and protected
f) monitoring FHT and cord for pulsation
g) increasing the mother's oxygen supply
h) facilitating immediate delivery, if birth is imminent
i) preparing to resuscitate the newborna) breech presentation4. management of meconium stained fluids by:
b) nuchal hand, arm presentationi. applying counter pressure to hand or arm and the perineumc) nuchal cord presentation
ii. sweeping arm outi. looping a finger under the cord, and sliding it over the newborn's faced) face and brow presentation
ii. looping a finger under the cord, and sliding it over the shoulder
iii. clamping the cord in two places, cutting the cord between the two clamps
iv. preparing to resuscitate the babyi. preparing for imminent birth by:e) multiple birth presentation and delivery(a) preparing resuscitation equipment
(b) preparing treatment for newborn bruising and swelling
(c) administering arnica
(d) positioning the mother in a squat
(e) performing an episiotomy if needed
(f) preparing for potential eye injuryi. shoulder dystocia repositioning should to oblique diameter
ii. repositioning the mother to:(a) hands and knees (Gaskin maneuver)iii. flexing he should s of newborn, then corkscrewing
(b) McRobert's position
(c) end of bed
(d) squat
iv. extracting the posterior arm
v. applying supra-pubic pressure
vi. applying gentle traction while encouraging pushing
vii. sweeping arm across newborn's face
viii. performing an episiotomy to allow the midwife to insert hand
ix. performing a pelvic press
x. fracturing the newborn's claviclea) eliciting the mother's cooperation to deliver the head quickly5. management of maternal exhaustion by:
b) instructing the mother to stop pushing
c) wiping out the inside of the baby's mouth
d) clearing the airway with suction of mouth and nose
e) preparing to resuscitate the babya) providing nutritional support
b) ensuring adequate hydration
c) providing non-allopathic treatments
d) evaluating the mother's psychological condition
e) encouraging rest
f) monitoring vital signs
g) monitoring fetal well-being
h) evaluating urine for ketones
i) evaluating for consultation and/or referral1. keeping the baby warmF. Assists in placental delivery and responds to blood loss by:
2. making initial newborn assessment
3. determining APGAR score at:a) 1 minute4. performing routine suctioning
b) 5 minutes
c) 10 minutes (as appropriate)
5. keeping baby and mother together
6. monitoring respiratory and cardiac function by assessing:a) the symmetry of the chest7. stimulating newborn respiration by:
b) the sound and rate of heart tones and respirations
c) nasal flaring
d) grunting
e) retractions
f) circumoral cyanosis
g) central cyanosis (check color)a) rubbing up the baby's spine8. responding to the need for newborn resuscitation by:
b) applying percussion massage for wet lungs
c) encouraging parental touch, and calling newborn's name
d) flicking or rubbing the soles of the baby's feet
e) placing baby in towel with hot water bottle or heating pad on top
f) rubbing skin with blanket
g) non-allopathic treatmentsa) administering several mouth-to-mouth breaths9. supporting the establishment of emotional bonds among the newborn, mother and family
b) applying positive pressure ventilation for 15-30 seconds
c) administering oxygen
d) consulting
e) transporting
10. clamping the cord after the cord stops pulsing
11. cutting the cord
12. caring for the cord including:a) evaluating the cord stump13. administering eye prophylaxis
b) collecting a cord blood sample
c) treating the cord stump with:i. alcohol
ii. non-allopathic remedies1. reminding the mother of the onset of third stage of laborG. Assesses general condition of mother and newborn by:
2. determining signs of placental separation such as:a) lengthening of cord3. facilitating the delivery of the placenta by:
b) separation gush
c) rise in fundus
d) contractions
e) urge to pusha) encouraging nursing4. after delivery, assessing the condition of the placenta
b) draining the cord
c) positioning mother on the toilet
d) changing the mother's position
e) administering non-allopathic treatments
f) manually removing the placenta
g) performing guarded cord traction
5. estimating the amount of blood loss responding to a trickle bleed by:a) assessing the origin of the blood6. responding to postpartum hemorrhage with:
b) responding to uterine bleeding by:i. nipple stimulation/breastfeedingc) responding to vaginal tear and bleeding with:
ii. fundal massage
iii. assessment of fundal height and uterine size
iv. non-allopathic treatments
v. administration of medication
vi. expression of clots
vii. emptying the bladder
viii. assessment of vital signsi. application of direct pressure on tear
ii. suturing
iii. continued assessment of blood color and volume
iv. non-allopathic treatmentsa) fundal massage7. manually removing placenta fragments and/or retained membranes with a sterile, gloved hand
b) external bimanual compression
c) internal bimanual compression
d) manual removal of clots
e) administration of medication
f) non-allopathic treatments
g) maternal focus on stopping the bleeding: tightening the uterus
h) administration of oxygen
i) administration of intravenous fluids
j) treatment for shock
k) consultation and/or transfer
l) activation of medical emergency backup plan
m) preparation to increase post-partum care1. assessing for bladder distention
2. encouraging urination
3. performing catheterization
4. assessing lochia
5. assessing the condition of vagina, cervix and perineum for:a) cystocele6. repairing the perineum by:
b) rectocele
c) hematoma
d) tears
e) lacerations
f) hemorrhoids
g) bruisinga) referring for repair7. providing instruction for care and treatment of the perineum
b) administering a local anesthetic
c) performing basic suturing of:i. 1st degree tearsd) providing alternate repair methods (non-suturing)
ii. 2nd degree tears
iii. labial tears
8. facilitating breastfeeding by assisting and teaching about:a) positioning for mother and baby9. assessing gestational age
b) skin-to-skin contact
c) latching on
d) adequate maternal hydration
e) adequate maternal nutrition
f) adequate maternal rest
g) feeding patterns
h) maternal comfort measures for engorgement
i) letdown reflex
j) milk expression
VI. The Postpartum Period: (15% of Exam - 54 Items)
A. Completes the birth certificateVII. Well-Baby Care: (5% of Exam - 16 Items)B. Provides contraceptive/family planning education and counseling
C. Performs post partum reevaluation of mother and baby at:
1. day-one to day-twoD. Assesses for, and treats jaundice by:
2. day-three to day-four
3. one to two weeks
4. three to four weeks
5. six to eight weeks
6. assesses for:a) post partum-subjective history
b) lochia
c) return of menses
d) systems function
e) breastfeeding, condition of breasts and nipples
f) muscle prolapse of vagina and rectum (cystocele, rectocele)
g) strength of pelvic floor
h) condition of the uterus, ovaries and cervix
i) condition of the vulva, vagina, perineum and anus1. administering non-allopathic remedies to nursing motherE. Provides direction for care of circumcised penis
2. administering non-allopathic remedies to baby
3. encouraging mother to breastfeed every two hours
4. exposing the front and back of newborn to sunlight through window glass
5. assessing baby for lethargy
6. consulting or referringF. Provides direction for care of uncircumcised penis
G. Treats thrush on nipples by encouraging/administering:
1. drying nipples after nursingH. Treats sore nipples with:
2. changing the pH of nipples by using non-allopathic remedies
3. rinsing nipples before next nursing1. application of lanolinI. Treats mastitis by:
2. exposure to the air
3. suggestions for alternate nursing positions
4. evaluation of the baby's sucking method
5. suggestion to use a nursing brassiere
6. application of expressed milk1. providing immune system support including:a) nutrition/hydration2. encouraging multiple nursing positions
b) vitamins
c) non-allopathic remedies
3. applying herbal compresses
4. applying warmth, soaking in tub or by shower
5. encouraging adequate rest/relaxation
6. wearing brassiere
7. assessing for signs and symptoms of infections
8. teaching mother to empty breasts at each feeding
9. providing/teaching gentle massage of sore spots
10. consulting/referring to:a) La Leche League
b) lactation counselor
c) other healthcare providers
A. Provides well-baby care during the first two - six weeksB. Assesses the general health and appearance of baby including:
1. temperatureC. Provides treatment of skin conditions such as:
2. heart rate, rhythm and regularity
3. respirations
4. weight
5. length
6. measurement of circumference of head
7. neuro-muscular response
8. level of alertness
9. wake/sleep cycles
10. feeding patterns
11. urination and stool for frequency, quantity and color
12. appearance of skin
13. jaundice
14. condition of cord1. diaper rashD. Provides treatment of thrush
2. cradle capE. Provides treatment for colic