NARM Candidate Information Bulletin (CIB)

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Table of Contents

• General Information
• Eligibility Requirements
• NARM Policy Statement on Preceptor/Student Documentation
• Written Examination Administration Schedule
• Candidates Who Are Taking the NARM Written Examination for State Recognition
• NARM CPM Candidates
• Skills Assessment Administration
• The NARM Written Examination
• Special Testing Needs
• NARM Written Examination Test Sites
• Examination Site Conduct/Nondisclosure (Test Security)
• Answer Sheets
• Candidate’s Examination Scores
• Rescheduling a CPM Examination
• Retesting for Failing Candidates
• Candidate’s Right to Appeal Eligibility Requirements
• Candidate’s Right to Appeal
• Examination Comment Form
• Refunds
• The Demonstration of Knowledge and Skills
• Suspension or Revocation of Application
• Revocation of Certification
• Recertification
• NARM Policy on Recertification and Inactive Status
• Fee Schedule
• Study Suggestions for Candidates Preparing for the Written Examination
• Test Specifications
• Written Test Specifications
• Example Questions Written
• Reference Lists
• Skills Assessment Test Specifications
• Skills Assessment Reference Text
• Example of an Assessed Skill
• MANA Core Competencies
• Guidelines for Informed Consent, by Suzanne Suarez, RN, BSN, JD
• Peer Review Process
• Grievance Mechanism
• Grievance Mechanism Flow of Activity
• CPM Practice Guidelines
• Appendix A
• Glossary
• Directory

General Information

Through Certified Professional Midwife (CPM) Certification, the North American Registry of Midwives (NARM) seeks to advance the profession of midwifery, to promote the Midwives Model of Care, and to facilitate its integration as a vital component of the health care system.

This Candidate Information Bulletin was designed to aid candidates in preparing for NARM’s Certified Professional Midwife certification process. The Certified Professional Midwife (CPM) process has two steps: educational validation and certification.

Step 1 – Educational Validation

The Certified Professional Midwife (CPM) may be educated through a variety of routes, including programs accredited by the Midwifery Education Accreditation Council (MEAC), the American College of Nurse Midwives Department of Accreditation (ACNM-DOA), apprenticeship education, and self-study. If the midwife’s education has been validated through graduation from a MEAC-accredited program; certification by the ACC as a CNM/CM; or legal recognition in a state listed in NARM’s State Educational Equivalency list, the midwife may submit that credential as evidence of educational evaluation, and may apply to take the CPM examination. If the midwife is preceptor-trained or received education outside of the United States,
s/he must complete the NARM Portfolio Evaluation Process (PEP).

The NARM Portfolio Evaluation Process (PEP) involves documentation of midwifery training under the supervision of a preceptor. (Please see NARM’s How To Become a CPM brochure for explanation of NARM’s PEP Program, as well as for the definition of a preceptor and the requirements for preceptor training.) Upon successful completion of the documentation portion of PEP Program, the applicant must successfully complete the NARM Skills Assessment Examination. Then the applicant will be issued a Letter of Completion that can be submitted to NARM’s Application Department as validation of midwifery education.

Step 2 - Certification

When the applicant has completed one of the approved educational routes of entry, the applicant may then apply to become a Certified Professional Midwife (CPM), and take the NARM Written Examination.

The Written Examination consists of 350 multiple-choice questions. This examination is administered in two 4-hour sessions, with a 1-hour break in between. The NARM Written Examination is the final step in the CPM certification process. This examination is also administered as the final part of national and international legal recognition processes.

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Eligibility Requirements

The CPM eligibility requirements are outlined in the How To Become A Certified Professional Midwife (CPM) brochure.

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NARM Policy Statement on Preceptor/Student Documentation

In validating the apprenticeship as a valuable form of education and training for midwifery, NARM appreciates the many variations in the preceptor/student relationship. In upholding the professional demeanor of midwifery, it is important that each party in the relationship strive to maintain a sense of cooperation and respect for one another. While some preceptor/student relationships develop into a professional partnership, others are brief and specifically limited to a defined role for each participant.

To help NARM candidates achieve exceptional training and a satisfactory relationship from their education, NARM makes the following recommendations:

1) A preceptor for a NARM candidate must be a nationally certified midwife (CPM, CNM, or CM); or legally recognized in a jurisdiction, province, or state as a practitioner who specializes in maternity care; or a midwife practicing as a primary attendant without supervision for a least 50 out-of-hospital births and a minimum of three years.

2) The clinical components of the education should include didactic and clinical experience. The clinical component must be at least one year in duration, and equivalent to 1350 clinical contact hours under supervision.

3) It is acceptable, even preferable, for the student to study under more than one preceptor. In the event that more than one preceptor is responsible for the training, each preceptor will sign off on those births and skills, which were adequately performed under the supervision of that preceptor. Each preceptor must also sign the Preceptor Verification Form (202) in the CPM Application Packet. The student should make multiple copies of all blank forms so that each preceptor will have a copy to sign.

4) The preceptor and student should have a clear understanding of the responsibilities of each person to the other, including the time expected to be spent in one-on-one training, classroom or small group study, self-study, clinical observation, opportunities for demonstration of skills, time on call, and financial obligations. An understanding should exist concerning the termination of the relationship by either party and the responsibilities of each in such an event. It may be helpful for this information to be written and signed by each party.

5) The student, if at all possible, should have the NARM application at the beginning of the apprenticeship, and should have all relevant documentation signed at the time of the experience rather than waiting until the completion of the education.

6) Preceptors are expected to sign the application documentation for the student at the time the skill is performed competently. Determination of “adequate performance” of the skill is at the discretion of the preceptor, and multiple demonstrations of each skill may be necessary. Documentation of attendance and performance at births, prenatals, postpartums, etc., should be signed only if mutually agreed that expectations have been met. Any misunderstanding regarding expectations for satisfactory completion of experience or skills should be discussed and resolved as soon as possible. The preceptor may also be asked to furnish NARM with additional documentation, such as client charts, for the births listed on the student’s NARM application.

7) The preceptor is expected to provide adequate opportunities for the student to observe clinical skills, to discuss clinical situations away from the clients, to practice clinical skills, and to perform the clinical skills in the capacity of a primary midwife, all while under the direct supervision of the preceptor. This means that the preceptor should be physically present when the student performs the primary midwife skills. The preceptor holds final responsibility for the safety of the client or baby, and should become involved, whenever warranted, in the spirit of positive education and role modeling.

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Written Examination Administration Schedule

The NARM Written Examination is administered three times a year, as follows:

• 3rd Wednesday in February
• 3rd Wednesday in August
• At the annual MANA Convention in the fall

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Candidates Who Are Taking the NARM Written Examination for State Recognition

Many states use the NARM Written Examination as part of their process for state recognition. In these states, midwives who are already CPMs may have a simplified route to legal recognition. Midwives who are not yet CPMs must meet the licensure criteria for the specific state, and will register for the NARM examination through their state agency. After passing the NARM examination and receiving state licensure, the midwife may apply for CPM certification through the “Midwives from States with Legal Recognition” category if their state is listed.

If you are a candidate from a state with legal recognition who is planning to take the NARM Written Examination through the state agency, the following information applies:

1) The state agency will determine which candidates are eligible to take the NARM Written Examination. All documentation for eligibility is processed through the state agency. When the candidate has met the eligibility requirements, s/he will receive a packet of information from the state agency, which will include:

a) The Candidate Information Bulletin (which includes the study outline and reference list).

b) The candidate application form to register for the NARM Examination

2) The candidate must send the application form and appropriate fee as instructed by the agency. Some states collect the applications and the fees, and other states ask the candidate to send the application and fee directly to NARM. If the fee is sent directly to NARM, it must be in the form of a certified check or money order. NARM does not accept personal or business checks.

3) If you want to verify that you are registered for the examination through the agency, please contact your state agency. In the cases where the applications and fees have been sent directly to NARM, NARM will notify the state agency of those who have registered for the examination. In either case, verification is done through the state agency.

4) The state agency arranges for the location of the examination as well as for any special testing needs. To verify the location where your examination will be given, contact your state agency. The NARM examination is given on the SAME DAY at all locations, whether administered by the agency or by NARM. The test dates are the third Wednesdays of February and August of every year. The examination is given in two parts, with four hours allotted for each part. Part One begins at 8:00 am and Part Two at 1:00 pm. There is a one-hour break for lunch.

5) You must receive an ADMISSION LETTER from your state agency prior to the examination. This letter will confirm the time, date, and location of the examination. The letter will instruct you to bring the letter, with a passport-type (head and shoulders) photo attached, to the examination site. You must have the letter, with photo attached, to be admitted to the examination. You will also be asked to show another form of photo ID for verification, such as a driver’s license.

6) The results of the NARM Written Examination will be sent directly to the state agency within 3-4 weeks of the test date. The agency will notify the candidates of the results. When permitted by the agency, NARM will send the results directly to the candidate.

7) The NARM Written Examination is also given a third time each year, at the location and date of the annual MANA conference. Agency candidates are welcome to test at the MANA conference, which is usually in the fall. Eligibility and registration will still be done through the state agency.

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NARM CPM Candidates

Sequence of Application and Testing Procedures

For Educational Validation:

1) Order your NARM Application

2) You will need two photos of yourself. These should be head and shoulders photos, similar to a passport photo. One photo is submitted with your Application, and one will be submitted later when you take the NARM Written Examination for certification

3) Submit the appropriate application materials with the required fee to the NARM Applications Department. The application is color coded according to routes of entry, such as Entry Level, MEAC Graduates, State Licensed, and Special Circumstances. All candidates should fill out General Form 100 and the specific pages for their route of entry. You will receive notification that your application materials have been received.

4) If you have submitted the PEP application and your application is approved, you will receive a Skills Assessment Intent Form and a list of Qualified Evaluators (QEs). You will schedule your Skills Assessment with the QE and send your Intent Form to the NARM Test Department. You will receive an Admission Letter and instructions for the Skills Assessment. To prepare for the Skills Assessment, study the Skills Test Specifications in the CIB, and the Practical Skills Guide for Midwifery. After you have successfully completed the Skills Assessment, you will receive a letter of completion of NARM’s PEP Program.

For CPM Certification:

5) All candidates should submit the CPM application along with Verification of Education (PEP Certificate, MEAC diploma or transcript, ACC certification, or state license) along with the Certification fee. The application, documentation, and fee should be sent to the NARM Applications Department

6) When the CPM application is approved, you will receive a NARM Written Examination Intent Form which lists the dates and sites for the Examination. Choose your test site and date and submit the Intent Form to the NARM Test Department. You will receive acknowledgment of receipt of your Intent Form. Approximately 2-3 weeks prior to the Written Examination, you will receive an Admission Letter and directions to the test site.

7) If you cancel or change your testing date after submitting the Intent Form but prior to ten days before the test date, there is a $100 fee to reschedule your examination. If you change or cancel your test within ten days of the examination, or if you do not show for your examination, you must pay the retake fee to be rescheduled for the examination.

8) The Test Department will send results of the NARM Written Examination by mail 3-4 weeks after the testing date.

9) When you have passed the NARM Written Examination, you will receive CPM Certification from the NARM Applications Department.

Please send your application and intent forms to the appropriate NARM address. Failure to do so may result in a delay of your application or your examinations. If you are unsure of the next step in your process, you may call NARM General Information at 1-888-842-4784. All applications are subject to random audit.

Relevant addresses and phone numbers appear on the last page of the Candidate Information Bulletin.

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Skills Assessment Administration

When the PEP application has been evaluated and approved, the candidate will be sent information about the Skills Assessment, including a Skills Assessment Intent Form and a list of Qualified Evaluators.

• The candidate chooses a Qualified Evaluator (QE) from the list. The QE may not have an educational or preceptor/mentor history with the candidate, nor have attended more than five births with the candidate.
• The candidate is responsible for providing models for the hands-on assessment, though the QE may assist in this arrangement if necessary.
• The candidate is responsible for providing the equipment needed for the Skills Assessment.
• The candidate will submit the Skills Assessment Intent Form to the NARM Test Department four weeks prior to the test date.
• The NARM Test Department will send a confirmation letter to the Qualified Evaluator.
• The NARM Test Department will send the candidate an Admission Letter, confirming the test time, date, and location. This Admission Letter must be brought to the test site. The QE will verify the candidate’s identity with a photo ID such as a Driver’s License, or other governmental, institutional, or employer-issued photo identification.
• The candidate will receive a list of equipment to bring to the test site. See Appendix A.
• The candidate should prepare for the Skills Assessment by studying the Practical Skills Guide for Midwifery, the test specifications for the skills examination in the Candidate Information Bulletin, and by practicing competent use of all equipment on the equipment list.
• The candidate will be notified in writing of the results of the Skills Assessment within four weeks of the assessment. The candidate will then be issued a Letter of Completion of NARM’s Portfolio Evaluation Process (PEP).

A Qualified Evaluator may not have an educational history or preceptor/mentor history with the applicant. The candidate and QE may not have attended more than five births together at any time (before, during, or after the training period.) Non-accredited schools may not provide Qualified Evaluators who are employees of that institution.

NARM Policy on Financial Reimbursement for the Skills Assessment:

The fees paid to NARM for the PEP Application cover the costs of processing and evaluating the application and for the administration of the Skills Assessment by a NARM Qualified Evaluator (QE).

The QE is paid a fee by NARM for administering the Skills Assessment. The candidate does not pay any fee directly to the QE for administering the Skills Assessment. However, the candidate may reimburse the QE for any travel expenses incurred if the QE has to travel out of town to the Skills Assessment site. It is recommended that the candidate reimburse the QE up to .36 cents per mile for car travel, which may be documented or estimated by the QE. Reimbursement for airline travel, meals, and lodging may also be offered, if appropriate. The candidate may avoid this extra cost by traveling to the QE for the Assessment.

A pregnant mother and a newborn baby are required as models for the demonstration of some of the skills. The candidate may seek volunteers as models through her own resources, or may ask the QE to provide models if the candidate is traveling to a site where she has no resources for models. The candidate may provide compensation to the models for their time, travel, or miscellaneous expenses such as babysitting. This is especially appropriate if the models are arranged by the QE and are not friends or clients of the candidate. It is recommended that the compensation to each model not exceed $25.00.

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The NARM Written Examination

• Candidates must submit the General Application Form 100, the CPM Application Form, and one of the following forms of documentation:
  • Notarized copy of diploma, or transcript with the school insignia, indicating graduation from a MEAC-accredited program.
  • Notarized copy of current ACC CNM/CM certificate.
  • Notarized copy of current state endorsement process, i.e. certification, licensure, registration, or documentation indicating legal recognition in states previously evaluated for educational equivalency (see the How To Become a CPM brochure for a list of states, or call 1-888-842-4784 for current listings).
  • Letter of completion of NARM’s Portfolio Evaluation Process (PEP) (see the How To Become a CPM brochure for a description of NARM’s PEP Program).
• Candidates will receive a Written Examination Intent Form, listing upcoming dates and locations for the Written Examination.
• Candidates must submit the Written Examination Intent Form to the NARM Test Department at least four weeks prior to the test date.
• Candidates will receive confirmation of receipt of their Intent Form.
• Candidates will receive a Written Examination Admission Letter, which will include the date, time, and location of their scheduled Written Examination, and directions to the test site. The candidate should receive this information two weeks prior to the examination. If you have not received your Admission Letter by the appropriate time, please notify the Test Department at 1-888-353-7089.
• Candidates must bring their Admission Letter and a small head and shoulders photo (like a passport photo) to the test site. Another photo ID, such as a Driver’s License, governmental or institutional identification, must be shown to verify both name and picture. The small passport photo should be stapled to the Admission Letter. The Admission letter will be signed by both the candidate and proctor and will be retained by the proctor and returned to the NARM Test Department.

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Special Testing Needs

The NARM Certified Professional Midwife (CPM) Certification Program, in accordance with the Americans with Disabilities Act (ADA), provides testing accommodations for candidates with disabilities. These accommodations are made at no cost to the candidate. Requests for special testing accommodations must be made in writing to the NARM Test Department and must contain the following information:

1) A letter from the candidate describing the requested accommodation; and

a) Documentation of a history of special accommodations for testing, such as letters from schools or testing agencies administering standardized tests indicating the accommodations granted; or

b) A report from an appropriate licensed or certified healthcare professional who has made an assessment of the candidate’s disability. The report must describe the tests and other assessment techniques used to evaluate the candidate, provide test results, indicate the test results that were out of normal range, and contain conclusions and recommendations for special accommodations based on those findings.

These documents must be submitted to the NARM Test Department with the Written Examination Intent Form. Although every effort will be made to arrange for the accommodation at the candidate’s choice of test sites, this cannot be guaranteed. The candidate may be asked to choose an alternate test site or date based on the ability of the test department to arrange special accommodations.

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NARM Written Examination Test Sites

The NARM Written Examination is given at regional test sites across the country on the third Wednesday of February and August; and on the site and date of the annual MANA conference. Listed below are the regional test sites that are usually available. A current list of test sites will be on the Written Examination Intent Form, which is sent to each candidate after approval of the Certification Application.

Regional Test Sites:

Oakland, California		Orlando, Florida
Boise, Idaho		Dubuque, Iowa
Baltimore, Maryland		Pittsfield, Massachusetts
Eugene, Oregon		Nashville, Tennessee
El Paso, Texas		Salt Lake (Murray), Utah
St. Johnsbury, Vermont		Charlottesville, Virginia

The following states administer the NARM Written Examination for licensure and will sometimes allow CPM candidates from other jurisdictions to take the examination at their agency location. Please contact the NARM Test Department if you are interested in taking the examination at one of these locations:

Juneau, Alaska		Phoenix, Arizona
Little Rock, Arkansas		Sacramento, California
New Orleans, Louisiana		Helena, Montana
Santa Fe, New Mexico		Columbia, South Carolina
Austin, Texas		Olympia, Washington

Candidates may also take the NARM Written Examination as a pre-conference activity on the Thursday prior at the annual MANA Conference, which is usually held in the fall. For more information on the MANA conference test site and date, call the NARM Test Department at 1-888-353-7089.

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Examination Site Conduct/Nondisclosure (Test Security)

The Examination Administrator or QE is NARM’s designated agent in maintaining a secure and valid examination administration.

Any individual found by NARM to have engaged in conduct, which compromises or attempts to compromise the integrity of the examination process will be subject to legal action as sanctioned by NARM. Any individual found cheating on any portion of the examinations will have their scores withheld or declared invalid, and their certification may be denied or revoked. Conduct that compromises or attempts to compromise the examination process includes:

• Removal of any examination materials from the examination room
• Reproducing or reconstructing any portion of the Written or Skills Assessment Examinations
• Aiding by any means in the reproduction or reconstruction of any portion of the Written or Skills Assessment Examinations
• Selling, distributing, buying, receiving, or having unauthorized possession of any portion of the Written or Skills Assessment Examinations
• Disclosure of any kind or manner of any CPM examinations
• Possession of any book, notes, written or printed materials or data of any kind other than those examination materials distributed by the Examination Administrator or QE during the examination administration
• Conduct that violates the examination process, such as falsifying or misrepresenting education credentials or prerequisite experience required to qualify for CPM Certification
• Impersonating a candidate or having an impersonator take the CPM examinations

Any violation of conduct as listed above will be documented in writing by the Examination Administrator or QE and will be presented to NARM for consideration and action.

Additionally, to protect the validity and defensibility of the examination process for all candidates, each candidate will be required to sign an Affidavit of Nondisclosure prior to taking any portion of the CPM examinations.

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Answer Sheets

All answers must be recorded on the answer sheet that is provided to the candidate at the beginning of the Written Examination administration. Do not write in the examination booklets. Any answers recorded in the examination booklet will not be scored.

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Candidate’s Examination Scores

• All candidate scores will be reported as pass or fail based on the cut score derived using a reverse Angoff method.
• Passing candidates will not receive a breakdown of their scores; they will only receive notification that they passed.
• Failing candidates will receive a report, which highlights their performance on major areas of the examination.
• In cases where candidates apply through a licensing agency, the examination results will be sent directly to the agency.
• Scores will usually be reported within 3 to 4 weeks of the examination date.
• Examination scores will NOT be given to any candidate over the phone.
• No credit is given for items with more than one response selected.
• The candidate’s answer sheet is machine-scored. Therefore, candidates are advised to explicitly follow all instructions given by the Examination Proctor for marking their answer sheets.

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Rescheduling a CPM Examination

Candidates electing to cancel their scheduled examination date must submit a written rescheduling request to the NARM Test Department. The NARM Test Department must receive the request ten days in advance of the candidate’s scheduled examination date. The candidate must reschedule the examination within one (1) year from submitting the CPM Certification application. The candidate will be charged a processing fee for rescheduling as outlined in the Fee Schedule. The remainder of the candidate’s initial examination fees will be applied towards the rescheduled examination.

• Candidate rescheduling requests that are not received by the NARM Testing Department ten days in advance of a scheduled examination date will result in the forfeiture of the candidate’s entire examination fee.
• If a candidate does not reschedule within the allowed timeframe or does not appear at a scheduled examination site, all examination fees will be forfeited; in which case the candidate will be required to pay the full examination fee prior to rescheduling another examination date.
• It is the candidate’s responsibility to contact the NARM Testing Department to request a rescheduled examination date.
• If a Qualified Evaluator is forced to cancel a candidate’s scheduled Skills Assessment Examination date, the examination will be rescheduled as soon as possible and at no penalty to the candidate.
• It is the candidate’s responsibility to obtain models AND back-up models for the Skills Assessment Examination. If a candidate’s model does not appear at the scheduled test site, and the candidate does not have a back-up model, the candidate will forfeit the examination fees.
• If any portion of the CPM examination is canceled due to events such as postal strikes, bad weather, or conditions beyond our control, the examination date will be rescheduled as soon as it is reasonably possible. The candidate will not be penalized for such an event.

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Retesting for Failing Candidates

If a CPM candidate fails either the Written or Skills Assessment Examinations, s/he will receive a Retake Intent Form from the Test Department. The candidate will be allowed to schedule a retest upon payment of a retake fee as outlined in the Fee Schedule. Failing candidates will not be retested using the same form of the examination they were given initially. However, they may be assigned the same Examination Administrator or QE.

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Candidate’s Right to Appeal Eligibility Requirements

• A Candidate who does not meet requirements for certification will be informed in writing. The candidate will have an opportunity to provide the missing information, or to write a letter of appeal.
• All appeals must be received in writing within (2) months of denial and will be processed according to policy.

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Candidate’s Right to Appeal

Comments on Examination Content

Candidates may provide written comments on the CPM Written Examination content. Comments may be submitted on the day of the test by completing an examination comment form and giving it to the examination administrator (proctor). Examination comment forms will be available from the examination administrator. Comments may also be submitted by mail to the NARM Test Department. Comments submitted by mail must be postmarked no later than seven (7) days after the test date to be considered as part of the appeals process. NARM will carefully consider all comments. If appropriate, changes will be made to the CPM Written Examination answer key.

Appeals

A candidate with a complaint about the certification process or examination may write a letter to the NARM Test Department. Letters appealing the content of the Written Examination must include or reference previously submitted examination comments as defined above. All appeals must be made prior to receipt of a pass/fail grade. NARM will carefully consider all comments. A written response will be provided only if the candidate has requested a response and has specifically proposed content, examination, or process changes.

Examination Hand Scoring

Candidates who fail the CPM Written Examination may submit a written request for hand scoring of their answer sheets within thirty (30) days of the postmark date of their examination results. A hand-scoring fee, as outlined in the Fee Schedule, must accompany the written request for hand scoring. Candidates will be notified of the outcome of the hand scoring within thirty days of the receipt of the request.

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Examination Comment Form

NARM encourages all candidates to submit comments on the CPM examination process at the time of their examination. The Examination Administrator or QE will have examination comment forms available on the day of the examination. NARM will not provide a written response to the comments unless a letter of appeal is written in addition to the comment form (see Candidate’s Right to Appeal).

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Refunds

• Refunds are not given to candidates who submit incomplete applications, or who fail the examinations.
• A partial refund of the PEP Application fee may be considered under extenuating circumstances. The candidate must request a partial refund in writing to the NARM Board, explaining why the process cannot be completed, and must be accompanied by supporting documentation. The request must be submitted within two months of approval of the application and prior to the submission of the Skills Assessment Intent Form. No refunds will be given outside of these parameters.
• A partial refund of the Certification fee may be considered if the candidate has not been scheduled for the Written Examination. The candidate must request a partial refund in writing to the NARM Board, explaining why the process cannot be completed, and must be accompanied by supporting documentation. The request must be submitted prior to the submission of the Written Examination Intent Form and within six months of approval of the certification application. No refunds will be given outside of these parameters.
• Supporting Documentation includes written evidence of circumstances that have arisen following the submission of the Application, which prohibit or severely limit the candidate’s ability to complete the remainder of the process.
• Refunds granted by the NARM Board will be prorated according to the processing of the application, with a minimum of $300 retained for processing fees.
• Candidates who receive a refund and later decide to reapply must pay all fees current at the time of reapplication.

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The Demonstration of Knowledge and Skills

Identification of the knowledge and skills necessary for certification is based on the actual practice of midwifery, and not on a specific set of protocols or regulations. The knowledge tested on the Written Exam and the skills tested on the Skills Assessment are identified from the Job Analysis. The Job Analysis is a survey of the current practice of midwives across the country. From this list come the test specifications for each exam. Many midwifery schools base their curriculum on these test specifications so that their graduates will be prepared for the certification exams. The skills checklist portion of the Portfolio Evaluation Process is also based on this list, so midwives training through a preceptor will also learn and demonstrate the same skills. This process assures that all CPMs, regardless of path of education or experience, will demonstrate competency in the same skills. NARM does NOT specify how a CPM will utilize the knowledge and skills in actual practice. In other words, NARM does not issue standardized practice protocols. NARM does require that each CPM candidate have practice protocols in writing and utilize informed consent in communicating the protocols to the clients.

The legal regulation of midwives varies in each state. Midwives practice completely unregulated in many states, and in other states they practice according to very specific protocols set by the state. In some states they are permitted to use emergency medications, or suture tears, or give oxygen. In other states, they may be forbidden from any of these procedures. The CPM credential verifies that the midwife knows these skills whether or not s/he chooses (or is allowed) to perform them. States that require the CPM credential for licensure are assured that every CPM has been through a rigorous process to verify knowledge and skills. The CPM is the standard for the knowledge and skills, regardless of the individual circumstances in which the CPM practices.

CPM candidates sometimes comment on the written exam questions or on skills tested on the assessment that they are not “allowed” to make that choice based on their state regulations. NARM does not say that the midwife must base protocols on that knowledge or include that skill in practice, but must demonstrate the knowledge or skill for purposes of national certification. NARM questions are based on the test specifications and are referenced to the bibliography listed in the Candidate Information Bulletin. Candidates should base their answers and demonstration of skills on the test specifications in the CIB, and not on specific individual or state protocols.

Passing the NARM Written Examination or the NARM Skills Assessment depends on receiving a minimum number of correct answers. Leaving a question blank or refusing to perform a specific assessment skill does not automatically result in failing the examination, but will affect the total score. Each question on the Written Examination is worth one point, but each skill on the Skills Assessment may count for several points. Refusing to perform a skill can cause you to fail the assessment and delay progress toward certification. Failing candidates must pay an additional fee to retake either examination.

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Suspension or Revocation of Application

The NARM Certified Professional Midwife application process may be suspended or terminated for any of the following reasons:

• If an applicant is found guilty of dishonesty, refusal to inform, negligent or fraudulent action in which the midwife compromised the well being of a client or a client’s baby;
• Compromising or attempting to compromise the integrity of the examination process;
• Cheating on any portion of the examinations;
• Falsification of Application information.

The NARM Board, in consultation with their testing company and legal consultant, will set criteria for possible reapplication.

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Revocation of Certification

The NARM Certified Professional Midwife credential may be revoked for the following reasons:

• Falsification of Application information.
• Failure to participate in the Grievance Mechanism or to abide by the conditions set as a result of the Grievance Mechanism.
• Infractions of the Non-Disclosure policy, which threaten the security of the NARM Examinations.
• If the Grievance Mechanism determines that the CPM acted with dishonesty, did not use appropriate informed consent with the client, or that negligent or fraudulent actions compromised the well being of a client or client’s baby, the CPM credential must be revoked.

Midwives with revoked certificates may reapply for certification after two years. Prior to recertification all outstanding complaints must be resolved, including completion of previous Grievance Mechanism requirements.

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Recertification

• Certification renewal is due every three years.
• Recertification forms are sent with the initial certification and with each recertification, and are also available on the NARM web site at www.narm.org.
• Thirty (30) Continuing Education Contact Hours (3.0 CEUs) are required during the three-year period.
• One Contact Hour is defined as fifty-five (55) clock minutes of time. To be awarded .5 (half) Contact Hours the time period is thirty (30) minutes to fifty-five (55) minutes. Less than 30 contact minutes will not be awarded Continuing Education Contact Hours.
• All recertifications are subject to random audit.

Mandatory Areas

A. Peer Review—5 Contact Hours Participates in Peer Review and/or Attends Peer Review Workshop

B. Current Adult CPR and either infant CPR or Neonatal Resuscitation

C. Affirmation of current use of Informed Consent

D. Demographic information

Two Options for Recertification

1. Mandatory Areas + 25 Contact Hours from a mixture of Categories

2. Mandatory Areas + retaking the NARM Written Examination

Continuing Education Categories

Category 1 (maximum-25 Contact Hours) MEAC, ACNM, BRN, ACOG, Lamaze International and ICEA are examples of approved sources for Continuing Education Contact Hours.

Any class or course work related to women’s health or midwifery that is granted contact hours in a health profession is eligible for this category.

Category 2 (maximum-10 Contact Hours)

Course work or classes in women’s health and midwifery, or in related fields that are not otherwise approved for Contact Hours.

Category 3 (maximum-15 Contact Hours)

Documented research in the field of midwifery, women’s health or related fields.

A. Each project will be granted 10 Contact Hours.

• Articles, thesis, creation of modular course work based on research.

B. Each project will yield 5 Contact Hours

• Writing as a contributing author in a larger work for publication.
• Writing technical or experience based articles intended for publication

C. Teaching classes or facilitating course work related to midwifery or women’s health. Each hour of teaching earns one hour of contact hour credit.

Category 4 (maximum-10 Contact Hours)

Document self study or life experience in the field of midwifery, women’s health or related fields on the form provided. One contact hour equals one contact hour.

Category 5 (maximum-5 Contact Hours)

Serving as a NARM QE, item writer, or a NARM subject matter expert, or participant in NARM’s Accountability Processes

Category 6 (maximum-9 Contact Hours)

Filing MANA Statistics Forms

3 Contact Hours for every 30 MANA Statistics forms

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NARM Policy on Recertification and Inactive Status

CPMs who wish to go on inactive status must:

• declare inactive status within 90 days of expiration date
• submit $35 each year to continue inactive status

Midwives who are listed as inactive:

• will receive CPM News and other NARM mailouts
• are bound to all policies regarding Peer Review and the Grievance Mechanism
• may NOT identify themselves as a CPM

Within the six year period of inactivity, the CPM may become recertified at any time by paying the $150 recertification fee, and submitting the Recertification Application and requirements for one recertification cycle (thirty contact hours, including five hours of peer review) from any of the categories defined in the Recertification Application. After six years of inactive status, the certification status will automatically become expired.

The CPM’s name will not be given to prospective clients. Inquiries about the status of a midwife will be answered that the CPM has been certified but is currently inactive.

Expired CPMs

A CPM will be considered expired:

• if she/he is more than 90 days past recertification deadline without declaring inactive status, or
• at the end of six years of inactive status.

Recertification after Expired Status

Should an expired CPM decide to reactivate certification she/he will be required to:

• attend five births
• order the Reactivation package ($50)
• submit evidence of 30 contact hours, including 5 hours of peer review as defined in the Reactivation packet
• meet reactivation requirements, including currency*, peer review, CPR, and CEUs
• submit Reactivation fee (includes exam)

*The births and the contact hours must have occurred within five years of reapplication.

To reactivate from an expired status, the midwife will be required to retake the NARM Written Examination. The NARM Written Examination will be scheduled after the application is received. The fee for reactivation, including the Written Examination, will be the current CPM application fee.

This policy takes effect January 1, 2004.

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Fee Schedule

All fees must be submitted by certified check or money order; personal or business checks will not be accepted.

All fees are subject to change without notice.

Application Fee	$ 50
Portfolio Evaluation Fee	$ 700
Certification Fee	$ 700
Retake Fee (Written Examination)	$ 400
Retake Fee (Skills Assessment Examination)	$ 400
Rescheduling Fee (Written Examination)	$ 75
Rescheduling Fee (Skills Assessment Examination)	$ 75
Handscore Fee	$ 50
Recertification Fee (before expiration)	$ 150
Recertification Fee (within 90 days after expiration)	$ 200
Inactive Fee (per year)	$ 35
Recertification from Expired Status	$ 700
Replacement Application	$25
Additional certificate and wallet card	$20
Additional certificate	$12
Additional wallet card	$12

Midwives who have previously passed the NARM Written Examination may subtract the fee paid for the examination from the certification fee. NARM Written Exams taken prior to 1995 will no longer be accepted for CPM Certification. Midwives choosing to recertify after expiration of their CPM must pay the current certification fee.

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Study Suggestions for Candidates Preparing for the Written Examination

It is NARM’s expectation that all midwives who have accrued the required levels of experience and who have diligently prepared will be able to pass the NARM Written Examination. We acknowledge that many factors affect a person’s ability to pass a written examination, and that even very experienced midwives may experience test anxiety. We therefore offer these suggestions for preparing for the NARM Written Examination.

1. Allow time to prepare for the examination. Even experienced midwives will benefit from a review of the reference books. Reading and studying will help prepare you to more effectively evaluate examination questions and answers.

2. Get a good night’s sleep before the examination. You will not have an opportunity to eat before noon, so nourish yourself before you begin.

3. If you experience “test anxiety,” work on relaxation exercises while you study. Plan a schedule for study so you don’t feel that you are cramming right before the test. Give yourself time to relax the day before. Remember that if you do not pass the examination on the first try, you may take it again at another time.

4. The NARM reference list (contained in the Candidate Information Bulletin) lists over twenty books for study. Read as many as you can. Strive for a good balance of the medical and midwifery sources. If you are limited on time and/or resources, read the ones that supplement your general knowledge rather than reinforce it. The NARM examination strives for a good balance of midwifery knowledge.

5. Utilize the information in your Candidate Information Bulletin, especially the test specifications, the reference list, the sample questions, and the Aids and Guides.

6. For those candidates whose first language is not English, it might be helpful to focus on activities that will enhance verbal skills and reading skills. Such activities might include attendance at midwifery association meetings, participation in study groups, and observation of local out-of-hospital midwives who provide prenatal care or teach childbirth classes.

7. As you are reading, try making 3x5 index cards with questions on each side and answers on the other. Use the cards to quiz yourself.

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Test Specifications

The Test Specifications were developed from a recent Job Analysis which was based on the Midwives’ Alliance of North America (MANA) Core Competencies. NARM strongly urges all candidates to thoroughly review both the Written and Skills Assessment test specifications and their associated reference lists to prepare for successful completion of the CPM Certification Examination process.

CPM Written Examination Matrix

Content Area	Total % of Exam/ # of Items
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 Care	5% / 16

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Written Test Specifications

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 providers
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 sites
2. the requirements of the birth site
3. how to prepare, equip and supply the birth site

E. Educates the mother and her family/support unit to share responsibility for optimal pregnancy outcome
F. Educates the mother concerning the natural physical and emotional processes of pregnancy, labor, birth and postpartum
G. Applies the principles of informed consent
H. Applies the principles of client confidentiality
I. Provides individualized care
J. Advocates for the mother during pregnancy, birth and postpartum
K. Provides culturally appropriate 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 and lab work
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 and safe sex practices
8. blood borne pathogens: HIV, Hepatitis B, Hepatitis C
9. complications of pregnancy
10. environmental risk factors
11. newborn care including normal/abnormal newborn activity, responses, vital signs, appearance, behavior, etc.
12. postpartum care concerning complications and self-care
13. contraception
14. female reproductive anatomy and physiology
15. monthly breast self examination techniques
16. implications for the nursing mother
17. the practice of Kegel exercises
18. risks to fetal health, including

a) TORCH viruses (toxoplasmosis, rubella, cytomegalovirus, herpes, other)
b) environmental hazards
c) teratogenic substances

II. General Healthcare Skills: (5% of Exam - 17 Examination Items)

A. Demonstrates the application of Universal Precautions as they relate to midwifery
B. Uses alternative healthcare practices (non-allopathic treatments) and modalities

1. herbs
2. hydrotherapy (baths, compresses, showers, etc.)
3. visualization

C. Refers to alternative healthcare practitioners for non-allopathic treatments
D. Manages shock by:

1. Recognition of shock, or impending shock
2. Assessment of the cause of shock
3. Treatment of shock

a) Provide fluids orally
b) Position mother flat, legs elevated 12 inches
c) Administer oxygen
d) Keep mother warm, avoid overheating
e) Administer/use non-allopathic remedies
f) Encourage deep, calm, centered breathing
g) Activate emergency medical services
h) Prepare to transport

E. Understands the benefits and risks and recommends the appropriate use of vitamin and mineral supplements including: (Prenatal Multi-Vitamin, Vitamin C, Vitamin E, Folic Acid, B-Complex, B-6, B-12, Iron, Calcium, Magnesium)
F. Demonstrates knowledge of the benefits and risks and appropriate administration of the following pharmacological (prescriptive) agents:

1. lidocaine
2. medical oxygen
3. methergine
4. prescriptive ophthalmic prophylaxis ointment (e.g., erythromycin)
5. Pitocin®
6. RhoGam
7. Vitamin K

a) Oral
b) IM

G. Demonstrates knowledge of benefits/risks of ultrasounds

1. provides counseling
2. makes appropriate referrals

H. Demonstrates knowledge of benefits/risks of biophysical profile

1. provides counseling,
2. makes appropriate referrals.

I. Demonstrates knowledge of how and when to use instruments and equipment including:

1. Amni-hook® / Ammnicot®
2. bag and mask resuscitator
3. bulb syringe
4. Delee® (tube/mouth suction device)
5. hemostats
6. lancets
7. nitrazine paper
8. scissors (all kinds)
9. suturing equipment
10. urinary catheter
11. vacutainer/blood collection tube
12. multidose vial; single dose ampule

J. Evaluates laboratory and medical records

1. hematocrit/hemoglobin
2. blood sugar (glucose)
3. HIV
4. Hepatitis B and C
5. Rubella
6. Syphilis (VDRL or RPR)
7. Group B Strep
8. Gonorrhea Culture
9. Complete Blood Count
10. Blood type and Rh factors
11. Rh antibodies
12. Chlamydia
13. PAP smear

III. Maternal Health Assessment: (10% of Exam - 35 Examination Items)

A. Obtain and maintain records of health, reproductive and family medical history and possible implications to current pregnancy, including

1. personal 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 history
b) gynecologic history
c) sexual history
d) childbearing history
e) contraceptive practice
f) history of sexually transmitted infections
g) history of behavior posing risk for sexually transmitted infection exposure
h) history of risk of exposure to blood borne pathogens
i) Rh type and plan of care if negative

7. family medical history
8. psychosocial history
9. history of abuse
10. mental health

B. Perform a physical examination, including assessment of:

1. general appearance/skin condition
2. baseline weight and height
3. vital signs
4. HEENT (Head, Eyes, Ears, Nose and Throat) including:

a) hair and scalp
b) eyes: pupils, whites, conjunctiva
c) thyroid by palpation
d) mouth, teeth, mucus membrane, and tongue

5. lymph glands of neck, chest and under arms
6. breasts

a) evaluates mother’s knowledge of self-breast examination techniques
b) performs breast examination

7. torso, extremities for bruising, abrasions, moles, unusual growths
8. baseline reflexes
9. heart and lungs
10. abdomen by palpation and observation for scars
11. kidney pain (CVAT)
12. pelvic landmarks (internal)
13. pelvic measurements (internal)
14. cervix (by speculum exam)

a) Papanicolaou (Pap) test results
b) gynecological culture results

15. size of the uterus and ovaries (by bimanual exam)
16. condition of the vulva, vagina, cervix, perineum and anus
17. musculo-skeletal system

a) joint pain
b) muscular strength
c) spine straightness and symmetry, posture

18. vascular system (edema, varicosities, thrombophlebitis)

IV. Prenatal: (25% of Exam - 88 Examination Items)

A. Assess results of routine prenatal physical exams including ongoing assessment of:

1. maternal psycho-social, emotional health and well-being
2. signs and symptoms of infection
3. maternal health by tracking variations and change in:

a) blood pressure
b) color of mucus membranes
c) general reflexes
d) elimination/urination patterns
e) sleep patterns
f) energy levels

4. nutritional patterns
5. hemoglobin/hematocrit
6. glucose levels
7. breast condition/implications for breastfeeding
8. vaginal discharge/odor
9. signs of abuse
10. urine for protein, glucose, ketones
11. fetal heart rate/tones auscultated with fetoscope or dopplar
12. vaginal discharge or odor
13. estimated due date based upon:

a) last menstrual period
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
g) quickening
h) fundal height
i) calendar date of conception/unprotected intercourse

14. assessment of fetal growth and well-being

a) auscultation of fetal heart
b) correlation of weeks gestation to fundal height
c) fetal activity and responsiveness to stimulation
d) fetal palpation

B. Records results of the examination in the prenatal records
C. Provides prenatal education, counseling, and recommendations for:

1. nutritional, and non-allopathic dietary supplement support
2. normal body changes in pregnancy
3. weight gain in pregnancy
4. common complaints of pregnancy:

a) sleep difficulties
b) nausea/vomiting
c) fatigue
d) inflammation of the sciatic nerve
e) breast tenderness
f) skin itchiness
g) vaginal yeast infections
h) symptoms of anemia
i) indigestion/heartburn
j) constipation
k) varicose veins
l) sexual changes
m) emotional changes
n) fluid retention

5. Physical preparation

a) preparation of the perineum
b) physical activities for labor preparation (e.g., movement and exercise)

D. Recognizes and responds to potential prenatal complications/variations by identifying/assessing:

1. antepartum bleeding

a) first trimester
b) second trimester
c) third trimester

2. identifying pregnancy-induced hypertension
3. assessing, educating and counseling for pregnancy-induced hypertension with:

a) nutritional/hydration assessment
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) increased frequency of maternal assessment
g) hydrotherapy

4. identifying and consulting, collaborating or referring for:

a) pre-eclampsia
b) gestational diabetes
c) urinary tract infection
d) fetus small for gestational age
e) intrauterine growth retardation
f) thrombophlebitis
g) oligohydramnios
h) polyhydramnios

5. breech presentations

a) identifying breech presentation
b) turning breech presentation with:

(1) alternative positions (tilt board, exercises, etc.)
(2) referral for external version
(3) non-allopathic methods

c) management strategies for unexpected breech delivery

6. multiple gestation

a) Identifying multiple gestation
b) management strategies for unexpected multiple births

7. vaginal birth after cesarean (VBAC)

a) identifying VBACs by history and physical
b) indications/contraindications for out-of-hospital births
c) management strategies for VBAC
d) recognizes signs, symptoms of uterine rupture and knows emergency treatment

8. identifying and dealing with pre-term labor with:

a) referral
b) consultation and/or treatment including:

(1) increase of fluids
(2) non-allopathic remedies
(3) discussion of the mother’s fears - emotional support
(4) consumption of an alcoholic beverage
(5) evaluation of urinary tract infection
(6) evaluation of other maternal infection
(7) bed rest
(8) pelvic rest (including no sexual intercourse)
(9) no breast stimulation (including nursing)

9. assessing and evaluating a post-date pregnancy by monitoring/assessing:

a) fetal movement, growth, and heart tone variability
b) estimated due date calculation
c) previous birth patterns
d) amniotic fluid volume
e) maternal tracking of fetal movement
f) consultation or referral for:

(1) ultrasound
(2) non-stress test
(3) biophysical profile

10. treating a post-date pregnancy by stimulating the onset of labor

a) sexual/nipple stimulation
b) assessment of emotional blockage and/or fears
c) stripping membranes
d) cervical massage
e) castor oil induction
f) non-allopathic therapies
g) physical activity

11. identifying and referring for:

a) tubal pregnancy
b) molar pregnancy
c) ectopic pregnancy
d) placental abruption
e) placenta previa

12. identifying premature rupture of membranes
13. managing premature rupture of membranes in a full-term pregnancy:

a) monitor fetal heart tones and movement
b) minimize internal vaginal examinations
c) reinforce appropriate hygiene techniques
d) monitor vital signs for signs of infection
e) encourage increased fluid intake
f) support nutritional/non-allopathic treatment
g) stimulate labor
h) consult for prolonged rupture of membranes

14. consult and refer for pre-term rupture of membranes
15. establishes and follows emergency contingency plans for mother/baby

V. Labor, Birth and Immediate Postpartum (35% of Exam - 123 Examination items)

A. Facilitates maternal relaxation and provides comfort measure throughout labor by administering/encouraging:

1. massage
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
6. silence
7. continued mobility throughout labor
8. pain management :

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 changes

B. Evaluates/responds to during first stage:

1. assess maternal/infant status based upon:

a) vital signs
b) food and fluid intake/output
c) dipstick urinalysis
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:

(1) visual observation
(2) abdominal palpation
(3) vaginal examination

h) effacement, dilation of cervix and station of the presenting part
i) maternal dehydration and/or vomiting by administering:

(1) fluids by mouth
(2) ice chips
(3) oral herbal/homeopathic remedies

2. anterior/swollen lip by administering/supporting

a) position change
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 treatments

3. posterior, asynclitic position by encouraging and/or supporting:

a) the mother’s choice of position
b) physical activities (pelvic rocking, stair climbing, walking, etc.)
c) non-allopathic treatments
d) rest or relaxation
e) manual internal rotation (“dialing the phone”)

4. pendulous belly inhibiting descent by:

a) positioning semi-reclining on back
b) assisting the positioning of the uterus over the pelvis
c) lithotomy position

5. labor progress by providing:

a) psychological support
b) nutritional support
c) non-allopathic treatments
d) physical activity
e) position change
f) rest
g) nipple stimulation

C. Demonstrates the ability to evaluate/support during second stage

1. wait for the natural urge to push
2. encourage aggressive pushing in emergency situations
3. allow the mother to choose the birthing position
4. recommend position change as needed
5. perineal massage
6. encourage the mother to touch the newborn during crowning
7. assist in normal spontaneous vaginal birth with perineal support
8. provide an appropriate atmosphere for the moment of emergence
9. document labor and birth

D. Demonstrates the ability to recognize and respond to labor and birth complications such as:

1. abnormal fetal heart tones and patterns by:

a) increase oxygen

(1) administer oxygen
(2) encourage deep breathing

b) change maternal position
c) facilitate quick delivery if birth is imminent
d) evaluate for consultation and referral
e) evaluate for transport

2. cord prolapse by

a) change maternal position to knee-chest
b) activate emergency medical services/medical backup plan
c) apply counter-pressure to the presenting part
d) place cord back into vagina
e) keep the presenting cord warm, moist and protected
f) monitor FHT and cord for pulsation
g) increase the mother’s oxygen supply
h) facilitate immediate delivery, if birth is imminent
i) prepare to resuscitate the newborn

3. variations in presentation

a) breech
b) nuchal hand/arm

(1) apply counter pressure to hand/or arm and the perineum
(2) sweep arm out

c) nuchal cord

(1) loop finger under the cord, and sliding it over head
(2) loop finger under the cord, and sliding it over the shoulder
(3) clamp cord in two places, cutting the cord between the two clamps
(4) press baby’s head into perineum and somersault the baby out
(5) prepare to resuscitate the baby

d) face and brow

(1) prepare for imminent birth
(2) prepare resuscitation equipment
(3) prepare treatment for newborn bruising/swelling
(4) administer arnica
(5) position the mother in a squat
(6) prepare for potential eye injury

e) multiple birth and delivery
f) shoulder dystocia

(1) reposition shoulders to oblique diameter
(2) reposition the mother to:

(a) hands and knees (Gaskin maneuver)
(b) exaggerated lithotomy (McRobert’s position)
(c) end of bed

(3) flex shoulders of newborn, then corkscrew
(4) extract the posterior arm
(5) apply supra-pubic pressure
(6) apply gentle traction while encouraging pushing
(7) sweep arm across newborn’s face

4. vaginal birth after cesarean (VBAC)
5. management of meconium stained fluids

a) prepare to resuscitate the baby
b) instruct the mother to stop pushing after delivery of head
c) clear the airway with suction of mouth and nose
d) prepare to resuscitate the baby

6. management of maternal exhaustion by:

a) nutritional support
b) adequate hydration
c) non-allopathic treatments
d) evaluate the mother’s psychological condition
e) increase rest
f) monitor vital signs
g) monitor fetal well-being
h) evaluate urine for ketones
i) evaluate for consultation and/or referral

E. recognize/consult/transport for signs of

1. uterine rupture
2. uterine rupture
3. amniotic fluid embolism
4. stillbirth

F. assesses the condition of, and provides care for the newborn:

1. keep baby warm
2. make initial newborn assessment
3. determine APGAR score at:

a) 1 minute
b) 5 minutes
c) 10 minutes (as appropriate)

4. keep baby and mother together
5. monitor respiratory and cardiac function by assessing:

a) symmetry of the chest
b) sound and rate of heart tones and respirations
c) nasal flaring
d) grunting
e) retractions
f) circumoral cyanosis
g) central cyanosis

6. stimulate newborn respiration:

a) rub up the baby’s spine
b) encourage parental touch, and call newborn’s name
c) flick or rub the soles of the baby’s feet
d) keep baby warm
e) rub skin with blanket

7. responding to the need for newborn resuscitation:

a) administer mouth-to-mouth breaths
b) positive pressure ventilation for 15-30 seconds
c) administer oxygen
d) leave cord unclamped until placenta delivers

8. Recognize and consult or transport for apparent birth defects
9. Recognizes signs and symptoms of Meconium Aspiration Syndrome and consults or refers as needed
10. Support family bonding
11. Clamping the cord after pulsing stops
12. Cutting the cord after clamping
13. Caring for the cord:

a) evaluating the cord stump
b) collecting a cord blood sample

14. administer eye prophylaxis
15. assess gestational age

G. assist in placental delivery and responds to blood loss:

1. remind mother of the onset of third stage of labor
2. determine signs of placental separation such as:

a) lengthening of cord
b) separation gush
c) rise in fundus
d) contractions
e) urge to push

3. facilitate the delivery of the placenta by:

a) breast feeding/nipple stimulation
b) change the mother’s position
c) administer non-allopathic treatments
d) perform guarded cord traction

4. after delivery, assess the condition of the placenta
5. estimate blood loss
6. respond to a trickle bleed by:

a) assess origin
b) respond to uterine bleeding by:

(1) breastfeeding/nipple stimulation
(2) fundal massage
(3) assess fundal height and uterine size
(4) non-allopathic treatments
(5) express clots
(6) empty bladder
(7) assess vital signs

c) respond to vaginal tear and bleeding with:

(1) direct pressure on tear
(2) suturing
(3) assessment of blood color and volume

7. respond to postpartum hemorrhage with:

a) fundal massage
b) external bimanual compression
c) internal bimanual compression
d) manual removal of clots
e) administer medication
f) non-allopathic treatments
g) maternal focus on stopping the bleeding/ tightening the uterus
h) administer oxygen
i) treat for shock
j) consult and/or transfer
k) activate medical emergency backup plan
l) prepare to increase postpartum care

H. Assess general condition of mother:

1. assess for bladder distension
2. encourage urination for bladder distension
3. perform catheterization for bladder distension
4. assess lochia
5. assess the condition of vagina, cervix and perineum for:

a) cystocele
b) rectocele
c) hematoma
d) tears
e) lacerations
f) hemorrhoids
g) bruising

6. repair the perineum:

a) refer for repair
b) administer a local anesthetic
c) perform basic suturing of:

(1) 1st degree tears
(2) 2nd degree tears
(3) labial tears

d) provide alternate repair methods (non-suturing)

7. provide instruction for care and treatment of the perineum
8. facilitate breastfeeding by assisting and teaching about:

a) colostrum
b) positions for mother and baby
c) skin-to-skin contact
d) latching on
e) maternal hydration
f) maternal nutrition
g) maternal rest
h) feeding patterns

(1) maternal comfort measures for engorgement
(2) letdown reflex
(3) milk expression

VI. The Postpartum Period: (15% of Exam - 54 Items)

A. Completes the birth certificate
B. Provides contraceptive/family planning education and counseling
C. Performs postpartum reevaluation of mother and baby at:

1. day-one to day-two
2. day-three to day-four
3. one to two weeks
4. six to eight weeks

D. assess, and provides counseling and education as needed, for:

1. postpartum-subjective history
2. lochia vs. abnormal bleeding
3. return of menses
4. vital signs, digestion, elimination patterns
5. breastfeeding, condition of breasts and nipples
6. muscle prolapse of vagina and rectum (cystocele, rectocele)
7. strength of pelvic floor
8. condition of the uterus (size and involution), ovaries and cervix
9. condition of the vulva, vagina, perineum and anus

E. educates regarding adverse factors affecting breastfeeding

1. environmental
2. biological
3. occupational
4. pharmacological

F. Facilitate psycho-social adjustment
G. Knows signs and symptoms, differential diagnosis, and appropriate midwifery management or referral for:

1. uterine infection
2. urinary tract infection
3. infection of vaginal tear or incision
4. postpartum depression
5. postpartum psychosis
6. late postpartum bleeding/hemorrhage
7. thrombophlebitis

H. Assesses for, and treats jaundice by:

1. encourage mother to breastfeed every two hours
2. expose the front and back of newborn to sunlight through window glass
3. assess newborn lethargy and hydration
4. consult or refer

I. Provide direction for care of circumcised penis
J. Provide direction for care of uncircumcised penis
K. Treat thrush on nipples

1. dry nipples after nursing
2. non-allopathic remedies
3. refer for allopathic treatments

L. Treat sore nipples with:

1. apply topical agents
2. expose to air
3. suggest alternate nursing positions
4. evaluate baby’s sucking method
5. apply expressed milk

M. treat mastitis by:

1. provide immune system support including:

a) nutrition/hydration
b) non-allopathic remedies
c) encourage multiple nursing positions
d) apply herbal/non-allopathic compresses
e) apply warmth, soaking in tub or by shower
f) encourage adequate rest/relaxation
g) assess for signs and symptoms of infections
h) teach mother to empty breasts at each feeding
i) provide/teach gentle massage of sore spots
j) consult/refer to:

(1) La Leche League
(2) lactation counselor
(3) other healthcare providers

VII. Well-Baby Care: (5% of Exam - 16 Items

A. Provide well-baby care up to six weeks
B. Instruct on newborn care including normal/abnormal newborn activity, responses, vital signs, appearance, behavior, etc.
C. Assess the current health and appearance of baby including:

1. temperature
2. heart rate, rhythm and regularity
3. respirations
4. appropriate weight gain
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 cord

D. instructs mother in care of:

1. diaper rash
2. cradle cap

E. Advises and facilitates treatment of thrush
F. Advises and facilitates treatment for colic
G. Recognizes signs/symptoms and differential diagnosis of:

1. infections
2. polycythemia
3. cardio-respiratory abnormalities
4. glucose disorders
5. hyperbilirubinemia
6. birth defects
7. failure to thrive
8. newborn hemorrhagic disease (early and late onset)

H. Provide information for referral for continued well-baby care
I. Support integration of baby into family
J. Perform or refer for newborn metabolic screening

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Example Questions

Example of a Knowledge Question

The knowledge question requires a Candidate to answer the question solely by memory and involves the recall of definitions, facts, rules, sequences, procedures, principles, and generalizations.

Constipation can be treated with

(A) calcium, warm moist heat and exercise.
(B) accupressure wrist band, frequent small meals and protein-rich snacks.
(C) vitamin E, support stockings and elevated legs.
(D) increased water, exercise and natural sources of iron.

ANSWER = (D)

Example of an Application Question

The application questions involve the use of abstracts in concrete situations. The abstractions may be in the form of general ideas, procedures, or methods. They may also be in the form of technical principles, ideas, and theories that must be remembered or applied.

What do white spots on the infant’s tongue and gums that can be easily removed indicate?

(A) Strep throat
(B) Milk residue
(C) Thrush
(D) Milk intolerance

ANSWER = (B)

Example of an Analysis Question

The analysis questions require a Candidate to break down information into its constituent parts. This may involve finding assumptions, distinguishing facts from opinion, discovering causal relationships, and finding fallacies in stories or arguments.

A mother who gave birth two weeks ago calls to report that this morning she awakened with a fever of 103°F, chills, a headache, and body aches. What is the MOST likely cause of these symptoms?

(A) Laceration infection
(B) Uterine infection
(C) Breast infection
(D) Respiratory infection

ANSWER = (C)

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Reference Lists

Written Examination Primary Reference List

• Davis, Elizabeth. Heart and Hands: A Midwife’s Guide to Pregnancy and Birth, 4th edition, Celestial Arts, 2004.
• Frye, Anne. Holistic Midwifery: A Comprehensive Textbook for Midwives and Home Birth Practice, Vol. 1, Care During Pregnancy, Labrys Press, revised 1995.
• Frye, Anne. Holistic Midwifery: A Comprehensive Textbook for Midwives and Home Birth Practice, Vol.II, Care During Labor and Birth, Labrys Press, 2004.
• Frye, Anne. Understanding Diagnostic Tests in the Childbearing Year, 6th edition, Labrys Press, 1997.
• Gaskin, Ina May. Spiritual Midwifery, 4rd edition, The Book Publishing Company, 2002.
• Myles, Margaret. Textbook for Midwives, 14th edition, Elsevier, 2003
• Page, Lesley Ann, The New Midwifery, Churchill Livingstone, 2000
• Simpkin & Ancheta, Labor Progress Handbook, Blackwell, 2000
• Sinclair, Constance, A Midwife’s Handbook, Saunders, 2004
• Thureen, Assessment & Care of the Well Newborn, Saunders, 1998
• Varney, Helen, Midwifery, 4th edition, Jones and Bartlett, 2003
• Walsh. Linda, Midwifery: Community Based Childbirth, Saunders, 2001

Written Examination Secondary Reference List

• Coad, Jane, Anatomy & Physiology for Midwives, Mosby, 2001
• Frye, Anne. Healing Passage, 5th edition. Labrys Press, 1995
• Goer, Henci, The Thinking Woman’s Guide to Birth, Penguin Putnam, 1999
• Hall, Jennifer, Midwifery Mind and Spirit, Elsevier, 2001
• Johnson &Taylor, Skills for Midwifery Practice, Churchill & Livingston, 2001
• La Leche League, International. The Breastfeeding Answer Book. Mohrbacker and Stock, 1997.
• Oxhorn and Foote. Human Labor and Birth, 5th edition. McGraw Hill, 1986.
• Pritchard and McDonald. William’s Obstetrics, 21th edition. Prentiss Hall, 2001
• Renfrew, Fisher, Arms. Bestfeeding: Getting Breastfeeding Right. 2nd edition, Celestial Arts, 2000
• Wickham, Sarah, Midwifery, Best Practice, Elsevier, 2003

Tabor’s Cyclopedic Medical Dictionary is an excellent resource for terminology.

For testing purposes, when checking off Comprehensive Skills, Knowledge, and Abilities Essential for Competent Midwifery Practice Verification Form 201, use the specific techniques as described in the Practical Skills Guide for Midwifery and the NARM Candidate Information Bulletin (CIB).

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Skills Assessment Test Specifications

I. General Healthcare Skills

A. Demonstrates aseptic technique

1. Handwashing
2. Gloving and ungloving
3. sterile technique

B. Demonstrates the use of instruments and equipment including:

1. Blood pressure cuff
2. Doppler or fetoscope
3. Gestation calculation wheel/calendar
4. Newborn and adult scale
5. Stethoscope
6. Tape measure
7. Thermometer
8. Urinalysis Strips

C. Injection Skills

1. Proper use of equipment

a) Syringe
b) Single dose vial
c) Multi dose vial
d) Sharps container

2. Demonstration of skill

a) Checking appearance, name, and expiration date
b) Observation of sterile technique
c) Drawing up fluids in the syringe
d) Injection of fluids
e) Disposal of needles

D. Oxygen

1. Proper set up of oxygen equipment
2. use of cannula and face mask
3. regulation of flow meter

II. Maternal Health Assessment

A. Performs a general physical examination, including assessment of:

1. Baseline weight and height
2. Vital signs: blood pressure, pulse, and temperature
3. Baseline reflexes
4. Abdomen, spine, and skin
5. Heart and lungs (auscultate)
6. Breast Examination
7. Kidney pain; Costovertable Angle Tenderness (CVAT)
8. Deep tendon reflexes of the knee
9. Extremities for edema

III. Prenatal

A. Performs prenatal physical exam including assessment of:

1. determination of due date by wheel or calendar
2. vital signs: blood pressure, pulse, temperature
3. respiratory assessment
4. weight
5. urine for:

a) appearance: color, density, odor, clarity
b) protein
c) glucose
d) ketones
e) PH
f) Leukocytes
g) Nitrites
h) Blood

6. costrovertebral angle tenderness (CVAT)
7. deep tendon reflexes (DTR) of the knee
8. clonus
9. fundal height
10. fetal heart rate/tones ausculated with fetoscope or doppler
11. fetal position, presentation, lie
12. assessment of edema

IV. Labor, Birth and Immediate Postpartum

A. performing a newborn examination by assessing:

1. the head for:

a) size/circumference
b) molding
c) hematoma
d) caput
e) sutures
f) fontanels
g) Measurement

2. the eyes for:

a) jaundice
b) pupil condition
c) tracking
d) spacing

3. the ears for:

a) positioning
b) response to sound
c) patency
d) cartilage

4. the mouth for:

a) appearance and feel of palate
b) lip and mouth color
c) tongue
d) lip
e) cleft
f) signs of dehydration

5. the nose for:

a) patency
b) flaring nostrils

6. the neck for:

a) enlarged glands; thyroid and lymph
b) trachea placement
c) soft tissue swelling
d) unusual range of motion

7. the clavicle for:

a) integrity
b) symmetry

8. the chest for:

a) symmetry
b) nipples
c) breast enlargement including discharge
d) measurement (chest circumference)
e) count heart rate
f) monitor heartbeat for irregularities
g) auscultate the lungs, front and back for:

(1) breath sounds
(2) equal bilateral expansion

9. the abdomen for:

a) enlarged organs
b) masses
c) hernias
d) bowel sounds

10. the groin for

a) femoral pulses
b) swollen glands

11. the genitalia for:

a) appearance
b) testicles for:

(1) descent
(2) rugae
(3) herniation

c) labia for:

(1) patency
(2) maturity of clitoris and labia

12. the rectum for:

a) patency
b) meconium

13. Abduct hips for dislocation
14. the legs for:

a) symmetry of creases in the back of the legs
b) equal length
c) foot/ankle abnormality

15. the feet for:

a) digits, number, webbing
b) creases
c) abnormalities

16. the arms for symmetry in:

a) structure
b) movement

17. the hands for:

a) number of digits, webbing
b) finger taper
c) palm crease
d) length of nails

18. the backside of baby for:

a) symmetry of hips, range of motion
b) condition of the spine:
c) dimpling
d) holes
e) straightness

19. temperature: axillary, rectal
20. reflexes:

a) flexion of extremities and muscle tone
b) sucking
c) moro
d) babinski
e) plantar/palmar
f) stepping
g) grasp
h) rooting

21. skin condition for:

a) color
b) lesions
c) birthmarks
d) milia
e) vernix
f) lanugo
g) peeling
h) rashes
i) bruising

22. length of baby
23. weight of baby

V. Well-Baby Care

A. Assesses the general health and appearance of baby including:

1. temperature
2. heart rate, rhythm and regularity
3. respirations
4. weight
5. length
6. measurement of circumference of head

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Skills Assessment Reference Text

Weaver and Evans. Practical Skills Guide for Midwifery, Morningstar Publishing, Third Edition - 2001.

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Example of an Assessed Skill

Obtaining a Clean Catch of Urine

QE Instructions:

QE Note: “Yes” means the Applicant performed each stated step. “No” means the Applicant did not perform step as stated.

QE Note: Please read the following Verbal Instructions to the Applicant.

Verbal Instructions:

The objective is to demonstrate the ability to give instructions for obtaining a clean catch of urine.

Equipment you will need is: Sterile urine container, at least 3 antiseptic towelettes, a pen, a lab slip.

Please demonstrate everything you know, verbalize what you are demonstrating and be very thorough.

Procedure:	Performed
	Yes	No
1 Labeled the specimen container	___	___
Explained to the woman that she must:
2 Part the labia	___	___
3 Wipe one side of the labia from front to back with a towelette, and discard	___	___
4 Wipe the other side of the labia from front to back with a towelette, and discard	___	___
5 Wipe the center from front to back with a third towelette, and discard	___	___
6 Continue to hold the labia apart while beginning to void	___	___
7 After voiding approximately one ounce, catch a sample in the specimen container and finish voiding	___	___
8 Filled out the requisition to order the appropriate test and packaged the specimen	___	___
9 Prepared the specimen appropriately for the lab	___	___
Number of tasks performed for this skill ________

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MANA Core Competencies

Guiding Principles of Practice

I. The midwife provides care according to the following principles:

A. Midwives work in partnership with women and their chosen support community throughout the caregiving relationship.
B. Midwives respect the dignity, rights and the ability of the women they serve to act responsibly throughout the caregiving relationship.
C. Midwives work as autonomous practitioners, collaborating with other health and social service providers when necessary.
D. Midwives understand that physical, emotional, psychosocial and spiritual factors synergistically comprise the health of individuals and affect the childbearing process.
E. Midwives understand that female physiology and childbearing are normal processes, and work to optimize the well-being of mothers and their developing babies as the foundation of caregiving.
F. Midwives understand that the childbearing experience is primary a personal, social and community event.
G. Midwives recognize that a woman is the only direct care provider for herself and her unborn baby; thus the most important determinant of a healthy pregnancy is the mother herself.
H. Midwives recognize the empowerment inherent in the childbearing experience and strive to support women to make informed decisions and take responsibility for their own well being.
I. Midwives strive to ensure vaginal birth and provide guidance and support when appropriate to facilitate the spontaneous processes of pregnancy, labor and birth, utilizing medical intervention only as necessary.
J. Midwives synthesize clinical observations, theoretical knowledge, intuitive assessment and spiritual awareness as components of a competent decision making process.
K. Midwives value continuity of care throughout the childbearing cycle and strive to maintain continuous care within realistic limits.
L. Midwives understand that the parameters of “normal” vary widely and recognize that each pregnancy and birth is unique.

General Knowledge and Skills

II. The midwife provides care incorporating certain concepts, skills and knowledge from a variety of health and social sciences, including but not limited to:

A. Communication, counseling and teaching skills.
B. Human anatomy and physiology relevant to childbearing
C. Community standards of care for women and their developing infants during the childbearing cycle, including midwifery and bio-technical medical standards and the rationale for and limitation of such standards
D. Health and social resources in her community.
E. Significance of and methods for documentation of care through the childbearing cycle.
F. Informed decision making.
G. The principles and appropriate application of clean and aseptic technique and universal precautions.
H. Human sexuality, including indication of common problems and indications for counseling.
I. Ethical considerations relevant to reproductive health.
J. The grieving process.
K. Knowledge of cultural variations.
L. Knowledge of common medical terms.
M. The ability to develop, implement and evaluate an individualized plan for midwifery care.
N. Woman-centered care, including the relationship between the mother, infant and their larger support community.
O. Knowledge of various health care modalities as they apply to the childbearing cycle.

Care During Pregnancy

III. The midwife provides health care, support and information to women throughout pregnancy. She determines the need for consultation or referral as appropriate. The midwife uses a foundation of knowledge and/or skill which includes the following:

A. Identification, evaluation and support of maternal and fetal well-being throughout the pr