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Core Competencies in Nurse-Midwifery - May 1985

The information contained within this document does not necessarily reflect the current positions or policies of the American College of Nurse-Midwives, however it is provided as a public service for the purpose of research. The current version of this document is: Core Competencies For Basic Midwifery Practice - May 2002 and may be found at www.midwife.org.

Core Competencies in Nurse-Midwifery - May 1985

Nurse-midwifery education is based upon theoretical preparation in the sciences and clinical preparation for the judgment and skills necessary for management and care of essentially normal women and newborns. The care as defined by the American College of Nurse-Midwives includes antepartum, intrapartum, postpartum, neonatal, and family planning/gynecology, and occurs within a health care system that provides for medical consultation, collaborative management, or referral. Nurse-midwifery practice is based upon a management process that is used in all aspects of care. It includes knowledge and skills for competent practice and incorporates the Functions, Standards, and Qualifications of the American College of Nurse-Midwives.

Core competencies are the fundamental knowledge, skills, and behaviors expected of a new graduate. This statement identifies the core of knowledge and skills basic to preparation for nurse-midwifery practice. Because we recognize that nurse-midwifery practice continues to be a dynamic and changing discipline, these core competencies are presented as a guideline only for educators, physicians and other professionals, consumers, and employers of nurse-midwives. They will continue to evolve with the practice of nurse-midwifery. The concepts and skills identified below and the aspects of the nurse-midwifery management process outlined in the following section apply to all components of nurse-midwifery care. This document must therefore be used in its entirety.

Because creativity, individuality, and experimentation in nurse-midwifery education are essential to the vitality of the profession, educational programs are encouraged to be innovative. Each program will develop its own characteristics and may extend into other areas of health care. (It is the responsibility of each graduate to adapt practice to be consistent with state laws and institutional protocols.) Core competencies remain, however, as the basic requisites for the graduate of any educational program.

Certain concepts and skills from the behavioral sciences, communication, and public health permeate all aspects of nurse-midwifery practice. The following have been identified:

1. Family-centered approach to client care.
2. Constructive use of communication and of guidance and counseling skills.
3. Communication and collaboration with other members of the health team.
4. Client education.
5. Continuity of care.
6. Use of appropriate community resources.
7. Health promotion and disease prevention.
8. Pregnancy as a normal physiologic process.
9. Informed client choice and decision making.
10. Bioethical considerations related to reproductive health.

Nurse-Midwifery Management

The nurse-midwifery management process has three aspects: primary management, collaborative management and referral as well as medical consultation. Implicit in the management process is the documentation of all its aspects.

I. Primary Management

A. Systematically obtains or updates a complete and relevant data base for assessment of the client's health status.

B. Accurately identifies problems/diagnoses based upon correct interpretation of the data base.

C. Formulates and communicates a complete needs/problems list with corroboration from the client.

D. Identifies need for consultation/collaboration/referral with appropriate members of the health care team.

E. Provides information to enable clients to make appropriate decisions and to assume appropriate responsibility for their own health.

F. Assumes direct responsibility for the development, with the client, of a comprehensive plan of care based upon supportive rationale.

G. Assumes direct responsibility for implementing the plan of care.

H. Initiates emergency management of specific complications/deviations.

I. Evaluates, with corroboration from the client, the achievement of health care goals and modifies the plan of care appropriately.

II. Collaborative Management

Collaborative management builds upon the steps of primary management; additionally the nurse-midwife:

A. Anticipates and identifies problems and related complications

B. Plans and implements physician consultation and nurse-midwifery/physician management.

C. Carries out the plan of care as appropriate.

D. Continues nurse-midwifery care, including teaching, counseling, support, and advocacy.

III. Referral

A. Identifies the need for management and/or care outside the scope of nurse-midwifery practice.

B. Selects an appropriate source of care in collaboration with the client.

C. Transfers the care of the client to medical management as appropriate.

Components Of Nurse-Midwifery Care

Implicit in a nurse-midwifery knowledge base is the ability to perform skills pertinent to each of the outlined areas of practice.

I. Antepartum Care

A. Assumes responsibility for management of the care of the pregnant woman, using the nurse-midwifery management process.

B. Uses a foundation for nurse-midwifery practice that includes but is not limited to the knowledge of:

1. Female anatomy and physiology.
2. Anatomy and physiology of conception and pregnancy.
3. Anatomy of the female bony pelvis.
4. Preconceptional factors likely to influence pregnancy outcome.
5. Clinical application of genetics, embryology, and fetal development.
6. Effects of pregnancy on the woman.
7. The etiology and management of common discomforts of pregnancy.
8. Parameters and methods for assessing the progress of pregnancy.
9. Parameters and methods for assessing fetal well-being.
10. Nutritional assessment of the maternal-fetal unit.
11. Environmental influences on the maternal-fetal unit.
12. Psychosocial/emotional/sexual changes during pregnancy.
13. Common screening/diagnostic tests used during pregnancy.
14. Pharmacology of medications commonly using during pregnancy.
15. Indicators of risk in pregnancy and appropriate intervention.
16. Assessment of relevant historical data regarding the client and her family.
17. Assessment of physical status.
18. Assessment of the soft and bony structures of the pelvis.
19. Assessment of the emotional status of the client and the dynamics in her support system.
20. Diagnosis of pregnancy.
21. Nutritional counseling.
22. Counseling in the physical and emotional changes of pregnancy and preparation for birth, parenthood, and change in the family constellation.
23. Prescription of medications.
24. Planning for individual/family birth experiences.
25. Planning and implementation of individual and/or group education.

II. Intrapartum Care

A. Assumes responsibility for management of the care of the client and neonate during the intrapartum period.

B. Uses a foundation for nurse-midwifery practice that includes but is not limited to the knowledge of:

1. Normal labor process, including the mechanisms of labor and delivery.
2. Pelvic anatomy and physiology.
3. Anatomy of the fetal skull and its critical landmarks.
4. Parameters and methods for assessing progress of labor and delivery.
5. Parameters and methods for assessing maternal and fetal status.
6. Common screening/diagnostic tests used during labor.
7. Emotional changes during labor and delivery.
8. Pharmacology of medications commonly used during labor and birth, including effects on mother and fetus.
9. Comfort and support measures used during labor and birth.
10. Anatomy, physiology, and indicators of normal adaptation of newborn to extrauterine life.
11. Methods to facilitate newborn's adaptation to extrauterine life.
12. Indicators of deviations from normal and appropriate interventions.
13. Assessment of relevant historical data about clients.
14. Assessment of general physical and emotional status of clients.
15. Diagnosis and assessment of labor and its progress through the four stages.
16. Prescription or administration of appropriate medications/solutions during labor and birth.
17. Techniques for spontaneous vaginal delivery.
18. Techniques for placental expulsion.
19. Techniques for repair of episiotomy and episiotomy/laceration.
20. Techniques for administration of local pudendal anesthesia.
21. Establishment of maternal/infant/family bonds.

III. Postpartum Care

A. Assumes responsibility for management of the care of the client and neonate during the postpartum period, using the nurse-midwifery management process.

B. Uses a foundation for nurse-midwifery practice that includes but is not limited to the knowledge of:

1. Anatomy and physiology of the puerperium, including the involutional process.
2. Anatomy and physiology of lactation and methods for its facilitation or suppression.
3. Parameters and methods for assessing the puerperium.
4. Etiology and methods for managing discomforts of the puerperium.
5. Emotional/psychosocial/ sexual changes of the puerperium.
6. Establishment of maternal/infant/family bonds.
7. Pharmacology of medications commonly used during the puerperium, including effects on lactation and the infant.
8. Prescription or administration of appropriate medications and solutions.
9. Common screening/diagnostic tests used during the puerperium.
10. Assessment of relevant historical data about the client.
11. Assessment of client's general physical and emotional status.
12. Nutritional needs during the puerperium.
13. Indicators of deviations from normal and appropriate interventions.
14. Appropriate anticipatory guidance regarding self-care, infant care, family planning, and family relationships.

IV. Neonatal Care

A. Assumes responsibility for management of the care of the neonate using the nurse-midwifery management process.

B. Uses a foundation for nurse-midwifery practice that includes but is not limited to the knowledge of:

1. Anatomy and physiology of continuing adaption to extrauterine life and stabilization of the neonate.
2. Parameters and methods for assessing neonatal status.
3. Parameters and methods for assessing gestational age of the neonate.
4. Nutritional needs of the neonate.
5. Establishment of maternal/infant/family bonds.
6. Pharmacology of medications commonly used for the neonate.
7. Screening/diagnostic tests performed on the neonate.
8. Assessment of relevant historical data about maternal and neonatal course.
9. Indicators of deviations from normal and appropriate intervention.
10. Resuscitation and emergency care of the newborn.

V. Family Planning/Gynecological Care

A. Assumes responsibility for management of the care of women seeking family planning and/or gynecological services, using the nurse-midwifery management process.

B. Uses a foundation for nurse-midwifery practice that includes but is not limited to the knowledge of:

1. Anatomy and physiology of the reproductive systems through the life cycle.
2. Anatomy and physiology of the female breast.
3. Anatomy, physiology, and psychosocial components of human sexuality.
4. Factors relating to steroid, mechanical, chemical, physiological, and surgical conception control methods, including:
   a. Rationale for use.
   b. Contraindications to use.
   c. Effectiveness rates.
   d. Mechanisms of action.
   e. Advantages/disadvantages.
   f. Side effects/complications.
   g. Cost.
   h. Client instructions/counseling.
   i. Psychological factors.
   j. Provision of appropriate method, including but not limited to, oral contraception, vaginal diaphragms, and IUDs.
   k. Discontinuation or change of method.
5. Indicators of common problems of sexuality and methods for counseling.
6. Factors involved in decision making regarding unplanned and/or undesirable pregnancies and resources for counseling and referral.
7. Indicators of deviations from normal and appropriate interventions, including but not limited to:
   a. Vaginal/pelvic infections.
   b. Sexually transmitted diseases.
   c. Pelvic and breast masses.
   d. Abnormal pap smears.
   e. Problems related to menstrual cycle.
   f. Pelvic relaxation.
   g. Urinary tract infections.
   h. Infertility
8. Assessment of relevant historical data about client/partner.
9. Assessment of general physical and emotional status of client.
10. Common screening and diagnostic tests.

VI. Complications

As members of the health care team, nurse-midwives might manage some deviations in collaboration with a physician, or they might refer clients to a physician with or without continued nurse-midwifery support and teaching. Basic knowledge of the more common complications is essential to preparation for nurse-midwifery practice. The depth of knowledge needed will vary with the frequency of the complication and the role of the nurse-midwife. This basic knowledge generally includes:

A. Causative and risk factors and preventive measures.

B. Anatomical and/or physiological deviations from normal.

C. Effects of these changes on the health of the woman.

D. Effects of these changes on the health of the fetus or infant.

E. Signs and symptoms for screening an detecting existing abnormality.

F. Adjunctive laboratory data.

Professional Aspect

Assumes the role and professional responsibilities of nurse-midwifery practice. As a leader or change agent, the nurse-midwife demonstrates:

1. Knowledge of the historical development of nurse-midwifery in the U.S., structure and function of the American College of Nurse-Midwives, and the legal base for nurse-midwifery practice.
2. Knowledge of contemporary issues and trends in maternal-child health care nationally and internationally.
3. Knowledge of standards for quality maternal and child health services.
4. Knowledge of current and pending health legislation.
5. Knowledge of the role and responsibilities of the nurse-midwife in supporting legislative contributions to high-quality maternal and child health services.
6. Knowledge of the various nurse-midwifery practice options and the resources available for their development and evaluation.
7. The ability to carry out the philosophy of the American College of Nurse-Midwives.
8. Respect for the dignity and rights of health care providers and clients.
9. Responsibility and accountability for:
   a. Personal management decisions made in caring for clients.
   b. Periodic self-evaluation and peer review.
   c. Administration and delivery of services to families in collaboration with other health care providers.
10. The ability to use and collaborate in research.
11. Awareness of the responsibility of the professional to participate in the education of nurse-midwives.

Prepared by ACNM Education Committee, Barbara Decker, CNM, Chairperson

Approved by ACNM Board of Directors, May 1985.