NARM CPM Written Exam — Study Guide

The NARM written examination is the knowledge test on the path to the Certified Professional Midwife (CPM) credential. It is built from the MANA Core Competencies by way of NARM's periodic Job Analysis, and it assesses competent midwifery practice in out-of-hospital settings — home and birth center. A recurring theme across every domain is judgment about scope: knowing what is normal, what is a variation you can manage, and what requires consultation, referral, or transfer.

The exam is roughly 300 multiple-choice, single-best-answer items delivered in two 3-hour sessions, and it is criterion-referenced — you pass by reaching a minimum number of correct answers. This guide follows the seven official domains and their exam weights. Because Domains IV (Prenatal, ~25%) and V (Labor, Birth & Immediate Postpartum, ~35%) together make up about 60% of the exam, weight your study there.

Educational use only. This guide is not clinical or medical advice and is not affiliated with or endorsed by NARM or MANA. Always practice within your legal scope, your written protocols, and current evidence.

Domain I — Professional Issues, Knowledge, and Skills (~5%)

This domain frames midwifery as a profession embedded in a legal, ethical, and social context.

Social determinants of health. Income, literacy, education, housing, sanitation, food security, and environmental hazards shape pregnancy outcomes as much as any clinical variable. Understand allostatic load — the cumulative physiologic wear from chronic stressors such as racism and resource scarcity — as a driver of disparities in maternal and neonatal morbidity and mortality.

Evidence-based practice. Be able to read the professional literature critically: distinguish study designs (randomized trial vs. observational), recognize the difference between relative and absolute risk, and interpret vital statistics such as the maternal mortality ratio (per 100,000 live births) and infant/neonatal mortality rates (per 1,000 live births). Know the leading direct causes of maternal death (hemorrhage, hypertensive disorders, sepsis, thromboembolism) and neonatal death (prematurity, intrapartum-related events/asphyxia, infection).

Resources and referral. Know how to connect families to WIC, breastfeeding support, mental-health and substance-use services, social services, and bereavement care — and how to activate referral to a higher level of care with appropriate communication and transport.

Legal, regulatory, and ethical framework. Understand the laws and professional guidelines that govern out-of-hospital midwifery in your jurisdiction, HIPAA/confidentiality, and informed, shared decision-making as an ongoing process (not a one-time signature). Human-rights awareness includes intimate-partner violence, female genital cutting, and the influence of culture and religion on care choices.

Choosing and equipping a birth site. Facilitate the client's decision about where to give birth by discussing the advantages, risks, and requirements of each setting, and how to prepare and equip the site. Participate in peer review of adverse outcomes to improve practice.

Domain II — General Healthcare Skills (~5%)

Infection control. Apply Universal/Standard Precautions: hand hygiene, correct gloving/ungloving, sterile technique, and safe injection practice (never recap needles two-handed; use a sharps container; one needle/syringe per patient).

Supplements and non-allopathic modalities. Know the rationale, benefits, and cautions for common supplements — prenatal multivitamin, folic acid (neural-tube-defect prevention, ideally preconception), iron (anemia), calcium, magnesium, vitamin D, B-complex/B6 (nausea), and vitamin C/E. Be able to counsel on herbs, hydrotherapy, waterbirth, homeopathy, chiropractic, and acupuncture, including their contraindications.

Pharmacology used in out-of-hospital midwifery. Know indications, benefits, and risks of the agents a CPM may carry or administer within scope and protocol:

Oxytocin (Pitocin) — postpartum hemorrhage (uterotonic).
Methylergonovine (Methergine) — PPH uterotonic; contraindicated in hypertension/pre-eclampsia.
Misoprostol (Cytotec) — PPH uterotonic (off-label), often rectal/sublingual.
Oxygen — maternal/neonatal support.
Vitamin K — newborn prophylaxis against vitamin-K deficiency bleeding.
Erythromycin ophthalmic ointment — neonatal eye prophylaxis.
RhoGAM (Rh immune globulin) — for the Rh-negative mother to prevent isoimmunization.
Antibiotics for GBS — intrapartum prophylaxis.
IV fluids, epinephrine, and local anesthetic (for laceration repair).

Instruments, equipment, and labs. Know when and how to use the amnihook, bulb syringe/DeLee suction, bag-and-mask resuscitator, doppler/fetoscope, nitrazine paper, speculum, catheter, and suturing equipment. Be able to order or refer for cultures and to interpret common labs — H&H/CBC, blood type & Rh with antibody screen, glucose/HbA1c, GBS, rubella immunity, syphilis (RPR/VDRL), HIV, hepatitis B/C, gonorrhea/chlamydia, thyroid panel, and urinalysis — and to counsel on ultrasound and the biophysical profile (indications, benefits, limits).

Domain III — Maternal Health Assessment (~10%)

History. Collect and maintain a thorough history: demographics and psychosocial context (including allostatic stressors), medical and surgical history, and a complete reproductive history — menstrual, gynecologic, sexual, and childbearing history; contraception; and STI history. Capture family/genetic history, mental-health and abuse history, and both parents' substance use. Establish Rh type and the plan of care if Rh-negative.

Physical examination. Perform and interpret a baseline exam: vital signs, height/weight, HEENT including thyroid palpation, heart and lungs, breast exam and self-exam teaching, abdominal exam, CVA tenderness (kidney), deep tendon reflexes (baseline for later pre-eclampsia assessment), a vascular check for edema/varicosities/thrombophlebitis, and pelvic assessment (bimanual sizing of uterus/ovaries, speculum exam of the cervix, and inspection of the vulva, vagina, perineum, and anus).

The goal of assessment is to establish a baseline of normal for this individual, so that later deviations — a rising blood pressure, a change in reflexes, an abnormal fundal-height trend — stand out early.

Domain IV — Prenatal Care (~25%)

This is the second-largest domain. Master both routine care and the recognition of complications.

Physiology and routine care. Understand the anatomy and physiology of pregnancy and the normal changes by trimester. At each visit, track blood pressure, weight, urine (dip for protein, glucose, ketones, leukocytes, nitrites, blood), fundal height, fetal heart tones (fetoscope/doppler), and fetal movement. Use Leopold's maneuvers to assess lie, presentation, position, and estimated fetal size, and estimate the due date with standard methods (Naegele's rule: LMP − 3 months + 7 days; confirm/adjust with early ultrasound). Correlate fundal height in cm ≈ weeks of gestation between roughly 20 and 36 weeks.

Counseling and common complaints. Counsel on nutrition, weight gain, exercise, and supplements, and manage the common discomforts of pregnancy — nausea/vomiting, heartburn, constipation, hemorrhoids, round-ligament pain, sciatica, leg cramps, backache, carpal tunnel, varicosities, and sleep and emotional changes — distinguishing normal discomforts from red flags.

Recognizing and responding to complications. Identify, assess, treat within scope, or refer:

Hypertensive disorders — gestational hypertension and pre-eclampsia (elevated BP with proteinuria and/or signs such as headache, visual changes, RUQ pain, hyperreflexia/clonus, edema). Pre-eclampsia is a referral/transfer situation; know the warning signs cold.
Gestational diabetes, UTI, anemia, thrombophlebitis, oligohydramnios/polyhydramnios, and IUGR / SGA / LGA.
Bleeding — first-trimester (threatened/spontaneous abortion, ectopic — a surgical emergency), and second/third-trimester bleeding: placenta previa (painless bleeding — no vaginal exam; refer) vs. placental abruption (painful bleeding, rigid tender uterus — emergency transfer).
Malpresentation — identify breech and occiput-posterior; know positioning, ECV referral, and non-allopathic options (e.g., moxibustion), plus management if an unexpected breech presents. Identify multiple gestation.
VBAC — indications/contraindications for out-of-hospital birth and uterine-rupture risk factors (classical vs. low-transverse incision, scar thickness, short interdelivery interval, multiple prior cesareans). Recognize the signs of uterine rupture (severe pain, loss of fetal station, abnormal FHTs, bleeding, maternal instability) as an emergency.
Preterm labor — risk assessment (infection, smoking, prior PTB, periodontal disease, stress), counseling against elective early induction, and prompt referral/consult. Post-date pregnancy — surveillance with fetal-movement counts, FHR, amniotic-fluid assessment, and referral for NST/BPP/ultrasound.
PROM — distinguish full-term from preterm. At term: monitor FHTs and temperature, minimize vaginal exams, reinforce hygiene, review GBS status, and consult for prolonged rupture. Preterm PROM: consult/refer.
Cholestasis of pregnancy, and identification of molar/ectopic pregnancy.

Emergency and transport planning. Establish contingency plans, educate on hospital transport (including augmentation and pharmacologic pain relief), and provide informed, supportive counseling around cesarean birth and recovery.

Domain V — Labor, Birth, and Immediate Postpartum (~35%)

The largest domain. It spans normal labor support, intrapartum complications, immediate newborn care, third stage, hemorrhage, repair, and breastfeeding initiation.

Normal labor. Support the normal physiologic process. Assess maternal and fetal status: vital signs, hydration/intake, membrane status, contraction frequency/duration/intensity, fetal heart tones, and fetal lie, presentation, position, and descent (station), along with cervical effacement and dilation. Provide comfort — position changes, counter-pressure, movement, hydrotherapy — and counsel on early labor and on waterbirth benefits/risks and setup.

Stalled or abnormal labor. Recognize and respond to causes of slow progress: an anterior/swollen cervical lip, occiput-posterior or asynclitic position, maternal exhaustion, fear, dehydration, deep transverse arrest, and obstructed labor. Use positioning, rest, hydration/nutrition, and non-allopathic measures, and know when slow progress warrants consultation or transfer.

Intrapartum emergencies. Recognize and manage or transfer:

Abnormal fetal heart-rate patterns — persistent bradycardia, or late/variable decelerations that don't resolve.
Cord prolapse — relieve pressure on the cord (knee-chest/Trendelenburg, lift the presenting part) and transport emergently.
Nuchal cord — reduce over the head, or use the somersault maneuver; clamp/cut only if truly tight and reduction fails.
Shoulder dystocia — a stepwise drill: call for help, McRoberts (hyperflexed hips) and suprapubic pressure, Gaskin (hands-and-knees) maneuver, deliver the posterior arm, and internal rotational (Rubin/Woods) maneuvers; avoid fundal pressure.
Breech, face, and brow presentations — understand the mechanisms and be ready to support delivery or transfer, and to resuscitate.
Meconium-stained fluid — assess degree and follow standard neonatal resuscitation (per AAP/NRP) if the newborn is non-vigorous.
Uterine rupture, uterine inversion, amniotic-fluid embolism, and stillbirth — recognize, stabilize, and transport.

Second stage and birth. Recognize progress, support spontaneous/physiologic pushing and positions, protect the perineum with appropriate hand techniques, and know the (limited) indications for episiotomy.

Immediate newborn care. Support normal transition: keep the newborn warm and skin-to-skin, assign APGAR at 1 and 5 minutes (and 10 if needed), and assess breathing and heart rate. If the newborn is not breathing/vigorous, begin NRP steps — warm, dry, stimulate, position the airway, and provide positive-pressure ventilation as the priority intervention. Delay cord clamping until pulsation stops when appropriate; assess the cord vessels (normally two arteries and one vein). Recognize and transport for birth defects, meconium aspiration syndrome, and signs of CNS compromise.

Third stage. Recognize signs of placental separation (a gush of blood, cord lengthening, a rise in the fundus, the urge to push). Facilitate delivery with maternal effort, nipple stimulation/position change, an empty bladder, and guarded (controlled) cord traction — never uncontrolled traction, which risks inversion. Inspect the placenta and membranes for completeness.

Blood loss and hemorrhage. Estimate and monitor blood loss. For a trickle, find the source, massage the fundus, empty the bladder, and encourage breastfeeding. For postpartum hemorrhage, the most common cause is uterine atony — respond in a stepwise way: fundal massage first, then uterotonics (oxytocin, then methylergonovine — not if hypertensive — or misoprostol), bimanual compression, IV fluids, treat for hypovolemic shock, and consult/transfer while activating the emergency plan. Remember the "4 T's" of PPH: Tone, Trauma, Tissue, Thrombin.

Maternal assessment and repair. Assess the bladder (encourage voiding or catheterize), and inspect the vagina, cervix, and perineum for hematoma, prolapse, and lacerations (know the degrees: 1st = skin/mucosa, 2nd = perineal muscle, 3rd = anal sphincter, 4th = rectal mucosa). Repair first- and second-degree tears within scope using local anesthetic; 3rd/4th-degree tears require referral. Instruct on perineal care and monitor vital signs.

Breastfeeding initiation and newborn exam. Facilitate early breastfeeding — colostrum, skin-to-skin, latch, positioning, and normal output. Perform a complete newborn exam head-to-toe (fontanels, red reflex, palate and tongue-tie, clavicles, heart/lung sounds, abdomen, genitalia, hip check for dislocation, spine, tone, and reflexes — suck, root, Moro, grasp, Babinski, step). Assess gestational age; administer eye prophylaxis and vitamin K with informed consent; and review GBS status with a follow-up plan.

Domain VI — Postpartum (~15%)

Involution and the postpartum timeline. Assess physical and emotional recovery, including normal involution of the uterus and the progression of lochia (rubra → serosa → alba). Evaluate mother and baby across the standard visit timeline: day 1–2, day 3–4, week 1–2, week 3–4, and week 5–6.

Counseling and complications. Counsel on lochia vs. abnormal bleeding, return of menses, elimination, pelvic-floor recovery, and the condition of the perineum. Distinguish and manage or refer for postpartum complications — endometritis (fever, uterine tenderness, foul lochia), mastitis (a red, tender, warm breast segment with fever/flu-like symptoms — usually managed with continued breastfeeding, rest, and antibiotics when indicated), delayed/secondary hemorrhage (often retained tissue or subinvolution), urinary retention, and thromboembolism (a swollen, painful calf, or chest pain/shortness of breath — an emergency).

Perinatal mental health. Distinguish transient "baby blues" (days 1–2 to ~2 weeks) from postpartum depression (persistent, functionally impairing) and postpartum psychosis (a psychiatric emergency — confusion, hallucinations, delusions, risk to self or infant — requiring immediate referral). Screen, counsel, mobilize support, and increase follow-up as needed.

Domain VII — Well Baby Care (~5%)

Normal newborn adaptation. Support thermoregulation, feeding adequacy, and normal urine/stool patterns (roughly one wet/stool per day of life in the first days, transitioning to regular output as milk comes in; stool transitions from meconium → transitional → milk stool).

Jaundice. Distinguish physiologic jaundice (appears after ~24 hours, peaks around days 3–5) from pathologic jaundice (appears in the first 24 hours, rises rapidly, or is prolonged — a referral situation). Support feeding and know when bilirubin evaluation and phototherapy referral are warranted.

Screening and follow-up. Educate on newborn screening: the metabolic/genetic heel-stick screen, hearing screening, and critical congenital heart disease pulse-oximetry screening. Counsel on cord care, safe sleep, and follow-up.

Danger signs. Recognize and refer/transport for newborn warning signs — poor feeding, lethargy or marked irritability, temperature instability, respiratory distress (grunting, flaring, retractions, persistent tachypnea, cyanosis), dehydration, and signs of sepsis. When in doubt about a sick newborn, escalate early.

How to use this guide

Study in proportion to the weights: spend the most time on Prenatal and Labor, Birth & Immediate Postpartum, which together are ~60% of the exam. For every topic, ask the CPM's central question: Is this normal, a manageable variation, or a reason to consult, refer, or transfer? Then reinforce with the practice questions and a blueprint-weighted mock.

Reminder: educational content only, not clinical advice. Practice within your legal scope, protocols, and current evidence.

Ready to practice? Practice questions Timed mock exam