This scenario presents a common yet critical challenge in rural and remote midwifery: managing a deviation from normal physiological progression during labour with limited immediate access to advanced medical support. The midwife must balance the inherent resilience of the physiological process with the potential for complications, all while operating within established professional standards and regulatory frameworks. The remoteness amplifies the need for astute clinical judgment, timely decision-making, and effective communication. The best professional approach involves a comprehensive assessment of the maternal and fetal well-being, coupled with a thorough understanding of the normal physiological parameters of labour progression. This includes continuous monitoring of uterine contractions, cervical change, and fetal heart rate, alongside maternal vital signs. When deviations from the expected norm are identified, the midwife must initiate evidence-based interventions within their scope of practice to support physiological labour. This might include positional changes, hydration, or comfort measures. Crucially, this approach mandates prompt and clear communication with the remote healthcare team or designated referral centre, outlining the clinical situation, the interventions already undertaken, and the rationale for any proposed escalation or continued observation. This aligns with the ethical duty of care, the principle of beneficence, and the regulatory requirement for midwives to practice within their competence and to seek appropriate consultation or transfer of care when necessary. The emphasis is on proactive, informed management that prioritizes maternal and fetal safety while respecting the physiological process. An incorrect approach would be to dismiss the observed changes as insignificant without a thorough reassessment, potentially delaying necessary interventions or consultation. This fails to uphold the duty of care and could lead to adverse outcomes. Another incorrect approach is to immediately escalate to the highest level of intervention without first attempting to manage the situation within the midwife’s scope of practice and assessing the response to those interventions. This can lead to unnecessary medicalization of labour and may not be the most appropriate course of action for the specific deviation observed. Furthermore, failing to document the assessment findings, interventions, and communication with the remote team constitutes a significant regulatory and ethical breach, compromising accountability and continuity of care. Professional reasoning in such situations requires a systematic approach: 1) Recognize and accurately assess deviations from normal physiological parameters. 2) Apply knowledge of normal and complex antenatal, intrapartum, and postnatal physiology to interpret these deviations. 3) Utilize evidence-based midwifery interventions within the scope of practice. 4) Communicate effectively and promptly with the remote healthcare team, providing clear and concise information. 5) Document all assessments, interventions, and communications meticulously. 6) Make timely decisions regarding escalation or transfer of care based on ongoing assessment and risk stratification.

Scenario Analysis: This scenario presents a professional challenge due to the inherent variability in rural and remote settings, where resources and immediate support may be limited. The midwife must balance the immediate needs of the mother and baby with the long-term implications of her actions, particularly concerning the establishment of a sustainable and culturally appropriate feeding plan. The decision-making process requires careful consideration of evidence-based practice, ethical principles, and the specific socio-cultural context of the family. Correct Approach Analysis: The best professional practice involves a comprehensive, individualized assessment of the mother’s and infant’s feeding capabilities and needs, followed by collaborative development of a feeding plan that respects the family’s cultural beliefs and practices. This approach prioritizes the well-being of both mother and infant, ensuring that the chosen feeding method is sustainable and supported within the community. It aligns with ethical principles of autonomy, beneficence, and non-maleficence, as it empowers the family to make informed decisions while ensuring the best possible health outcomes. Regulatory frameworks for midwifery emphasize individualized care and informed consent, which are central to this approach. Incorrect Approaches Analysis: One incorrect approach involves solely recommending formula feeding without a thorough assessment of the mother’s ability or desire to breastfeed, or the availability of safe water and sanitation for formula preparation. This fails to uphold the principle of beneficence by potentially overlooking the benefits of breastfeeding and the risks associated with improper formula preparation in a remote setting. It also disregards the mother’s autonomy and may not be culturally sensitive. Another incorrect approach is to insist on exclusive breastfeeding without considering potential challenges or the mother’s physical or emotional capacity, especially in a remote context where support may be scarce. This could lead to maternal exhaustion, infant distress, and failure to thrive, violating the principle of non-maleficence. It also fails to acknowledge the diverse circumstances of families and the potential need for supplementation or alternative feeding methods. A further incorrect approach is to defer entirely to the family’s wishes without providing evidence-based information and guidance on infant feeding. While respecting autonomy is crucial, midwives have a professional and ethical responsibility to provide accurate information to ensure the health and safety of the infant. Failing to do so could result in suboptimal feeding practices that compromise the infant’s health, contravening the principle of beneficence. Professional Reasoning: Professionals should employ a decision-making framework that begins with a thorough, holistic assessment of the mother, infant, and their environment. This assessment should include physical, emotional, and psychosocial factors, as well as cultural considerations. Following the assessment, open and honest communication with the family is paramount, presenting evidence-based options for infant feeding while actively listening to their preferences and concerns. The chosen feeding plan should be a collaborative decision, with ongoing support and follow-up to ensure its success and the well-being of both mother and infant. This process ensures care is individualized, ethical, and aligned with professional standards.

Research into the purpose and eligibility for the Advanced Mediterranean Rural and Remote Midwifery Licensure Examination highlights the critical need for midwives to possess specialized skills and knowledge to serve diverse and often underserved populations. This scenario is professionally challenging because it requires a nuanced understanding of both general midwifery competencies and the unique demands of rural and remote settings within the Mediterranean context, which may include varying cultural practices, limited access to resources, and specific epidemiological profiles. Careful judgment is required to ensure that only those midwives demonstrably equipped to meet these challenges are licensed, thereby safeguarding maternal and infant health. The best approach involves a comprehensive assessment of a candidate’s prior experience and specialized training directly relevant to advanced rural and remote midwifery practice in the Mediterranean region. This includes evaluating their demonstrated ability to manage complex obstetric emergencies with limited support, their understanding of culturally sensitive care, and their proficiency in utilizing available resources effectively. Regulatory frameworks for professional licensure in specialized fields typically prioritize evidence of competence that directly aligns with the scope of practice. Eligibility criteria are designed to ensure that advanced practitioners can independently and safely provide high-level care in challenging environments, reflecting a commitment to public safety and quality of care as mandated by professional midwifery standards and health authority guidelines. An approach that focuses solely on general midwifery experience without considering the specific demands of rural and remote Mediterranean practice is professionally unacceptable. This fails to acknowledge the distinct skill set required for such settings, potentially leading to the licensure of individuals who are not adequately prepared for the unique challenges they will face, thereby compromising patient safety. Similarly, an approach that prioritizes theoretical knowledge gained through general continuing professional development courses without practical application or demonstrated experience in the target environment is insufficient. Licensure for advanced practice necessitates a proven track record of hands-on competence and adaptability in the specific context of rural and remote care. Finally, an approach that relies on anecdotal evidence or personal recommendations without objective assessment of skills and knowledge does not meet the rigorous standards expected for advanced professional licensure and undermines the integrity of the examination process. Professionals should employ a decision-making framework that begins with a clear understanding of the examination’s stated purpose and the specific competencies it aims to assess. This involves meticulously reviewing the eligibility criteria and comparing them against the candidate’s documented qualifications, experience, and any specialized training. A systematic evaluation of evidence, prioritizing practical experience and demonstrated skills in relevant settings, is crucial. Ethical considerations demand that the primary focus remains on ensuring the safety and well-being of the population served, which is achieved by licensing only those who meet the highest standards of competence for the intended practice environment.

This scenario presents a professional challenge due to the sensitive nature of reproductive healthcare decisions, the potential for cultural or personal beliefs to influence a client’s choices, and the midwife’s ethical and legal obligations to provide comprehensive, unbiased care. Balancing a client’s autonomy with the provision of accurate information and support requires careful judgment and adherence to established professional standards. The best approach involves a comprehensive, client-centered discussion that prioritizes informed consent and respects the client’s autonomy. This entails providing detailed, evidence-based information about all available family planning methods, including their benefits, risks, and effectiveness, without expressing personal opinions or steering the client towards a particular choice. The midwife must actively listen to the client’s concerns, values, and preferences, ensuring they understand all options and feel empowered to make a decision that aligns with their personal circumstances and reproductive goals. This aligns with the ethical principles of beneficence, non-maleficence, and respect for autonomy, as well as regulatory frameworks that mandate informed consent and the provision of comprehensive reproductive health services. An approach that focuses solely on methods the midwife personally prefers or has more experience with is professionally unacceptable. This demonstrates a failure to uphold the principle of client autonomy and may lead to the client not receiving information about methods that might be more suitable for their individual needs. It also risks imposing the midwife’s own biases, which is contrary to ethical practice and may violate regulations requiring unbiased provision of care. Another unacceptable approach is to provide only a superficial overview of family planning options without delving into the specifics of each method’s efficacy, risks, and benefits. This fails to equip the client with the necessary information for truly informed consent. Such a limited approach neglects the midwife’s duty to educate and empower the client, potentially leading to a decision based on incomplete understanding and contravening regulatory requirements for comprehensive reproductive health counseling. Finally, an approach that dismisses the client’s stated preferences or concerns without adequate exploration is also professionally flawed. This disrespects the client’s lived experience and autonomy. It can create a barrier to trust and effective care, and may violate ethical guidelines that emphasize empathetic and responsive care, as well as legal obligations to respect patient choices within the bounds of safe practice. Professionals should employ a decision-making framework that begins with understanding the client’s needs and preferences. This involves active listening, open-ended questioning, and a commitment to providing unbiased, evidence-based information. The midwife must then assess the client’s understanding and address any misconceptions or fears, ensuring they have the capacity to make an informed decision. Throughout the process, maintaining confidentiality and respecting the client’s right to choose, or to change their mind, are paramount. Adherence to professional codes of conduct and relevant healthcare regulations should guide every step of the interaction.

The monitoring system demonstrates a critical need for nuanced understanding of community midwifery, continuity models, and cultural safety within the context of Mediterranean rural and remote settings. This scenario is professionally challenging because it requires balancing the established protocols of a continuity model with the unique cultural beliefs and practices of a specific community, ensuring that care is not only clinically effective but also respectful and acceptable to the birthing person and their family. The pressure to adhere to a standardized monitoring schedule, while seemingly efficient, risks alienating individuals who may have different understandings of health, birth, and the role of healthcare providers. Careful judgment is required to adapt practices without compromising safety or professional standards. The best approach involves actively engaging with the community to understand their cultural practices related to pregnancy, birth, and postpartum care. This includes inquiring about traditional remedies, family involvement, spiritual beliefs, and preferred communication styles. By integrating this knowledge into the continuity of care plan, the midwife can build trust and ensure that the monitoring system is perceived as a supportive, rather than intrusive, element of care. This collaborative approach aligns with the ethical imperative of patient-centered care and the principles of cultural safety, which mandate that healthcare providers recognize and respect the cultural identity and needs of their patients. Regulatory frameworks governing midwifery in many Mediterranean regions emphasize holistic care and respect for diverse cultural norms, underscoring the importance of this adaptive strategy. An incorrect approach would be to rigidly enforce the standardized monitoring schedule without seeking to understand or accommodate the community’s cultural practices. This failure to engage with cultural nuances can lead to mistrust, non-adherence to care recommendations, and a perception of disrespect, thereby undermining the continuity of care model and potentially compromising the birthing person’s well-being. Ethically, this approach violates the principle of respect for autonomy and dignity. Another incorrect approach would be to dismiss or disregard the community’s cultural practices as irrelevant or superstitious. This paternalistic stance not only demonstrates a lack of cultural competence but also actively creates barriers to effective care. It fails to acknowledge the holistic nature of health and well-being, which is often deeply intertwined with cultural identity and community support. Such an approach is ethically unsound and likely to contravene regulatory guidelines that promote culturally sensitive healthcare. Finally, an incorrect approach would be to delegate the responsibility of cultural understanding to another member of the healthcare team without the primary midwife actively participating in the process. While collaboration is important, the midwife responsible for the continuity of care must be the one to build rapport and integrate cultural considerations directly into their practice. This ensures that the continuity of care is genuinely personalized and culturally safe, rather than being a fragmented or superficial effort. Professionals should employ a decision-making framework that prioritizes cultural humility and active listening. This involves: 1) Self-reflection on personal biases and assumptions. 2) Open-ended inquiry to understand the patient’s perspective and cultural context. 3) Collaborative planning that integrates patient preferences and cultural practices with clinical evidence and safety standards. 4) Ongoing evaluation of the effectiveness of the care plan from both a clinical and cultural standpoint.

Scenario Analysis: This scenario presents a professional challenge for a midwife preparing for their Advanced Mediterranean Rural and Remote Midwifery Licensure Examination. The challenge lies in understanding and applying the examination board’s policies regarding blueprint weighting, scoring, and retake procedures. Misinterpreting these policies can lead to significant anxiety, wasted preparation time, and potentially failure to pass the examination, impacting their ability to practice in rural and remote settings. Careful judgment is required to ensure accurate comprehension and strategic preparation based on official guidelines. Correct Approach Analysis: The best professional approach involves proactively seeking and thoroughly reviewing the official examination blueprint and associated policies published by the Mediterranean Midwifery Board. This document details the weighting of different content areas, the scoring methodology, and the specific conditions and limitations for retaking the examination. Adhering to this official documentation ensures that preparation efforts are focused on the most heavily weighted topics and that the candidate understands the consequences of not passing, including the process and frequency of retakes. This approach is ethically sound as it demonstrates diligence, respect for the examination process, and a commitment to meeting the established standards for licensure. It aligns with the professional responsibility to be fully informed about the requirements for practice. Incorrect Approaches Analysis: Relying solely on anecdotal information from colleagues or study groups about the examination’s structure and retake policies is professionally unacceptable. This approach risks propagating misinformation, leading to an inaccurate understanding of blueprint weighting and scoring, and potentially misinformed decisions about retake strategies. Such reliance fails to meet the ethical obligation to base professional actions on verified information and can result in inadequate preparation or missed opportunities. Assuming that the examination’s blueprint and retake policies are static and have not been updated since previous examination cycles is also professionally unsound. Examination boards periodically review and revise their policies to reflect evolving professional standards and best practices. Failing to consult the most current official documentation could lead to preparation based on outdated information, rendering study efforts inefficient and potentially leading to failure. This demonstrates a lack of due diligence and a failure to adhere to current professional standards. Focusing exclusively on mastering a few perceived “high-yield” topics without understanding their official weighting on the blueprint is a flawed strategy. While identifying important topics is part of preparation, an exclusive focus without considering the official weighting can lead to neglecting other critical areas that may contribute significantly to the overall score. This approach risks an unbalanced preparation and a misunderstanding of the comprehensive knowledge required for advanced rural and remote midwifery practice as defined by the licensing body. Professional Reasoning: Professionals facing licensure examinations should adopt a systematic and evidence-based approach to preparation. This involves: 1. Identifying the official governing body for the examination. 2. Locating and meticulously reviewing all official documentation, including the examination blueprint, candidate handbooks, and policy statements regarding scoring and retakes. 3. Prioritizing study areas based on the official weighting provided in the blueprint. 4. Understanding the scoring mechanism and any potential penalties or considerations. 5. Familiarizing oneself with the complete retake policy, including eligibility, frequency, and any additional requirements. 6. Seeking clarification from the examination board directly if any aspect of the policies remains unclear. This structured approach ensures that preparation is targeted, efficient, and aligned with the established requirements for professional licensure, promoting ethical practice and competence.

This scenario is professionally challenging because it requires the midwife to navigate a complex interplay between the birthing person’s deeply held cultural beliefs and established medical best practices, all within the framework of the Advanced Mediterranean Rural and Remote Midwifery Licensure Examination’s regulatory and ethical guidelines. The midwife must balance respecting autonomy and cultural sensitivity with ensuring the safety and well-being of both the birthing person and the neonate, adhering to the principles of shared decision-making. The best approach involves a comprehensive, culturally sensitive holistic assessment that prioritizes open communication and collaborative decision-making. This means actively listening to the birthing person’s concerns, understanding the cultural significance of their requests, and then clearly explaining the medical rationale behind recommended interventions or potential risks associated with their preferred approach. The midwife should explore all available options, respecting the birthing person’s right to informed consent and refusal, while ensuring they have a thorough understanding of the implications of their choices. This aligns with the ethical imperative to uphold autonomy and beneficence, as mandated by professional midwifery standards that emphasize person-centered care and collaborative partnership. An approach that dismisses the birthing person’s cultural beliefs outright, labeling them as “uninformed” or “unnecessary,” fails to uphold the principle of respect for autonomy and cultural diversity. This can lead to a breakdown in trust and a failure to achieve genuine shared decision-making, potentially causing distress and disempowerment for the birthing person. It also risks overlooking valid concerns that, while perhaps not framed in Western medical terms, may still have implications for the birthing person’s well-being. Another incorrect approach would be to proceed with interventions without adequately explaining the rationale or exploring alternatives that might accommodate the birthing person’s beliefs, even if they deviate slightly from standard protocols. This bypasses the essential element of informed consent and shared decision-making, treating the birthing person as a passive recipient of care rather than an active partner. This can be seen as paternalistic and may violate the birthing person’s right to self-determination. Finally, an approach that solely focuses on medical protocols without acknowledging or attempting to integrate the birthing person’s cultural context risks alienating the individual and their family. While adherence to safety guidelines is paramount, the process of achieving that safety must be a collaborative one, respecting the individual’s values and beliefs. Professionals should employ a decision-making process that begins with active listening and empathetic inquiry into the birthing person’s values, beliefs, and preferences. This should be followed by a clear, jargon-free explanation of medical information, including potential risks and benefits of various options. The midwife should then work collaboratively with the birthing person to identify mutually agreeable care plans that prioritize safety while respecting autonomy and cultural considerations. Documentation of these discussions and decisions is crucial.

The scenario presents a common challenge in rural and remote midwifery: balancing the immediate needs of a pregnant individual with limited local resources and the established protocols for specialist referral. The professional challenge lies in accurately assessing the urgency of the situation, understanding the scope of practice within the remote setting, and navigating the referral pathways effectively while ensuring continuity of care and patient safety. This requires a nuanced understanding of both clinical judgment and the regulatory framework governing midwifery practice in the specified jurisdiction. The best approach involves a comprehensive risk assessment and timely, appropriate referral. This includes a thorough clinical evaluation of the pregnant individual and fetus, identifying any deviations from normal pregnancy progression that might indicate a need for higher-level care. Based on this assessment, the midwife must then initiate a referral to the nearest appropriate specialist service, providing clear and concise clinical information. This aligns with the regulatory framework that mandates midwives to practice within their scope, recognize limitations, and refer to specialists when necessary to ensure optimal maternal and fetal outcomes. Ethical considerations of beneficence and non-maleficence are paramount, requiring proactive measures to prevent harm and promote well-being. An incorrect approach would be to delay referral due to perceived inconvenience or a desire to manage the situation independently without adequate justification. This could lead to a deterioration of the patient’s condition, potentially resulting in adverse outcomes that could have been prevented with timely specialist intervention. Such a delay would contravene the professional duty of care and could be seen as a breach of regulatory requirements concerning referral protocols. Another incorrect approach is to refer without a clear clinical indication or sufficient information. This can overburden specialist services with non-urgent cases, leading to inefficiencies and potentially delaying care for those who genuinely require it. It also fails to demonstrate the midwife’s ability to critically assess the situation and make informed decisions, which is a core competency expected within the regulatory framework. Finally, an approach that involves referring to a service that is not the most appropriate for the specific clinical need, even if it is a specialist service, is also professionally unacceptable. This demonstrates a lack of understanding of the referral network and the specific expertise required for the patient’s condition, potentially leading to further delays and suboptimal care. The professional decision-making process in such situations should involve a systematic assessment of the patient’s condition, a clear understanding of the midwife’s scope of practice and available resources, and a thorough knowledge of the established referral pathways and criteria. When in doubt, consulting with a senior midwife or a medical professional is crucial. The primary focus must always be on the safety and well-being of the pregnant individual and their fetus, guided by regulatory requirements and ethical principles.

The risk matrix shows a candidate preparing for the Advanced Mediterranean Rural and Remote Midwifery Licensure Examination who is struggling to balance comprehensive study with limited time and access to specialized resources. This scenario is professionally challenging because the candidate’s success directly impacts patient safety in remote and potentially underserved areas. The high stakes of rural and remote midwifery necessitate a thorough understanding of unique challenges, including resource limitations, cultural considerations, and emergency preparedness, which are often not covered in standard midwifery education. Careful judgment is required to ensure the candidate is adequately prepared without compromising their well-being or the quality of their learning. The best approach involves a structured, evidence-based preparation strategy that prioritizes core competencies and leverages available, reputable resources. This includes identifying specific knowledge gaps through self-assessment and diagnostic tools, then creating a realistic study timeline that allocates sufficient time for each topic. Prioritizing official examination syllabi, recommended reading lists from the licensing body, and peer-reviewed literature relevant to rural and remote midwifery practice is crucial. Engaging with professional midwifery organizations for guidance on best practices and potentially connecting with experienced rural midwives for mentorship can also be invaluable. This method ensures preparation is aligned with regulatory expectations and ethical obligations to provide safe, competent care. An approach that relies solely on general midwifery textbooks and a haphazard study schedule is professionally unacceptable. This fails to address the specific nuances of rural and remote practice, potentially leaving the candidate unprepared for unique clinical scenarios and patient populations. It also disregards the importance of adhering to the examination’s defined scope and recommended resources, which are established to ensure a consistent standard of competence. Another unacceptable approach is to focus exclusively on memorizing past examination questions without understanding the underlying principles. While familiarity with question formats is helpful, this method does not foster deep comprehension or the ability to apply knowledge to novel situations, which is essential for effective midwifery practice, especially in unpredictable remote settings. This approach risks producing a candidate who can pass an exam but may lack the critical thinking and clinical judgment needed to provide safe care. Finally, an approach that neglects to seek out resources specifically tailored to rural and remote midwifery, such as case studies, guidelines on managing limited resources, or information on interprofessional collaboration in isolated settings, is also professionally deficient. This oversight can lead to a significant gap in knowledge and skills, potentially compromising the candidate’s ability to practice effectively and ethically in the intended environment. Professionals should employ a decision-making framework that begins with understanding the examination’s requirements and the specific demands of the practice setting. This involves a thorough self-assessment of knowledge and skills, followed by the development of a personalized, realistic study plan. Prioritizing reputable, jurisdiction-specific resources and seeking guidance from professional bodies and experienced practitioners are key steps. Continuous evaluation of progress and adaptation of the study plan are also vital to ensure comprehensive and effective preparation.

Scenario Analysis: This scenario presents a critical challenge for a rural midwife managing a complex obstetric emergency in a remote setting with limited immediate access to advanced medical support. The core difficulty lies in balancing the need for rapid, decisive action with the constraints of resources and the imperative to provide evidence-based, safe care within the established regulatory framework. The midwife must act as the primary decision-maker, coordinating care and ensuring the best possible outcome for both mother and fetus, while adhering to professional standards and ethical obligations. Correct Approach Analysis: The best professional practice involves immediate stabilization of the mother, continuous fetal monitoring to assess fetal well-being, and prompt communication with the nearest tertiary care facility for guidance and potential transfer. This approach prioritizes the immediate physiological needs of the mother and fetus, utilizes available resources effectively, and adheres to the principle of timely escalation of care. Regulatory frameworks governing midwifery practice, such as those overseen by the relevant national midwifery council or regulatory body, mandate that midwives act within their scope of practice, prioritize patient safety, and seek appropriate consultation or transfer when a situation exceeds their capacity to manage safely. Ethical guidelines emphasize the duty of care, beneficence, and non-maleficence, all of which are served by this comprehensive and proactive strategy. Incorrect Approaches Analysis: Initiating immediate transfer to the tertiary center without first stabilizing the mother and assessing fetal status is professionally unacceptable. This approach risks exacerbating the mother’s condition during transport and fails to address immediate life-threatening issues. It disregards the regulatory requirement to provide immediate care and assessment before transfer and violates the ethical principle of beneficence by potentially compromising the patient’s stability. Delaying intervention and solely relying on the arrival of a more senior clinician or specialist without initiating any management steps is also professionally unsound. This passive approach neglects the midwife’s responsibility to act decisively in an emergency and can lead to irreversible fetal compromise or maternal deterioration. It contravenes regulatory expectations for emergency management and the ethical duty to act promptly to prevent harm. Focusing exclusively on fetal surveillance without addressing the mother’s critical condition is an incomplete and potentially dangerous strategy. While fetal well-being is paramount, the mother’s physiological stability is the prerequisite for a positive fetal outcome. This approach fails to meet the comprehensive care requirements mandated by regulatory bodies and breaches the ethical obligation to treat the mother and fetus as an interconnected unit requiring integrated management. Professional Reasoning: Professionals should employ a structured approach to emergency management, often guided by protocols such as ABCDE (Airway, Breathing, Circulation, Disability, Exposure) for maternal assessment, coupled with continuous fetal monitoring. The decision-making process should involve rapid assessment, immediate interventions to stabilize, concurrent communication with higher levels of care, and a clear plan for transfer if indicated, all within the scope of practice and regulatory guidelines.