Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Emergency Obstetric First-Response for the MidwifeCheat Sheet
Cheat sheet for Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Emergency Obstetric First-Response for the Midwife. Compact, printable, and organised around the concepts Professional Regulation Commission (PRC) — Board of Midwifery tests most frequently in the Midwife Licensure Exam 2026. Perfect for the week before exam day.
Exam context
For the Midwife Licensure Examination, Professional Regulation Commission (PRC) — Board of Midwifery tests Independent Delivery & Emergency Obstetric Care under a "Core" label, with Emergency Obstetric First-Response for the Midwife in the 4th slot across 4 chapters. Midwife Licensure Exam candidates must clear the 75% weighted average cut on the 2026 paper, which draws about a meaningful share of Independent Delivery & Emergency Obstetric Care questions. Date to watch: April and November 2026 (expected).
Emergency Obstetric First-Response for the Midwife - Cheat Sheet
Your 30-minute exam-ready reference for recognizing and managing the five obstetric emergencies a midwife must master: PPH, shoulder dystocia, cord prolapse, eclampsia, and newborn resuscitation. Every fact here could be tested. Know the sequences, drugs, doses, and WHEN TO REFER.
Sections
Formulas
Formula
PPH defined: ≥500 mL blood loss (vaginal delivery) OR ≥1000 mL (cesarean) OR any blood loss making mother symptomatic
Meaning
Symptomatic = dizzy, pale, rising pulse, falling BP. The DEFINITION depends on volume OR clinical signs, whichever comes first.
Watch Out
Students confuse PPH threshold — remember: 500 mL vaginal, 1000 mL cesarean, OR symptomatic (lower threshold = more important clinically).
When To Use
Assess every patient in first 2 hours postpartum. Document estimated blood loss (EBL) carefully.
Common Values
Value
≥500 mL
Symbol
500 mL
Quantity
PPH threshold (vaginal delivery)
Value
≥1000 mL
Symbol
1000 mL
Quantity
PPH threshold (cesarean delivery)
Value
10 IU IM
Symbol
10 IU
Quantity
Oxytocin first-line dose
Value
0.2 mg IM
Symbol
0.2 mg
Quantity
Methylergometrine dose
Value
800 mcg SL (or 600–800 mcg rectal)
Symbol
800 mcg
Quantity
Misoprostol dose
Value
1 g IV
Symbol
1 g
Quantity
Tranexamic acid dose
Value
~70%
Symbol
70%
Quantity
Percentage of PPH caused by atony
Section Title
Postpartum Hemorrhage (PPH)
Important Facts
- PPH is the LEADING CAUSE of maternal death globally.
- First action: FUNDAL MASSAGE (firm, continuous) until firm — atony resolves with massage alone in many cases.
- Oxytocin 10 IU IM is FIRST-LINE uterotonic; can also give 20 IU in 1 L IV fluid running fast.
- Empty the bladder (catheterize) — a full bladder prevents uterine contraction.
- IV fluids (normal saline or Ringer's lactate) run FAST; large-bore IV line is essential.
- Methylergometrine 0.2 mg IM is CONTRAINDICATED in hypertension or pre-eclampsia (risk of stroke).
- Second-line uterotonics: Methylergometrine 0.2 mg IM, Misoprostol 800 mcg SL (or 600–800 mcg rectal), Tranexamic acid 1 g IV.
- Bimanual uterine compression: one fist in anterior vaginal fornix (pushing UP), other hand on abdomen behind fundus (pushing DOWN) — compresses uterus between hands.
- Aortic compression (pressing fist into abdomen below umbilicus, against aorta) is a temporizing measure only — hold maximum 5 minutes.
- Check placenta: is it complete? Retained tissue = tissue hemorrhage = manual removal at hospital.
Key Definitions
Term
Uterine Atony
Example
Fundus feels doughy, not firm; bleeding continues with a soft uterus = atony = massage immediately.
Definition
Failure of the uterus to contract after delivery; soft, boggy fundus; the cause of ~70% of PPH.
Term
The 4 T's of PPH
Example
Firm uterus + heavy bleeding = suspect Trauma; soft uterus + bleeding = suspect Tone.
Definition
Tone (atony, 70%), Trauma (lacerations, hematoma, inversion, rupture), Tissue (retained placenta/fragments), Thrombin (coagulation failure).
Term
Uterotonic
Example
Oxytocin 10 IU IM is given immediately after delivery or at signs of PPH.
Definition
Drug that causes the uterus to contract; first-line is oxytocin; second-line are methylergometrine and misoprostol.
Diagrams To Know
- The 4 T's — causes of PPH (Tone, Trauma, Tissue, Thrombin)
- Fundal massage technique (firm, circular, through the abdomen)
- Bimanual uterine compression (position of both hands)
Section Title
Shoulder Dystocia
Important Facts
- Shoulder dystocia is UNPREDICTABLE — can occur in any delivery, not just high-risk.
- Key first action: call for help and note the time.
- DO NOT apply strong traction on the head — this WORSENS dystocia and injures the baby.
- DO NOT apply fundal pressure — this pushes the baby further into dystocia.
- HELPERR sequence: Help (call), E (McRoberts), P (suprapubic pressure), E (enter/episiotomy), R (roll onto all fours/Gaskin), R (refer if unresolved).
- McRoberts maneuver (hyperflex thighs) resolves ~50–60% of cases — do this FIRST.
- Suprapubic pressure: assistant applies downward and LATERAL pressure above symphysis pubis to dislodge the anterior shoulder.
- Internal maneuvers (Rubin/Woods screw) and delivery of the posterior arm are advanced — refer if not successful with simple maneuvers.
- Episiotomy may be needed to make room for internal maneuvers.
- Gaskin maneuver: roll mother onto all fours (hands and knees) — gravity assists, posterior shoulder delivers first.
Key Definitions
Term
Shoulder Dystocia
Example
Baby's head delivers but then retracts back tightly; body does not follow = turtle sign.
Definition
After the head delivers, the anterior shoulder impacts behind the symphysis pubis and the body will not deliver with normal traction — a true emergency.
Term
Turtle Sign
Example
Recognize this immediately — do NOT pull harder on the head.
Definition
The head delivers but retracts back against the perineum; restitution does not occur; classic sign of shoulder dystocia.
Term
McRoberts Maneuver
Example
Mother supine, legs fully flexed — this single maneuver frees the shoulder in many cases.
Definition
Sharply hyperflex the mother's thighs onto her abdomen (knees to chest); rotates symphysis pubis and flattens sacrum; FIRST-LINE and resolves most cases.
Diagrams To Know
- McRoberts maneuver (maternal position — thighs maximally flexed)
- Suprapubic pressure technique (direction and hand placement)
- Gaskin maneuver (all-fours position)
Section Title
Umbilical Cord Prolapse
Important Facts
- Cord prolapse is a TRUE OBSTETRIC EMERGENCY — baby will die without immediate relief of cord compression.
- First action: call for help IMMEDIATELY and arrange emergency cesarean transport.
- While preparing transport: keep the presenting part ELEVATED and OFF the cord by pushing it UP with a gloved hand.
- Position the mother to reduce compression: KNEE-CHEST or exaggerated Sims/left lateral with hips elevated (Trendelenburg).
- DO NOT try to push the cord back inside the vagina — this is futile and wastes time.
- DO NOT handle the cord excessively — handling causes vasospasm and reduces placental blood flow.
- If cord is outside the vagina: keep it WARM and MOIST with a warm, saline-soaked pad.
- STOP any oxytocin (inhibits contractions that might compress the cord further).
- Give oxygen to the mother (increases oxygen in fetal blood even with cord compression).
- Monitor fetal heart rate, but transfer is the ONLY definitive treatment — cesarean is required.
- Maintain elevation of the presenting part throughout transport to the operating room.
Key Definitions
Term
Cord Prolapse
Example
Membranes rupture, cord visible at introitus or in vagina, baby's heart rate drops = cord prolapse = emergency cesarean.
Definition
Umbilical cord slips below the presenting part (into or out of the vagina) after membranes rupture; presents part compresses the cord, cutting off baby's oxygen.
Term
Knee-Chest Position
Example
Immediately position mother this way while keeping presenting part elevated off the cord.
Definition
Mother on knees with chest to the floor, head down, hips elevated; relieves pressure on the cord by changing the angle of descent.
Diagrams To Know
- Knee-chest position (body posture)
- Hand placement for relieving cord compression (gloved hand in vagina, pushing presenting part UP)
- Trendelenburg position (elevated hips, mother on left side)
Formulas
Formula
Pre-eclampsia: New hypertension (BP ≥140/90 mmHg) + proteinuria after 20 weeks
Meaning
Both elevated BP AND proteinuria must be present; new onset after 20 weeks.
Watch Out
Students forget BOTH criteria are needed — hypertension alone is NOT pre-eclampsia without proteinuria (unless severe features present).
When To Use
Screen all pregnant women at each antenatal visit; assess at labor admission.
Formula
Severe pre-eclampsia: BP ≥160/110 mmHg OR BP ≥140/90 WITH severe features
Meaning
Either very high BP (≥160/110) alone, OR lower BP (≥140/90) but WITH symptoms: severe headache, visual disturbances, epigastric/RUQ pain, hyperreflexia.
Watch Out
Severe features can occur at lower BP readings — the SYMPTOM CLUSTER is as important as the numbers.
When To Use
Determine need for emergency treatment and urgent referral.
Formula
Eclampsia: Pre-eclampsia or severe pre-eclampsia + SEIZURES (convulsions)
Meaning
The addition of convulsions defines eclampsia as the most severe and immediately life-threatening form.
Watch Out
Do NOT confuse eclampsia with other causes of seizures — eclampsia is defined by the obstetric context (pregnancy/postpartum + hypertension + seizure).
When To Use
A seizing pregnant or postpartum woman = eclampsia until proven otherwise.
Common Values
Value
≥140/90 mmHg
Symbol
140/90
Quantity
Pre-eclampsia BP threshold
Value
≥160/110 mmHg
Symbol
160/110
Quantity
Severe pre-eclampsia BP threshold
Value
20% solution
Symbol
4 g
Quantity
MgSO4 IV loading dose concentration
Value
4 g over 5–20 minutes
Symbol
4 g
Quantity
MgSO4 IV loading dose volume
Value
50% solution
Symbol
10 g total
Quantity
MgSO4 IM loading dose concentration
Value
5 g each buttock
Symbol
5 g
Quantity
MgSO4 IM loading dose per buttock
Value
5 g IM every 4 hours
Symbol
5 g
Quantity
MgSO4 maintenance dose
Value
24 hours after last fit or delivery
Symbol
24 hours
Quantity
MgSO4 maintenance duration
Value
1 g IV (10 mL of 10% solution)
Symbol
1 g
Quantity
Calcium gluconate antidote
Value
16 breaths/minute
Symbol
16 bpm
Quantity
Minimum respiratory rate (toxicity threshold)
Value
30 mL/hour (100 mL per 4 hours)
Symbol
30 mL/hr
Quantity
Minimum urine output (toxicity threshold)
Section Title
Eclampsia & Severe Pre-eclampsia
Important Facts
- Magnesium sulfate (MgSO4) is the DRUG OF CHOICE for eclampsia — NOT diazepam (which is less effective and outdated).
- Pritchard loading dose: 4 g IV (20% solution) over 5–20 minutes PLUS 10 g IM (50% solution) — 5 g deep into each buttock with 1 mL of 2% lignocaine to reduce pain.
- Zuspan regimen (alternative): 4–6 g IV loading, then 1–2 g/hour by IV infusion.
- Midwife's role: give loading dose and arrange urgent referral — MAINTENANCE is continued at receiving facility or during accompanied transport.
- Maintenance dose: 5 g of 50% MgSO4 deep IM every 4 hours, alternating buttocks, for 24 hours after last fit or after delivery.
- MONITOR for toxicity BEFORE each maintenance dose: respiratory rate (RR) ≥16, patellar reflexes present, urine output ≥30 mL/hour.
- WITHHOLD MgSO4 if: RR < 16 breaths/min, patellar reflexes absent, or urine < 30 mL/hour (or < 100 mL in 4 hours).
- Antidote for MgSO4 toxicity: Calcium gluconate 1 g IV (10 mL of 10% solution) given slowly over ~3 minutes if respiratory depression occurs.
- First-response to eclamptic fit: turn mother onto LEFT SIDE, clear airway, give oxygen, do NOT restrain, do NOT force objects into mouth, stay with her.
- Severe hypertension control (if trained/ordered): aim to lower dangerous BP (not normalize it); agents include hydralazine, labetalol, nifedipine.
- Definitive treatment of eclampsia/pre-eclampsia is DELIVERY — refer urgently to CEmONC facility.
Key Definitions
Term
Magnesium Sulfate (MgSO4)
Example
Pritchard regimen: 4 g IV (20%) over 5–20 min PLUS 10 g IM (5 g each buttock, 50%) = loading dose.
Definition
The anticonvulsant of choice for prevention and treatment of eclamptic seizures; NOT diazepam (outdated in eclampsia).
Term
Pritchard Regimen (MgSO4 loading)
Example
Given at first eclamptic fit or in severe pre-eclampsia with severe features; maintain therapy for 24 hours after last fit or after delivery.
Definition
Standard loading dose in Philippines/BEmONC: 4 g of 20% MgSO4 IV slowly + 10 g of 50% MgSO4 IM (5 g each buttock with lignocaine 2% 1 mL to reduce pain).
Term
Magnesium Toxicity Signs
Example
Before each maintenance dose, check knee reflexes; if absent, do NOT give dose.
Definition
RR < 16 breaths/min, absent patellar (knee) reflexes, or urine output < 30 mL/hour (< 100 mL in 4 hours) — withhold next MgSO4 dose if any present.
Diagrams To Know
- Pritchard MgSO4 loading regimen (IV + IM breakdown)
- Signs of magnesium toxicity (RR, reflexes, urine output)
- Position of mother during eclamptic fit (left side, airway clear)
Formulas
Formula
Golden Minute: Within 60 seconds of birth, a non-breathing baby should be BREATHING WELL or being VENTILATED with a bag and mask.
Meaning
The first 60 seconds are critical for preventing hypoxic brain injury; delayed resuscitation = increased risk of death or disability.
Watch Out
Students delay — remember, 60 seconds is the limit; start bag-mask ventilation at the bedside, do NOT wait to transport.
When To Use
Use this principle for every birth; start ventilation immediately if baby is not breathing after stimulation.
Common Values
Value
60 seconds
Symbol
0–60 sec
Quantity
Golden Minute window
Value
~1 in 10
Symbol
10%
Quantity
Proportion of newborns needing help
Value
40–60 breaths per minute
Symbol
40–60 bpm
Quantity
Bag-and-mask ventilation rate
Value
21% oxygen
Symbol
21%
Quantity
Room air oxygen concentration
Value
< 60 beats per minute
Symbol
< 60 bpm
Quantity
Heart rate threshold (low)
Section Title
Neonatal Resuscitation — Helping Babies Breathe (HBB)
Important Facts
- About 1 in 10 newborns need help to start breathing.
- FIRST step: dry the baby thoroughly and provide warmth — drying itself is stimulation.
- Assess immediately: is the baby CRYING/BREATHING? A crying baby = no immediate resuscitation needed; provide routine EINC care (skin-to-skin, keep warm).
- If NOT breathing or gasping after drying/stimulation: clamp and cut cord, move to warm resuscitation surface.
- Position the head in NEUTRAL ('sniffing') position to open airway — not flexed, not extended.
- Clear the airway ONLY if secretions or meconium are OBSTRUCTING it — gentle suction mouth first, then nose.
- Start bag-mask ventilation immediately if no breathing — use self-inflating bag with correctly sized mask (covers nose and mouth, chin included, NOT eyes).
- Ventilation rate: 40–60 breaths per minute.
- Key sign of EFFECTIVE ventilation: RISING CHEST — this is how you know the bag-mask is working.
- If chest is NOT rising: reapply mask seal, reposition head, clear airway if needed, open mouth slightly, try again.
- Use ROOM AIR (21% oxygen) for term newborns initially — high oxygen is not given first-line.
- Reassess heart rate after effective ventilation: if heart rate remains low (< 60), continue ventilating.
- Heart rate < 60 despite good ventilation requires advanced help (chest compressions, medications) — refer urgently.
- Effective ventilation alone corrects the VAST MAJORITY of newborns — most do not need medications or compressions.
- Once baby breathes well: return to mother for SKIN-TO-SKIN and monitoring; refer any baby needing prolonged resuscitation or remaining unwell.
Key Definitions
Term
Bag-and-Mask Ventilation (BMV)
Example
Mask covers nose and mouth (chin included, eyes NOT); ventilate at 40–60 breaths/min; success = rising chest.
Definition
Manual ventilation of a non-breathing newborn using a self-inflating bag and correctly sized mask; the first-line resuscitation technique.
Term
Golden Minute
Example
Baby born at 0:00; by 0:60, baby must be breathing or ventilated — this is the exam-critical principle.
Definition
The critical first 60 seconds after birth during which breathing should be established or ventilation begun; delay increases hypoxic damage risk.
Diagrams To Know
- HBB decision tree (crying vs. non-breathing vs. gasping pathway)
- Bag-and-mask ventilation technique (hand position, mask placement, chest rise indicator)
- Neutral head position (sniffing position) — correct and incorrect
- Signs of effective ventilation (rising chest, color change)
Section Title
Core Principles Across ALL Obstetric Emergencies
Important Facts
- CALL FOR HELP is the FIRST action in EVERY emergency — do not manage alone.
- Start an IV line (large-bore) in EVERY emergency — it is the highway for fluids and drugs.
- STAY WITH THE WOMAN — do not leave her unattended in an emergency.
- BEGIN FIRST-LINE MANAGEMENT immediately — do not wait for transport to start life-saving interventions.
- PREPARE TO REFER — have transport arranged; keep management running during transfer.
- The midwife's role: recognize the emergency, perform first-line stabilization, and refer to CEmONC.
- Do NOT attempt definitive management (surgery, advanced medications) — that is not the midwife's scope in emergencies.
- Document everything: time of onset, interventions given, response, and time of referral.
- In remote/underserved areas: use phone/radio to consult with receiving facility about management during transport.
- Maintain clear communication with the patient and family about the emergency and the need for referral — informed consent/agreement is important even in emergencies.
Key Definitions
Term
Basic EmONC (BEmONC)
Example
At an RHU or BHS, a midwife does PPH first-response, eclampsia loading, and resuscitation — then refers to CEmONC.
Definition
Basic emergency obstetric and neonatal care — life-saving interventions a midwife must provide (e.g., IV fluids, uterotonic, magnesium sulfate, bag-mask ventilation); recognize complications and refer.
Term
Comprehensive EmONC (CEmONC)
Example
Cord prolapse, failed shoulder dystocia, eclamptic coma = CEmONC referral.
Definition
Full surgical and specialist care — cesarean section, blood transfusion, laparotomy — available only at tertiary hospitals; the destination for referred emergencies.
Term
Recognize and Refer
Example
See PPH → massage + oxytocin + IV → refer. See cord prolapse → keep presenting part UP → refer urgently for cesarean.
Definition
The midwife's core duty in emergencies: recognize the condition, start first-line management, and REFER without delay — NOT to attempt definitive management.
Diagrams To Know
- Generic emergency response flow: Call → Assess → First-line manage → Refer → Transport
- IV fluid management in emergencies (large-bore line, run fast, monitor intake/output)
Must Remember
- PPH ≥500 mL (vaginal) OR ≥1000 mL (cesarean) OR symptomatic (dizzy/pale/tachycardic); uterine ATONY (~70%) = soft uterus + massage FIRST.
- PPH management order: Fundal MASSAGE → Oxytocin 10 IU IM → Large-bore IV + fluids fast → Empty bladder → Bimanual compression if needed → Second-line drugs (methylergometrine, misoprostol, tranexamic acid) → REFER.
- Shoulder dystocia = turtle sign (head retracts after delivery); McRoberts maneuver (hyperflex thighs) FIRST, then suprapubic pressure; NEVER fundal pressure or strong head traction.
- Cord prolapse = cord below presenting part after membrane rupture; KNEE-CHEST or Trendelenburg position, push presenting part UP off cord with gloved hand, keep cord warm/moist, do NOT push cord back in, urgent cesarean referral.
- Eclampsia = pre-eclampsia + SEIZURES; Magnesium sulfate (NOT diazepam) = Pritchard loading: 4 g IV (20%) + 10 g IM (5 g each buttock, 50%) immediately; maintenance 5 g IM every 4 hours for 24 hours.
- MgSO4 toxicity signs = RR < 16, absent patellar reflex, urine < 30 mL/hour; WITHHOLD dose if any present; antidote = calcium gluconate 1 g IV (10 mL of 10%).
- Newborn resuscitation (HBB) = GOLDEN MINUTE (60 seconds to breathing or ventilation); dry/stimulate, assess cry, bag-mask ventilate at 40–60 bpm if not breathing, success = rising chest, use room air (21%).
- Across ALL obstetric emergencies: CALL FOR HELP → START IV LINE → STAY WITH WOMAN → FIRST-LINE MANAGE → REFER TO CEmONC WITHOUT DELAY.
- The midwife's scope in emergencies: RECOGNIZE the condition, STABILIZE with first-line BEmONC, and REFER for definitive care — NOT to attempt surgical or advanced specialist management.
- Pre-eclampsia = BP ≥140/90 + proteinuria (both required); severe = BP ≥160/110 or BP ≥140/90 WITH severe features (headache, visual disturbance, epigastric pain, hyperreflexia).
Last Minute Tips
- EXAM TIP: Any question about a seizing pregnant woman = answer is MAGNESIUM SULFATE LOADING (Pritchard: 4 g IV + 10 g IM), NOT diazepam. This is heavily tested and is the single most important drug in obstetric emergencies.
- EXAM TIP: Shoulder dystocia = the TURTLE SIGN is the giveaway. Students sometimes confuse it with arrest of descent; remember restitution fails and head retracts. The answer is always McRoberts FIRST (hyperflex thighs), NEVER fundal pressure.
- EXAM TIP: PPH causes (the 4 T's) — memorize the percentage: Tone ~70%, Trauma ~15%, Tissue ~10%, Thrombin ~5%. Know that atony is most common, so MASSAGE FIRST is always the first action. Methylergometrine is CONTRAINDICATED in hypertension/pre-eclampsia (high stroke risk).
- EXAM TIP: Cord prolapse scenarios will test your knowledge of knee-chest positioning and the principle of KEEPING PRESENTING PART ELEVATED OFF CORD — DO NOT push cord back in (this is a common wrong answer). Know that cesarean is the only definitive treatment.
- EXAM TIP: The 'Golden Minute' for newborn resuscitation (60 seconds to breathing/ventilation) is HEAVILY TESTED. Know the HBB sequence: dry/stimulate → assess → if not breathing → bag-mask at 40–60 bpm, room air, continue until chest rises or heart rate improves. Effective ventilation alone fixes most babies (no compression/meds needed).
Comparison Tables
Rows
Values
- Uterus fails to contract after delivery
- Soft, boggy, non-contracted uterus
- Bleeding with SOFT fundus = MASSAGE IMMEDIATELY
- Fundal massage, oxytocin 10 IU IM, empty bladder
Property
TONE (Atony) — ~70% of cases
Values
- Lacerations, hematoma, inversion, rupture
- Vaginal/perineal tears; hematoma swelling; inverted/ruptured uterus
- Bleeding with FIRM uterus = look for injury
- Inspect cervix/vagina, apply pressure, repair if trained, refer if severe
Property
TRAUMA — ~15% of cases
Values
- Retained placenta or placental fragments/membranes
- Placenta/fragments left in uterus; bleeding continues
- Incomplete placenta at delivery; heavy bleeding persists
- Check placenta completeness, refer for manual removal if retained
Property
TISSUE — ~10% of cases
Values
- Coagulation disorder (clotting failure)
- Blood does not clot; oozing from all sites
- Bleeding that does NOT stop despite uterine contraction
- IV fluids, tranexamic acid 1 g IV, refer urgently for transfusion
Property
THROMBIN — ~5% of cases
Columns
- Cause (The T)
- Mechanism
- Clinical Clue
- First-Response Action
Table Title
The 4 T's of PPH — Quick Identification
Rows
Values
- BP ≥140/90 mmHg
- YES (required)
- Usually asymptomatic or mild headache
- Monitor closely, antihypertensive if BP uncontrolled, plan delivery
Property
Pre-eclampsia (Mild)
Values
- BP ≥160/110 mmHg OR BP ≥140/90 WITH severe features
- YES (if BP ≥140/90); NO if BP ≥160/110 alone
- Severe headache, visual disturbances, epigastric/RUQ pain, hyperreflexia, seizure risk
- Give MgSO4 loading (Pritchard), control BP if trained, urgent delivery/referral
Property
Severe Pre-eclampsia
Values
- Variable (usually elevated)
- Often present (pre-eclampsia history)
- SEIZURES (convulsions) — the defining feature
- MgSO4 loading immediately, manage airway, urgent cesarean referral, consider ICU care
Property
Eclampsia
Columns
- Condition
- BP Threshold
- Proteinuria Required?
- Symptoms/Features
- Management Priority
Table Title
Pre-eclampsia vs. Severe Pre-eclampsia vs. Eclampsia
Rows
Values
- Call for help (pediatrics, anesthesia), note time
- Team-based approach; time documentation for cord damage risk
- Essential — baby is at risk of asphyxia
Property
H — Help
Values
- Sharply hyperflex mother's thighs onto abdomen (knees to chest)
- Rotates symphysis pubis, flattens sacrum, increases pelvic outlet diameter
- Resolves ~50–60% of cases; do this FIRST
Property
E — McRoberts
Values
- Assistant applies downward and lateral pressure above symphysis pubis
- Dislodges anterior shoulder from under pubic arch
- Effective in ~20–30% additional cases
Property
P — Suprapubic Pressure (Mazzanti)
Values
- Episiotomy to create room; Rubin/Woods screw maneuver (internal rotation); deliver posterior arm
- Adds room for maneuvers; internal rotation frees stuck shoulder
- Advanced technique — refer if not successful with simple maneuvers
Property
E — Episiotomy / Enter Maneuvers
Values
- Roll mother onto all fours (hands and knees); or prepare for urgent referral if unresolved
- Gravity-assisted delivery; posterior shoulder often delivers in this position
- If still unresolved → urgent cesarean or advanced facility; baby's life at risk
Property
R — Roll (Gaskin) / Refer
Columns
- Step (HELPERR)
- Action
- Rationale
- Success Rate / Notes
Table Title
Shoulder Dystocia — HELPERR Sequence at a Glance
Rows
Values
- 4 g of 20% MgSO4 IV over 5–20 minutes
- 10 g of 50% MgSO4 IM (5 g each buttock) with 1 mL 2% lignocaine
- ~30–60 minutes total
- Most commonly taught; easy to remember and deploy in RHU/BHS settings
Property
Pritchard (Standard in PH/BEmONC)
Values
- 4–6 g IV bolus over 20–30 minutes, then 1–2 g/hour IV infusion
- None (all IV)
- Infusion continues until 24 hours post-delivery
- Used where continuous IV infusion available; less IM injections
Property
Zuspan (Alternative)
Columns
- Regimen
- IV Component
- IM Component
- Total Time
- Notes
Table Title
Magnesium Sulfate Loading Regimens — PH Context
Rows
Values
- RR < 16 breaths/minute
- Respiratory depression from magnesium overdose
- WITHHOLD dose; give oxygen; monitor closely; have calcium gluconate ready
Property
Respiratory Rate (RR)
Values
- Absent (cannot elicit knee-jerk reflex)
- Deep CNS magnesium toxicity
- WITHHOLD dose immediately; high risk of respiratory failure next
Property
Patellar Reflex
Values
- < 30 mL/hour (or < 100 mL in 4 hours)
- Kidney unable to clear magnesium; accumulating to toxic levels
- WITHHOLD dose; catheterize if not already done; monitor I&O closely
Property
Urine Output
Values
- Both signs present together
- SEVERE magnesium toxicity; respiratory failure imminent
- STOP all MgSO4; give oxygen; prepare to ventilate; give calcium gluconate 1 g IV immediately
Property
Loss of Patellar Reflex + Respiratory Depression
Columns
- Sign
- Threshold / Finding
- What It Means
- Action
Table Title
When to WITHHOLD MgSO4 — Toxicity Signs Checklist
Rows
Values
- YES — good cry, active movement
- Routine EINC care: dry, skin-to-skin, keep warm, delayed cord clamping if stable
- Return to mother; monitor breathing and color; no resuscitation needed
Property
Vigorous/Crying
Values
- NO — gasping or silent
- Dry thoroughly (stimulation), position head neutral, clear airway if obstructed
- Reassess in 10 seconds: is baby now breathing? If YES → EINC care; if NO → START BAG-MASK VENTILATION IMMEDIATELY (Golden Minute)
Property
Non-breathing/Gasping
Values
- Monitor for chest rise (sign of effective ventilation)
- Ventilate at 40–60 breaths/min with room air (21%); reassess heart rate after 15–30 seconds
- If heart rate rising and baby starts breathing → wean ventilation; return to mother. If HR < 60 and not rising → continue ventilation, consider advanced help (compressions, drugs) and REFER urgently
Property
During Bag-Mask Ventilation
Columns
- Baby's State at Birth
- Is Baby Crying/Breathing Well?
- Next Action
- Outcome / Monitoring
Table Title
Newborn Resuscitation Decision Tree — HBB Pathway
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