Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Emergency Obstetric First-Response for the MidwifeConcept Map

Concept

Postpartum Hemorrhage (PPH)

Sub Concepts

• The 4 T's framework (Tone, Trauma, Tissue, Thrombin)
• Uterine atony as primary cause (~70%)
• First-response sequence: massage → oxytocin → IV fluids → catheter → trauma check
• Second-line uterotonics and advanced management
• Signs of shock and fluid resuscitation
• Bimanual compression and aortic compression

Relationship To Central

Leading cause of maternal death; midwife's primary emergency management skill

Concept

Shoulder Dystocia

Sub Concepts

• Turtle sign as key recognition feature
• HELPERR sequence (Help, McRoberts, suprapubic pressure, internal maneuvers, episiotomy, roll)
• McRoberts maneuver as first-line intervention
• Prevention of fundal pressure and forceful traction
• Suprapubic (Mazzanti) pressure technique
• Gaskin maneuver and positional management

Relationship To Central

Unpredictable obstetric emergency requiring immediate recognition and specific maneuvers

Concept

Umbilical Cord Prolapse

Sub Concepts

• Recognition: cord below presenting part after membrane rupture
• Pathophysiology of cord compression and fetal hypoxia
• Knee-chest and Trendelenburg positioning
• Manual elevation of presenting part
• Care of prolapsed cord outside vagina
• Urgent cesarean referral protocol
• Maintenance of cord compression relief during transport

Relationship To Central

True obstetric emergency requiring immediate pressure relief and urgent referral for cesarean

Concept

Eclampsia and Severe Pre-eclampsia

Sub Concepts

• Definitions: hypertension criteria (BP ≥140/90), proteinuria, severe features
• Magnesium sulfate (MgSO4) as anticonvulsant of choice
• Pritchard regimen loading dose (4 g IV + 10 g IM)
• Maintenance dosing and timing (every 4 hours for 24 hours post-fit/delivery)
• Magnesium toxicity signs and monitoring parameters
• Calcium gluconate as antidote
• Airway protection during seizure management
• Severe hypertension control principles

Relationship To Central

Hypertensive emergency in pregnancy requiring magnesium sulfate first-line management

Concept

Neonatal Resuscitation (Helping Babies Breathe - HBB)

Sub Concepts

• The Golden Minute principle (60-second window)
• Drying, warming, and stimulation
• Assessment of breathing and crying
• Airway positioning and clearance
• Bag-and-mask ventilation technique
• Ventilation rate (40-60 breaths/min) and room air use
• Rising chest as success indicator
• Heart rate assessment and ongoing evaluation
• EINC and Unang Yakap post-resuscitation care

Relationship To Central

Core midwifery skill for newborns requiring first-response breathing support

Concept

Universal First-Response Principles

Sub Concepts

• Call for help immediately
• Stay with the woman/baby
• Start large-bore IV line
• Begin first-line interventions
• Monitor vital signs and response
• Prepare for urgent referral to CEmONC facility
• Maintain continuity of care during transport
• Document and communicate findings

Relationship To Central

Common emergency management framework across all obstetric emergencies

Concept

BEmONC and CEmONC Competencies

Sub Concepts

• BEmONC: Basic Emergency Obstetric and Neonatal Care at RHU/lying-in level
• CEmONC: Comprehensive Emergency Obstetric and Neonatal Care at hospital level
• Midwife's role: detect, initiate first-line care, and refer
• Appropriate referral timing and protocols
• Communication with receiving facility

Relationship To Central

Organizational framework for midwife emergency responsibilities

Concept

Shock Management and Fluid Resuscitation

Sub Concepts

• Recognition of shock signs: tachycardia, hypotension, pallor, weak pulse
• Large-bore IV access (18-20G needle)
• Rapid IV fluid infusion (normal saline or Ringer's lactate)
• Positioning: keep warm, elevate legs
• Oxygen therapy when available
• Continuous vital sign monitoring
• Target BP and perfusion restoration

Relationship To Central

Critical support measure across hemorrhagic and hypertensive emergencies

To

Universal First-Response Principles

From

Postpartum Hemorrhage

Strength

strong

Relationship

PPH follows the same call-help, IV-line, and referral framework as all obstetric emergencies

To

Shock Management and Fluid Resuscitation

From

Postpartum Hemorrhage

Strength

strong

Relationship

Blood loss leads to shock; IV fluids and positioning are critical support measures in PPH

To

First-Response Sequence

From

The 4 T's Framework

Strength

strong

Relationship

The 4 T's guide which action to prioritize: massage for atony first, then check for trauma/tissue/clotting

To

HELPERR Sequence

From

Shoulder Dystocia

Strength

strong

Relationship

HELPERR is the mnemonic that organizes the exact steps a midwife performs in shoulder dystocia

To

Suprapubic Pressure

From

McRoberts Maneuver

Strength

strong

Relationship

Both are first-line positional and mechanical approaches; McRoberts is tried first, suprapubic is concurrent if needed

To

Urgent Cesarean Referral

From

Umbilical Cord Prolapse

Strength

strong

Relationship

Cord prolapse cannot be managed vaginally; immediate cesarean delivery is the only definitive solution

To

Umbilical Cord Prolapse

From

Knee-Chest and Trendelenburg Positioning

Strength

strong

Relationship

These positions relieve pressure on the prolapsed cord while awaiting transport and cesarean delivery

To

Magnesium Sulfate Management

From

Eclampsia

Strength

strong

Relationship

Magnesium sulfate is the only first-line drug for eclamptic seizures; no alternative drug is as effective

To

Maintenance Dosing

From

Pritchard Loading Dose

Strength

strong

Relationship

Loading dose (4g IV + 10g IM) is followed immediately by maintenance (5g IM every 4 hours for 24 hours)

To

Calcium Gluconate Antidote

From

Magnesium Toxicity Monitoring

Strength

strong

Relationship

Respiratory depression, absent reflexes, or low urine output indicate toxicity; calcium gluconate reverses it

To

Golden Minute Principle

From

Neonatal Resuscitation

Strength

strong

Relationship

The 60-second window from birth is critical; effective ventilation must begin within this window

To

Rising Chest Sign

From

Bag-Mask Ventilation

Strength

strong

Relationship

Rising chest indicates effective ventilation; absence of chest rise means technique needs correction

To

EINC and Unang Yakap

From

Neonatal Resuscitation

Strength

moderate

Relationship

After successful resuscitation, care transitions to skin-to-skin contact and routine essential newborn care

To

All Five Emergencies

From

Call for Help

Strength

strong

Relationship

The first action in every obstetric emergency is calling for help; delays cost lives

To

IV Fluid Resuscitation

From

Large-Bore IV Line

Strength

strong

Relationship

Large-bore access (18-20G) enables rapid fluid administration to prevent/treat shock

To

All Five Emergencies

From

Urgent Referral to CEmONC

Strength

strong

Relationship

Every obstetric emergency requires timely referral to a facility with advanced capability

To

Midwife Role: Detect and Refer

From

BEmONC Competencies

Strength

strong

Relationship

BEmONC defines what midwives can manage (first-line care); CEmONC defines what requires referral

To

Eclampsia

From

Severe Pre-eclampsia

Strength

moderate

Relationship

Severe pre-eclampsia with seizures becomes eclampsia; magnesium sulfate prevents progression

To

Shock Management

From

Vital Sign Monitoring

Strength

strong

Relationship

Rising pulse, falling BP, and pale/cold skin indicate shock progression; guide fluid infusion rate

To

Continuity of Treatment

From

Maintain Care During Transport

Strength

strong

Relationship

First-line maneuvers and medications must be continued without interruption during referral transport

To

Methylergometrine 0.2 mg IM

From

Oxytocin 10 IU IM

Strength

strong

Relationship

Oxytocin is first-line uterotonic; ergometrine is second-line if oxytocin fails; never use ergometrine in hypertension

To

Eclamptic Seizure Management

From

Airway Protection

Strength

strong

Relationship

Turning onto left side and clearing mouth are first protective actions before magnesium administration

To

Neonatal Breathing Assessment

From

Drying and Stimulation

Strength

strong

Relationship

Drying is stimulation; if baby does not cry/breathe after drying, resuscitation begins immediately

To

Continued Ventilation Decision

From

Heart Rate Assessment

Strength

strong

Relationship

If heart rate remains below 100 after effective ventilation, continue bag-mask; below 60 requires advanced help

To

Tissue Cause of PPH

From

Placenta Inspection

Strength

strong

Relationship

Incomplete or retained placenta is the 'tissue' cause of PPH; must be recognized and referred for removal

To

HELPERR Sequence

From

Episiotomy in Shoulder Dystocia

Strength

moderate

Relationship

Episiotomy is the fifth step in HELPERR, performed to create room for internal maneuvers if positional maneuvers fail

To

Safe Handover

From

Document and Report

Strength

moderate

Relationship

Complete documentation of emergency recognition, actions taken, and maternal/neonatal response ensures continuity of care at receiving facility