Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Emergency Obstetric First-Response for the MidwifeDetailed Explanation

Postpartum Hemorrhage (PPH)

PPH is the LEADING CAUSE of maternal death in the Philippines and worldwide. It is defined as blood loss of 500 mL or more after a vaginal birth (or 1,000 mL or more after a cesarean section). Any blood loss that causes the mother to become symptomatic — pale, dizzy, heart rate rising (tachycardia), blood pressure falling — is also considered PPH, even if you have not measured exactly 500 mL. Early recognition is critical because a healthy woman can lose up to 500 mL before showing obvious shock signs, and by the time she is visibly in shock, she has already lost significant blood. The causes of PPH are remembered using the '4 T's' mnemonic: 1. TONE — Uterine Atony: The uterus is soft (boggy) and fails to contract after delivery. This is the MOST COMMON cause, responsible for approximately 70% of all PPH cases. After delivering the placenta, the uterus should feel hard and round (like a firm ball) when you palpate the fundus. If it is soft and squishy, that is atony. 2. TRAUMA — Lacerations of the cervix, vagina, or perineum; hematoma (blood collection under the skin); uterine inversion (uterus turns inside out); uterine rupture. With trauma, the uterus may be firm, but bleeding continues from the injury site. 3. TISSUE — Retained placenta or fragments of placenta/membranes that were not fully expelled. The placenta site cannot close if something is still attached. If after inspecting the placenta you find it is not complete (pieces missing), suspect retained tissue. 4. THROMBIN — Coagulation disorders (clotting failure). Blood simply will not clot. This is the least common but most difficult to manage at the BEmONC level. FIRST-RESPONSE MANAGEMENT — The midwife acts in this order while simultaneously calling for help: Step 1: MASSAGE THE FUNDUS — Place one hand just above the symphysis pubis to stabilize the uterus, and with the other hand firmly massage the fundus in a circular motion until the uterus contracts and becomes hard. This is done first because atony is the most common cause and massage alone can often stop the bleeding. Step 2: OXYTOCIN 10 IU IM — Give immediately after the fundal massage. If IV access is already in place, 20 IU in 1 liter of IV fluid running fast is also acceptable. Oxytocin is the FIRST-LINE uterotonic. It causes the uterus to contract. Step 3: IV FLUIDS — Start a large-bore IV line and infuse normal saline (NSS) or Ringer's Lactate (RL) fast to replace lost volume and prevent/treat hypovolemic shock. Step 4: EMPTY THE BLADDER — A full bladder physically pushes the uterus up and prevents it from contracting down. Insert a urinary catheter if the woman cannot void on her own. Step 5: CHECK FOR TRAUMA — Inspect the vagina, perineum, and cervix for lacerations. Apply direct firm pressure to any actively bleeding laceration while preparing for referral. Step 6: CHECK THE PLACENTA — Inspect the delivered placenta for completeness. If parts are missing, suspect retained tissue — this requires referral for manual removal or curettage (NOT done independently at BEmONC level). Step 7: BIMANUAL COMPRESSION — If the uterus still will not stay contracted despite the above, perform bimanual uterine compression: with one hand in a fist inside the anterior vaginal fornix, and the other hand behind the uterine fundus on the abdomen, squeeze the uterus between both hands. This compresses the uterine sinuses. Aortic compression (pressing down on the aorta through the abdomen) can temporarily reduce blood flow while arranging urgent transport. Step 8: SECOND-LINE UTEROTONICS if oxytocin is not enough: - Methylergometrine (ergometrine) 0.2 mg IM — IMPORTANT CONTRAINDICATION: DO NOT GIVE in hypertension or pre-eclampsia (it can spike the blood pressure to dangerous levels). - Misoprostol 800 mcg sublingual (under the tongue) — an excellent community-level option because it does not need refrigeration. - Tranexamic acid 1 g IV — given early (within 3 hours of PPH onset) helps reduce death by preventing clot breakdown. Step 9: REFER URGENTLY to a CEmONC facility — while keeping fundal massage and IV fluids running during transport, and positioning the woman with legs slightly elevated to support blood flow to vital organs.

Shoulder Dystocia

Shoulder dystocia occurs when the baby's HEAD delivers normally, but then the ANTERIOR SHOULDER gets stuck (impacted) behind the mother's symphysis pubis, and the rest of the body cannot be delivered with normal downward traction. This is one of the most frightening obstetric emergencies because it is UNPREDICTABLE — it can happen even without any risk factors — and because the baby is at immediate risk of asphyxia (oxygen deprivation) with every passing minute. The key RECOGNITION SIGN is the 'TURTLE SIGN' — after the head delivers, instead of proceeding with normal restitution and descent of the shoulders, the head appears to retract back tightly against the perineum, like a turtle pulling its head into its shell. Normal delivery does not resume. The two most DANGEROUS MISTAKES are: 1. APPLYING FUNDAL PRESSURE — pressing down on the top of the uterus (fundus) to try to push the baby out. This worsens the impaction by forcing the shoulder harder against the symphysis pubis. 2. APPLYING EXCESSIVE TRACTION ON THE HEAD — forceful pulling on the baby's head to try to deliver the shoulder. This can cause Erb's palsy (brachial plexus injury) or even snap the baby's clavicle or humerus, and does not release the shoulder. FIRST-RESPONSE — The HELPERR Mnemonic guides management: H — CALL FOR HELP: Shout for assistance immediately. Note the exact time — every minute matters for the baby. Assign one person to time the event. E — EVALUATE FOR EPISIOTOMY: An episiotomy alone does NOT release a bony impaction, but it creates space for the midwife's hands to perform internal maneuvers if needed. Consider it before proceeding to internal maneuvers. L — LEGS (McRoberts Maneuver): This is the FIRST PHYSICAL MANEUVER and MOST EFFECTIVE for most cases. The mother's thighs are sharply hyperflexed (bent) upward onto her abdomen, with knees pressed toward her chest. This rotates the symphysis pubis superiorly and flattens the curve of the sacrum, enlarging the pelvic outlet and often freeing the stuck shoulder. Assistants or the mother's own hands can hold her thighs in this position. P — SUPRAPUBIC PRESSURE (Mazzanti Technique): An assistant places the heel of one hand just ABOVE (not on) the symphysis pubis and applies firm downward and lateral pressure toward the side where the baby's face is pointing. This tries to dislodge the anterior shoulder from behind the pubic bone. This is performed SIMULTANEOUSLY with McRoberts. NEVER APPLY FUNDAL PRESSURE. E — ENTER (Internal Maneuvers): If McRoberts + suprapubic pressure fails, a trained attendant can insert a hand into the vagina to rotate the baby's shoulders (Rubin II or Woods Screw maneuver) or to deliver the posterior arm first. R — REMOVE THE POSTERIOR ARM: Reach in, locate the baby's posterior arm, flex it at the elbow, and sweep it across the baby's chest and out. This reduces the diameter of the baby's shoulders inside the pelvis. R — ROLL onto all fours (Gaskin Maneuver): Help the mother onto her hands and knees. This position can shift the baby's position by gravity and may free the anterior or posterior shoulder. KEY PRIORITY: McRoberts + Suprapubic Pressure are ALWAYS FIRST. They are simple, safe, and resolve the majority of cases. The midwife at BEmONC level must master these two. After attempting these maneuvers, REFER URGENTLY because the baby needs immediate assessment for asphyxia and possible birth trauma.

Umbilical Cord Prolapse

Umbilical cord prolapse occurs when the umbilical cord slips BELOW the presenting part (the baby's head, shoulder, or buttocks) and into or out of the vagina AFTER the membranes have ruptured. Once the cord is below the presenting part, every uterine contraction — or the weight of the baby — can COMPRESS THE CORD, cutting off oxygen and blood flow to the baby. Fetal hypoxia sets in within minutes. This is one of the most time-critical obstetric emergencies: every second that the cord is compressed increases the risk of permanent brain damage or death for the baby. IMPORTANT: The definitive treatment is IMMEDIATE DELIVERY, which usually means emergency cesarean section. This is BEYOND the midwife's independent scope. Therefore, the midwife's entire job in cord prolapse is to: (a) RELIEVE CORD COMPRESSION by physically holding the presenting part up off the cord, AND (b) TRANSFER THE WOMAN TO A CEMONCE FACILITY AS FAST AS POSSIBLE while maintaining that relief. FIRST-RESPONSE STEPS: 1. CALL FOR HELP IMMEDIATELY. Note the time. Arrange emergency transport/referral to a CEmONC facility for emergency cesarean section RIGHT NOW — this is done simultaneously with everything else. 2. RELIEVE CORD COMPRESSION — this is the MOST CRITICAL first-response action the midwife can do. With a sterile gloved hand inserted into the vagina, locate the presenting part and PUSH IT UPWARD, away from the cord. Keep your hand in place, holding the presenting part elevated, and do NOT remove your hand until the baby is delivered at the hospital. Yes — the midwife may need to maintain this position throughout the entire transport in the vehicle. This is acceptable and necessary. 3. POSITION THE MOTHER to use gravity to reduce compression: - KNEE-CHEST (GENUPECTORAL) POSITION: The mother kneels with her knees on the bed and her chest down, buttocks up in the air. Gravity pulls the presenting part away from the cord. - Alternatively: EXAGGERATED SIMS/LEFT LATERAL POSITION with hips elevated on pillows (Trendelenburg — head lower than hips). Either position helps reduce pressure on the cord when the midwife's hand cannot maintain elevation alone. 4. DO NOT PUSH THE CORD BACK INTO THE VAGINA (DO NOT REPOSITION THE CORD INSIDE): Attempting to replace a prolapsed cord back into the uterus causes vasospasm (the cord vessels spasm from handling and cold), which worsens fetal oxygenation. Handle the cord as LITTLE AS POSSIBLE. 5. If the cord is outside the vagina (overt prolapse), keep the cord WARM AND MOIST by covering it with a WARM, SALINE-SOAKED PAD. Do not allow it to dry out or become cold. 6. STOP OXYTOCIN if it is running — uterine contractions worsen cord compression. 7. Give OXYGEN to the mother (if available) — increases oxygen available to the baby. 8. MONITOR THE FETAL HEART RATE throughout while waiting for transport. 9. TRANSPORT URGENTLY with the midwife's hand still elevating the presenting part, the mother in knee-chest or left lateral position, and IV line running.

Eclampsia and Severe Pre-eclampsia

Pre-eclampsia is a serious complication of pregnancy defined as NEW ONSET HYPERTENSION (blood pressure ≥140/90 mmHg) with PROTEINURIA (protein in the urine) occurring AFTER 20 WEEKS of pregnancy. It is a multi-organ disease that can silently worsen until it becomes dangerous. SEVERE features of pre-eclampsia are present when: BP ≥160/110 mmHg AND/OR any of these symptoms: severe headache, visual disturbances (blurring, flashes of light — 'parang kidlat'), epigastric or right upper quadrant pain (the liver is swelling), or hyperreflexia (brisk deep tendon reflexes). These severe features signal that the brain, kidneys, liver, and blood are all being affected. ECLAMPSIA is the most dangerous development: it is pre-eclampsia PLUS CONVULSIONS (seizures). The convulsion looks like a grand mal epileptic seizure. Eclampsia can occur BEFORE delivery, DURING labor, or AFTER delivery (even up to 48 hours postpartum) — so a midwife must be alert even after the birth. DRUG OF CHOICE for preventing and treating eclamptic seizures: MAGNESIUM SULFATE (MgSO4) — NOT diazepam or phenytoin. This is one of the most heavily tested points in the PRC Midwife Licensure Examination. FIRST-RESPONSE TO AN ACTIVE ECLAMPTIC FIT: 1. PROTECT THE AIRWAY AND PREVENT INJURY — Turn the woman onto her LEFT SIDE (left lateral position). This prevents aspiration if she vomits and reduces aorto-caval compression on the large vessels. Clear the mouth and airway of secretions. DO NOT force anything into her mouth during the seizure (not a tongue depressor, not a spoon, not fingers) — this can break teeth or injure the attendant. DO NOT RESTRAIN her limbs forcefully — guide them gently to prevent self-injury. Give OXYGEN. 2. GIVE MAGNESIUM SULFATE (MgSO4) — Loading Dose using the PRITCHARD REGIMEN (the most commonly used regimen in Philippine BEmONC/DOH protocols): - 4 g of 20% MgSO4 intravenously (IV) given SLOWLY over 5–20 minutes - PLUS 10 g of 50% MgSO4 intramuscularly (IM) — given as 5 g deep IM into EACH BUTTOCK simultaneously (use 1 mL of 2% lignocaine in each injection to reduce the pain of the IM injection). This loading dose is within the BEmONC midwife's scope — the midwife gives the loading dose, then REFERS. 3. MAINTENANCE DOSE — 5 g of 50% MgSO4 IM every 4 hours alternating buttocks, continued for 24 hours after the last fit OR after delivery — this is continued at the receiving CEmONC facility or during transport under protocol. 4. THE ALTERNATIVE: ZUSPAN REGIMEN — 4–6 g MgSO4 IV loading over 15–20 minutes, then 1–2 g per hour by continuous IV infusion. Used when IV pump is available. MONITOR FOR MAGNESIUM TOXICITY — before EACH maintenance dose, check these three safety signs: - RESPIRATORY RATE must be ≥16 breaths/minute (normal). If RR < 16 — WITHHOLD the dose. - PATELLAR (knee) REFLEX must be PRESENT. Test by tapping the patellar tendon with a reflex hammer. If the knee jerk is ABSENT — WITHHOLD the dose. - URINE OUTPUT must be ≥30 mL/hour (or ≥100 mL in 4 hours). If urine output is less — WITHHOLD the dose. These three checks are remembered as: BREATHE, REFLEX, URINATE. If all three are normal = safe to give the next dose. If any one is abnormal = withhold and reassess. ANTIDOTE FOR MAGNESIUM TOXICITY: CALCIUM GLUCONATE 1 g IV (= 10 mL of a 10% solution) given SLOWLY over about 3 minutes. Keep calcium gluconate at the bedside whenever MgSO4 is being administered. ANTIHYPERTENSIVE THERAPY for severe hypertension (BP ≥160/110): Medications like hydralazine IV, labetalol IV, or oral nifedipine may be used to lower dangerously elevated BP. The goal is NOT to normalize blood pressure — it is to lower it to a safe level to prevent maternal stroke. This is typically under physician order/protocol. REFER URGENTLY — The ONLY definitive treatment for pre-eclampsia/eclampsia is DELIVERY of the baby and placenta. The woman needs a CEmONC facility for this. Transfer her with MgSO4 running, oxygen, IV fluids, and in the left lateral position.

Neonatal Resuscitation — Helping Babies Breathe (HBB)

About 1 in 10 newborns needs some help to start breathing after birth. Most of these babies need only stimulation and warmth — but about 1 in 100 needs ventilation with a bag and mask. The Helping Babies Breathe (HBB) program, adopted in the Philippines alongside EINC/Unang Yakap, provides a simple, practical protocol for neonatal resuscitation at the community/BEmONC level. THE GOLDEN MINUTE: This is the central concept of HBB. Within the FIRST 60 SECONDS of life, a newborn who is not breathing should already be BREATHING WELL or be receiving bag-and-mask ventilation. Every second of delay in ventilation increases the risk of brain damage from hypoxia. FIRST-RESPONSE SEQUENCE: STEP 1: DRY AND WARM — Immediately after birth, vigorously dry the baby from head to toe with a clean, warm, dry towel or cloth. Drying IS stimulation — the rubbing action stimulates the baby to breathe. This also prevents hypothermia (a newborn can lose heat rapidly). Place the baby on the mother's chest or a warm, clean, firm surface. ASSESSMENT AT BIRTH (happens simultaneously with/after drying): - Is the baby CRYING or BREATHING? — If YES: the baby is vigorous. Proceed with routine EINC/Unang Yakap care: keep on mother's chest skin-to-skin, do NOT suction unless airway is visibly obstructed, allow delayed cord clamping (1–3 minutes), and monitor. - Is there GOOD MUSCLE TONE? A limp baby needs more attention. - What is the HEART RATE? (Assess by feeling the cord pulse or listening to the chest with a stethoscope.) STEP 2: IF BABY IS NOT CRYING/BREATHING AFTER DRYING AND STIMULATION: - CLAMP AND CUT THE CORD (immediate cutting is needed now because the baby must be moved to the resuscitation surface — delayed clamping is set aside in the event of resuscitation). - MOVE THE BABY to a warm, flat resuscitation surface (e.g., a warm, dry towel on a table or resuscitation station). - POSITION THE HEAD in a 'NEUTRAL/SNIFFING POSITION' — slightly extended, not flexed and not hyperextended. This aligns the airway. A small shoulder roll (a folded cloth under the shoulders) can help maintain this position. - CLEAR THE AIRWAY ONLY IF NEEDED: If you can see secretions or meconium blocking the airway, suction the MOUTH FIRST, then the NOSE (MOUTH FIRST, then NOSE — M before N). Use a bulb syringe or suction catheter. Do this gently and briefly. IMPORTANT: Do NOT routinely suction all babies — suction only if the airway appears obstructed. STEP 3: IF STILL NOT BREATHING → BAG-AND-MASK VENTILATION (Positive Pressure Ventilation / PPV): - Use a SELF-INFLATING BAG (250–500 mL for newborns) with a correctly sized mask (size 0 for preterm, size 1 for term newborns). - MASK SEAL: The mask should cover the baby's nose and mouth, with the chin inside the mask and the eyes OUTSIDE. A good seal is critical. - RATE: Ventilate at 40–60 BREATHS PER MINUTE. Count aloud: 'Breathe... two... three... Breathe... two... three...' (squeeze on 'Breathe,' release for 'two... three'). - PRESSURE: Gentle — use the MINIMUM pressure needed to see the chest rise. - KEY SIGN OF EFFECTIVE VENTILATION: A RISING CHEST with each squeeze. If the chest is NOT rising: → Recheck the MASK SEAL (most common problem) → REPOSITION THE HEAD (neutral position) → CLEAR THE AIRWAY (secretions blocking) → Try opening the baby's MOUTH SLIGHTLY → Consider whether the bag is working - GAS: Use ROOM AIR (21% oxygen) to start for term babies. Supplemental oxygen may be added if the baby does not respond. STEP 4: REASSESS after 30–60 seconds of effective ventilation: - If baby is BREATHING WELL and heart rate is GOOD (≥100 bpm): Stop ventilation, proceed with EINC care (skin-to-skin, monitor). - If HEART RATE < 60 bpm despite good ventilation for 30 seconds: The baby needs CHEST COMPRESSIONS and MEDICATIONS — this is BEYOND BEmONC independent scope. REFER URGENTLY while continuing ventilation. - If heart rate is 60–100: Continue ventilation and reassess. EINC CONTEXT: Under the Unang Yakap (EINC) protocol, the FOUR CORE PRACTICES are: (1) Immediate drying, (2) Delayed cord clamping, (3) Early skin-to-skin contact, (4) Early breastfeeding initiation. In RESUSCITATION, the baby's need to breathe takes priority over delayed cord clamping — the cord is clamped and the baby is moved to begin resuscitation. Once stable, the baby returns to the mother for skin-to-skin and monitoring.

A soft, boggy fundus with heavy bleeding after delivery = uterine atony, the most common cause of PPH (~70%). The correct first response is immediate firm fundal massage to stimulate uterine contraction. After massage, give Oxytocin 10 IU IM, start IV fluids, empty the bladder, and refer if bleeding does not stop.

Shoulder dystocia occurs when the anterior shoulder is stuck behind the symphysis pubis. The turtle sign (head retracting after delivery) is the classic recognition sign. McRoberts + suprapubic pressure is the first-line, most effective combination. Fundal pressure WORSENS impaction and is absolutely contraindicated.

Cord prolapse requires immediate cord decompression while arranging emergency CS referral. Manual elevation of the presenting part is maintained throughout transport. Replacing the cord causes vasospasm. Knee-chest position uses gravity to further reduce compression.

Eclampsia = pre-eclampsia + seizures. MgSO4 is the drug of choice. The Pritchard regimen's loading dose (4 g IV + 10 g IM) is within BEmONC scope. All three toxicity parameters must be NORMAL before each maintenance dose. If any one is abnormal, withhold MgSO4 and have calcium gluconate ready.

The Golden Minute principle means this baby must be ventilated without delay. The most common reason ventilation fails is a poor mask seal — always check seal first if the chest is not rising. Room air (21% O2) is used first for term babies.

Postpartum eclampsia can occur up to 48 hours after delivery. The initial safety checks apply before giving MgSO4. During the active seizure, the priority is protecting the airway and preventing injury — left lateral position prevents aspiration. Forcing objects into the mouth during a seizure is dangerous and contraindicated.