Emergency Obstetric First-Response for the Midwife - Memory Anchors
When you are in the exam room and a question about PPH or eclampsia appears, you do not want to search your memory — you want the answer to POP immediately. This set of anchors uses mnemonics, vivid stories, analogies, and visual hooks to wire every critical number, drug, dose, and sequence into long-term memory. Think of each anchor as a mental shortcut: instead of re-reading ten pages, one funny image or catchy rhyme recalls the whole concept in seconds. For Filipino midwifery reviewees, mastering these anchors means fewer panics during the exam and more lives saved in practice.
Memory anchors
The 4 T's of PPH causes — Tone, Trauma, Tissue, Thrombin
Memory aid
Think of a mother shouting 'TTT-T!' when bleeding starts. The four T's are her 4 complaints: her uterus has no TONE (it's soft and boggy), she suffered TRAUMA (tears), she has leftover TISSUE (retained placenta), and her blood won't clot (THROMBIN problem). Picture a kapre sitting on four treasure chests labeled TONE, TRAUMA, TISSUE, THROMBIN — that kapre is PPH sitting on all four causes.
Why it works
The 4 T's acronym uses the first letter of each cause. The kapre image adds a vivid Filipino cultural hook that makes the visual stick.
Example usage
Exam question: 'What is the most common cause of PPH?' You recall the 4 T's and know TONE (uterine atony) is #1 at ~70%.
Recall trigger
See '4 T's' or 'PPH causes' — immediately picture the kapre on four chests.
Uterine atony is the #1 cause of PPH (~70%)
Memory aid
The uterus is like a bilao (round bamboo tray). After delivery, it should clamp down tightly like squeezing the bilao into a firm ball to stop bleeding. Uterine ATONY means the bilao refuses to squeeze — it stays flat and floppy. Seven out of ten PPH cases are caused by this floppy bilao. When you feel a soft, boggy uterus, shout 'Ang bilao ay malata!' — that's atony.
Why it works
Connecting the uterus to a familiar Filipino kitchen item (bilao) makes the concept of muscle tone loss tangible and culturally relatable.
Example usage
A patient delivers and her fundus feels soft and high. You think 'floppy bilao = atony = #1 cause of PPH' and immediately begin uterine massage.
Recall trigger
Think 'floppy bilao' whenever you see 'uterine atony' or 'soft boggy uterus'.
PPH first-response sequence: Massage → Oxytocin 10 IU IM → IV fluids → Empty bladder → Bimanual compression
Memory aid
Use the phrase: 'MOIEB' — pronounce it 'Moy-eb' like a Filipino nickname. M = Massage the fundus. O = Oxytocin 10 IU IM. I = IV fluids (NS or Ringer's lactate). E = Empty the bladder. B = Bimanual compression if still bleeding. Tell yourself: 'Si Moy-eb ay nakatulong sa pagstop ng dugo.' Every time you see PPH management, think of your friend 'MOYEB'.
Why it works
Turning the sequence into a Filipino-sounding nickname creates a phonological hook. The story sentence gives emotional context, aiding narrative memory.
Example usage
Exam: 'What is the correct order of first-line PPH management?' Recall MOYEB: Massage, Oxytocin, IV fluids, Empty bladder, Bimanual compression.
Recall trigger
PPH → think 'MOYEB' → unpack each letter in order.
PPH definition: ≥500 mL blood loss after vaginal birth (≥1000 mL after cesarean)
Memory aid
Think of a standard 500 mL soft drink bottle (like a grande Coke). One full grande Coke of blood lost after a normal delivery = PPH. After CS, it takes TWO grande Cokes (1000 mL). Chunk it: VAGINAL = 1 Coke (500). CESAREAN = 2 Cokes (1000). Write it in your mind: '1 Coke after VB, 2 Cokes after CS.'
Why it works
Chunking abstract volumes into a familiar Filipino consumer item (softdrink bottle) transforms numbers into physical, relatable quantities.
Example usage
Exam: 'PPH is defined as blood loss of at least ___.' Recall one Coke = 500 mL after vaginal birth.
Recall trigger
See 'PPH definition' → picture a 500 mL Coke bottle.
Methylergometrine is CONTRAINDICATED in hypertension
Memory aid
Story: 'Aling Ergo' is a strict barangay tanod (Methylergometrine). She is excellent at controlling crowds (uterine bleeding), BUT she has a rule: she is BANNED from entering any house with a red banner outside (high blood pressure). If she enters, she raises the tension inside even more and chaos happens. So whenever you see HIGH BP on the chart, remember: Aling Ergo cannot enter. Use misoprostol or oxytocin instead.
Why it works
Personification of methylergometrine as a tanod with a rule creates a narrative memory. The 'red banner = high BP' visual cue is strong and intuitive.
Example usage
Exam: 'A PPH patient has BP 160/110. Which uterotonic should be AVOIDED?' Recall Aling Ergo's rule — answer: Methylergometrine is contraindicated.
Recall trigger
See methylergometrine or ergometrine → picture Aling Ergo and the red banner.
Tranexamic acid 1 g IV given early reduces PPH deaths
Memory aid
Remember this chant: 'When bleeding won't stop and the clots are thin, give TRANEXAMIC — 1 gram — put it in! Early is better, don't delay a beat, tranexamic acid makes the bleeding defeat!' The number 1 g is locked: TranEXAmic = 1 g IV. EX = one letter = 1 gram.
Why it works
Rhymes exploit the brain's phonological loop, making numerical dosage memorable through rhythm and repetition.
Example usage
Exam: 'What adjunct drug is given early to reduce PPH mortality?' Answer: Tranexamic acid 1 g IV.
Recall trigger
Heavy bleeding persists → chant 'tranexamic acid, 1 gram in!'
Shoulder dystocia — 'Turtle Sign': head delivers then retracts back against the perineum
Memory aid
Visualize a large marine turtle trying to crawl out of a small barangay drain. Its head pokes out, then — THUD — it pulls back in because its wide shoulders got stuck. That is exactly the turtle sign: the baby's head delivers, then snaps back (retracts) tightly against the perineum because the anterior shoulder is stuck behind the symphysis pubis. The image of a turtle in a drain = shoulder dystocia recognized.
Why it works
Visual associations create mental snapshots. The turtle-in-a-drain image directly mirrors the pathophysiology, making it self-explanatory.
Example usage
Exam: 'After delivery of the head, the baby retracts back against the perineum and the body does not deliver. This is called?' Answer: Turtle sign — shoulder dystocia.
Recall trigger
Any mention of 'turtle sign' → picture the turtle in the drain trying and failing to come through.
Shoulder dystocia management: McRoberts + Suprapubic Pressure FIRST — NEVER fundal pressure
Memory aid
Remember 'MC SUPER, NO FUNDAL.' MC SUPER = McRoberts (hyperflexing thighs) + Suprapubic pressure. NO FUNDAL = never ever apply fundal pressure (it impacts the shoulder further and injures the baby). Imagine a basketball player named 'MC Super' who always opens the court — MC Super opens the pubic arch. And remember the strict coach's rule: 'NO FUNDAL PRESSURE — YOU ARE BENCHED!'
Why it works
The 'MC SUPER NO FUNDAL' phrase creates a paired memory: what to DO first and what to NEVER do — encoded together so one cannot be recalled without the other.
Example usage
Exam: 'What is the FIRST maneuver for shoulder dystocia?' MC Super = McRoberts + Suprapubic pressure. 'What should NEVER be applied?' Fundal pressure.
Recall trigger
Shoulder dystocia → chant 'MC SUPER, NO FUNDAL' before doing anything.
McRoberts Maneuver — hyperflexing the mother's thighs onto her abdomen (knees to chest)
Memory aid
Think of a mother doing a CANNONBALL jump at the pool — she pulls her knees tightly to her chest and curls forward. That is exactly McRoberts: knees pulled to chest (hyperflexion of the thighs onto the abdomen). This position rotates the symphysis pubis upward and flattens the sacrum, giving the stuck shoulder a wider exit. Filipino tip: it looks like the 'kulob' position — curling up tightly.
Why it works
The cannonball analogy maps an everyday physical action onto the clinical maneuver, making it easy to recall the exact body position.
Example usage
Exam: 'Describe the McRoberts maneuver.' Recall cannonball: both knees hyperflexed against the abdomen, done by assistants, resolves most shoulder dystocia cases.
Recall trigger
McRoberts → picture cannonball dive position (knees to chest).
Cord prolapse: push the presenting part UP off the cord — do NOT push the cord back in
Memory aid
Story: Imagine the umbilical cord is a garden hose lying under a flat rock (the baby's head). The hose (cord) is being crushed and no water (blood) flows. The solution is NOT to yank the hose out from under the rock — you might damage it. The solution is to LIFT THE ROCK (push the presenting part upward) off the hose. The midwife's gloved hand acts as a hydraulic jack — it pushes the presenting part UP and holds it there until the operating room is ready. Never try to stuff the hose back into the wall.
Why it works
The garden hose story is a direct mechanical analogy for cord compression. It makes the forbidden action (pushing cord back) feel obviously wrong and the correct action feel obviously right.
Example usage
Exam: 'What is the FIRST action for cord prolapse?' Push the presenting part upward off the cord with a gloved hand; do not attempt to replace the cord.
Recall trigger
Cord prolapse → picture a hose under a rock → lift the rock (push presenting part up).
Cord prolapse position: knee-chest (genupectoral) or Trendelenburg with hips elevated
Memory aid
Visualize the mother doing a 'bow position' in prayer — down on hands and knees with the bottom UP (knee-chest). Gravity pulls the baby's head away from the cord. Picture a jeepney parked on an incline with the back end raised — the passengers (baby's head) slide toward the front, away from the door (the cord). Both images = gravity working FOR you, relieving cord compression during transport.
Why it works
Two complementary visual images (prayer bow and tilted jeepney) reinforce the same mechanism — gravity reducing cord compression — through distinctly Filipino contexts.
Example usage
Exam: 'What position relieves cord compression in cord prolapse?' Knee-chest (genupectoral) position or Trendelenburg with hips elevated.
Recall trigger
Cord prolapse + positioning → prayer bow or tilted jeepney.
Eclampsia drug of choice = Magnesium Sulfate (MgSO4) — NOT Diazepam
Memory aid
Story: Dr. Diazepam used to be the go-to doctor for seizures. Then one day, a wise senior consultant named 'Prof. Magnesium' came to the hospital and proved that for ECLAMPSIA specifically, only he had the right medicine. The professor put up a sign in the eclampsia ward: 'DIAZEPAM IS NOT ALLOWED HERE — I, MAGNESIUM, AM IN CHARGE.' Filipino shortcut: 'Ang MgSO4 ang BOSS ng eclampsia.' Diazepam is for general seizure disorders, NOT for eclampsia.
Why it works
The rivalry story creates an episodic memory that specifically encodes the exclusion of diazepam — the most common wrong-answer trap on the MLE.
Example usage
Exam: 'A pregnant woman at 36 weeks convulses. What is the drug of choice?' Answer: Magnesium sulfate (MgSO4), NOT diazepam.
Recall trigger
Eclampsia seizure → immediately picture the professor's sign: 'MgSO4 is in charge — not diazepam.'
MgSO4 Pritchard Regimen: Loading = 4 g IV (20%) + 10 g IM (5 g each buttock, 50%); Maintenance = 5 g IM every 4 hours
Memory aid
Use the number pattern: 4-10-5-5. Loading: 4 g IV + 10 g IM (split as 5+5, one cheek each). Maintenance: 5 g IM every 4 hours. Chunk it as a phone number: 4-10-5-5 (loading) then 5-every-4 (maintenance). Say it like a jeepney route call: 'Prito! Prito! Four-Ten-Five-Five then Five-every-Four!' PRITO = PRITchard rEGimen = the Filipino way to roast something = the regimen that 'roasts' eclampsia.
Why it works
Chunking doses into a phone-number pattern exploits the brain's digit-span memory. The jeepney caller voice adds auditory and cultural encoding.
Example usage
Exam: 'What is the Pritchard loading dose for eclampsia?' 4 g IV (20% solution) + 10 g IM (5 g each buttock of 50% solution).
Recall trigger
MgSO4 Pritchard → chant '4-10-5-5, then 5-every-4!'
MgSO4 toxicity signs — withhold if: RR <16, absent patellar reflex, urine output <30 mL/hr
Memory aid
Remember 'RAU' — Respiration, Areflexia (absent reflex), Urine. Think of a 'ROW' — R = Rate of breathing <16, A = Absent patellar reflex, U = Urine output <30 mL/hr. Picture a rower (RAU) who STOPS rowing when these three danger signs appear. Filipino version: 'Huwag ibigay ang MgSO4 kung ROWER na ang pasyente!' — R = respirasyon mababa, A = absent reflex, U = urine mababa.
Why it works
RAU is a short, pronounceable acronym. Pairing it with a Filipino phrase creates bilingual encoding, doubling the memory pathway.
Example usage
Exam: 'What signs indicate MgSO4 toxicity? When should the next dose be held?' Answer: Respiratory rate <16, absent patellar reflexes, urine output <30 mL/hr.
Recall trigger
MgSO4 toxicity → RAU → R, A, U — check before each dose.
MgSO4 antidote = Calcium Gluconate 1 g IV (10 mL of 10% solution) slowly
Memory aid
Magnesium and Calcium are chemical opposites in the body — when Magnesium gets dangerously high, Calcium is the antidote that kicks it out. Think of it like a referee blowing the whistle: 'CALCIUM, get in there!' The dose: 10 mL of 10% = 1 g, given slowly over ~3 minutes. Memory trick: 'TEN-TEN-ONE' — 10 mL, 10%, 1 gram. Imagine a sports jersey with number 10 on each side and a #1 in the middle: '10 | 1 | 10'.
Why it works
The chemical opposition principle (Ca vs Mg) gives a logical reason to remember the antidote. The TEN-TEN-ONE numeric pattern is easily recalled under pressure.
Example usage
Exam: 'What is the antidote for MgSO4 toxicity and what is the dose?' Calcium gluconate 10 mL of 10% solution (=1 g) IV given slowly.
Recall trigger
MgSO4 overdose → 'Call Calcium! TEN-TEN-ONE!'
Eclampsia MgSO4 maintenance continued for 24 hours after last fit OR after delivery
Memory aid
Chant: 'MgSO4 does not quit — keep it running 24 hours after the last fit! If baby's out and the fit has stopped, twenty-four hours before it's dropped!' The rule is simple: whether it's the last seizure or the delivery, count 24 hours forward and only then stop the MgSO4.
Why it works
The rhyme encodes both trigger conditions (last fit OR delivery) and the duration (24 hours) in a single memorable verse, reducing recall errors.
Example usage
Exam: 'Mrs. X delivered at 3 PM after her last fit at 2 PM. Until when do you continue MgSO4?' Until 3 PM the next day (24 hours post-delivery, which is later than 24 hours post-last fit).
Recall trigger
'How long do you continue MgSO4?' → chant the rhyme.
Pre-eclampsia BP thresholds: ≥140/90 (pre-eclampsia), ≥160/110 (severe)
Memory aid
Use the '14-9 and 16-11' pattern. Think of BASKETBALL: normal pre-eclampsia diagnosis = player jersey #14 and #9 (140/90). Severe = jersey #16 and #11 (160/110). 'The heavy players (16 and 11) are the SEVERE ones.' Filipino tip: basketball numbers 14/9 and 16/11 are easy to visualize on a jersey. When you see a BP ≥160/110, the game gets SEVERE — call for backup (refer).
Why it works
Chunking BP values as jersey numbers links abstract numbers to a familiar sport, reducing the cognitive load of memorizing two thresholds.
Example usage
Exam: 'At what BP level is pre-eclampsia classified as SEVERE?' ≥160/110 mmHg (with symptoms).
Recall trigger
Pre-eclampsia BP → jersey numbers: 14/9 = mild threshold; 16/11 = severe.
Neonatal Resuscitation — The Golden Minute: within 60 seconds, baby must be breathing or being ventilated
Memory aid
Story: In a barangay basketball court, the buzzer sounds — the team has exactly 60 seconds to score or they lose. The newborn is the basketball. The midwife is the player. The GOLDEN MINUTE is the 60-second buzzer. The goal: the baby breathes on its own, or the midwife is already ventilating by the time the buzzer sounds. If the baby is not breathing and you are still 'deciding what to do' at 61 seconds, you have already lost. Dry, stimulate, assess — and if not breathing, BAG AND MASK. That is the winning shot.
Why it works
The basketball buzzer story creates urgency and embeds the 60-second time frame through an emotionally charged Filipino cultural context (love of basketball).
Example usage
Exam: 'What is the Golden Minute in newborn resuscitation?' Within 60 seconds of birth, the baby must be breathing or receiving bag-and-mask ventilation.
Recall trigger
Newborn resuscitation → picture the 60-second buzzer countdown.
Neonatal Resuscitation sequence: Dry/Stimulate → Assess breathing → If not breathing: Position, Clear airway, Bag-mask ventilate at 40-60 breaths/min
Memory aid
Use 'DABPV' — say it as 'DAB-PV' like a DJ scratching: D = Dry and stimulate. A = Assess breathing. B = Bag-mask if not breathing (after Position and Clear). P = Position head neutral ('sniffing position'). V = Ventilate at 40-60 breaths per minute. The DJ 'DAB-PV' is scratching to keep the baby's rhythm alive! And the key sign: CHEST RISES = good ventilation.
Why it works
The DJ analogy connects the resuscitation sequence to youth Filipino pop culture. The acronym provides a pronounceable handle for a 5-step process.
Example usage
Exam: 'What are the steps in newborn resuscitation?' Dry/stimulate, Assess breathing, Position, clear airway, Bag-mask ventilate at 40-60 bpm using room air.
Recall trigger
Newborn not breathing → DJ DAB-PV → go through each letter.
Bag-mask ventilation: use ROOM AIR (21% O2) for term newborns; effective sign = rising chest
Memory aid
Think of blowing air into a birthday balloon — you use regular air from your lungs (not pure oxygen). For a term newborn, room air (what we breathe every day, 21% O2) is the correct starting gas. The balloon analogy also shows you when it is working: the balloon RISES when air goes in. A rising chest = your ventilation is effective. If the chest does not rise, your 'balloon seal' is broken — fix the mask, reposition the head, check the airway.
Why it works
Birthday balloons are universally familiar to Filipino students. The inflation analogy directly maps to chest rise assessment, connecting technique to evaluation in one image.
Example usage
Exam: 'What is the correct gas to use for bag-mask ventilation in a term newborn?' Room air (21% oxygen). 'What indicates effective ventilation?' A visibly rising chest.
Recall trigger
Bag-mask ventilation → blowing up a birthday balloon — chest should rise like a balloon.
Universal emergency first-response for ALL obstetric emergencies: Call for help, Stabilize, Start IV, Refer to CEmONC
Memory aid
Remember 'CSIR' — Call for help, Stabilize (first-line management), IV line, Refer. Pronounce it as 'SIR!' — because in every emergency, you call out to the senior 'SIR!' for help and then follow the four steps. Or remember it as: 'Sa bawat emergency: Sigaw (call), Stabilize, IV, Refer — SSIR!' The midwife's golden rule: you are not the endpoint — you are the bridge to the CEmONC facility.
Why it works
The 'SIR' pronunciation creates a memorable phonological anchor. The 'bridge' metaphor reinforces the midwife's scope — detect, first-line manage, and refer.
Example usage
Exam: 'What are the universal first steps for any obstetric emergency?' Call for help, start first-line stabilization, insert IV line, arrange urgent referral to CEmONC.
Recall trigger
Any obstetric emergency → shout 'SIR!' in your mind → Call, Stabilize, IV, Refer.
Revision game
I am the most common cause of PPH. I make the uterus feel like a wet sponge instead of a hard ball. What am I?
Answer
Uterine atony (the 'T' for Tone in the 4 T's)
Memory link
A2 — the floppy bilao analogy
I am a uterotonic drug. I am great at stopping PPH bleeding, but I am strictly BANNED from the rooms of hypertensive patients. Who am I?
Answer
Methylergometrine (ergometrine) 0.2 mg IM
Memory link
A5 — Aling Ergo and the red banner story
A baby's head delivers, then suddenly it snaps back tight against the perineum and the body will not follow. What sign is this, and what is the name of this emergency?
Answer
Turtle sign — Shoulder Dystocia
Memory link
A7 — the turtle stuck in the drain visual
I am the FIRST and MOST IMPORTANT maneuver for shoulder dystocia. I look like a mother doing a cannonball dive. What maneuver am I?
Answer
McRoberts maneuver (hyperflexion of thighs onto abdomen)
Memory link
A9 — cannonball dive analogy
I am the antidote for magnesium sulfate toxicity. My dose is remembered as TEN-TEN-ONE. What am I and what is my dose?
Answer
Calcium Gluconate 10 mL of 10% solution = 1 g IV slowly
Memory link
A15 — TEN-TEN-ONE calcium gluconate
Three things must be checked BEFORE giving each maintenance dose of MgSO4. The midwife uses the acronym RAU to remember them. Name all three.
Answer
R = Respiratory rate less than 16/min; A = Absent patellar reflex; U = Urine output less than 30 mL/hour
Memory link
A14 — the RAU ROWER stopping
In newborn resuscitation, I am the 60-second window within which a non-breathing baby must be ventilated. I am made of GOLD. What am I?
Answer
The Golden Minute
Memory link
A18 — the basketball buzzer story
The cord has prolapsed and is outside the vagina. Your first action is to push something UP. What do you push, and what should you NEVER do to the cord itself?
Answer
Push the presenting part UPWARD off the cord; NEVER push the cord back inside
Memory link
A10 — hose under a rock analogy
Formula mnemonics
PPH = blood loss ≥500 mL (vaginal delivery) or ≥1000 mL (cesarean section)
Mnemonic
1 Coke (500 mL) = PPH threshold for vaginal. 2 Cokes (1000 mL) = PPH threshold for cesarean. 'V for Vaginal = V for venti-small (500 mL); C for Cesarean = C for couple of Cokes (1000 mL).'
When to use
Use this to IDENTIFY PPH. When assessing postpartum blood loss at a lying-in or RHU after vaginal delivery, ≥500 mL = activate PPH protocol.
What each part means
500 mL is the standard definition for vaginal births. 1000 mL accounts for the normal physiologic blood loss expected with cesarean surgery. Any symptomatic blood loss (dizziness, pallor, tachycardia, falling BP) counts as PPH regardless of measured volume.
MgSO4 Pritchard Loading: 4 g IV (20% solution) + 10 g IM (5 g each buttock of 50% solution)
Mnemonic
Phone number code: 4-10-5-5. Say 'PRITO: Four-Ten-Five-Five!' Four grams goes in the vein (IV), Ten grams split into Five-Five goes in the buttocks (IM). The '20%' for IV and '50%' for IM: 'Two-Zero for the Vein, Five-Zero for the Buns.'
When to use
Use this regimen immediately upon recognizing an eclamptic seizure or imminent eclampsia. Give the loading dose then arrange urgent referral. Maintenance doses (5 g IM every 4 hours) are continued at the receiving facility.
What each part means
4 g IV: given slowly over 5-20 minutes as a loading bolus to rapidly achieve therapeutic blood magnesium levels. 10 g IM (5 g each buttock): provides sustained release from the muscle. 20% solution for IV = diluted to be safe for vein. 50% solution for IM = concentrated for depot effect. 1 mL of 2% lignocaine added to each IM dose to reduce injection pain.
MgSO4 Maintenance: 5 g IM (50% solution) every 4 hours for 24 hours after last fit or after delivery
Mnemonic
'Five-Four-Twenty-Four': 5 g every 4 hours for 24 hours. Think of it as 'Five-at-Four o'clock' repeated six times (6 × 4 = 24 hours). '5-4-24 = MgSO4 maintenance math!'
When to use
Applied during transfer and at the receiving CEmONC/hospital after the midwife has given the loading dose. The midwife must know this formula to answer MLE questions and to monitor a patient during transport.
What each part means
5 g IM = dose per injection (into alternating buttocks). Every 4 hours = frequency to maintain therapeutic blood levels. 24 hours after LAST FIT or after DELIVERY (whichever is later) = duration. Dose is WITHHELD if RAU signs appear (RR <16, absent patellar reflex, urine <30 mL/hr).
MgSO4 Antidote: Calcium Gluconate 10 mL of 10% solution (= 1 g) IV slowly over ~3 minutes
Mnemonic
TEN-TEN-ONE: 10 mL, 10%, 1 gram. Or: '1010 = the emergency hotline for calcium.' When Mg toxicity hits, dial '10-10-1' for calcium gluconate.
When to use
When MgSO4 toxicity is confirmed: respiratory depression (RR <16), absent knee jerks, or cardiac arrest. This is a life-saving reversal agent — always keep it at the bedside whenever MgSO4 is running.
What each part means
10 mL volume × 10% concentration = 1 gram of elemental calcium gluconate. Calcium ions directly antagonize the neuromuscular and cardiac effects of excess magnesium. Given IV slowly (over ~3 minutes) to avoid cardiac dysrhythmia.
Newborn bag-mask ventilation rate: 40-60 breaths per minute
Mnemonic
'Four-Six for baby fix.' 40 = low end (normal breathing rate for an adult). 60 = high end (normal resting breathing rate for a neonate). So 40-60 bridges the adult-to-baby range. Say: 'Forty to Sixty keeps the newborn nifty!'
When to use
When a newborn fails to breathe after drying, stimulation, positioning, and clearing the airway. Ventilate with room air using a correctly sized self-inflating bag and mask until the baby breathes adequately or help arrives.
What each part means
40 breaths/min = the minimum effective ventilation rate for a non-breathing newborn. 60 breaths/min = maximum recommended. Higher than 60 may cause air trapping. Lower than 40 is insufficient. The counting trick: '1-and-2-and' gives ~30/min; 'squeeze-release-squeeze-release' at a brisk pace gives ~40-60.
Quick recall chains
PPH First-Response Steps (MOYEB)
Recall test
Cover this card. Name the 5 PPH first-response steps in order using only 'MOYEB'. Can you do it in under 10 seconds?
Memory chain
Picture your friend MOYEB running into the delivery room in order: first he MASSAGES the uterus (rubbing his hands together), then he pulls out an OXYTOCIN syringe from his pocket, then he hooks up an IV LINE on the patient, then he grabs a CATHETER to empty the bladder, and finally he performs the BIMANUAL squeeze with both arms. MOYEB always does these five steps in the same order — never skips, never reorders.
Items to remember
- Massage the uterine fundus
- Oxytocin 10 IU IM (first-line uterotonic)
- IV fluids — Normal Saline or Ringer's Lactate
- Empty the bladder (catheterize)
- Bimanual uterine compression if still bleeding
The 4 T's of PPH Causes (with percentages)
Recall test
Say all 4 T's and estimate the percentage contribution of TONE without looking. (Answer: ~70%)
Memory chain
A kapre sits on 4 treasure chests in the delivery room. Chest #1 (labeled TONE) is the biggest and heaviest — it is locked 70% shut. Chest #2 (TRAUMA) has torn edges. Chest #3 (TISSUE) has red placental pieces hanging out. Chest #4 (THROMBIN) has a broken key (coagulation failure). The kapre represents PPH — it unlocks the largest chest (Tone/Atony) first, most of the time.
Items to remember
- Tone — uterine atony (~70%, most common)
- Trauma — lacerations, hematoma, inversion, rupture
- Tissue — retained placenta or membranes
- Thrombin — coagulation failure
MgSO4 Toxicity Warning Signs — When to HOLD the Dose (RAU)
Recall test
Close your eyes. What are the 3 RAU signs? What is the urine output threshold? What do you do if ANY of these appears?
Memory chain
The RAU ROWER stops rowing when three alarms sound: Alarm 1 (R) — the rower is gasping, breathing fewer than 16 times per minute. Alarm 2 (A) — the rower's knee reflex is gone, they cannot push the pedal. Alarm 3 (U) — the urine gauge shows less than 30 mL flowing per hour. When ANY one alarm sounds, the ROWER STOPS — hold the MgSO4 dose and give calcium gluconate if needed.
Items to remember
- Respiratory rate < 16 breaths/minute
- Absent patellar (knee-jerk) reflex
- Urine output < 30 mL/hour
Shoulder Dystocia First-Response (HELPERR abbreviated for midwife)
Recall test
Without looking, describe the FIRST and the FORBIDDEN action in shoulder dystocia management.
Memory chain
Imagine a coach (HELP) who: (1) blows a whistle CALLING for help and starts the clock; (2) tells the player to do the CANNONBALL (McRoberts); (3) has an assistant push ABOVE THE PELVIS (suprapubic); (4) BANS the player from pushing the fundus; (5) makes a CUT to widen the field (episiotomy); (6) ROLLS the player to all fours; and if still stuck, (7) REFERS the player to the specialist team. Remember: MC SUPER NO FUNDAL is the core.
Items to remember
- Call for Help and note the time
- McRoberts maneuver — hyperflexion of thighs
- Suprapubic pressure — downward/lateral above symphysis
- Never apply fundal pressure
- Episiotomy if needed for internal maneuvers
- Roll to all-fours (Gaskin maneuver)
- Refer if unresolved
Newborn Resuscitation Golden-Minute Steps (DABPV)
Recall test
What is the Golden Minute? Name the 5 DABPV steps. What is the SIGN of effective bag-mask ventilation?
Memory chain
DJ DAB-PV is performing live. He DRIES his vinyl records (drying = stimulation). He ASSESSES the crowd (is anyone responding?). He POSITIONS the microphone perfectly (neutral head position). He CLEARS feedback noise from the speakers (suction mouth, then nose). Then he VENTILATES the crowd with his amazing music (bag-mask at 40-60 bpm). The rising hands in the crowd = a rising chest = effective ventilation. All of this happens within the GOLDEN MINUTE — the first 60 seconds of his set.
Items to remember
- Dry and stimulate (assess at the same time)
- Assess breathing — is the baby crying/breathing?
- If not breathing: Position head in neutral (sniffing position)
- Clear airway: suction mouth first, then nose
- Ventilate with bag and mask at 40-60 breaths/min (room air)
Diagrams
Emergency Obstetric First-Response: Master Mind Map
A comprehensive mind map showing all five obstetric emergencies (PPH, Shoulder Dystocia, Cord Prolapse, Eclampsia, Neonatal Resuscitation) branching from a central root. Each emergency branches into recognition, first-response actions, key drugs/doses, and referral triggers. Use this as your chapter overview diagram and final review snapshot.
PPH First-Response Decision Flowchart
A step-by-step flowchart showing the complete PPH first-response algorithm. Starts with identifying PPH (blood loss ≥500 mL or symptomatic), then follows the MOYEB sequence, branches at the hypertension decision point (methylergometrine vs misoprostol), and ends with urgent referral to CEmONC. Use this flowchart when practicing PPH management questions.
Eclampsia First-Response Flowchart with MgSO4 Protocol
A detailed flowchart of eclampsia first-response, from seizure recognition through airway protection, MgSO4 Pritchard loading dose (4 g IV + 10 g IM), pre-dose RAU toxicity screening, maintenance dosing (5 g IM every 4 hours), and urgent referral to CEmONC. The branching at the RAU check shows when to hold the dose and administer calcium gluconate as antidote.
Neonatal Resuscitation — Golden Minute Algorithm (HBB)
Complete newborn resuscitation flowchart following the Helping Babies Breathe (HBB) / EINC protocol. Shows the Golden Minute algorithm from birth through drying/stimulation, breathing assessment, airway positioning and suctioning, bag-mask ventilation with room air at 40-60 breaths/min, effectiveness assessment (rising chest), heart rate reassessment, and referral trigger for heart rate below 60 bpm despite good ventilation.
PPH Causes by Proportion — The 4 T's
Pie chart visually demonstrating that uterine atony (Tone) accounts for approximately 70% of PPH cases, making it the dominant cause by a large margin. This visual reinforces why uterine massage and uterotonics are always the first-line response — you are treating the most probable cause first.