Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Emergency Obstetric First-Response for the MidwifeRevision Notes

Exam Tips

• MLE loves asking: 'What is the FIRST action?' or 'What is the PRIORITY?' — always think: call for help + stabilize + refer.
• Know which drugs are BEmONC signal functions: oxytocin (uterotonic), MgSO4 (anticonvulsant), antibiotics.
• Remember: the midwife INITIATES management — the hospital COMPLETES it.

Key Points

• The midwife is a BEmONC provider — she initiates FIRST-LINE, life-saving steps and REFERS to a CEmONC facility for definitive care.
• Universal first actions for ANY obstetric emergency: (1) Call for help, (2) Stay with the woman, (3) Start a large-bore IV line, (4) Prepare for urgent referral.
• BEmONC (Basic Emergency Obstetric and Newborn Care) = 7 signal functions: parenteral antibiotics, uterotonics, anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery, newborn resuscitation.
• CEmONC (Comprehensive EmONC) adds cesarean section and blood transfusion — beyond the midwife's independent scope.
• Under the MNCHN strategy and DOH protocols, midwives in RHU/BHS lying-in clinics must recognize complications early and transfer using a functional referral system.
• Early detection and timely referral SAVE LIVES — delayed referral is a major cause of maternal and neonatal death.
• Documentation: always note the time of onset, drugs given with dose and route, and vital signs before transfer.

Definitions

Section Title

Overview of Emergency Obstetric First-Response Principles

Common Mistakes

• Confusing BEmONC and CEmONC — midwives do NOT perform cesarean sections or blood transfusions independently.
• Delaying referral while trying to do too much at the primary facility level.
• Forgetting to start an IV line before transfer — this is part of first-response.
• Not documenting time of emergency onset and drugs given before transfer.

Formulas

Exam Tips

• Memorize the ORDER: Massage → Oxytocin 10 IU IM → IV fluids → Empty bladder → Check for tears → Bimanual compression.
• 4 T's mnemonic: TONE is #1 (70%) — always think uterine atony first.
• Methylergometrine is CONTRAINDICATED in pre-eclampsia/hypertension — a favorite MLE trap.
• Misoprostol is given SUBLINGUALLY (800 mcg) or rectally — NOT orally — for PPH.
• Tranexamic acid is given EARLY — within 3 hours — for maximum benefit.
• PPH definition: ≥500 mL vaginal, ≥1000 mL cesarean — memorize these numbers.

Key Points

• PPH is the LEADING CAUSE of maternal death in the Philippines and worldwide.
• Definition: Blood loss ≥500 mL after vaginal birth, OR ≥1000 mL after cesarean, OR ANY blood loss causing maternal symptoms (dizziness, pallor, tachycardia, hypotension).
• The 4 T's of PPH causes: TONE (most common ~70%), TRAUMA, TISSUE, THROMBIN.
• TONE = uterine atony — the uterus is soft and boggy, fails to contract after delivery.
• TRAUMA = lacerations (cervical, vaginal, perineal), hematoma, uterine inversion or rupture.
• TISSUE = retained placenta or placental fragments/membranes.
• THROMBIN = coagulation disorders (clotting failure).
• Prevention of PPH: Active Management of the Third Stage of Labor (AMTSL) — oxytocin 10 IU IM immediately after birth of baby, controlled cord traction, uterine massage.
• First-line drug: Oxytocin 10 IU IM (or 20 IU in 1 L IV fluid running fast if IV access exists).
• Second-line uterotonics: Methylergometrine 0.2 mg IM (CONTRAINDICATED in hypertension/pre-eclampsia), Misoprostol 800 mcg sublingual or rectal.
• Tranexamic acid 1 g IV given early reduces death from PPH bleeding.
• Bimanual uterine compression is used when fundal massage alone fails — one fist in anterior vaginal fornix pushing uterus up, other hand behind fundus compressing.
• A full bladder prevents uterine contraction — ALWAYS empty the bladder (catheterize if needed).
• Refer urgently to CEmONC if bleeding is uncontrolled — continue massage and fluids during transport.

Definitions

Section Title

Postpartum Hemorrhage (PPH)

Common Mistakes

• Giving methylergometrine (ergometrine) to a hypertensive mother — this is CONTRAINDICATED and can cause stroke/seizure.
• Forgetting to empty the bladder — a full bladder is a reversible and easily fixed cause of continued atony.
• Applying fundal massage before giving oxytocin — give the drug AND massage simultaneously.
• Delaying referral while waiting to see if bleeding will stop on its own.
• Not checking the completeness of the placenta after delivery — retained tissue is a fixable cause.
• Confusing bimanual compression with fundal massage — bimanual uses a hand inside the vagina.

Exam Tips

• HELPERR mnemonic: Help → Episiotomy → Legs (McRoberts) → Pressure (suprapubic) → Enter → Remove posterior arm → Roll.
• McRoberts + suprapubic pressure = FIRST COMBINATION to attempt — memorize this pairing.
• The MLE will present a scenario with a head delivering and then the body not following — think SHOULDER DYSTOCIA.
• Fundal pressure and forceful traction = WRONG answers — these are dangerous and always distractor choices.
• Gaskin maneuver (all-fours) is a simple positional change that can be done quickly and safely.

Key Points

• Shoulder dystocia = after the head delivers, the ANTERIOR SHOULDER is impacted behind the symphysis pubis and the baby's body cannot be delivered with normal traction.
• Recognition: the TURTLE SIGN — the head delivers then retracts tightly against the perineum; normal restitution does not occur.
• It is an UNPREDICTABLE emergency — cannot always be anticipated even with known risk factors.
• NEVER apply fundal pressure (worsens impaction) and NEVER apply forceful downward traction on the head (causes brachial plexus injury — Erb's palsy).
• First-line maneuver: McROBERTS MANEUVER — sharply hyperflex mother's thighs onto her abdomen (knees to chest). Rotates symphysis pubis and flattens the sacrum, freeing the anterior shoulder. Resolves MOST cases.
• Second simultaneous step: SUPRAPUBIC PRESSURE (Mazzanti) — assistant applies downward and lateral pressure just ABOVE (NOT ON) the symphysis pubis to push the anterior shoulder under the pubic arch.
• HELPERR mnemonic: Help, Episiotomy (for maneuver room), Legs (McRoberts), Pressure suprapubic, Enter (internal rotations — Rubin/Woods screw), Remove posterior arm, Roll (Gaskin/all-fours maneuver).
• Gaskin maneuver (all-fours): rolling the mother onto hands and knees can dislodge the impacted shoulder through gravity and positional change.
• Time is critical — baby is at risk of asphyxia; all maneuvers are done simultaneously with urgent referral arrangements.
• After delivery: assess the baby for brachial plexus injury (Erb's palsy) and birth asphyxia; refer if any concern.

Definitions

Section Title

Shoulder Dystocia

Common Mistakes

• Applying FUNDAL PRESSURE — this worsens shoulder impaction and is a major MLE wrong-answer trap.
• Applying strong, forceful traction on the head — causes Erb's palsy (brachial plexus injury).
• Forgetting the turtle sign as the diagnostic feature.
• Confusing suprapubic pressure (above the symphysis) with fundal pressure (above the uterus).
• Panicking and not following the HELPERR sequence systematically.

Exam Tips

• Key actions in order: Push presenting part UP → Position mother (knee-chest/Trendelenburg) → Stop oxytocin → Keep cord warm/moist → Refer for cesarean.
• The single most important action: GLOVED HAND INTO VAGINA TO LIFT THE PRESENTING PART OFF THE CORD.
• Never push the cord back in — this is always a WRONG answer choice on MLE.
• Cord prolapse = cesarean section needed = refer to CEmONC = beyond the midwife's independent scope.
• Remember: the midwife maintains the elevated presenting part DURING transport, not just at the BHS/RHU.

Key Points

• Cord prolapse = umbilical cord slips BELOW the presenting part (into the vagina or outside the body) after the membranes rupture.
• The presenting part compresses the cord → cuts off baby's oxygen → TRUE obstetric emergency.
• The midwife's role: RELIEVE CORD COMPRESSION immediately + URGENT REFERRAL for cesarean section (CEmONC).
• STEP 1: Call for help; note the time; arrange EMERGENCY TRANSFER for cesarean IMMEDIATELY.
• STEP 2: With a gloved hand inserted into the vagina, PUSH THE PRESENTING PART UP AND OFF THE CORD and HOLD IT ELEVATED until delivery at the CEmONC facility.
• STEP 3: Position the mother — KNEE-CHEST (genupectoral) position, OR exaggerated Sims/left lateral with hips elevated (Trendelenburg) — gravity helps keep presenting part off the cord.
• DO NOT attempt to push the cord back inside the vagina — this causes vasospasm and worsens outcome.
• Handle the cord as LITTLE AS POSSIBLE — handling causes vasospasm.
• If the cord is outside the vagina: keep it WARM AND MOIST with a warm saline-soaked pad.
• Stop any oxytocin infusion immediately.
• Give oxygen to the mother; monitor fetal heart rate.
• MAINTAIN elevation of the presenting part THROUGHOUT transport — the midwife must continue this manually during the referral.
• Cord prolapse requires cesarean section — a BEmONC facility cannot manage this definitively.

Definitions

Section Title

Umbilical Cord Prolapse

Common Mistakes

• Trying to PUSH THE CORD BACK INTO THE UTERUS — this is WRONG and dangerous; it causes vasospasm.
• Removing the gloved hand from the vagina during transport — the presenting part elevation must be MAINTAINED.
• Forgetting to STOP OXYTOCIN — oxytocin causes contractions that worsen cord compression.
• Not positioning the mother correctly (knee-chest or Trendelenburg) while preparing transport.
• Allowing the cord outside the vagina to dry — always keep it warm and moist.

Formulas

Exam Tips

• DRUG OF CHOICE = MgSO4 (not diazepam) — this distinction is tested repeatedly.
• Pritchard loading: 4 g IV (20%) + 10 g IM (50%) [5 g each buttock] — memorize every number.
• Toxicity triad: RR <16, absent patellar reflex, urine <30 mL/hr — any ONE of these = WITHHOLD next dose.
• Antidote = CALCIUM GLUCONATE 1 g IV (10 mL of 10% solution) — keep at bedside always.
• Maintenance continues for 24 hours after LAST FIT or after DELIVERY.
• Severe pre-eclampsia threshold: BP ≥160/110 — know both mild (≥140/90) and severe (≥160/110) cutoffs.
• BP ≥140/90 = pre-eclampsia; BP ≥160/110 = severe pre-eclampsia — these are MLE gimme points.

Key Points

• Pre-eclampsia = new hypertension (BP ≥140/90 mmHg) WITH proteinuria after 20 weeks of pregnancy.
• Severe pre-eclampsia features: BP ≥160/110 + symptoms (severe headache, visual disturbances, epigastric/RUQ pain, hyperreflexia, decreased urine output).
• Eclampsia = pre-eclampsia PLUS CONVULSIONS (seizures).
• DRUG OF CHOICE for preventing and treating eclamptic seizures: MAGNESIUM SULFATE (MgSO4) — NOT diazepam.
• Pritchard Regimen (used in Philippine BEmONC):
• → LOADING DOSE: 4 g of 20% MgSO4 IV slowly over 5-20 minutes + 10 g of 50% MgSO4 deep IM (5 g each buttock with 1 mL of 2% lignocaine to reduce pain).
• → MAINTENANCE DOSE: 5 g of 50% MgSO4 deep IM every 4 hours alternating buttocks — continued for 24 hours after the LAST FIT or after delivery.
• Zuspan Regimen (alternative): 4-6 g IV loading + 1-2 g/hour by IV infusion maintenance.
• Midwife's role: administer the LOADING DOSE + IMMEDIATE REFERRAL to CEmONC. Maintenance is continued at receiving facility or during accompanied transport.
• MgSO4 TOXICITY monitoring — WITHHOLD the next dose if ANY of these: RR <16 breaths/min, ABSENT patellar (knee-jerk) reflex, urine output <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.
• Airway protection during a seizure: turn to LEFT LATERAL SIDE, clear airway, do NOT restrain or force anything into the mouth, give oxygen.
• Definitive treatment of eclampsia is DELIVERY — this happens at the CEmONC hospital.
• Control of severe hypertension (if trained/ordered): agents include hydralazine, labetalol, or oral nifedipine — goal is to bring dangerously high BP down, NOT necessarily to normal.

Definitions

Section Title

Eclampsia and Severe Pre-eclampsia

Common Mistakes

• Giving DIAZEPAM (Valium) instead of MgSO4 for eclamptic seizures — MgSO4 is FIRST-LINE, not diazepam.
• Forgetting the lignocaine additive in the IM dose — lignocaine reduces pain of the deep IM injection.
• Confusing the loading and maintenance dose routes — loading is BOTH IV and IM; maintenance is IM only (Pritchard).
• Forgetting the THREE toxicity monitoring signs (RR, patellar reflex, urine output) before each maintenance dose.
• Using the wrong antidote — calcium GLUCONATE (not calcium chloride routinely, as chloride can cause tissue necrosis if extravasated) given IV slowly.
• Saying 'manage eclampsia' — midwives INITIATE loading dose and REFER; they do not independently manage the full course.

Formulas

Exam Tips

• GOLDEN MINUTE = 60 seconds → dry → assess → if not breathing → ventilate. This is the framework for all HBB MLE questions.
• Ventilation rate: 40-60 breaths/min — memorize this number.
• Key sign of effective PPV = RISING CHEST (not color change, not breath sounds).
• Room air FIRST for term babies — do not automatically reach for 100% O2.
• Mouth BEFORE NOSE for suctioning — always.
• Neutral (sniffing) head position — not hyperextended like adults.
• Heart rate <60 despite good ventilation = REFER — beyond routine midwife BEmONC scope.
• EINC/Unang Yakap 4 core steps appear in almost every MLE — know them by heart.

Key Points

• About 1 in 10 newborns need help to start breathing.
• The GOLDEN MINUTE: within 60 seconds of birth, a non-breathing baby should be breathing well OR being ventilated with a bag and mask.
• Step 1 — DRY AND WARM: Dry the baby thoroughly with a clean towel; drying IS stimulation. Keep warm (skin-to-skin or under radiant warmer).
• Assessment question: Is the baby CRYING or BREATHING normally? A crying, active baby needs only routine EINC care (skin-to-skin, cord care, early breastfeeding).
• If NOT breathing or gasping after drying/stimulation:
• → Clamp and cut the cord.
• → Move to a warm, firm resuscitation surface.
• → Position head in NEUTRAL (sniffing) position to open the airway.
• → Clear airway ONLY IF NEEDED — suction MOUTH FIRST, then NOSE, gently and briefly.
• If STILL not breathing → START BAG-AND-MASK VENTILATION immediately:
• → Use self-inflating bag with correctly sized mask (covers nose and mouth, not eyes).
• → Ventilate at 40-60 breaths per minute.
• → KEY SIGN OF EFFECTIVE VENTILATION: RISING CHEST.
• → If chest NOT rising: recheck mask seal, reposition head, clear airway, open mouth slightly.
• → Use ROOM AIR (21% oxygen) for term newborns to start — supplemental O2 only if heart rate does not improve.
• Reassess heart rate after 1 minute of effective ventilation.
• Heart rate <60 despite good ventilation → advanced help needed (chest compressions + medications) → REFER URGENTLY.
• Most newborns respond to effective ventilation alone — chest compressions and medications are rarely needed.
• EINC/Unang Yakap: routine births at BHS/lying-in — immediate drying, skin-to-skin, delayed cord clamping (≥1-3 min if baby is vigorous), early breastfeeding within 1 hour.
• Meconium-stained amniotic fluid (MSAF): if the baby is NOT vigorous (absent/weak cry, poor tone, HR <100), do NOT stimulate at the perineum; move to resuscitation surface and suction airway before ventilation.

Definitions

Section Title

Neonatal Resuscitation — Helping Babies Breathe (HBB)

Common Mistakes

• Suctioning the NOSE BEFORE THE MOUTH — always mouth first, then nose (to prevent aspiration of secretions triggered by suction).
• Hyperextending the newborn's neck — use NEUTRAL position, not hyperextension.
• Starting with supplemental oxygen automatically — room air (21%) is used FIRST for term newborns.
• Counting bag-mask ventilation rate too slowly — must be 40-60/min, not the adult CPR rate.
• Forgetting that chest RISE is the key indicator of effective ventilation — not breath sounds or color.
• Delaying ventilation to keep trying stimulation — if not breathing after 30-60 seconds of stimulation, ventilate.
• Applying suction forcefully or deeply — can cause vagal bradycardia and mucosal injury.