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

Obstetric emergencies are life-threatening conditions that demand immediate recognition and swift action. In the Philippine healthcare context, most midwives work in settings with limited resources—an RHU may have no operating theater, a BHS may have only basic equipment, and a lying-in clinic serves as a community hub for normal deliveries. Your responsibility is dual: (1) recognize that normal has become abnormal, and (2) initiate the correct first-line response while arranging urgent transfer to a CEmONC facility (usually a hospital with obstetric surgery, anesthesia, and blood bank capacity). The concept of BEmONC (Basic Emergency Obstetric and Newborn Care) defines what a midwife must do: administer uterotonics, manage postpartum hemorrhage, manage sepsis, manage eclampsia with magnesium sulfate, manage complications of abortion, and perform neonatal resuscitation. You are not expected to perform emergency cesarean section, manual removal of retained placenta under general anesthesia, or laparotomy—these are CEmONC functions. However, you must master the life-saving first steps. The "Golden Window" principle applies: the first few minutes determine outcomes. A mother with PPH who receives uterotonic and IV fluids within 5 minutes has a far better prognosis than one whose care is delayed. A newborn not breathing who receives effective bag-and-mask ventilation within the first minute (the "Golden Minute") is far more likely to survive without brain damage. Delay in referral—even if initial management is correct—can be fatal. Key to safe practice is humility: know your limits. You are the first responder, not the definitive caregiver. Your job ends when you hand over to the receiving specialist or when the emergency resolves and the mother/baby is stable for community care.

Postpartum hemorrhage is the leading cause of maternal death globally and in the Philippines. It accounts for nearly 1 in 4 maternal deaths and is 100% preventable with rapid recognition and correct first-line care. Every midwife must master PPH response. **Definition and Recognition:** PPH is defined as blood loss ≥500 mL in the first 24 hours after a vaginal birth (≥1000 mL after cesarean section). However, clinical signs of shock are equally important: a mother who is pale, dizzy, with a rising pulse (>100) and falling blood pressure is in PPH shock, even if exact blood loss is hard to measure. In a home or BHS setting without scales, look for soaked cloths, a boggy (soft) uterus, and maternal distress. Trust the clinical signs. **The Four T's—Understanding the Causes:** All PPH causes fit into four categories. Knowing these helps you diagnose and manage: 1. **Tone (Uterine Atony)** — The uterus fails to contract and compress bleeding vessels. The uterus feels soft, boggy, enlarged. This causes ~70% of PPH and is the most common. Risk factors: prolonged labor, rapid labor, multiparity, uterine overdistension (twins, polyhydramnios), high regional anesthesia, magnesium sulfate use. Atony is managed by fundal massage and uterotonic drugs. 2. **Trauma** — Lacerations of the cervix, vagina, or perineum; or deeper injury (uterine rupture, inversion). A woman may have a soft, well-contracted uterus but still bleed from a cervical tear. Trauma is managed by inspection, repair (sutures for lacerations), and sometimes transfer if the injury is deep. 3. **Tissue** — Retained placenta or placental fragments, or retained membranes. The placenta may be partially separated or adherent (accreta). Tissue is managed by careful fundal massage (do not be aggressive—you may worsen inversion), gentle traction on the cord, and controlled delivery of the placenta. If the placenta does not deliver within 30 minutes of active management, refer for manual removal under anesthesia. 4. **Thrombin (Coagulation Disorders)** — Rare at first contact but critical. Severe hemorrhage can deplete clotting factors (consumptive coagulopathy). Hemophilia, anticoagulant therapy, or liver disease predispose. Thrombin disorders are managed by transfusion and specialist care at a CEmONC facility. **First-Response Sequence for PPH:** If a mother bleeds excessively after delivery, follow this sequence (call for help immediately; do steps simultaneously): 1. **Fundal Massage (first action):** Use a firm, circular motion through the abdomen to palpate and contract the uterus. Massage until it is firmly contracted and stays firm. Atony is the #1 cause—massage alone often stops bleeding. Do this even while arranging IV access. 2. **Uterotonic Drugs:** Once you confirm heavy bleeding: - **Oxytocin 10 IU IM** is first-line. It contracts the uterus within 2–3 minutes. Alternatively, give oxytocin IV: 20 IU diluted in 1 L of IV fluid running fast (run it quickly, not slowly). - **Methylergometrine (ergotamine) 0.2 mg IM** is second-line if oxytocin fails. **CRITICAL: Ergometrine is CONTRAINDICATED in hypertension, pre-eclampsia, or eclampsia**—it causes dangerous vasoconstriction and hypertensive crisis. If the mother is hypertensive, do not use it. - **Misoprostol 800 mcg sublingual (under the tongue)** acts in 5–10 minutes; use if oxytocin and ergometrine are not available or as adjunct. - **Tranexamic acid (TXA) 1 g IV** given early (within the first 3 hours of bleeding onset) reduces death from hemorrhage by ~30%. It is increasingly part of BEmONC protocols in the Philippines. Give it early; it works best in the first hour. 3. **Start a Large-Bore IV Line (Cannula):** Establish two large-bore (18G or better) IV lines if possible. Run IV fluids (normal saline or Ringer's lactate) rapidly to restore circulating volume and treat shock. The target is to keep systolic BP ≥100 mmHg and urine output ≥30 mL/hour. 4. **Empty the Bladder:** A full bladder physically prevents the uterus from contracting down. Insert a urinary catheter (Foley) and drain urine. A full bladder can account for surprising blood loss once drained. 5. **Inspect for Trauma:** Look for: - Cervical lacerations: inspect the cervix visually with gentle retraction; repair with absorbable sutures (0 chromic) if trained. - Perineal and vaginal tears: grade them and repair (first/second-degree are midwife scope; third/fourth-degree refer). - Signs of uterine inversion: the fundus is missing from the abdomen, the mother has sudden shock and pain, and you may feel the inverted uterus at the introitus or extending into the vagina. If inverted, **do not attempt to replace it yourself**—refer urgently. (If caught very early and the mother is still under anesthesia, the receiving doctor may replace it, but this is specialist care.) - Signs of uterine rupture: severe abdominal pain, loss of contractions, fetal parts palpable in the abdomen, severe shock. This is surgical emergency—refer urgently. 6. **Check the Placenta and Membranes:** Inspect for completeness. If pieces are missing or membranes are torn and fragments retained, you have "tissue" PPH. Attempt gentle fundal massage and encourage the mother to void (urine may help expel fragments). Do NOT aggressively try to curette or remove fragments blindly—you risk uterine perforation. If bleeding continues and the placenta is incomplete, refer for manual removal under anesthesia (CEmONC). 7. **Bimanual Uterine Compression (if bleeding persists despite a firm uterus):** This is an emergency temporizing measure. Insert one gloved hand into the vagina and make a fist in the anterior vaginal fornix, pushing upward behind the symphysis pubis. Place the other hand on the abdomen behind the fundus. Compress the uterus between the two hands. This compresses the uterine vessels and may control bleeding temporarily while you arrange transfer. Aortic compression (pushing the aorta against the spine at the level of the umbilicus for a few minutes) is an alternative emergency measure but is rarely used; focus on bimanual compression and transfer. 8. **Monitor Vital Signs and Output:** Watch for signs of shock: rising pulse, falling BP, pale/cold skin, restlessness. Keep the mother warm (blankets), elevate the legs slightly, give oxygen if available (SpO₂ target >94%), and measure urine output hourly (should be ≥30 mL/hour if fluids are running and uterus is contracted). 9. **Refer Urgently to CEmONC:** Do not wait for bleeding to stop completely; arrange transfer as soon as PPH is diagnosed. During transport, continue fundal massage, keep IV fluids running, maintain warmth, and monitor vital signs. Bring the placenta with you to the hospital so the team can verify completeness. **Special Scenario: Retained Placenta:** If the placenta does not deliver within 30 minutes of the birth (with controlled cord traction and gentle fundal massage), suspect retention. **Do not:** - Pull hard on the cord (you may tear it or invert the uterus). - Give ergot drugs yet (they may trap a partially separated placenta). - Attempt manual removal without training (risk of hemorrhage and uterine perforation). **Do:** - Give oxytocin (it may help separation). - Position the mother sitting upright or squatting to help gravity. - Encourage toileting (urination and defecation can stimulate expulsion). - Avoid over-aggressive fundal massage. - If bleeding is minimal and the mother is stable, it is safe to wait 30–45 minutes more, giving oxytocin. - If bleeding becomes heavy or the mother is unstable, refer for manual removal under anesthesia.

Shoulder dystocia is an unpredictable, obstetric emergency in which the anterior (front) shoulder becomes impacted behind the mother's symphysis pubis (the bony joint at the front of the pelvis) after the fetal head has delivered. The fetal body will not deliver with normal downward traction, and prompt maneuvers are needed to free the baby within seconds to prevent asphyxia. Unlike PPH (which develops over minutes to hours), shoulder dystocia is a race against the clock—you have approximately 5–10 minutes before the baby suffers severe hypoxia. **Recognition—The "Turtle Sign":** After the fetal head crowns and delivers, the head should rotate (restitution—usually to the side), and the shoulders deliver easily with the next contractions. In shoulder dystocia: - The head delivers but then **retracts back tightly against the perineum** (like a turtle withdrawing into its shell). - **Restitution does not occur**—the head stays in a fixed position. - The rest of the body does not follow despite gentle downward traction. This is the "turtle sign," and it signals shoulder dystocia immediately. **The key is: the instant you see the turtle sign, do NOT apply strong downward traction or fundal pressure.** Both make it worse by driving the anterior shoulder deeper behind the pubic bone. **Why It Happens:** Shoulder dystocia is mostly unpredictable. Risk factors include fetal macrosomia (large baby), maternal obesity, maternal diabetes, and prolonged second stage, but many cases occur with no risk factors. It is a mechanical problem, not a failure of descent during labor. Forceful traction or pressure worsens it. **First-Response: The HELPERR Sequence:** This acronym guides the bedside maneuvers a midwife performs immediately while calling for help and preparing to refer: 1. **Call for Help** (H): The moment you suspect shoulder dystocia, call the hospital, call your backup (doctor, senior midwife), and note the **exact time**. Time is critical because hypoxia worsens minute by minute. 2. **McRoberts Maneuver (E—"Evaluate"/position; first-line):** This is the single most effective maneuver and resolves ~60% of cases. - **Sharply hyperflex the mother's thighs onto her abdomen** (knees to chest, sometimes called the "M" position). - This maneuver rotates the symphysis pubis upward, flattens the sacrum, and increases the pelvic outlet diameter—room opens up and the shoulder frees itself. - The mother may need help from an assistant to hold her legs in this position. - It is painless (unlike some other maneuvers) and there are no contraindications. - **Always do McRoberts first; it works remarkably often.** 3. **Suprapubic Pressure (L—"Lucy" pressure, or Mazzanti maneuver; second-line):** - An assistant applies **firm, downward AND lateral (sideways) pressure just above the symphysis pubis** with the heel of the hand or a closed fist. - The pressure pushes the anterior (impacted) shoulder toward the baby's chest, rotating the baby so the shoulder can slip under the pubic arch. - **Do NOT apply fundal pressure** (downward pressure on the uterus from above)—this drives the baby deeper into the pelvis and worsens dystocia. This is a common mistake; avoid it. - Suprapubic pressure + McRoberts together are often enough. 4. **Enter Maneuvers (P—"Position" changes):** If McRoberts + suprapubic pressure do not work, the mother can change position: - **All-fours position (Gaskin maneuver):** The mother rolls to her hands and knees. This opens the posterior pelvic outlet and sometimes frees the baby. - This requires the mother to cooperate (she is on her back in McRoberts, so she must roll or be rolled), but some midwives include it early. 5. **Internal Maneuvers (E—"Enter"; third-line):** Trained attendants (doctors, senior midwives) can perform: - **Rubin maneuver:** A hand is inserted into the vagina posteriorly, and the posterior aspect of the anterior shoulder is pushed inward, reducing the shoulder diameter. - **Woods screw maneuver:** A hand reaches in posteriorly and pushes the posterior shoulder forward, rotating the baby 180 degrees to align the shoulders differently. - **These require training and are not routine midwife management; they are done at the hospital or by a trained doctor at the scene.** However, a midwife should know they exist. 6. **Deliver the Posterior Arm (R—"Roll"/remove):** A trained attendant reaches in posteriorly and sweeps the posterior arm across the baby's chest and out of the vagina, reducing the diameter of the shoulder girdle. The baby can then deliver. 7. **Roll to All-Fours (R—"Roll"; Gaskin maneuver, repeated if not done earlier):** If still unresolved, the mother goes to all-fours, which sometimes dislodges the impacted shoulder. **Episiotomy (Optional):** An episiotomy may be considered to give more room for internal maneuvers, but it does not resolve the bony obstruction and is not the priority. If you are trained to do one, it is a minor aid, not the solution. **What NOT to Do:** - **Do NOT apply fundal pressure** (downward pressure on the uterus). This is the most common error and worsens dystocia. - **Do NOT pull hard on the baby's head.** Gentle downward traction is OK, but forceful pulling injures the brachial plexus (nerve bundle to the arm) and risks clavicular fracture. The problem is bony impingement, not soft-tissue resistance. - **Do NOT panic.** McRoberts and suprapubic pressure work in most cases; you likely have a few minutes before hypoxia becomes severe. - **Do NOT delay transfer.** Even if you resolve the dystocia at the bedside, arrange hospital transfer to assess the baby for nerve injury or fracture. **Neonatal Outcome:** If the baby is freed within ~5 minutes with good oxygenation (the mother was breathing throughout), the baby usually survives without brain damage. If maneuvers are prolonged or delayed, the baby may suffer hypoxic-ischemic encephalopathy (HIE) or brachial plexus injury (Erb's palsy). This reinforces why rapid recognition and the right maneuvers are critical. **After Delivery (Post-Dystocia Care):** Once the baby delivers, cut the cord, dry and stimulate the baby, and assess for breathing. Even if the baby was compressed for a few minutes, most breathe and cry. If the baby is floppy or not breathing, start bag-and-mask ventilation (see Neonatal Resuscitation section). Refer the baby to the hospital for observation—brachial plexus injury and clavicular/humerus fracture may not be immediately obvious. The mother also needs hospital evaluation to rule out uterine rupture or maternal trauma from the maneuvers.

Umbilical cord prolapse is one of the most time-critical obstetric emergencies. It occurs when the umbilical cord slips **below the level of the presenting part** (the baby's head or buttocks) after the membranes rupture. The presenting part then compresses the cord against the pelvis, cutting off fetal blood supply and causing rapid hypoxia. The baby can suffer severe hypoxia or death in minutes. The only definitive treatment is emergency cesarean section, so your role is to relieve cord compression immediately and arrange emergency transfer. **Recognition and Types:** 1. **Occult Prolapse:** The cord is below the presenting part but still inside the vagina—not visible. You may suspect it if: - Membranes rupture and the FHR drops suddenly (a sign of cord compression). - The presenting part seems to "pop up" after membrane rupture (loss of buoyancy as amniotic fluid drains). - There is a sudden deceleration on fetal monitoring. - However, you cannot see the cord; diagnosis is clinical (suspicious FHR changes + risk factors). 2. **Overt Prolapse:** The cord is visible at the introitus or hanging out of the vagina—obvious and dramatic. You see a loop or length of umbilical cord. This is the classic presentation. **Risk Factors:** - Polyhydramnios (excessive amniotic fluid increases likelihood that cord is lowest part). - High head at time of membrane rupture (baby not well-engaged). - Footling breech presentation (feet first, not head—higher risk of cord prolapse). - Multiparity (uterine laxity). - IVF pregnancy (sometimes). - Artificial rupture of membranes (ARM) if head is high. **Pathophysiology—Why Time Matters:** Once the cord is compressed, fetal oxygen supply is cut off. The baby's blood oxygen (pO₂) falls, and the baby becomes hypoxic. Without fetal breathing or placental oxygen transfer, the baby's brain begins to be damaged within 5–10 minutes. This is why cord prolapse is an absolute obstetric emergency requiring immediate delivery (cesarean). A baby who is delivered within 5–10 minutes has a good chance of intact survival; one who waits 30 minutes often suffers irreversible brain damage or death. **First-Response:** 1. **Call for Help and Note the Time:** The moment you suspect or see cord prolapse, call the hospital and request an emergency cesarean section. Call your backup (doctor, supervisor). Note the exact time—this helps the hospital team know how long the baby has been compressed. 2. **Relieve Compression of the Cord (Immediate Priority):** - **Insert a gloved hand into the vagina immediately.** Use the hand (not instruments). - **Push the presenting part (baby's head or buttocks) UP and off the cord.** You are lifting the baby's weight off the compressed cord. - **Keep the presenting part elevated with your hand/arm throughout the assessment and transport.** Do not remove your hand until the baby is delivered (at the operating room) or the cord is no longer compressed. - This simple maneuver restores blood flow to the baby and buys time for emergency transfer. 3. **Position the Mother to Reduce Compression:** - **Knee-chest position (genupectoral):** The mother kneels and bends forward, with her forehead and chest on the bed/floor and her pelvis elevated. This gravity-assisted position keeps the presenting part off the cord. - Alternatively, **exaggerated Sims position (left lateral) with hips elevated (Trendelenburg):** The mother lies on her left side with the left leg straight and the right knee bent and drawn up; the foot of the bed (or a pillow under the hips) elevates the pelvis. This also reduces cord compression by gravity. - **Knee-chest is most effective but may be uncomfortable; Trendelenburg is also good.** 4. **Do NOT Attempt to Push the Cord Back Inside:** This is a common mistake. Pushing on the cord or trying to manually replace it causes: - Vasospasm (the blood vessels in the cord constrict painfully, worsening hypoxia). - Trauma to the cord (bruising, possible rupture). - Delay in moving toward delivery. - **Instead, handle the cord as little as possible. Leave it alone except to assess that it is not traumatized.** 5. **If the Cord Is Outside the Vagina (Overt Prolapse):** - Keep it **warm and moist** with a **warm, sterile, saline-soaked gauze pad or cloth.** Do not wrap it in dry material (drying harms the umbilical vessels). - Do not try to push it back in. Keep it loosely in a pad, not compressed or kinked. - Expose it to the open air as little as possible (prevents drying). 6. **Stop Any Oxytocin or Labor-Stimulating Drugs:** If the mother is on oxytocin (Pitocin) or ergot drugs, stop the infusion immediately. Contractions will compress the cord further. Once emergency transfer is arranged, you may restart oxytocin only if the transfer is delayed and the mother is having contractions; but generally, avoid stimulating labor before delivery is under way. 7. **Monitor Fetal Heart Rate if Possible:** If you have a Doppler or can hear the FHR, listen briefly. A normal FHR (120–160 bpm) is reassuring; a slow rate (<100) suggests cord compression is ongoing and reinforces the urgency. Do not spend time on monitoring; priority is maintaining the elevation of the presenting part and arranging transfer. 8. **Maintain the Elevated Position Throughout Transport:** - You or an assistant must keep one hand in the vagina holding the presenting part elevated during the entire journey to the hospital. - This is uncomfortable for the mother and for you, but it is life-saving. - The mother should remain in knee-chest or Trendelenburg position if possible. - If the distance is short (<30 min), this is manageable. If the distance is long (>1 hour), the strain is severe, but the alternative is fetal death. - Some settings have used a Foley catheter balloon inflated in the vagina to reduce the presenting part, but this is not standard and may damage the cervix; manual elevation is safer. 9. **Arrange Urgent Emergency Cesarean Section at CEmONC:** - Cord prolapse is an absolute indication for emergency cesarean delivery. - The baby cannot be safely delivered vaginally because the cord is in the way. - Call ahead so the operating room is ready, anesthesia is alerted, and neonatal team is standing by. - The goal is delivery within 15–30 minutes of the diagnosis if possible. 10. **Neonatal Outcome:** - If the baby is delivered within 5–10 minutes of prolapse, most babies survive without neurologic damage. - If the delay is 15–20 minutes, the risk of hypoxic-ischemic encephalopathy (HIE) or death increases sharply. - Every minute counts. Speed of diagnosis and transfer directly determines outcome. **After Delivery:** Once the baby is delivered by cesarean and the cord is clamped and cut, neonatal resuscitation is provided as needed. The baby may need bag-mask ventilation or other support if hypoxic. The baby will be monitored in hospital for signs of HIE (poor feeding, seizures, etc.). The mother recovers from anesthesia and cesarean section with routine postoperative care.

Pre-eclampsia is a potentially life-threatening hypertensive disorder of pregnancy. Eclampsia is pre-eclampsia complicated by convulsions (seizures). Both are obstetric emergencies that can cause maternal death, fetal death, and fetal brain damage if not recognized and managed rapidly. The midwife's role is to recognize severe pre-eclampsia and eclampsia, administer the anticonvulsant magnesium sulfate (MgSO₄), and refer urgently to a CEmONC facility. **Definitions and Thresholds:** **Pre-eclampsia** = New-onset hypertension (BP ≥140/90 mmHg measured on two occasions at least 15 minutes apart) that develops after 20 weeks of pregnancy, with proteinuria (≥1+ on dipstick, or ≥300 mg/24 hours) and/or signs of end-organ dysfunction. **Severe Pre-eclampsia** features any of: - **Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg** (measured twice, at least 15 minutes apart). - **Severe headache** (not relieved by paracetamol). - **Visual disturbances** (scotomata—flashing lights, blurred vision, temporary blindness). - **Epigastric or right upper-quadrant pain** (liver capsule distension—a sign of HELLP syndrome risk). - **Nausea and vomiting** (especially if associated with pain). - **Hyperreflexia (brisk reflexes) with clonus** (rhythmic muscular contractions when a tendon is tapped)—a sign of CNS irritability. - **Oliguria** (urine output <400 mL in 24 hours). - **Liver enzyme elevation** (on labs, if available). - **Low platelets** (<100,000/μL; part of HELLP—Hemolysis, Elevated Liver enzymes, Low Platelets). - **Pulmonary edema** (crackles on lung exam, shortness of breath). **Eclampsia** = Severe pre-eclampsia **PLUS convulsions (seizures).** The seizure is generalized tonic-clonic: the mother's body goes rigid (tonic phase), then shakes (clonic phase). She may bite her tongue, foam at the mouth, or lose consciousness. After the seizure, she may be confused or sleep deeply (postictal state). A mother can have multiple seizures before or during labor, or in the postpartum period. **Why It Matters:** Eclamptic seizures can cause: - Maternal aspiration (vomit enters the lungs), hypoxia, or death. - Fetal hypoxia and death (the placenta is stressed, the baby does not get oxygen). - Placental abruption (the placenta separates from the uterus, causing massive bleeding and fetal death). - Maternal stroke, pulmonary edema, or acute kidney injury. - If untreated or improperly treated, eclampsia is 100% fatal. With magnesium sulfate, the risk of a second seizure drops from ~60% to <5%, saving lives. **Why Not Diazepam or Phenytoin?** Many hospitals and some midwives still use diazepam (Valium) to treat eclamptic seizures. **This is incorrect and dangerous.** Diazepam: - Does not prevent eclamptic seizures (it sedates but does not treat the underlying problem). - Causes maternal respiratory depression (the mother may stop breathing). - Crosses the placenta and depresses the baby (floppy, poor feeding). - Delays the correct treatment (magnesium sulfate). **Magnesium sulfate is the correct, evidence-based drug.** It: - Prevents convulsions in ~90% of women with severe pre-eclampsia (even without eclampsia yet). - Stops recurrent seizures in eclampsia (prevents a second fit). - Is safe for mother and baby at correct doses. - Works by stabilizing the cerebral vasculature and reducing CNS irritability. **First-Response to an Eclamptic Fit (During a Seizure):** 1. **Protect the Airway and Prevent Injury:** - **Turn the mother onto her left side** (recovery position). This prevents aspiration if she vomits, and helps airflow. - **Clear her mouth of any dentures or food** (do this quickly and gently; do NOT force your fingers in). - **Do NOT force anything (a tongue depressor, fingers) between her teeth.** Biting down during a seizure is normal; you cannot prevent it, and you will only injure your hand. - **Do NOT restrain her.** Let her shake. Restraint causes rhabdomyolysis (muscle breakdown) and injury. - **Move her away from hard surfaces or edges** so she does not strike her head. - **Stay with her.** Do not leave her alone. 2. **Give Oxygen** (if available): - Administer oxygen by face mask or nasal cannula to keep SpO₂ >94%. Hypoxia during the fit is bad for her and the baby. 3. **Administer Magnesium Sulfate (MgSO₄)—Loading Dose:** This is the critical, life-saving intervention. The regimen most commonly used in the Philippines (Pritchard regimen) is: **IV Dose:** 4 g of 20% magnesium sulfate solution, given IV slowly over 5–20 minutes. - Dilute the 4 g in 100–200 mL of normal saline (so it is not hypertonic, which causes vessel damage). - Run the IV slowly to avoid flushing, but do not delay (aim for 5–10 minutes if possible). - Watch the IV site for leakage (magnesium is irritating if it infiltrates). **IM Doses (Given Simultaneously or Shortly After the IV):** 10 g total of 50% magnesium sulfate, given as: - **5 g deep IM into the left buttock** (upper outer quadrant), PLUS - **5 g deep IM into the right buttock**, using a large needle (18–20G) and injecting deeply into the muscle (not subcutaneously, or it will be very painful and ineffective). - **To reduce pain at the injection site, mix 1 mL of 2% lignocaine (local anesthetic) with each 5 g dose of magnesium sulfate** before injecting. This is standard practice in the Philippines and reduces maternal discomfort significantly. - Inject slowly. **Alternative: Zuspan Regimen (IV-only, if IM is not available or preferred):** - 4–6 g of 20% MgSO₄ IV over 20 minutes (loading), followed by - 1–2 g/hour IV infusion (maintenance). - This avoids IM injection pain but requires IV access and infusion capability. **The goal: MgSO₄ onboard within ~5–10 minutes of the seizure.** 4. **After the Seizure Ends:** - The mother will likely be confused, sleepy, or unconscious for a few minutes (postictal state). This is normal. - Check her breathing and pulse; they should be normal. - Keep her on her left side. - Do not leave her unattended (she might have another seizure). - Monitor her closely—another seizure may occur within minutes to hours. 5. **Monitor for Magnesium Sulfate Toxicity (Before Each Maintenance Dose):** - Magnesium is a depressant; too much causes respiratory failure, loss of reflexes, and even cardiac arrest. - **Before giving the next maintenance dose (or every 4 hours), check for signs of toxicity:** - **Respiratory rate:** Should be ≥16 breaths/minute. If <16, **withhold the next dose**—respiratory depression is a sign of magnesium overdose. - **Patellar (knee) reflex:** Tap the tendon just below the kneecap with a reflex hammer. A normal reflex is a brisk kick of the lower leg. **If the reflex is absent (no kick), withhold the next dose**—absent reflexes signal toxicity. - **Urine output:** Should be ≥30 mL/hour (≥100 mL in 4 hours). **If urine output is <30 mL/hour, withhold the next dose**—poor renal clearance leads to magnesium accumulation. - If any of these are abnormal, **do not give the next dose; inform the receiving facility.** The magnesium will gradually clear from the body. 6. **Antidote for Magnesium Toxicity: Calcium Gluconate:** - If the mother develops severe magnesium toxicity (respiratory depression, absent reflexes, cardiac arrhythmias), give **calcium gluconate 1 g IV (10 mL of a 10% solution) slowly over 2–3 minutes.** - Calcium antagonizes magnesium and reverses toxicity acutely. - Have this available if you are giving MgSO₄, even though toxicity is rare if you monitor carefully. **Maintenance Magnesium Sulfate (Continuation After the Loading Dose):** After the loading dose, the mother continues MgSO₄ to prevent another seizure: - **Pritchard regimen:** 5 g of 50% MgSO₄ deep IM every 4 hours, alternating left and right buttock. - With lignocaine added (1 mL per 5 g dose) for pain relief. - **Continue for 24 hours after the last seizure or after delivery**, whichever is longer. - Alternatively, **Zuspan regimen:** 1–2 g/hour IV infusion (started after the loading dose IV). The goal is to keep blood magnesium levels high enough to prevent seizures but not so high that toxicity occurs. **The midwife's role is to give the loading dose and monitor for toxicity if maintenance is given at the RHU/clinic setting.** More often, maintenance is given at the hospital after referral. **Managing Severe Hypertension (If Trained/Ordered):** If the mother's BP is dangerously high (≥160/110) and she is symptomatic (severe headache, visual symptoms), it may need treatment before transfer, although **the priority is magnesium sulfate and referral.** Treatment options include: - **Hydralazine:** 5–10 mg IV or IM; effect in 10–20 minutes; can repeat every 20 minutes (max 30 mg per dose or 200 mg total per day). - The target is NOT to normalize the BP, but to lower it to a safer level (e.g., from 180/110 to 160/100) to prevent stroke. - Lower the BP too much and the placenta loses perfusion (bad for the baby). - **Nifedipine (modified-release):** 10–20 mg oral, effect in 30 minutes; less reliable in acute settings. - **Labetalol:** 20–40 mg IV; less common in the Philippines but useful. **Check with local protocols** before giving antihypertensive drugs; not all RHUs stock these, and aggressive BP lowering is not always recommended. **Magnesium sulfate and referral are the priorities.** **Refer Urgently to CEmONC:** - After an eclamptic seizure (or suspected eclampsia), the mother must be admitted to a CEmONC facility. - Definitive treatment is delivery (vaginal or cesarean, depending on obstetric factors like cervical dilation and fetal condition). - The hospital will: - Continue magnesium sulfate maintenance. - Monitor BP and proteinuria. - Manage labor/delivery as appropriate. - Monitor for complications (placental abruption, HELLP, pulmonary edema, acute kidney injury). - Assess the baby for fetal distress or growth restriction. **Special Scenario: Severe Pre-eclampsia (No Seizure Yet):** If a mother has severe pre-eclampsia features (BP ≥160/110, severe headache, right-upper-quadrant pain, hyperreflexia) but has NOT had a seizure yet, should you give magnesium sulfate? - **Yes, according to evidence.** Magnesium sulfate given to women with severe pre-eclampsia (even without seizure) **halves the risk of eclampsia developing** and improves outcomes. - The same loading dose and maintenance regimen apply. - Refer urgently after the loading dose; hospital management continues. **Neonatal Outcome After Maternal Eclampsia:** Babies born to mothers with eclampsia or severe pre-eclampsia may be growth-restricted (small for gestational age), preterm, or hypoxic. The baby will be monitored closely at the hospital. Maternal magnesium sulfate does NOT harm the baby; in fact, it protects the baby's brain if hypoxia occurs (neuroprotection).

About 1 in 10 newborns needs help to start breathing; 1 in 100 needs more intensive support. The midwife's skill in rapid neonatal resuscitation is critical. Unlike adult resuscitation (CPR), which relies on chest compressions, newborn resuscitation emphasizes ventilation—most babies who are not breathing need oxygen delivery to the lungs, not heart massage. The "Golden Minute" is the key concept: within 60 seconds of birth, a baby who is not breathing should either be breathing well or being ventilated effectively with a bag and mask. **The HBB (Helping Babies Breathe) protocol** is endorsed by the Philippines Department of Health (DOH) and UNICEF and is part of the EINC (Essential Intrapartum and Newborn Care) and Unang Yakap programs. It is based on the recognition that most newborns do not need complicated interventions—they need warmth, drying, and gentle stimulation. A minority need ventilation. A rare few need further resuscitation. The midwife's job is to rapidly assess which category the baby is in and provide appropriate care. **The First Minute—The Golden Minute (First Steps):** 1. **Prepare for Every Birth:** - Before the baby is born, ensure you have a clean, warm resuscitation surface ready (cloth on a warm table, away from drafts). - Have a newborn-sized self-inflating bag (240–500 mL), face masks (preterm and term sizes), and suction (bulb syringe or wall suction) nearby and functional. - Have an assistant or family member available to help. - Know the baby's risk factors (prematurity, maternal fever, meconium, fetal distress)—these alert you that the baby might not breathe well. 2. **Immediately After Delivery of the Baby's Body:** - **Dry the baby thoroughly** with a pre-warmed, clean cloth. Drying is stimulation—it often triggers the baby to breathe and cry. - **Assess: Is the baby breathing or crying?** - **If yes (breathing/crying):** Congratulations! Skin-to-skin with the mother, routine EINC care (warmth, breastfeeding, monitoring). - **If no (gasping, limp, or silent):** Proceed to next steps. 3. **Assess Breathing and Heart Rate (First 10 Seconds):** - **Gasping or No Breathing + Heart Rate <100 bpm or undetectable** = The baby needs ventilation. Do not delay; ventilate immediately. - **Gasping but heart rate ≥100 bpm** = Watch closely; the baby may begin effective breathing. If after 30 seconds the baby is still only gasping (not effective breaths), ventilate. - **Effective breathing (good cry) + heart rate ≥100 bpm** = Routine care. 4. **If Not Breathing Effectively:** - **Clamp and cut the cord immediately** (or within 30–60 seconds; some prefer to wait 1–3 minutes if the baby is well, but if the baby is not breathing, cut it now). - **Move the baby to the warm resuscitation surface** (not the mother's chest yet; you need good access and a firm, flat surface). - **Dry the baby completely** (if not already done); remove wet cloths and replace with dry, warm ones. - **Assess the baby's position:** The head should be in a **neutral position** (like "sniffing" position—the chin slightly forward, as if smelling the air). This opens the airway. If the head is flexed (chin tucked to chest), the airway is kinked and closed. If the head is extended too far back, it also closes the airway. Adjust with a small towel roll under the shoulders if needed. 5. **Clear the Airway (Only If Needed):** - If the baby has visible secretions, blood, or meconium obstructing the mouth, **suction gently:** - **Mouth first, then nose** (always mouth first; if you suction nose first, the baby may gasp and aspirate mouth contents). - Use a **bulb syringe** (compress the bulb, insert the tip into the corner of the mouth, release the bulb to suction gently, then remove). - Or use **wall suction briefly** (not more than 5–10 seconds; prolonged suction causes reflex apnea in some babies). - If the baby has expelled meconium (greenish stool in the amniotic fluid), be vigilant for meconium aspiration during the first breaths, but do NOT over-suction the airway (this is outdated teaching and can delay ventilation; modern guidance says suction only if the airway is obstructed). - **Do NOT spend time on airway clearing if the baby's mouth is clear.** Delay ventilation is worse than not suctioning. 6. **If the Baby Is Still Not Breathing → Start Bag-and-Mask Ventilation Immediately:** **Bag Selection:** - Use a **self-inflating bag** (240–500 mL for a term newborn; smaller for preterm). - A self-inflating bag is best for the first few breaths because it does not require compressed gas (no oxygen tank needed) and is simple to use. - Have a **correctly sized face mask** (preterm size = smaller, term size = larger). The mask should cover the nose and mouth (chin is included inside the mask) but NOT the eyes (eyes are not inside the mask edge). **Technique:** - **Position the mask on the baby's face:** - Place the mask over the nose and mouth, ensuring a good seal. - Use the thumb and index finger of one hand to hold the mask on the baby's face (applying gentle pressure). - Use the other fingers (middle and ring fingers) to lift the baby's lower jaw forward (jaw thrust), keeping the head in neutral position. - Your other hand squeezes the bag. - **Ventilate at 40–60 breaths per minute** (about one breath every 1 second): - Compress the bag to deliver a breath (the chest should rise with each breath). - Release the bag (it re-expands, drawing in room air or oxygen). - **Use room air (21% oxygen) to start** (not pure oxygen, which may cause lung injury in term babies; oxygen is reserved for babies who are not responding or are very premature). - **The key sign of effective ventilation is a rising chest:** Watch the chest wall rise with each breath. If the chest is NOT rising, the ventilation is ineffective. **Troubleshoot:** - **Reapply the mask seal** (maybe it is not sealing tightly). - **Reposition the head** to neutral position (check for flexion or extension). - **Clear the airway again** (maybe secretions or meconium are blocking it). - **Open the baby's mouth slightly** (sometimes the mouth is held closed; opening it helps air go in). - **Continue ventilation** until the baby takes effective breaths on its own, the heart rate is ≥100 bpm and improving, and color is pink. 7. **Reassess After Effective Ventilation (Every 30–60 Seconds):** - **Check the heart rate:** Feel the pulse at the umbilicus or listen to the chest. If the heart rate is <60 bpm despite good ventilation, the baby needs chest compressions (call for help and prepare for advanced resuscitation at the hospital). If the heart rate is 60–100 bpm and rising, continue ventilation. If the heart rate is >100 bpm and the baby is breathing, stop ventilation and provide routine care. - **Check for spontaneous breathing:** If the baby starts to breathe on its own or cry, you can stop ventilation and allow the baby to breathe naturally. 8. **Once the Baby Is Breathing Well:** - **Clamp and cut the cord** (if not already done). - **Return the baby to the mother for skin-to-skin contact** (EINC protocol; this maintains warmth and bonding). - **Monitor the baby's breathing, color, and behavior** as you provide routine newborn care (vitamin K, eye ointment, identification, etc.). - If the baby needed resuscitation, **arrange referral to hospital** for observation and assessment of possible causes (infection, birth asphyxia, etc.). **Special Situations:** **Meconium-Stained Amniotic Fluid:** - If the amniotic fluid is greenish (meconium-stained) and the baby is vigorous (crying, moving well), routine care is fine. - If the baby is not vigorous (limp, poor cry) and has meconium, suction the mouth and nose gently, but do NOT perform prolonged deep suctioning (this delays ventilation and is not proven to prevent aspiration). - Start ventilation as needed based on breathing/heart rate, not just because meconium is present. - The old practice of "suctioning out meconium" is no longer recommended; ventilate the baby and let the hospital manage any aspiration. **Preterm Baby (Before 37 Weeks):** - Preterm babies are more fragile and more likely to need help breathing. - Use a smaller bag and mask. - Have a heat source ready (plastic wrap to reduce evaporation if very preterm). - Use low concentrations of oxygen initially (room air); oxygen at high concentrations can cause blindness (retinopathy of prematurity) in preterm babies. - Follow the same principles: dry, assess, ventilate if needed, monitor heart rate. - Refer to hospital (preterm babies need NICU care). **Congenital Abnormalities (Visible):** - If you see obvious congenital abnormalities (e.g., cleft lip/palate, tracheoesophageal fistula, gastroschisis), be alert during ventilation (facial cleft may affect mask seal; tracheoesophageal fistula means air goes into the stomach, not lungs). - Still attempt ventilation with the best technique; then refer to hospital. - In settings without specialist care nearby, provide supportive care (warmth, monitoring) while arranging referral; do not attempt surgical repair. **When to Refer the Baby (After Resuscitation):** - Any baby who needed bag-and-mask ventilation should be referred for hospital observation (rule out aspiration, infection, birth asphyxia). - Any baby who is not breathing normally after the first minute should be referred. - Any baby with color abnormalities (central cyanosis, pallor), poor tone, or poor feeding should be referred. - Preterm babies, babies with maternal risk factors (fever, prolonged rupture of membranes), and babies who are smaller or larger than expected should be referred. **High-Yield Points for the Examination:** - **Golden Minute: 60 seconds.** Within this time, a baby should be breathing or being ventilated. - **Assessment: Breathing + Heart Rate.** The baby who is gasping or not breathing with a heart rate <100 needs immediate ventilation. - **Bag-and-mask ventilation: 40–60 breaths/minute; chest must rise** (if it does not, troubleshoot: mask seal, head position, airway). - **Room air is first-line** (oxygen later if the baby is not responding). - **Chest compressions are rare** (needed only if heart rate <60 after good ventilation for 30 seconds, which is exceptional). - **Most babies need only drying, warmth, and stimulation.** A minority need ventilation. A very few need chest compressions or drugs (these are sent to hospital).

Across all five obstetric emergencies (PPH, shoulder dystocia, cord prolapse, eclampsia, and neonatal resuscitation), a consistent algorithm applies. This universal approach ensures you do not miss critical steps and prioritize actions in a logical sequence. Use this framework for every emergency. **The Universal Obstetric Emergency Algorithm:** **Step 1: Call for Help (Immediately)** - The moment you suspect an emergency, call for help. Do not wait to confirm the diagnosis. - Call the hospital (request emergency transfer or emergency cesarean, depending on the emergency). - Call a backup midwife, doctor, or nurse if available. - Call family members to assist (hold legs in McRoberts, help with positioning, drive the vehicle, etc.). - **Note the exact time** of the emergency—this is critical for the receiving facility to understand how long the baby or mother has been affected. **Step 2: Stay With the Woman/Baby (Do Not Leave)** - Remain at the bedside. Do not step away to call (have someone else call, or use a phone without leaving). - Your presence reassures the woman and allows you to monitor closely and respond immediately to changes. - If alone, position the woman safely, then call briefly, then return immediately. **Step 3: Initiate Immediate, Life-Saving First-Line Care (Simultaneous With Calling)** - The specific actions depend on the emergency: - **PPH:** Massage uterus, give oxytocin, start IV fluids, empty bladder, inspect for trauma, check placenta. - **Shoulder dystocia:** McRoberts position, suprapubic pressure, consider Gaskin maneuver. - **Cord prolapse:** Elevate presenting part vaginally, position mother (knee-chest or Trendelenburg), keep cord warm/moist. - **Eclampsia:** Turn on left side, clear airway, give magnesium sulfate IV + IM, give oxygen. - **Neonatal non-breathing:** Dry, position, clear airway, start bag-and-mask ventilation. - These actions are **simultaneous with calling for help,** not after. **Step 4: Start Intravenous Access and Maintain Fluids (Obstetric Emergencies)** - For PPH, eclampsia, and some cord prolapse cases, start a large-bore IV line (18G or larger if possible). - Run IV fluids (normal saline or Ringer's lactate) rapidly or as appropriate. - This treats/prevents shock and is essential while awaiting transfer. - For neonatal resuscitation, IV access is done at the hospital, not by the midwife (unless very delayed transfer). **Step 5: Monitor Vital Signs and Maternal/Fetal Status** - Check blood pressure, pulse, respiratory rate, temperature (if available). - Listen to or assess fetal heart rate (if baby is still in utero, as in eclampsia or cord prolapse). - Monitor urine output (catheterize for PPH, eclampsia; measure each void). - Monitor the baby's breathing, heart rate, color, and tone (if neonatal resuscitation). - **Reassess every few minutes.** Do vital signs improve or worsen? Is the emergency resolving or worsening? **Step 6: Prepare for Referral (Before It Is Urgent)** - Have a plan for transport: who will drive, what vehicle, what route, what to bring. - Alert the receiving facility of the specific emergency (they will prepare an operating room for emergency cesarean if cord prolapse, for example). - Gather relevant supplies: IV fluids, medications, oxygen, resuscitation equipment, the placenta (for PPH), delivery records, etc. - If the mother is stable enough, have a family member accompany her. **Step 7: Transfer to CEmONC Without Delay** - Do not wait for the emergency to completely resolve before transferring. For example: - In PPH: do not wait for bleeding to stop; transfer as soon as PPH is diagnosed and first-line care is underway. - In cord prolapse: do not wait for the baby to be born at the RHU; arrange emergency transfer immediately (cesarean is definitive). - In eclampsia: do not wait for seizures to stop completely; transfer as soon as the loading dose of magnesium sulfate is given. - In neonatal resuscitation: if the baby needed ventilation, arrange transfer for observation/further management. - During transport, **continue first-line management:** maintain uterine massage (PPH), maintain elevated presenting part (cord prolapse), monitor vital signs, continue magnesium sulfate administration if ordered, provide oxygen and monitoring, etc. - Accompany the mother/baby if possible, or send detailed handover notes with the transport team. **Step 8: Handover to the Receiving Facility** - When arriving at the hospital, give a clear, brief summary: - **What is the emergency?** (e.g., "PPH with uterine atony, bleeding 1.5 liters in 20 minutes") - **What is the timeline?** (e.g., "started at 14:30, fundal massage and oxytocin given, BP now 95/55, HR 115") - **What has been done?** (e.g., "IV line started, 1.5 L normal saline given, uterus remains soft, I did not attempt to explore") - **What is the current status?** (e.g., "Mother is pale, alert but anxious, urine output minimal since admission") - **What complications occurred?** (e.g., "No lacerations visible, placenta delivered intact") - **Pass on responsibility clearly:** "I am handing over to you for management of severe PPH. I have given oxytocin and fluids. Please take it from here." **Contextual Adaptations (RHU vs. BHS vs. Lying-in Clinic):** - **RHU (Rural Health Unit):** Usually has basic equipment, some medications, able to start IV, and may have telephone for referral. - **BHS (Barangay Health Station):** More limited; may not have IV access setup. Call for ambulance first, then start what you can (oral medications not applicable to acute emergencies; mobilize the woman carefully). - **Lying-in Clinic:** Midwife-led, minimal equipment. Call for transfer immediately; provide supportive care until ambulance arrives. - **Home Birth:** Most dangerous setting. Call for emergency transfer immediately if an emergency is suspected; provide first-line care while awaiting ambulance (can take 1–2 hours in remote areas). The algorithm is the same everywhere: **call, stay, manage, monitor, refer.**