Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Essential Intrapartum & Newborn Care (EINC / "Unang Yakap")Detailed Explanation

Examples

Applications

• At every normal delivery in any Philippine health facility or home, the midwife must apply EINC principles without exception.
• During BEmONC orientation and competency assessments, EINC compliance is a core indicator.
• EINC documentation in the partograph and facility records is monitored by DOH as a quality indicator.
• When reporting maternal-newborn outcomes to the RHU or municipality, EINC compliance rates are tracked.

Misconceptions

• MISCONCEPTION: EINC is only for hospital deliveries. FACT: EINC applies at ALL birth settings — BHS, RHU, lying-in, and home births.
• MISCONCEPTION: EINC is a suggestion; the midwife can choose whether to follow it. FACT: EINC is the STANDARD OF CARE mandated by DOH AO 2009-0025.
• MISCONCEPTION: Routine suctioning clears the airway and helps the baby breathe. FACT: In a baby with clear fluid who is already breathing, routine suctioning is harmful and has been eliminated by EINC.

Related Concepts

• DOH AO 2009-0025 (Unang Yakap)
• BEmONC (Basic Emergency Obstetric and Newborn Care)
• MNCHN (Maternal, Newborn, Child Health and Nutrition) Strategy
• The Warm Chain
• Four Core EINC Steps

Common Exam Questions

Key Points To Remember

• EINC is mandated by DOH Administrative Order No. 2009-0025.
• It is popularly known as 'Unang Yakap' (First Embrace).
• It targets the three leading newborn killers: hypothermia, infection, and failure to breathe/feed.
• It is a LOW-COST, HIGH-IMPACT intervention deliverable anywhere — BHS, RHU, lying-in, or home.
• EINC replaced harmful 'routine' practices (early cord clamping, immediate bathing, routine suctioning, immediate separation) with evidence-based ones.
• The midwife is the primary provider of EINC at the community level.

Examples

Applications

• Before every delivery, the midwife should check that the room is warm and draft-free and prepare two clean, warm cloths.
• In home deliveries, the midwife must instruct the family to close windows, prepare warm water, and have cloths and a bonnet ready.
• During transport/referral of a newborn, the baby must be wrapped warmly and skin-to-skin with the mother inside the vehicle when possible.
• The Warm Chain is assessed during BEmONC competency evaluations.

Misconceptions

• MISCONCEPTION: Bathing the newborn immediately after birth is good hygiene. FACT: Immediate bathing removes the protective vernix and causes dangerous hypothermia; it is an eliminated practice.
• MISCONCEPTION: The baby will be fine in an air-conditioned room if wrapped in a blanket. FACT: Even a wrapped baby loses heat rapidly in a cold, drafty room, especially if wet. The room itself must be 25–28°C.
• MISCONCEPTION: Removing the wet cloth will expose the baby to cold. FACT: Leaving the wet cloth ON causes evaporative heat loss. Remove it promptly AFTER drying and replace with a dry cloth.

Related Concepts

• Four Core EINC Steps
• Step 1: Immediate Drying
• Step 2: Skin-to-Skin Contact
• Delayed Bathing
• Hypothermia Prevention

Common Exam Questions

Key Points To Remember

• The delivery room should be 25–28°C, warm and draft-free.
• A newborn loses heat by evaporation, radiation, convection, and conduction.
• Immediate drying (within 30 seconds) is the FIRST defense against hypothermia.
• Remove the wet cloth promptly — leaving it on continues evaporative heat loss.
• Skin-to-skin contact uses the mother as a natural incubator.
• A bonnet on the head prevents the greatest area of heat loss.
• Do NOT bathe the newborn for at least 6 hours (DOH EINC: delay at least 6–24 hours).
• The Warm Chain must be unbroken — every step must preserve warmth.

Examples

Applications

• At every normal delivery, the midwife sequences care around these four steps regardless of how busy the facility is.
• The midwife documents the time of each EINC step in the delivery record and partograph.
• During supervisory visits, the RHN or PHN assesses EINC compliance by reviewing records and observing practice.
• EINC is a core competency assessed in the BEmONC training and certification.
• In advocacy, the midwife educates family members and traditional birth attendants (hilots) on the importance of not immediately bathing, separating, or clamping the cord of the newborn.

Misconceptions

• MISCONCEPTION: Milking/stripping the cord is an acceptable substitute for delayed clamping. FACT: EINC explicitly states do NOT milk the cord as a routine substitute. Only true delayed clamping provides the full placental transfusion.
• MISCONCEPTION: Alcohol should be applied to the cord stump to prevent infection. FACT: Dry cord care (nothing applied) is the EINC standard. Alcohol and antiseptics are not routinely used on the stump.
• MISCONCEPTION: The baby should be weighed first so the weight at birth is accurate, then placed skin-to-skin. FACT: Weighing is deferred until after the first breastfeed. The baby's birth weight can still be accurately recorded at that point.
• MISCONCEPTION: Colostrum is insufficient and the baby needs water or formula in the first hour. FACT: Colostrum is the ideal first feed — it is nutritionally and immunologically perfect for the newborn. Nothing else is needed.
• MISCONCEPTION: The cord should be clamped as soon as the baby is born to prevent the baby from losing blood. FACT: It is the PLACENTA losing blood to the BABY during pulsation — delaying clamping is beneficial, not harmful.

Related Concepts

• The Warm Chain
• AMTSL (Active Management of Third Stage of Labor)
• Newborn Resuscitation (when Step 1 shows no breathing)
• Colostrum and Exclusive Breastfeeding
• Vitamin K Prophylaxis
• Eye Prophylaxis
• Newborn Immunizations (BCG, Hepatitis B)

Common Exam Questions

Key Points To Remember

• STEP 1: Dry immediately and thoroughly (~30 seconds); remove wet cloth; do NOT wipe off vernix; assess breathing.
• STEP 2: Skin-to-skin, prone on mother's bare chest; cover with dry cloth; bonnet on head; continuous and uninterrupted.
• STEP 3: Cord clamping at 1–3 minutes AFTER pulsations stop; 2 cm and 5 cm from umbilicus; sterile cut; dry cord care (nothing applied to stump).
• STEP 4: Non-separation; first breastfeed within the first hour; watch for feeding cues; colostrum = first vaccine; defer all routine procedures until after the first feed.
• All four steps must happen IN ORDER and within the first 90 minutes.
• A baby that does not breathe after drying/stimulation exits the sequence and goes to resuscitation.
• Vitamin K 1 mg IM and eye prophylaxis are given AFTER the first breastfeed.
• First bath is delayed at least 6 hours (ideally 24 hours).

Examples

Applications

• The midwife counsels pregnant women during prenatal care that they may bring a companion of their choice during labor and delivery.
• At the RHU or lying-in clinic, the midwife ensures the facility policy allows companions and freedom of movement.
• The midwife uses the WHO partograph at every delivery to monitor labor progress and detect abnormalities early for timely referral.
• AMTSL is performed at every normal delivery by the midwife as a non-negotiable step to prevent PPH.

Misconceptions

• MISCONCEPTION: Episiotomy should be done routinely to prevent tears. FACT: Routine episiotomy is an eliminated EINC practice. Episiotomy is only done when clinically indicated (e.g., fetal distress requiring faster delivery, or severe perineal rigidity preventing progress).
• MISCONCEPTION: The mother must be on IV fluid throughout labor. FACT: Routine IV line is NOT required in normal labor under EINC. The mother may drink oral fluids.
• MISCONCEPTION: Perineal shaving prevents infection. FACT: Evidence shows perineal shaving does not reduce infection and may increase it through microabrasions. It is eliminated under EINC.

Related Concepts

• Partograph and Labor Monitoring
• PPH (Postpartum Hemorrhage) Prevention
• AMTSL
• Non-pharmacologic pain relief in labor
• Four Core EINC Newborn Steps

Common Exam Questions

Key Points To Remember

• Companion of choice: the mother has the RIGHT to continuous labor support.
• Freedom of movement: mother chooses her position; no routine flat/supine confinement.
• Oral fluids allowed in normal labor; routine NPO is eliminated.
• Non-pharmacologic pain relief first: breathing, massage, warm compress, reassurance.
• Partograph is used to monitor labor progress.
• ELIMINATED intrapartum routines: enema, perineal shaving, episiotomy, routine IV, routine oxytocin augmentation.
• AMTSL = Oxytocin 10 IU IM within 1 minute of birth + controlled cord traction + uterine massage.
• AMTSL prevents PPH — the leading cause of maternal death in the Philippines.

Examples

Applications

• The midwife prepares Vitamin K, eye ointment, BCG, and Hepatitis B vaccine BEFORE the delivery so they are ready to give after the first breastfeed.
• During parent education (prenatal and postpartum), the midwife explains why the baby will not be washed immediately and why it will be placed on the mother's chest.
• The midwife counsels families not to apply anything to the cord stump at home (no ash, garlic, oil, or antiseptic).
• The midwife reminds families that newborn screening (NBS) must be done ideally 24–72 hours after birth at the RHU or hospital.

Misconceptions

• MISCONCEPTION: Suctioning always helps a newborn breathe better. FACT: In a vigorous baby with clear fluid, routine suctioning causes harm (bradycardia, apnea, mucosal injury). It is an eliminated EINC practice.
• MISCONCEPTION: Applying betadine or alcohol to the cord prevents infection. FACT: Dry cord care (nothing applied) has been shown to be superior. Topical antiseptics can cause skin irritation and are no longer the standard.
• MISCONCEPTION: The bath should be done immediately to remove blood and vernix — for hygiene. FACT: The vernix is protective and should not be removed. The bath is delayed at least 6 hours (up to 24 hours) to prevent hypothermia.
• MISCONCEPTION: Vitamin K is optional if the baby looks healthy. FACT: Vitamin K 1 mg IM is mandatory for ALL newborns after the first breastfeed to prevent VKDB, which can be life-threatening.

Related Concepts

• Newborn Screening Program (Republic Act 9288)
• Hemorrhagic Disease of the Newborn / VKDB
• Ophthalmia Neonatorum
• Expanded Program on Immunization (EPI)
• Newborn Resuscitation (when baby does not breathe after drying)

Common Exam Questions

Key Points To Remember

• ELIMINATED: routine suctioning, early cord clamping, immediate bathing, immediate separation, substances on cord, aggressive stimulation, routine gastric suction.
• AFTER FIRST FEED: Vitamin K 1 mg IM (0.5 mg for preterm), eye prophylaxis, BCG, Hepatitis B, weighing, examination, newborn screening.
• First BATH: delayed at least 6 hours (DOH: 6–24 hours after birth).
• Vitamin K prevents Hemorrhagic Disease of the Newborn (VKDB).
• Eye ointment (erythromycin/tetracycline) prevents ophthalmia neonatorum.
• Newborn screening must be done 24–72 hours after birth (ideally after 24 hours and before discharge for early detection).
• Drying is the CORRECT stimulation — NOT slapping, hanging, or squeezing.

Examples

Applications

• During every newborn assessment in the first 90 minutes and at discharge, the midwife systematically checks for all danger signs.
• The midwife counsels mothers before discharge on danger signs to watch for at home, and instructs them to bring the baby immediately to the RHU or hospital if any sign appears.
• In the MNCHN tracking system, the midwife documents any danger signs detected and referrals made.
• Community health education sessions include newborn danger sign recognition for parents and caregivers.

Misconceptions

• MISCONCEPTION: Acrocyanosis (blue hands and feet) in the first few minutes is a danger sign. FACT: Acrocyanosis (blue extremities with pink body) in the first few minutes is NORMAL. Central cyanosis (blue lips, tongue, or body) is the danger sign.
• MISCONCEPTION: Mild jaundice appearing at 48 hours needs immediate referral. FACT: Physiological jaundice typically appears after 24 hours and peaks at day 3–5. It is jaundice in the FIRST 24 hours or severe jaundice (palms and soles) that warrants urgent referral.
• MISCONCEPTION: The midwife should give medications to a convulsing newborn before referral. FACT: The midwife's role is to detect and refer. She stabilizes (warmth, airway, position) and refers immediately — she does not independently prescribe anticonvulsants.

Related Concepts

• Newborn Resuscitation Protocol
• BEmONC Referral System
• Physiological vs. Pathological Jaundice
• Neonatal Sepsis Signs
• Normal Newborn Parameters

Common Exam Questions

Key Points To Remember

• Normal newborn respirations: 30–60 breaths per minute.
• Normal newborn temperature: 36.5°C–37.5°C (axillary).
• Danger signs: not breathing/gasping, fast or slow RR, severe chest in-drawing, grunting, convulsions, floppiness, temperature instability, poor feeding, severe jaundice, bleeding cord.
• Jaundice in the FIRST 24 hours (palms and soles) is ALWAYS pathological — refer immediately.
• The midwife's role: DETECT and REFER — she does not independently manage newborn emergencies.
• Keep the baby warm (skin-to-skin in transport) and refer URGENTLY.

Problem

A midwife is conducting a delivery at a Barangay Health Station. The baby is born and placed on the mother's abdomen. List the CORRECT sequence of the four EINC core steps, including the timing for each step.

Solution

Step 1: Immediate and thorough drying — within the first 30 seconds of birth. Step 2: Early skin-to-skin contact — immediately after drying, if baby is vigorous. Step 3: Properly-timed cord clamping — at 1–3 minutes after birth, after pulsations stop. Step 4: Non-separation for early breastfeeding — continue skin-to-skin; support first breastfeed within the first hour of life.

Problem

The mother in a lying-in clinic refuses to have her baby placed on her chest, saying she is tired and wants the baby taken to the nursery. What does the midwife say and do?

Solution

The midwife respectfully and compassionately explains the benefits of skin-to-skin contact — warmth, feeding, bonding, and infection protection. She asks the mother if there is a specific concern (pain, discomfort) and addresses it. She continues to support and encourage skin-to-skin. If the mother still refuses, the baby is kept warm by another means (wrapped in warm cloths) and the midwife supports the earliest possible breastfeed. She documents the mother's refusal and the counseling done.

Problem

A midwife discovers that a newly hired clinic assistant has been applying betadine to all newborns' cord stumps 'to keep it clean.' What should the midwife do?

Solution

The midwife should immediately correct this practice. She explains that dry cord care (nothing applied to the stump) is the EINC standard of care per DOH AO 2009-0025. She conducts in-service orientation/education for the clinic assistant on proper cord care, demonstrates the correct technique, and documents the correction. She monitors subsequent cord care practices.

Problem

At 30 minutes after birth, a midwife notes the following in a newborn at the BHS: breathing rate 55/min, skin color pink, muscle tone vigorous, temperature 36.8°C (axillary), cord stump clean and dry. The mother is breastfeeding. What is the midwife's assessment?

Solution

This is a NORMAL newborn with no danger signs. All parameters are within normal range: RR 30–60, warm temperature 36.5–37.5°C, pink and vigorous, breastfeeding. The midwife continues to monitor and supports the ongoing breastfeed.

Problem

A midwife delivers a baby and immediately clamps the cord at 20 seconds after birth before the pulsations stop. List TWO consequences of this action according to EINC principles.

Solution

1. The baby is deprived of the placental transfusion — approximately 80–100 mL of iron-rich blood that should have flowed from the placenta to the baby does not transfer. 2. This increases the baby's risk of neonatal anemia and iron-deficiency anemia during infancy.

Problem

A 2-hour-old newborn at the lying-in clinic is noted to be yellow (jaundiced) with yellow color extending to the palms and soles. The mother says the baby is not feeding well. What is the midwife's priority action?

Solution

The midwife recognizes TWO newborn danger signs: (1) jaundice within the first 24 hours with extension to palms and soles (pathological jaundice), and (2) poor feeding. Priority action: keep the baby warm (skin-to-skin with the mother or wrapped in warm cloths), explain to the mother the need for urgent referral, and IMMEDIATELY REFER to a BEmONC-capable facility (RHU with BEmONC capability or district/government hospital).