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

Exam Tips

• Memorize: DOH AO 2009-0025 = EINC = Unang Yakap. These three must come together in your mind automatically.
• Remember the three newborn killers EINC prevents: Hypothermia, Infection, Failure to breathe/feed.
• EINC is deliverable at ALL levels of care — this is a favorite exam statement to either confirm or deny.

Key Points

• Before EINC, routine practices like immediate bathing, early cord clamping, routine suctioning, and mother-baby separation were common — and all are now known to be harmful or unnecessary.
• Three major killers of newborns that EINC directly addresses: HYPOTHERMIA, INFECTION (sepsis), and FAILURE TO BREATHE or FEED.
• EINC is a low-cost, high-impact protocol deliverable anywhere: BHS, RHU, lying-in clinic, or home birth — only a warm room, clean cloths, clean hands, and a trained midwife are required.
• DOH AO 2009-0025 is the legal basis. Know this order number for the exam.
• The Filipino term 'Unang Yakap' means 'First Embrace' — representing the first skin-to-skin contact of mother and baby.

Definitions

Section Title

Why EINC Exists: The Evidence-Based Rationale

Common Mistakes

• Confusing EINC with a newborn-only protocol — EINC also covers intrapartum (labor and delivery) care of the mother.
• Forgetting the DOH AO number: 2009-0025. This is a direct recall question on the MLE.
• Underestimating the warm chain — heat loss in a newborn begins within seconds of birth; every delay costs warmth.

Exam Tips

• Use the mnemonic D-S-C-B: Dry → Skin-to-skin → Cord clamp → Breastfeed. This is the correct MLE sequence.
• Key timing numbers to memorize: 30 seconds (drying), 1–3 minutes (cord clamp), 1 hour (first breastfeed), 6–24 hours (first bath).
• Cord clamp distances: 2 cm first clamp, 5 cm second clamp — 'two comes first, five comes second.'
• If a question asks 'when is the baby weighed?' — always answer AFTER the first breastfeed, not before.
• For vitamin K dosing: 1 mg IM for normal newborn; 0.5 mg for low-birth-weight/preterm — know the difference.

Key Points

• STEP 1 — Immediate and Thorough Drying: Done within the FIRST 30 SECONDS. Place baby prone on mother's abdomen and dry head, back, trunk, arms, and legs thoroughly. Remove the wet cloth. Do NOT wipe off the vernix.
• STEP 2 — Early Skin-to-Skin Contact: Immediately after drying, if baby is breathing/crying, place baby prone and skin-to-skin on the mother's bare chest. Cover both with a warm dry cloth and put a bonnet on the baby's head. This contact must be CONTINUOUS and UNINTERRUPTED.
• STEP 3 — Properly-Timed Cord Clamping: Clamp and cut the cord ONLY AFTER PULSATIONS STOP — between 1 and 3 MINUTES after birth. First clamp at 2 cm from the base; second clamp at 5 cm from the base; cut between them with a sterile instrument. Practice DRY CORD CARE — nothing applied to the stump.
• STEP 4 — Non-Separation for Early Breastfeeding: Keep baby skin-to-skin and do NOT separate. Support the FIRST BREASTFEED WITHIN THE FIRST HOUR. Weighing, vitamin K, eye care, BCG, Hep B, and bathing are ALL DEFERRED until AFTER the first feed.
• The entire sequence unfolds within the first 90 minutes of life.
• The sequence is STRICT — the steps must be done in order and the timing honored.
• A baby that does NOT breathe after drying and stimulation is taken OFF this sequence and resuscitated immediately.

Definitions

Section Title

The Four Time-Bound Core Steps of EINC (Newborn Sequence)

Common Mistakes

• Reversing the order: e.g., clamping the cord before drying or bathing before the first feed — both are WRONG and exam traps.
• Stating cord clamping is done at '1 minute' alone — the correct answer is 'after pulsations stop, between 1 and 3 minutes.'
• Thinking weighing, vitamin K, and injections come BEFORE the first breastfeed — they do NOT.
• Applying alcohol or antiseptic to the cord stump — this is an ELIMINATED practice under EINC.
• Saying 'routine suctioning' is part of the EINC sequence for a vigorous, crying baby — it is NOT.
• Confusing cord clamp placement: 1st clamp = 2 cm from base; 2nd clamp = 5 cm from base. Not the other way around.

Exam Tips

• Remember: ALL deferred care comes AFTER the first breastfeed — Vitamin K, eye care, BCG, Hep B, weighing, and bath.
• The bath has TWO correct timing answers depending on the question: 'at least 6 hours' (minimum) or '24 hours' (ideal/recommended). Both may appear as choices — pick the one that matches the question stem.
• Newborn screening (NBS) is required by LAW under RA 9288 — the midwife must inform parents and facilitate it.

Key Points

• VITAMIN K (Phytomenadione) 1 mg IM — given after the first feed to prevent Hemorrhagic Disease of the Newborn (Vitamin K Deficiency Bleeding). Dose for preterm/LBW: 0.5 mg IM.
• EYE PROPHYLAXIS — Erythromycin or Tetracycline ophthalmic ointment applied to both eyes to prevent ophthalmia neonatorum (gonococcal/chlamydial eye infection).
• IMMUNIZATIONS — BCG vaccine (tuberculosis) and Hepatitis B birth dose — both given after the first feed per the national immunization schedule.
• NEWBORN EXAMINATION — Full head-to-toe physical assessment, weighing, and anthropometric measurements (weight, length, head circumference).
• NEWBORN SCREENING — Heel-prick blood test for metabolic disorders (PKU, congenital hypothyroidism, CAH, G6PD deficiency, galactosemia) done 24–48 hours after birth or before hospital discharge.
• FIRST BATH — Delayed for at least 6 hours; many protocols recommend delaying up to 24 hours. This preserves body heat and the protective vernix.
• VITAMIN A — Given per program guidelines.

Definitions

Section Title

Care Deferred AFTER the First Breastfeed

Common Mistakes

• Giving vitamin K BEFORE the first breastfeed — incorrect under EINC sequence.
• Saying the eye ointment is given to prevent conjunctivitis generically — be specific: it prevents OPHTHALMIA NEONATORUM.
• Bathing the baby within the first hour — a major EINC violation and a common wrong answer choice.
• Confusing vitamin K dose for normal newborn (1 mg) with LBW dose (0.5 mg).

Exam Tips

• AMTSL timing: oxytocin 10 IU IM within 1 minute of BIRTH (not after placenta). This distinction is an MLE trap.
• The four eliminated routine intrapartum interventions: enema, perineal shaving, episiotomy, IV line/oxytocin augmentation in normal labor.
• Companion of choice = any person the mother wants, not limited to a health worker or family member.

Key Points

• COMPANION OF CHOICE — The mother has the right to a companion (partner, relative, friend) throughout labor and delivery. Continuous support shortens labor and reduces interventions.
• FREEDOM OF MOVEMENT AND POSITION — The mother walks and changes position freely during labor. She gives birth in the position SHE CHOOSES (not necessarily flat on her back).
• ORAL FLUIDS AND LIGHT FOOD — Permitted during normal labor as tolerated. Routine 'nothing by mouth' (NPO) is NOT required for normal labor.
• NON-PHARMACOLOGIC PAIN RELIEF — Breathing techniques, back massage, warm compresses, reassurance, and hydrotherapy as available.
• PARTOGRAPH — The standard tool for monitoring labor progress and detecting abnormal labor. Reduces unnecessary interventions.
• RESTRICTED ROUTINE INTERVENTIONS — No routine enema, no routine perineal shaving, no routine episiotomy, no routine IV lines, no routine oxytocin augmentation in normal labor.
• AMTSL (Active Management of the Third Stage of Labor) — OXYTOCIN 10 IU IM within ONE MINUTE of birth of the baby, followed by controlled cord traction and uterine massage — to prevent postpartum hemorrhage (PPH).

Definitions

Section Title

EINC Intrapartum Care of the Mother

Common Mistakes

• Thinking EINC only covers newborn care — it has a complete INTRAPARTUM (mother) component.
• Stating that routine episiotomy is part of normal care — EINC eliminated routine episiotomy.
• Giving oxytocin for AMTSL AFTER placental delivery — it must be given within ONE MINUTE of BIRTH OF THE BABY (not after the placenta).
• Forgetting that the partograph is an EINC tool — monitoring labor correctly IS part of EINC.

Exam Tips

• In exam questions listing EINC steps, if routine suctioning appears as an option, it is ALWAYS WRONG for a normal vigorous baby.
• Dry cord care = NOTHING on the stump. If a question asks 'what do you apply to the cord?', the answer is NOTHING (keep clean and dry).
• Remember: drying IS the stimulation. No need for slapping, hanging, or squeezing.
• Exam favorite: 'Which of the following is NOT part of EINC?' — eliminated practices are always the correct answer to this type.

Key Points

• ROUTINE SUCTIONING — Eliminated for a vigorous, crying baby born with clear amniotic fluid. Routine suctioning causes bradycardia, apnea, and mucosal injury.
• IMMEDIATE (EARLY) CORD CLAMPING — Eliminated. Robs the baby of the placental transfusion and increases risk of neonatal anemia.
• IMMEDIATE BATHING / WASHING OFF VERNIX — Eliminated. Causes rapid hypothermia and removes the protective vernix.
• ROUTINE SEPARATION OF MOTHER AND BABY — Eliminated in the first hour for routine procedures (weighing, footprinting, injections).
• AGGRESSIVE STIMULATION — Eliminated. Slapping, hanging upside down, squeezing are harmful. DRYING is the correct and sufficient stimulation.
• APPLYING SUBSTANCES TO CORD STUMP — Eliminated. Alcohol, antiseptics, and dressings on the cord stump are NOT done under EINC. Dry cord care is the standard.
• ROUTINE GASTRIC SUCTION/ASPIRATION in a well baby — Eliminated.
• ROUTINE EPISIOTOMY — Eliminated for normal deliveries.
• ROUTINE ENEMA AND PERINEAL SHAVING — Eliminated in normal labor.

Definitions

Section Title

Eliminated and Harmful Practices Under EINC

Common Mistakes

• Including routine suctioning as a step in EINC newborn care — it is specifically ELIMINATED.
• Thinking dry cord care means wrapping the cord — it means leaving it CLEAN, DRY, and UNCOVERED.
• Confusing 'vigorous baby' with 'non-vigorous baby' criteria — suctioning for meconium is only for non-vigorous babies and is a REFER/hospital scenario, not a midwife at BHS scenario.

Exam Tips

• Jaundice on DAY 1 (within 24 hours) = PATHOLOGICAL = REFER. Jaundice on Day 2–3 = physiological (watch and monitor).
• The midwife's action for ALL danger signs is the same: REFER to a higher facility. Do not attempt to manage at BHS level.
• Temperature danger signs in newborns: below 36.5°C (hypothermia) OR above 37.5°C (fever) — both are danger signs.

Key Points

• A newborn showing any danger sign is taken OFF the EINC sequence immediately and requires URGENT REFERRAL.
• BREATHING PROBLEMS: Not breathing, gasping, breathing very fast (>60 breaths/min) or very slow (<30 breaths/min).
• SEVERE CHEST INDRAWING or GRUNTING on every breath.
• CONVULSIONS (fits/seizures) in the newborn.
• FLOPPINESS / LETHARGY — no muscle tone, no spontaneous movement.
• TEMPERATURE INSTABILITY — cold to touch (hypothermia <36.5°C) or hot to touch (fever >37.5°C in a newborn is a danger sign).
• POOR FEEDING or INABILITY TO FEED after two attempts.
• SEVERE JAUNDICE — jaundice appearing within 24 hours of birth, or yellow palms and soles, is PATHOLOGICAL. Refer urgently.
• BLEEDING from the cord stump — may indicate HDN; refer immediately.
• The midwife's role: DETECT early and REFER promptly to a higher level of care (RHU, BEmONC/CEmONC facility, hospital).

Definitions

Section Title

Newborn Danger Signs: Detect and Refer

Common Mistakes

• Confusing physiological jaundice (after 24 hours) with pathological jaundice (within 24 hours) — the timing distinction is critical.
• Thinking the midwife 'manages' newborn danger signs — the midwife DETECTS and REFERS. Management is at the hospital/BEmONC level.
• Forgetting that poor feeding is a danger sign — if a baby cannot feed after two attempts, this is significant.

Exam Tips

• Room temperature for delivery: 25–28°C. This is a direct recall number.
• The bonnet is specifically mentioned in EINC because the baby's head is a major site of heat loss — always include it when describing skin-to-skin care.
• Bath timing: both '6 hours' and '24 hours' are defensible — read the question context carefully.

Key Points

• Delivery room temperature: 25–28°C. Doors and windows must be CLOSED. Fans/air-conditioning directed AWAY from the baby.
• IMMEDIATE DRYING — the first defense against hypothermia. Wet surface = rapid evaporative heat loss.
• REMOVE THE WET CLOTH IMMEDIATELY after drying — a cold, wet cloth is a heat sink.
• SKIN-TO-SKIN CONTACT — the mother's body acts as a biological warmer, regulating the baby's temperature better than an incubator in a normal baby.
• BONNET on the head — the head is a large surface area for heat loss in a newborn.
• COVER both mother and baby with a dry blanket.
• DELAY THE FIRST BATH — at least 6 hours, ideally 24 hours. Early bathing is the #1 cause of iatrogenic hypothermia in newborns.
• Keep baby DRESSED or WRAPPED when not skin-to-skin.
• WARM HANDS and WARM SURFACES for any examination.
• During transport for referral: maintain warmth using skin-to-skin or warm wrapping — this is part of the warm chain even outside the facility.

Definitions

Section Title

The Warm Chain: Preventing Hypothermia

Common Mistakes

• Thinking bathing at 1 hour is acceptable — it is NOT. The minimum is 6 hours; some protocols say 24 hours.
• Forgetting to REMOVE the wet cloth after drying — leaving a wet cloth on the baby causes continued heat loss.
• Not putting a bonnet on the baby — the head loses a disproportionate amount of heat.