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

Before EINC, many newborns died or suffered harm from practices that seemed routine but were actually dangerous. Three of the largest preventable causes of newborn death are **hypothermia** (dangerously low body temperature), **infection/sepsis** (from poor hand hygiene or environmental contamination), and **failure to establish breathing and feeding**. EINC directly attacks all three. A wet newborn loses heat rapidly through evaporation—a baby can lose 0.2°C per minute if not dried immediately. Early bathing accelerates heat loss. Routine suctioning of the mouth and nose in a breathing baby causes oxygen-depriving bradycardia (slow heart rate) and can damage the delicate mucous membranes. Separating the mother and baby for weighing or injections breaks the skin-to-skin warmth that stabilizes the newborn's heart rate, blood sugar, and breathing, and prevents colonization with the mother's protective flora—instead, the baby colonizes with hospital organisms. Early cord clamping (within seconds) robs the baby of the placental transfusion—blood still flowing from the placenta that contains iron and blood volume; delayed clamping gives the infant a 'natural blood transfusion' that reduces neonatal anemia by up to 40% and provides iron stores that protect against anemia into childhood. Colostrum (the first milk) is the 'baby's first vaccine,' rich in antibodies (immunoglobulins) that protect against infection; early, exclusive breastfeeding establishes this protection within minutes of birth. EINC is therefore a **low-cost, high-impact intervention** that requires no expensive equipment—only the knowledge and discipline to follow a strict, time-sequenced protocol. The evidence base comes from the World Health Organization (WHO), UNICEF, and multiple randomized controlled trials showing that EINC reduces neonatal mortality, hypothermia, infection, and failure to feed. For the Filipino midwife working in resource-limited settings—RHUs, barangay health stations, or homes—EINC is the intervention that **directly saves lives**.

Hypothermia (body temperature below 36.5°C) is a **silent killer** of newborns. A cold newborn becomes lethargic (sleepy, hard to wake), stops feeding, becomes susceptible to infection, and may develop respiratory distress. Newborns cannot shiver to generate heat and have limited brown fat (especially preterm or small babies). Heat loss in a newborn happens through four mechanisms: **evaporation** (wet skin exposed to air), **convection** (cold air moving over the skin), **conduction** (contact with cold surfaces), and **radiation** (heat radiating away to cold surroundings). To prevent hypothermia, the midwife must maintain an unbroken **warm chain**—a series of steps that keep the baby warm from birth through the first hours. The warm chain is not a single action; it is a **chain of interlocking practices** that each stop one mode of heat loss. If the chain breaks at any point, the baby loses heat. The warm chain begins **before birth** with environmental preparation and continues through the first hours of life. A baby wrapped in a cold blanket loses heat to that cold blanket (conduction). A baby in a draft loses heat (convection). A baby bathed and left uncovered loses heat (evaporation and radiation). A baby separated from the mother for weighing loses access to the mother's body heat (radiation loss to a cold scale or crib). The midwife's role is to **think like a heat-preservation engineer**: every step must be warm, every transition must be quick, and the baby must stay in contact with a warm surface (the mother) as much as possible in the first hours.

The heart of EINC is a **strict sequence of four actions**, each tied to a **specific time window in the first 90 minutes of life**. The timing is what makes the protocol work. The midwife must know both the action AND the clock. Deviating from the sequence or timing undermines the entire protocol. These four steps are the foundation of every exam question on EINC and every clinical scenario a midwife will face. **STEP 1: Immediate and Thorough Drying (First 30 seconds)** The moment a baby is born and the cord is still pulsating, place the baby **prone (face-down, not face-up) on the mother's dry abdomen** (not on cold metal, not in wet cloths). Using a pre-dried, warm cloth, **dry the baby thoroughly and quickly**: head, face, back, trunk, arms, legs, and between fingers and toes. This takes approximately **30 seconds**. While drying, you are also **assessing breathing**. A baby that is breathing or crying vigorously needs no resuscitation—drying and tactile stimulation are sufficient to trigger breathing in a healthy newborn. A baby that is NOT breathing after drying and a brief additional stimulation (gentle rubbing of the back or flicking the feet) requires immediate resuscitation (see emergency chapter on neonatal resuscitation). Drying serves two critical functions: (1) **tactile stimulation** that triggers the breathing reflex and (2) **prevention of heat loss** (the biggest killer). Do **NOT wipe off the vernix** (the white, creamy coating on the skin). Vernix is a natural protective barrier against infection and helps thermoregulation; washing it off removes this protection. After drying, **immediately remove the wet cloth** and cover the baby with a dry cloth. The newborn at this moment is still attached to a pulsating cord; the midwife does NOT clamp the cord yet. **STEP 2: Early Skin-to-Skin Contact (After Step 1, immediate)** If the baby is breathing and vigorous (normal cry, good color, moving), place the baby **prone, directly on the mother's bare chest or abdomen, skin-to-skin** (bare chest preferred for closer warmth and access to the breast). Cover both mother and baby immediately with a **warm, dry cloth** and put a **bonnet on the baby's head**. This skin-to-skin contact is **continuous and uninterrupted**—the mother and baby are not separated for weighing, footprinting, measuring, or any other procedure during the first hour. Skin-to-skin contact accomplishes several life-saving things at once: (1) **thermoregulation**—the mother's body temperature is slightly higher than the baby's and acts as a living thermostat, maintaining the baby's temperature; (2) **cardiovascular stabilization**—skin-to-skin contact reduces the baby's heart rate variability, stabilizes blood pressure, and prevents the stress response; (3) **blood glucose stabilization**—the mother's warmth and the baby's contact with amniotic fluid on the skin trigger glucose regulation; (4) **colonization with protective flora**—the baby's skin colonizes with the mother's bacteria and flora, which are adapted to protect her baby (rather than hospital organisms); (5) **calm state**—the baby is calmer, more alert, and better able to find the breast; (6) **oxytocin surge in the mother**—the mother's body releases oxytocin (the hormone of bonding and milk release), preparing for breastfeeding and helping the uterus contract (preventing postpartum hemorrhage). The cord is still pulsating; it has not been clamped. **STEP 3: Properly-Timed Cord Clamping (1–3 minutes after birth)** After the baby is born and skin-to-skin contact is established, the midwife watches the umbilical cord. Do **NOT clamp immediately**. Instead, **wait until the pulsations in the cord have stopped**, which typically occurs **between 1 and 3 minutes** after delivery. The cord pulsations represent placental blood still flowing to the baby. Clamping early (within 15–30 seconds) cuts off this flow prematurely. Delaying the clamp allows the **placental transfusion** to continue—approximately 80 mL of extra blood volume and 30–40 mg of iron transfer from the placenta to the baby. This extra blood and iron reduce the baby's risk of neonatal anemia and anemia in early infancy by up to 40%. Iron is essential for brain development; iron-deficiency anemia in infancy is associated with poor cognitive development. Proper technique: (1) **Clamp placement**: Place the **first clamp approximately 2 cm from the base of the cord** (measured from the baby's abdomen). Place a **second clamp approximately 5 cm** from the base (or about 3 cm from the first clamp). (2) **Cutting**: Using a **sterile blade or sterile scissors**, cut cleanly between the two clamps. (3) **Cord stump care**: After clamping and cutting, the cord stump is exposed. Do **NOT apply alcohol, antiseptic solution, chlorhexidine, or any dressing** to the stump. **Dry cord care** is the standard—simply keep the stump clean and dry. Dry cord care reduces infection risk compared to any applied substance. Advise the mother to keep the cord area clean and dry, expose it to air when possible, and watch for signs of infection (oozing, foul smell, redness, swelling). Educate the family: do not apply ash, oil, charcoal, or traditional remedies to the cord. The cord typically falls off by day 7–14; the family should bring the baby to the health center if there are signs of infection or if the stump has not separated by day 21. **STEP 4: Non-Separation and Early Breastfeeding (Within the first hour)** After skin-to-skin contact is established with the cord pulsating (or just clamped), the midwife does **NOT separate the mother and baby**. The mother and baby remain together continuously. **Weighing, measuring, vitamin K, eye prophylaxis, footprinting, BCG, Hepatitis B vaccination, bathing, and detailed examination are all deferred** until **after the first successful breastfeed**. The midwife's role is to **watch for feeding cues** while the mother and baby are skin-to-skin. These cues appear as the baby 'awakens' during skin-to-skin: drooling, tongue movements (tonguing), licking movements, rooting (turning the head and opening the mouth), 'crawling' or moving toward the breast, and mouthing at the chest. The baby is neurologically programmed to search for and latch onto the breast during the first 1–2 hours of life; this is called the **'breast crawl' reflex**. When the midwife observes these cues, she gently **supports the first breastfeed**—helping the baby achieve a correct latch (baby's mouth covering the entire areola, not just the nipple) and ensuring the baby drinks the precious colostrum. Colostrum is the first milk, appearing within hours of birth; it is small in volume (5–20 mL per feed) but enormously rich in **immunoglobulins** (especially IgA), which coat the baby's mouth and digestive tract, protecting against bacteria and viruses. Colostrum is the 'first vaccine.' Exclusive breastfeeding from the first feed protects against infection and establishes the nursing relationship. The first breastfeed typically lasts 20–45 minutes and results in the baby ingesting colostrum and emptying the breast somewhat; the midwife does not interrupt this. Once this first feed is complete and the mother and baby are comfortable, **then and only then** do you proceed with the 'after-feeding' procedures (see section below).

Once the baby has completed the first breastfeed and mother and baby are comfortable (typically 45 minutes to 1.5 hours after birth), the midwife proceeds with the remaining essential newborn care procedures. These procedures are done while the mother and baby are still together (skin-to-skin or with the baby in the mother's arms), not in a separate nursery. The order is flexible as long as the procedures are deferred until after the first feed. **Vitamin K (Phytomenadione)**: Administer **1 mg intramuscularly** to the newborn (intramuscular injection into the anterolateral aspect of the thigh; the midwife should have learned correct IM injection technique in basic pharmacology). For **low-birth-weight or preterm newborns**, follow local protocol (typically 0.5 mg IM). Vitamin K prevents **hemorrhagic disease of the newborn (HDN)** or **vitamin K deficiency bleeding (VKDB)**—a rare but life-threatening condition where the newborn bleeds from the gums, intestines, umbilical stump, or intracranially due to lack of vitamin K-dependent clotting factors. Vitamin K is not synthesized by the fetal gut (babies are born with sterile bowels); maternal vitamin K does not cross the placenta effectively. A single IM dose of vitamin K within the first hours provides protection for weeks. In the Philippines, this is part of the newborn care package and is standard at every birth. **Eye Prophylaxis**: Apply **erythromycin ointment (0.5%) or tetracycline ointment (1%)** to both eyes (not the eyelids, but the conjunctival sac—the space between the lower lid and the eye). Use a single-dose tube or clean applicator to prevent cross-contamination. Eye prophylaxis prevents **ophthalmia neonatorum**, a severe conjunctivitis caused by **Neisseria gonorrhoeae** or **Chlamydia trachomatis** acquired from the mother during delivery through an infected birth canal. Ophthalmia neonatorum causes redness, discharge, and swelling; if untreated, it can cause corneal scarring and blindness. A single application of erythromycin or tetracycline ointment within the first hours is effective. In the Philippines, this is mandatory at every birth. **Immunizations**: Administer per the national immunization schedule: **BCG (Bacille Calmette-Guérin)** and **Hepatitis B vaccine (birth dose)**. These are given as IM injections (BCG intradermally into the upper arm; Hep B IM into the anterolateral thigh). BCG protects against tuberculosis (TB); the birth dose of Hepatitis B provides the first dose of protection and must be given within 24 hours of birth (ideally within the first 12 hours). In the Philippines, these vaccines are provided free through the MIDAS (Maternal and Infant Dental and Accessory Supplies) program and are part of the DOH Expanded Program on Immunization (EPI). The midwife must ensure both vaccines are given and documented. **Newborn Screening**: After feeding and the initial care, arrange for **newborn screening** (heel prick blood test) to detect congenital disorders such as **congenital hypothyroidism, phenylketonuria (PKU), galactosemia**, and other metabolic/hemoglobinopathies (varies by facility). This is typically done at 24–48 hours of age and is referred to as **Newborn Screening Program (NSP)** in the Philippines (under the Philippine Health Insurance Corporation—PhilHealth). The midwife's role is to ensure the baby is screened (at the health center, hospital, or via home follow-up) and that results are communicated to the family. **Weighing and Anthropometric Measurements**: Record **birth weight** (target: 2.5–4.0 kg for term newborns; low birth weight <2.5 kg, macrosomia >4.0 kg), **length** (target: 46–54 cm), **head circumference** (target: 32–36 cm), and **chest circumference**. Plot these on a growth chart. A baby significantly below or above normal ranges may indicate prematurity, growth restriction, or other concerns and may require referral or closer follow-up. **Newborn Physical Examination**: Perform a **systematic head-to-toe examination** to screen for visible congenital anomalies or birth injuries. Examine for: (1) cleft lip/palate, (2) imperforate anus, (3) undescended testes or ambiguous genitalia, (4) clubfoot or other limb abnormalities, (5) spina bifida or other spinal defects, (6) skin lesions or rashes, (7) signs of birth injury (caput succedaneum, cephalohematoma, bruising). Any visible major anomaly should be documented and discussed with the family; referral to a pediatrician or higher facility may be needed. **Vitamin A Supplementation**: Administer **200 IU (or 50,000 IU per local protocol) of Vitamin A** by mouth at the first feeding or shortly after (varies by facility protocol; in the Philippines, this is part of MNCHN guidelines). Vitamin A prevents childhood blindness and respiratory infections. **Cord Care**: Ensure the cord stump is clean and dry. Educate the mother on how to keep the cord area clean (wash hands before handling), exposed to air, and free of any traditional remedies. Advise return to the health center if there are signs of cord infection (oozing, foul smell, redness, swelling, discharge). **Delayed First Bath (at least 6 hours, preferably 24 hours)**: Do NOT bathe the baby in the first 6 hours (many protocols extend this to 24 hours). The bath is deferred because: (1) it causes heat loss (breaking the warm chain), (2) it removes the protective vernix (which provides natural antibacterial protection and thermoregulation), (3) it separates the mother and baby, disrupting bonding and early feeding. After 6–24 hours, when the baby is stable and the thermal shock of birth has passed, a gentle bath may be given using warm water and mild soap (or no soap if possible). Use warm water (37°C), work quickly, and dry immediately. Return the baby to the mother's arms or skin-to-skin contact immediately after drying. **Documentation and Counseling**: The midwife documents all EINC steps and procedures, including times (drying, cord clamping, first feed, procedures), vital signs (temperature, heart rate, respiratory rate), and any observations or concerns. Counsel the mother and family on: (1) exclusive breastfeeding for the first 6 months, (2) how to recognize signs of good latch (baby's mouth covers the areola, no clicking sounds, baby swallows and drains the breast), (3) how often to feed (8–12 times in 24 hours; on demand), (4) cord care (keep dry, no remedies, bring to health center if signs of infection), (5) signs of newborn illness (fever, poor feeding, lethargy, convulsions, severe jaundice, difficulty breathing), (6) importance of follow-up visits and immunization completion, (7) safe sleep (supine position, firm surface, room-sharing without bed-sharing), and (8) when to return to the health center (cord signs of infection, fever, poor feeding, yellow palms/soles appearing, difficulty breathing).

A crucial part of EINC is understanding and **actively NOT doing** several once-'routine' procedures that are now known to be useless or harmful. The midwife must recognize these outdated practices and resist them—whether from family expectations, facility tradition, or pressure from others. Knowing what NOT to do is as important as knowing what TO do. **Routine Suctioning of Mouth and Nose**: In the past, virtually every newborn was suctioned—a catheter inserted into the mouth and nose to 'clear secretions.' This is NO LONGER DONE unless there is meconium aspiration (see respiratory chapter) or the baby is not breathing and requires resuscitation. A healthy newborn breathing immediately after delivery does NOT need suctioning. Why not? Because suctioning of a breathing, non-distressed baby triggers a vagal response (irritation of the vagus nerve), which causes **bradycardia** (sudden drop in heart rate, often to 60–80 bpm or lower) and **apnea** (temporary cessation of breathing). The baby's oxygen saturation drops, the baby becomes floppy, and a normal newborn is now distressed. Suctioning can also cause mucosal (tissue) damage. The correct action is: if the baby is breathing and crying, **do NOT suction**. If the baby is NOT breathing and requires help, gentle opening of the airway and bag-and-mask ventilation are used (see neonatal resuscitation chapter). **Early (Immediate) Cord Clamping**: Clamping the cord within 15–30 seconds (the old routine) deprives the baby of the placental transfusion. This is now known to be harmful long-term (increased infant anemia and iron-deficiency anemia in childhood). The correct action is: **wait until cord pulsations stop, typically 1–3 minutes**. **Immediate Bathing and Vernix Removal**: Bathing the baby immediately after birth (or within the first 1–2 hours) causes heat loss and removes the protective vernix. Vernix is not 'dirt' to be washed off; it is a protective coating. The correct action is: **defer the bath for at least 6 hours, preferably 24 hours**. In the first hours, drying the baby and skin-to-skin contact keep the baby warm and protected. **Mother-Baby Separation for Routine Procedures**: Separating the mother and baby to weigh, footprint, measure, or perform procedures breaks the warm chain (separation from the mother's warmth), disrupts bonding (oxytocin surge stops), interrupts early feeding, and deprives the baby of the mother's protective flora colonization. The midwife must resist the urge to 'get the paperwork done' by taking the baby to another room. Instead, procedures are done with the baby in the mother's arms or on the bed next to the mother. **Routine Application of Substances to the Cord Stump**: In the past, alcohol, povidone-iodine (Betadine), chlorhexidine, gentian violet, and various traditional remedies were applied to the cord stump. This is NO LONGER DONE. **Dry cord care** (no substances) is superior. Why? Because applied substances prevent the cord from drying properly, can irritate the skin, and have not been shown to reduce infection better than dry care. The correct action is: keep the cord stump clean and dry, and educate the family on this. **Aggressive Stimulation (Flicking, Slapping, Hanging Upside Down)**: In very old practices, providers would forcefully flick the baby's feet, slap the baby's back, or hang the baby upside down to 'stimulate' breathing. This is dangerous and ineffective. Appropriate stimulation is **drying the baby thoroughly**, which is enough to trigger breathing in a healthy newborn. If the baby does not breathe after drying, the baby is moved to bag-and-mask ventilation, not more aggressive stimulation. **Routine Gastric Suction or Aspiration**: Some facilities routinely passed a feeding tube into the baby's stomach and aspirated ('suctioned out') the stomach contents. This is unnecessary in a well newborn and can cause aspiration, mucosal injury, and delay in feeding. The correct action is: if the baby is well, allow the baby to feed without routine gastric aspiration. **Routine Enema or Manual Evacuation of Meconium**: Some facilities gave newborns an enema to evacuate meconium (the first stool). This is unnecessary and can cause fluid/electrolyte imbalance and trauma. The correct action is: allow the baby to pass meconium spontaneously. The first meconium is typically passed within 12–24 hours. **Foot-Printing and Other Procedures That Interrupt Skin-to-Skin**: Foot-printing for identification is sometimes routine, but if done in the first hour and the baby is removed from the mother, it interrupts non-separation and early feeding. Some facilities now use **mother-baby identification bands** instead, applied while the mother and baby are together skin-to-skin. **Covering or Isolating the Cord Stump**: Some families or traditional practices involve wrapping the cord stump in cloth or tape, or applying dressings. This prevents air circulation and can trap moisture, increasing infection risk. The correct action is: educate the family that the cord should be **exposed to air** as much as possible; any covering should be removed when the clothing is changed or when air circulation is possible. **Summary**: The midwife's discipline is to follow EINC as written and to NOT do the outdated, harmful procedures. When a family member or colleague suggests one of these old practices ('Why aren't you suctioning the baby?' 'Why not bathe the baby now?'), the midwife calmly explains the evidence: 'The baby is breathing well; suctioning would harm him. We keep him warm and with his mother now.' 'We delay the bath to keep him warm and let him feed first.' Education and evidence-based advocacy are part of the midwife's role.

EINC is not only about the newborn—the **intrapartum** care of the mother during labor and delivery is equally important. A calm, supported mother has a smoother labor and is better positioned to receive a healthy baby. The midwife's role in labor is to create an environment of **physiologic birth**—one that respects the mother's body and her emotional needs, minimizes unnecessary interventions, and sets the stage for a healthy start for both mother and baby. **A Companion of Choice**: One of the most powerful evidence-based interventions is **continuous support in labor**—a person of the mother's choosing who stays with her throughout labor and birth. This companion (partner, mother, sister, friend, or a trained doula or peer supporter) provides emotional reassurance, physical comfort, and advocacy. Continuous support reduces labor duration, reduces the need for pain relief medications, reduces the rate of operative delivery (cesarean or instrumental), and improves maternal and newborn outcomes. The midwife must **invite and welcome** the companion into the delivery room. Some facilities have restricted visitors; EINC philosophy requires the companion to be present. Many Philippine families include the partner, mother, or sister; the midwife should ask the laboring woman, 'Who would you like with you?' and ensure that person is present. **Freedom of Movement and Position**: In the past, laboring mothers were confined to bed, often lying flat on their backs (lithotomy position). EINC encourages the mother to **walk, stand, sit, squat, rock, or change position freely** during labor, as long as there is no contraindication (e.g., severe complications, epidural anesthesia). Upright positions and movement: (1) use gravity to help the baby descend, (2) reduce pain perception (movement distracts and engages the mother's own pain-coping mechanisms), (3) improve placental blood flow and fetal oxygenation, (4) reduce the duration of labor, and (5) reduce the need for operative delivery. The mother may walk the halls, squat, sit on a birth ball, or use whatever position feels comfortable. She can give birth in any position she chooses—standing, squatting, on hands and knees, or seated upright. The midwife must **provide space and support** (but not force) for freedom of movement. Many lying-in clinics in the Philippines now have 'delivery balls' and teaching on upright positioning; some traditional homes are naturally conducive (the mother can move freely at home). **Oral Fluids and Light Food**: Routine 'nothing by mouth' (NPO) during labor is not necessary for normal labor. The mother may drink **clear fluids** (water, juice, coconut water, broth) and eat **light foods** (bread, fruit, rice, soup) if she desires. Offering fluids and food: (1) prevents dehydration and hypoglycemia, (2) provides energy, (3) allows the mother to maintain autonomy and control, and (4) can reduce the need for IV fluids. Some mothers do not want to eat; they should not be forced. The midwife's role is to offer: 'Would you like some water? A snack?' and respect the mother's choice. In community settings, families naturally offer water and food; EINC endorses this rather than restricting it. **Non-Pharmacologic Pain Relief and Comfort Measures**: The midwife uses several evidence-based comfort measures instead of routine pain medications: (1) **Continuous support and reassurance**—the presence of the companion and the midwife's encouragement ('You're doing well, your labor is progressing'); (2) **Positioning and movement**—the freedom to move reduces pain perception and can shorten labor; (3) **Breathing and relaxation techniques**—the midwife teaches simple techniques: slow, deep breathing during contractions, or patterned breathing (e.g., in-2-3, out-2-3); relaxing shoulders and jaw between contractions; (4) **Counterpressure and massage**—the companion or midwife applies firm pressure to the mother's lower back during contractions (especially effective for back labor), or gentle massage of the shoulders and neck; (5) **Warm compresses or showers**—warm water (not hot) on the lower abdomen, back, or perineum reduces pain and helps the mother relax; many mothers find immersion in warm water (shower or bath) very helpful for pain management in labor; (6) **Vocalization**—allowing the mother to vocalize (low moans, groans, or singing) during contractions; this is normal and helps, not a sign of distress; (7) **Continuous presence and verbal encouragement**—'You're so strong. Your baby is coming. Rest between contractions.' These measures cost nothing, have no side effects, and are often more effective than medications. Many Filipino mothers respond well to these approaches, especially in community settings where the mother, companion, and midwife work together. **Monitoring with the Partograph**: The midwife uses the **partograph** (a simple graphical record) to monitor labor progress, rather than repeated vaginal examinations. The partograph tracks: cervical dilation (plotted against time), descent of the baby's head, fetal heart rate, and uterine contractions. A single vaginal examination every 2–4 hours (not every 30–60 minutes) is sufficient to plot cervical progress. Frequent vaginal examinations increase discomfort, risk of infection, and stress to the mother. The partograph allows the midwife to visually recognize prolonged labor (crossing the 'action line' on the graph indicates need for intervention or referral) and to monitor progress without repeated exams. **Restricted Routine Interventions**: EINC does NOT do the following routinely (unless there is a specific indication): (1) **Routine IV lines**—IV fluid is not needed for every laboring mother; fluids by mouth are sufficient for normal labor. IV lines are used if there is a complication (hemorrhage, dehydration, need for medications), or if referral to a facility with cesarean capability is needed. (2) **Routine enema**—enemas were given to empty the colon, but evidence shows they do not improve outcomes; mothers do not require them. (3) **Routine perineal shaving**—shaving was done for 'cleanliness,' but it increases irritation and does not reduce infection. (4) **Routine episiotomy**—routine cutting of the perineum does not prevent tearing and adds to trauma; episiotomy is used only for a specific indication (fetal distress requiring rapid delivery, instrumental delivery). The midwife instead uses **perineal massage** (gentle stretching of the perineum in the weeks before labor and during pushing) and allows the perineum to stretch and tear naturally if it tears (small tears often heal better than a surgical incision). **Active Management of the Third Stage of Labor (AMTSL)**: The third stage of labor is the delivery of the placenta. AMTSL consists of three evidence-based steps performed together to reduce postpartum hemorrhage by approximately 60%: (1) **Oxytocin 10 IU IM within one minute of the baby's birth** (not waiting for the placenta to deliver; the oxytocin is given as soon as the baby is completely out and the cord is pulsating). Oxytocin causes strong uterine contractions, which compress the placental blood vessels and prevent bleeding. Standard dose is 10 IU IM in the outer thigh or arm; no more than 10 IU should be given at once (higher doses can cause hypertension). (2) **Controlled cord traction**—after the oxytocin is given and the uterus is firm (check by gently palpating the fundus), the midwife gently pulls on the clamped cord while applying downward then upward pressure on the fundus (one hand above the pubic bone, supporting the uterus as the cord is pulled) to help deliver the placenta. This is done smoothly, not forcefully. (3) **Uterine massage**—after the placenta is delivered, massage the uterus (feeling the fundus and rubbing it in circular motions) to stimulate further contractions and compress bleeding vessels. AMTSL reduces postpartum hemorrhage from approximately 5–15% to 2–5%; it is a critical skill for all birth attendants. **Perineal Care and Repair**: If the perineum is intact (no tear), the midwife simply cleans the area with clean water and a clean cloth; no special treatment is needed. If there is a tear: (1) **First-degree tear** (superficial, into the dermis only)—small tears (<0.5 cm) do not require stitching and heal on their own with good hygiene; the midwife cleans and observes. Larger first-degree tears may be sutured if the mother wishes (reduces pain with sitting and healing time). (2) **Second-degree tear** (deeper, involving muscle)—these are sutured with absorbable sutures (chromic catgut or polyglactin) to improve healing and reduce pain. The midwife must have adequate training and equipment. (3) **Third- or fourth-degree tear** (involving anal sphincter or deeper)—these require specialist repair (referral to hospital). If the midwife is not trained to repair, or if there is extensive trauma, **refer to a facility with surgical capability**. **Post-Delivery Care of the Mother**: After the baby is born and the placenta is delivered, the mother requires: (1) **Rest and reassurance**—allow the mother to rest with her baby; offer warm drinks and light food; (2) **Vital signs monitoring**—check blood pressure, pulse, temperature hourly for the first 2 hours, then every 4 hours for the first 24 hours (signs of postpartum hemorrhage, infection, or hypertension); (3) **Fundal checks**—palpate the uterus to ensure it is firm (contracted); if it is soft, perform uterine massage until it firms; (4) **Lochia assessment**—monitor vaginal bleeding; light to moderate bleeding is normal; heavy soaking or clots passing continuously may indicate hemorrhage (refer); (5) **Perineal assessment**—inspect the perineum every 4 hours for swelling, hematoma, or infection signs; apply cold compresses for swelling in the first 24 hours; (6) **Bladder care**—encourage the mother to void within 4 hours; a full bladder can prevent uterine contraction and increase hemorrhage risk; (7) **Pain management**—paracetamol or ibuprofen for perineal pain; avoid NSAIDs if there is heavy bleeding; (8) **Breastfeeding support**—encourage early and frequent breastfeeding; it stimulates uterine contractions and reduces hemorrhage; (9) **Health education**—counsel on self-care, nutrition, rest, emotional support, danger signs (fever, heavy bleeding, chest pain, severe headache), and the importance of follow-up.

As an independent provider of normal newborn care who **recognizes complications and refers**, the midwife must be skilled at identifying **newborn danger signs** that indicate the baby needs evaluation at a facility with **BEmONC** (Basic Emergency Obstetric and Newborn Care) or **CEmONC** (Comprehensive Emergency Obstetric and Newborn Care) capabilities. The midwife does NOT attempt to manage a sick newborn; instead, she **detects the problem early** and **refers urgently**. Early recognition and referral can be lifesaving. **Critical Danger Signs (Refer Immediately—Within Minutes)**: (1) **Not breathing, gasping, or severely abnormal breathing**—a baby who is apneic (not breathing), gasping for air, or having very slow/very fast breathing is in respiratory distress and needs immediate help. Refer urgently with bag-and-mask ventilation if available, or prepare for resuscitation during transport. (2) **Severe chest in-drawing**—the skin pulls inward deeply with each breath (the ribs and abdomen are sucked in); this indicates the baby is working very hard to breathe (respiratory distress). Refer urgently. (3) **Stridor or grunting**—stridor (a high-pitched sound with breathing, usually on inspiration) may indicate airway obstruction; grunting (a low sound at the end of exhalation) is a sign of respiratory distress (the baby is trying to keep air in the lungs). Both require urgent evaluation and possible referral. (4) **Convulsions or seizures**—any jerking, tremors, or repetitive eye movements may indicate seizures (from infection, hypoglycemia, hypoxia, or congenital neurologic disorder). Refer urgently. (5) **Severe floppiness or complete unresponsiveness (lethargy)**—a baby that is extremely limp, does not respond to stimulation, or has no tone is in serious danger. Refer urgently. (6) **Severe jaundice (yellow palms, soles, and trunk)**—visible jaundice in the first 24 hours of life, or very deep yellow color (especially if palms and soles are yellow) indicates severe hyperbilirubinemia that requires phototherapy or exchange transfusion. Refer urgently for bilirubin measurement. (7) **Umbilical cord stump bleeding that doesn't stop with pressure**—if the cord stump is bleeding heavily and does not stop after applying firm pressure with a clean cloth for 5 minutes, refer. This may indicate a bleeding disorder or improper clamping. (8) **Temperature instability (hypothermia <36°C or fever >38°C in first 24 hours)**—a very cold or very hot baby needs evaluation; fever in the first day may indicate serious infection (sepsis). **Important Danger Signs (Refer Urgently)**: (1) **Poor feeding or refusal to feed**—a baby who does not latch, sucks weakly, spits up all feeds, or shows no interest in the breast by 4–6 hours of age may have an underlying problem (prematurity, infection, neurologic issue). Assess latch, educate on hand expression and cup feeding if needed, and if feeding does not improve, refer. (2) **Persistent vomiting or green/bile-stained vomiting**—occasional spit-up is normal; persistent vomiting (most or all feeds) or green-colored vomit may indicate bowel obstruction or infection. Refer. (3) **Abdominal distension, rigidity, or tenderness**—a swollen, hard, tender abdomen may indicate infection (peritonitis), obstruction, or necrotizing enterocolitis (NEC, a serious bowel infection in premature babies). Refer. (4) **No urine output by 24 hours or no stool by 48 hours**—newborns should pass urine within 24 hours and stool within 48 hours. Lack of either may indicate feeding issues, dehydration, or anomaly. If delayed, assess feeding and ensure adequate milk transfer; refer if not improving. (5) **Skin rash, pustules, or bleeding into the skin**—a new rash, especially petechiae (small red/purple dots that don't blanch with pressure), may indicate infection (sepsis, meningitis). Purpura fulminans (widespread bleeding into skin) is a medical emergency. Refer urgently. (6) **Excessive drooling, difficulty swallowing, or choking with feeds**—may indicate esophageal atresia (abnormal anatomy) or other swallowing problem. Refer. (7) **Swelling, pus, or foul odor from the umbilical stump**—signs of cord infection (omphalitis). Refer for IV antibiotics. (8) **Persistent crying, high-pitched cry, or unusual positioning**—may indicate pain (from trauma, fracture, or internal injury), neurologic problem, or infection. Assess carefully and refer if you cannot determine cause. (9) **Very small size (weight <2.0 kg) or very large size (weight >4.5 kg)** at birth—may indicate prematurity, growth restriction, or other issues requiring pediatric evaluation. Arrange close follow-up and lower threshold for referral. (10) **Visibly obvious birth defects** (cleft palate, imperforate anus, spina bifida, ambiguous genitalia, absent limbs)—note and discuss with family; referral timing depends on severity; some require urgent surgical evaluation, others can wait; counsel the family and arrange pediatric evaluation. **Red Flags Specific to First 48 Hours**: (1) **Not feeding well by 12 hours**—a baby should show interest in feeding, root, and attempt to latch by 6–12 hours. If not, investigate: is the baby too cold? Too tired? Does the latch need help? If feeding does not improve with support, refer. (2) **Weight loss >10% by 48 hours**—some weight loss (7–10%) is normal (loss of meconium and urine); greater loss suggests inadequate feeding or other problem. Assess feeding and refer if not improving. (3) **Prolonged jaundice (lasting >2 weeks) or worsening jaundice after 48 hours**—suggests possible hemolytic disease, infection, or liver problem. Refer for evaluation. (4) **Cephalohematoma or severe bruising**—bleeding under the scalp (cephalohematoma) or extensive bruising may indicate birth trauma or bleeding disorder; rare but needs evaluation. (5) **Abnormal behavior**: extreme irritability, tremors, high-pitched cry, poor suck—may indicate withdrawal syndrome (if mother used opioids/alcohol), infection, or metabolic problem. Refer. **Midwife's Action When Danger Sign Identified**: (1) **Assess and stabilize**—ensure the baby is warm, check airway, give oxygen or bag-and-mask if available and needed. (2) **Inform the family**—explain what you observed and why you are concerned. (3) **Refer urgently**—contact the receiving facility (hospital with pediatric care), explain the problem, and arrange immediate transport. Do NOT delay to 'observe longer.' (4) **Supportive care during transport**—keep the baby warm, maintain airway, and provide any available emergency care (e.g., bag-and-mask ventilation for a non-breathing baby). (5) **Documentation and communication**—write down the time of observation, the danger sign, the baby's vital signs and status, any interventions done, and the time of referral. Hand over all documentation to the receiving facility. **Prevention of Danger Signs Through EINC**: Many newborn complications are prevented by strict adherence to EINC: hypothermia is prevented by the warm chain; infection is reduced by early breastfeeding (colostrum) and good hygiene; poor feeding is prevented by early, uninterrupted skin-to-skin and breastfeeding; jaundice is detected early if the baby is kept with the mother and feeding frequently. The midwife's best tool is **EINC done perfectly**—and the second tool is **early detection of problems and urgent referral**.

The midwife's role extends beyond the birth itself to **health education and counseling** that empower the mother and family to care for the newborn and support healthy development in the first days and weeks of life. Education is provided in an accessible, respectful way, free of jargon, and tailored to the family's cultural context and learning needs. **Exclusive Breastfeeding for the First 6 Months**: The most important health message is **exclusive breastfeeding for 6 months**—the baby receives only breast milk, no formula, no water, no other foods. Breast milk is the perfect food, containing all nutrients, antibodies, and protective factors. The midwife explains: colostrum (the first milk) is rich in antibodies; transitional milk (days 3–7) is rich in fat and protein; mature milk (after day 7) maintains perfect nutrition for 6 months. Exclusive breastfeeding protects against infection, reduces the risk of allergy and obesity, and supports optimal brain development. Counsel the mother on: (1) how often to feed (8–12 times in 24 hours, or on demand—the baby signals hunger by rooting, bringing hand to mouth, or waking restlessly; do NOT go longer than 3–4 hours between feeds initially), (2) correct latch (baby's mouth covers the entire areola, not just the nipple; no clicking or painful sensation; mother can see the baby's chin and hear swallowing), (3) signs of adequate milk transfer (baby has >6 wet diapers in 24 hours by day 3; passes yellow stool by day 4; baby returns to birth weight by day 10–14), (4) common breastfeeding problems and solutions: sore nipples (correct latch, air-dry between feeds, use expressed milk), engorgement (frequent feeds, warm compresses, manual expression to soften the areola), perceived low milk supply (ensure frequent feeds, 8–12/day; most mothers have adequate milk if baby is feeding properly; refer to lactation specialist if concern persists), (5) support resources: encourage the mother to contact the local health center or a peer support group if she has questions or difficulties. **Assessment of Latch**: The midwife teaches the mother how to recognize a good latch by visual and tactile cues. A **good latch** includes: (1) Baby's mouth wide open, covering the entire areola (the dark area around the nipple), not just the nipple. (2) Baby's chin touching the breast. (3) Baby's lips flanged out (not tucked in). (4) No pain or clicking sounds. (5) Baby's cheeks full and rounded (not sucked in). (6) Visible swallowing, especially after the first few sucks. If the latch is incorrect, the midwife gently helps the mother reposition: break the latch (insert a finger into baby's mouth to release), help the baby open wide, and guide the baby's mouth to the breast with the areola in the mouth first, then the nipple. Practice and patience help. Many mothers need support with the first few feeds. **Danger Signs in the Newborn**: Counsel the mother on **when to return to the health center immediately**. Red flags include: (1) **Difficulty feeding or refusal to feed** for >4 hours. (2) **Excessive sleepiness (lethargy)** or difficulty arousing the baby. (3) **Fever** (body temperature >38°C taken rectally or axillary) or **very cold** (<36°C). (4) **Convulsions, tremors, or stiffness**. (5) **Severe jaundice** (deep yellow color, or yellow palms/soles). (6) **Severe rash** or bleeding into the skin. (7) **Difficulty breathing**, fast breathing, grunting, or chest in-drawing. (8) **Cord stump bleeding, oozing, swelling, redness, or foul smell**. (9) **Vomiting everything** or green/bile-colored vomiting. (10) **Abdominal swelling** or hardness. (11) **Umbilical swelling or drainage**. The mother should bring the baby to the health center if ANY of these occur. Early detection saves lives. **Cord Care Education**: Emphasize: (1) **Keep the cord clean and dry**. (2) **Do NOT apply anything** to the cord—no alcohol, no antiseptic, no ash, no oil, no traditional remedies. (3) **Allow the cord to air-dry** when possible (expose to air when changing the diaper; keep the area ventilated). (4) **Fold the diaper below the cord stump** so urine does not wet it. (5) **Wash hands before handling the cord**. (6) **Bring the baby to the health center immediately if** the cord stump has oozing, pus, foul smell, redness, or swelling. The cord typically falls off by day 7–14; the family should bring the baby for a check if it has not fallen off by day 21 or if there are signs of infection. **Safe Sleep Practices**: Counsel on safe sleep to reduce the risk of sudden unexplained nocturnal death syndrome (SUNDS) and sudden infant death syndrome (SIDS): (1) **Place the baby on the back to sleep** (supine position), not on the side or prone. (2) **Use a firm sleeping surface** (firm mattress, not a pillow or couch). (3) **Room-sharing without bed-sharing**—the baby sleeps in the parents' room but on a separate surface (crib, bassinet, or a mat next to the bed) for the first 6 months or longer. This is common in Philippines (co-sleeping in the same room is often the norm), but the baby should sleep on a separate surface to reduce the risk of accidental smothering. (4) **Avoid overheating**—keep the room at a comfortable temperature; avoid excessive blankets or pillows in the crib. (5) **Consider offering a pacifier at nap time and bedtime** after breastfeeding is established (around 3–4 weeks) to reduce SIDS risk. (6) **Avoid smoke, alcohol, and drug use** during pregnancy and after birth; secondhand smoke increases SIDS risk. **Newborn Screening and Follow-Up Visits**: Explain the importance of: (1) **Newborn screening (heel prick test)** at 24–48 hours to detect congenital hypothyroidism, PKU, and other metabolic disorders. Results are available in 1–2 weeks; if abnormal, the family is contacted and the baby is referred. (2) **Immunization schedule**: BCG and Hepatitis B at birth; Rotavirus, Pneumococcal, and other vaccines at 6 weeks, 10 weeks, and 14 weeks per the EPI schedule. Remind the mother to keep the immunization card and attend all scheduled visits. (3) **Health center follow-up**: the baby should be brought to the health center for check-ups at day 3, day 7, day 14, 6 weeks, 3 months, 6 months, and beyond per the MNCHN (Maternal, Newborn, and Child Health and Nutrition) program. **Nutrition and Maternal Self-Care**: Advise the mother to: (1) **Eat a balanced diet** (rice/grains, vegetables, protein, fruit, healthy fats) to produce good-quality milk and recover from birth. (2) **Drink plenty of fluids** (water, soup, milk) to stay hydrated and support milk production. (3) **Rest adequately**—sleep when the baby sleeps; limit visitors in the first few days to allow rest. (4) **Avoid excessive physical work** in the first 2 weeks while the body recovers. (5) **Use a postpartum binder or traditional wrap** (if culturally preferred) for support and comfort. (6) **Watch for signs of postpartum depression or mood disturbance**—if the mother feels sad, hopeless, anxious, or has thoughts of harming herself or the baby, she should contact the health center immediately. **Family Planning and Spacing**: If the mother is interested in family planning, counsel on: (1) **Lactational amenorrhea method (LAM)**—exclusive breastfeeding can suppress ovulation and prevent pregnancy for the first 6 months if used correctly (8–12 feeds/day, no other foods/formula). (2) **Barrier methods** (condom)—can be used during breastfeeding if the mother desires. (3) **Hormonal methods**—discuss options (minipill, implant, injection) that are safe during breastfeeding; combined oral contraceptives (containing estrogen) can reduce milk supply and are generally avoided during exclusive breastfeeding. (4) **Long-acting reversible contraception (LARC)**—intrauterine device (IUD) or implant can be inserted after breastfeeding is established or at 6 weeks postpartum. (5) **Optimal spacing**—encourage spacing of pregnancies by at least 18–24 months to allow recovery and reduce risk of maternal and neonatal complications. **Emotional Support and Bonding**: Emphasize that **bonding and love are as important as nutrition**. Encourage: (1) **Skin-to-skin contact** with the baby regularly (beyond the first hour) to strengthen bonding and regulate the baby's physiology. (2) **Responding to the baby's cues**—picking up the baby when he cries is not 'spoiling'; it is building trust and attachment. (3) **Talking, singing, and playing with the baby**—these stimulate brain development and bonding. (4) **Including the father and family** in care—the baby benefits from love and attention from multiple caregivers. **Cultural Sensitivity**: While providing education, respect cultural practices that are safe (e.g., traditional wrapping, family involvement in care) and gently redirect practices that are harmful (e.g., applying substances to the cord) by explaining the evidence and offering culturally acceptable alternatives.