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

EINC is the DOH-sanctioned, evidence-based protocol for the management of normal labor, birth, and immediate newborn care. It was formally adopted through DOH Administrative Order No. 2009-0025 and emphasizes physiological processes, minimal unnecessary intervention, and continuity of care for mother and baby. 'Unang Yakap' translates to 'First Embrace,' symbolizing the emphasis on skin-to-skin contact and mother-baby non-separation. The protocol is designed to be implementable in low-resource settings (RHUs, barangay health stations, lying-in clinics) using simple, clean equipment and trained attendants.

The 'warm chain' is a series of unbroken steps designed to maintain the newborn's body temperature from the moment of birth through the first hours of life. Newborns lose heat rapidly through evaporation, radiation, conduction, and convection because they cannot regulate their own temperature. The chain includes: (1) a warm, draft-free delivery room (25–28°C with no direct fans or air-conditioning); (2) immediate drying of the wet newborn (~30 seconds) and removal of wet cloths; (3) skin-to-skin contact with the mother as a heat source, covered with dry blankets; (4) a bonnet on the baby's head (large surface area for heat loss); (5) delayed bathing (at least 6 hours, many protocols 24 hours); (6) keeping the baby dressed or wrapped when not skin-to-skin; and (7) use of warm hands, warm surfaces, and warm transport if referral is needed. Breaking any link in the chain can result in hypothermia—a killer that increases susceptibility to infection, hypoglycemia, and respiratory distress.

Within the first few seconds of birth, the newborn is placed prone on the mother's abdomen and dried thoroughly over approximately 30 seconds. The drying covers the head, back, trunk, arms, and legs. The wet cloth is then removed and replaced with a dry cloth. The act of drying provides two critical functions: (1) tactile stimulation that triggers the baby's breathing reflex and helps establish respiratory effort, and (2) prevention of heat loss through evaporation, which occurs rapidly in a wet newborn. Importantly, the vernix caseosa (the white, waxy coating on the skin) is NOT wiped off—it is left in place because it provides thermoregulation and acts as a natural barrier against infection. During drying, the midwife briefly observes the baby's breathing: if the baby is breathing or crying, it is vigorous and requires no resuscitation. If the baby is not breathing after drying and gentle stimulation, the midwife transitions to resuscitation using the newborn emergency protocol (see emergency chapter). The timing is critical: drying is complete by 30 seconds, and the next step begins immediately.

If the newborn is breathing, crying, and vigorous after drying, the baby is placed prone (chest-to-chest or abdomen-to-abdomen) directly on the mother's bare chest or abdomen and both are covered together with a warm, dry cloth; a bonnet is placed on the baby's head. The baby is not removed from this contact for weighing, examination, or routine procedures during the first hour and beyond. Skin-to-skin contact (also called 'kangaroo care' in the premature/low-birth-weight context, though here it is applied universally) provides multiple benefits: (1) the mother's body acts as a living incubator, maintaining the baby's temperature through heat transfer; (2) it stabilizes the baby's heart rate, respiratory rate, and blood glucose; (3) it calms the baby and reduces stress; (4) it colonizes the newborn with the mother's protective skin flora (microbiota) rather than environmental or healthcare-associated organisms, reducing infection risk; and (5) it facilitates the release of maternal oxytocin and prolactin, supporting bonding and the preparation for breastfeeding. This contact is not brief or intermittent—it is continuous and uninterrupted for the first hour and as long as possible thereafter. In the Philippine context of home birth and lying-in clinics, skin-to-skin care is easily provided and costs nothing.

The umbilical cord is clamped and cut only AFTER the pulsations (blood flow) have ceased, which typically occurs 1 to 3 minutes after the birth of the baby. This delayed clamping allows continued blood transfer from the placenta to the baby—the 'placental transfusion.' This blood transfer provides the newborn with additional blood volume, oxygen, and iron stores. The placental blood contains fetal hemoglobin and red blood cells that significantly reduce the risk of neonatal anemia and iron-deficiency anemia in infancy (one of the most common nutritional deficiencies in Philippine children). The technique for clamping is standardized: place the first clamp approximately 2 cm from the base of the cord (near the baby's abdomen) and the second clamp approximately 5 cm from the base; cut cleanly between the two clamps using a sterile blade or scissors. The practice of 'milking' or stripping the cord—compressing it to push blood toward the baby—is not a substitute for proper delayed timing and is not routinely recommended. After clamping, the cord stump is left as 'dry cord care': no alcohol, antiseptic solution, or dressing is applied routinely. The stump is kept clean and dry, and the parents are instructed to keep the diaper below the stump and wash hands before touching it. The baby's own immune system and the dry environment prevent most cord infections.

After the first three steps (drying, skin-to-skin, cord clamping), the mother and baby remain in continuous, uninterrupted contact. Weighing, vitamin K prophylaxis, eye ointment, immunizations, footprinting, examination, and bathing are all deliberately DEFERRED so they do not interrupt bonding and the initiation of breastfeeding. The mother and baby are observed together for feeding cues: drooling, tonguing, licking, rooting (searching for the breast), 'crawling' movements toward the breast, and mouthing. In the ideal scenario, the baby self-attaches to the breast during this first hour—a process sometimes called the 'breast crawl'—and takes the first feed. The first milk, colostrum, is small in volume but extremely nutrient-dense and rich in antibodies (immunoglobulins, especially IgA), white blood cells (leukocytes), and proteins. Colostrum is often called the baby's 'first vaccine' because it provides immediate passive immunity against many infections, particularly those of the gastrointestinal and respiratory tracts. Early, exclusive breastfeeding also stimulates the baby's own digestive system, establishes the mother's milk supply, and strengthens the mother-baby bond. Only after the first full breastfeed (which typically takes longer than the first hour, but the baby is with the mother throughout) does the midwife proceed with the deferred care: weighing and anthropometrics, vitamin K 1 mg IM, eye prophylaxis (erythromycin or tetracycline ointment to prevent ophthalmia neonatorum), newborn immunizations (BCG and Hepatitis B birth dose), newborn examination and screening, vitamin A supplementation as per program, and the first bath (delayed at least 6 hours, often 24 hours).

Vitamin K (phytomenadione) is administered intramuscularly to the newborn after the first breastfeed, following the EINC sequence. The standard dose is 1 mg IM for term newborns; preterm or low-birth-weight babies may receive 0.5 mg per protocol. Vitamin K prevents hemorrhagic disease of the newborn (HDNB), also called vitamin K deficiency bleeding (VKDB), a rare but serious bleeding disorder that can occur in the first days to weeks of life. Newborns have immature hepatic synthesis of vitamin K–dependent clotting factors (II, VII, IX, X) and are particularly vulnerable. VKDB can present as bleeding from the umbilical stump, GI bleeding, or intracranial hemorrhage and can be fatal if not recognized and treated. Prophylactic vitamin K is simple, inexpensive, and highly effective. In the Philippines, vitamin K prophylaxis is part of the standard newborn care package and is often provided at the RHU or barangay health station.

Eye prophylaxis involves the application of antibiotic ointment (erythromycin 0.5% or tetracycline 1%) to the eyes of the newborn shortly after the first breastfeed. The purpose is to prevent ophthalmia neonatorum, an acute conjunctivitis caused by maternal sexually transmitted infections—most commonly Neisseria gonorrhoeae or Chlamydia trachomatis. Transmission occurs during passage through the birth canal. Untreated gonococcal ophthalmia can cause blindness within days; chlamydial infection causes less severe conjunctivitis but can lead to pneumonia if untreated. Erythromycin ointment is the preferred agent in most low-resource settings because it is effective against both gonorrhea and chlamydia, is inexpensive, and has few side effects. The ointment is applied to the lower conjunctival sac of each eye. In the Philippine context, eye prophylaxis is routinely provided at health facilities and is part of the newborn care package. Note that silver nitrate, once used, has been largely replaced by antibiotics in modern practice.

Newborn immunizations are administered following the first breastfeed and in alignment with the national immunization schedule. Two vaccines are given at birth: (1) Bacillus Calmette-Guérin (BCG), which protects against tuberculosis, particularly severe disseminated TB in infants; and (2) Hepatitis B vaccine (birth dose), which initiates protection against Hepatitis B virus. BCG is given intradermally (intradermal injection into the skin of the upper arm), leaving a small papule that forms a scar over several weeks. The Hepatitis B birth dose is given intramuscularly (usually into the anterolateral thigh in a newborn) and is critical because it provides the first of three doses and establishes early protection, particularly in infants born to Hepatitis B-positive mothers. Both vaccines are part of the DOH Expanded Program on Immunization (EPI) and are available free at RHUs, barangay health stations, and health facilities throughout the Philippines. Proper technique, including accurate identification of the newborn, correct site preparation, and appropriate needle size, is essential.

The newborn's first bath is deliberately delayed for at least 6 hours after birth, with many protocols recommending 24 hours. This delay serves multiple purposes: (1) it allows the baby to maintain warmth and body temperature stability, as bathing with water causes rapid evaporative heat loss even in a warm environment; (2) it preserves the vernix caseosa, the protective waxy coating on the skin that provides thermoregulation and antimicrobial protection; (3) it reduces the risk of hypothermia-related complications, including increased metabolic demand, hypoglycemia, and poor feeding; and (4) it allows the baby and mother to remain undisturbed during the critical bonding and breastfeeding period. When the bath does occur, it is done quickly in a warm room with warm water (approximately 36–37°C), and the baby is dried immediately and returned to skin-to-skin contact or warm wrapping. Many mothers in the Philippine context are familiar with delaying the bath—traditional practices in some communities recommend waiting until the stump falls off—and the evidence aligns with this cultural wisdom.

EINC deliberately eliminates several once-'routine' newborn practices that evidence shows are useless or harmful. The midwife must actively and consciously NOT perform these procedures on a normal newborn: (1) Routine suctioning of the mouth and nose—in a baby born with clear amniotic fluid who is breathing or crying, routine suctioning can cause bradycardia (slowed heart rate), apnea (cessation of breathing), and mucosal injury; suctioning is only indicated if the baby has thick meconium or is having difficulty breathing; (2) Early (immediate) cord clamping—clamping the cord within seconds of birth robs the baby of the placental transfusion and reduces blood volume and iron stores; (3) Washing off the vernix or early bathing—removes the protective, thermoregulatory coating and causes hypothermia; (4) Separation of the mother and baby for routine weighing, footprinting, vitamin K, and other procedures in the first hour—interrupts bonding, breastfeeding, and thermoregulation; (5) Routine aggressive stimulation such as slapping, hanging the baby upside down, or vigorous squeezing—can cause injury and is unnecessary; gentle drying is the correct stimulation; (6) Applying substances (alcohol, antiseptics, dressings, powders) to the cord stump—interferes with the natural drying process and increases infection risk; dry cord care is the evidence-based standard; and (7) Routine footprinting or other identification procedures that separate mother and baby or interrupt skin-to-skin contact. For the midwife, knowing these eliminated practices and the evidence against them is important for recognizing outdated institutional practices and advocating for change.

EINC is not only about the newborn; its intrapartum half addresses the care of the mother during labor and birth. The midwife provides: (1) A companion of choice—the mother may have a partner, relative, or trusted friend with her continuously for emotional, physical, and informational support; continuous support has been shown to shorten labor, reduce the need for interventions, and improve maternal satisfaction; (2) Freedom of movement and position—the mother is encouraged to walk, move, and change position during labor as she wishes; she gives birth in the position of her choice (sitting, squatting, side-lying, hands-and-knees, or any position she finds comfortable), rather than being confined to a supine (lying flat on her back) position; (3) Oral fluids and light food—the mother is permitted to drink water, herbal tea, juice, or light meals as tolerated during labor; routine 'nothing by mouth' (NPO) orders are not necessary for normal labor; (4) Non-pharmacologic pain relief and comfort measures—breathing techniques, back massage, warm compresses, reassurance, position changes, and emotional support reduce pain perception and the need for pharmacologic analgesia; (5) Monitoring with the partograph—the midwife uses the partograph (a simple graphical tool) to track labor progress and identify deviations, rather than relying on repeated, often uncomfortable vaginal examinations; (6) Restricted routine interventions—no routine enema, no routine pubic hair shaving, no routine episiotomy (perineal incision), no routine IV lines, and no routine oxytocin augmentation in normal labor; and (7) Active Management of the Third Stage of Labor (AMTSL)—oxytocin 10 IU IM is given within one minute of birth, controlled cord traction is applied, and uterine massage is performed to prevent postpartum hemorrhage, which transitions directly into the newborn care steps. These intrapartum practices create an environment where normal labor can progress with minimal interference, reducing unnecessary cesarean sections and operative deliveries.

The midwife's role is to recognize normal newborn physiology and to DETECT and REFER danger signs promptly rather than attempt to manage complications. Key newborn danger signs that warrant immediate detection and referral to a higher-level facility (such as a BEmONC center or hospital) include: (1) Not breathing, gasping for air, or absent respiratory effort after drying and gentle stimulation—indicates respiratory distress or failure and requires resuscitation and possible transfer; (2) Severe chest in-drawing (recession of the muscles between the ribs) or grunting—indicates respiratory distress; (3) Convulsions or seizures—indicates serious neurological distress; (4) Floppiness, lethargy, unresponsiveness, or absence of movement—indicates severe illness or perinatal depression; (5) Fever (temperature >38°C) or hypothermia (temperature <36.5°C)—both indicate risk of infection or thermoregulation failure; (6) Poor feeding, difficulty latching, or inability to swallow—prevents adequate nutrition and hydration; (7) Yellow palms and soles (severe jaundice), jaundice appearing in the first 24 hours, or rapidly progressive jaundice—indicates risk of bilirubin encephalopathy and kernicterus; (8) Bleeding from the umbilical cord stump, mouth, or other sites—may indicate vitamin K deficiency bleeding or coagulopathy; (9) Umbilical cord stump that is red, draining, or foul-smelling—suggests cord infection; (10) Abdominal distension, vomiting, or refusal to feed—suggests GI obstruction or sepsis; and (11) Pallor, cyanosis (blue discoloration), or signs of shock—indicate cardiovascular compromise. The midwife's responsibility is to educate the mother on these signs, monitor the baby closely in the first hours and days, and refer immediately if any danger sign is observed. The midwife is NOT responsible for managing these conditions but for recognizing them early and ensuring timely transfer to a facility with BEmONC capacity.

For the midwife to deliver EINC successfully, several preconditions must be in place: (1) Environment preparation—before every birth, ensure the delivery room is warm (25–28°C), draft-free, with windows and doors closed and fans/air-conditioning directed away from the baby area; have two clean, dry cloths ready; ensure clean supplies and sterile equipment are available; ensure adequate lighting and space for mother-baby contact; (2) Hand washing and asepsis—wash hands thoroughly and observe standard precautions at every step; (3) Timing discipline—the midwife must know and adhere to the strict timing of each step: drying at ~30 seconds, cord clamping at 1–3 minutes, first feed within the first hour, vitamin K and eye care after the first feed, and bath delayed at least 6 hours; using a clock or watch is practical; (4) Advocacy for the mother during labor—ensure the mother has a companion of choice, freedom to move, access to fluids and light food, and non-pharmacologic pain relief; (5) Recognition of normal vs. abnormal—the ability to identify a baby that is breathing and vigorous vs. one that needs help, and to know when to refer; and (6) Continuity and communication—maintaining mother-baby contact throughout the first hours and communicating with the mother and family about what to expect, why procedures are deferred, and what newborn danger signs to watch for at home. In the Philippine context, where the midwife may work alone or with limited resources at an RHU, barangay health station, or lying-in clinic, these competencies are not optional—they define the quality of care.

EINC was formally adopted and institutionalized through DOH Administrative Order (AO) No. 2009-0025, which issued policies and guidelines for Essential Newborn Care. This AO represents the Department of Health's official commitment to implement evidence-based, physiological newborn care across all health facilities in the Philippines. The AO mandates that all healthcare providers—nurses, midwives, physicians—follow the EINC protocol and integrate it into their facilities' policies and training. The popularization of EINC as 'Unang Yakap' (First Embrace) was part of a national awareness and advocacy campaign to emphasize the emotional and bonding significance of the protocol, not just the medical aspects. Understanding that EINC is not a suggestion but a mandate from the DOH reinforces its importance for the midwife and makes it clear that institutional practices that contradict EINC are non-compliant with national policy. In the exam, references to 'DOH AO 2009-0025' or 'EINC protocol' signal that a question is testing knowledge of the official, evidence-based standard.

Early breastfeeding, initiated within the first hour of life through skin-to-skin contact and the baby's own feeding cues, is a cornerstone of EINC because it provides multiple protective effects. The first milk, colostrum, is distinct from mature milk: it is produced in small volumes (typically 5–20 mL per feed in the first days) but is highly concentrated in nutrients and bioactive substances. Colostrum contains high concentrations of immunoglobulins (antibodies), especially IgA, which coat the baby's mucous membranes of the mouth, throat, and gastrointestinal tract, providing a barrier against pathogens. It also contains white blood cells (leukocytes), lactoferrin (an iron-binding protein with antimicrobial properties), lysozyme (an enzyme that breaks down bacterial cell walls), and other immune factors. These components give the newborn immediate, passive immunity—the 'first vaccine'—and are particularly protective against infections common in the baby's environment, because the mother's antibodies are specifically tailored to threats she has encountered. Early breastfeeding also stimulates the baby's digestive system, helps clear meconium, establishes proper feeding mechanics, and triggers the mother's milk production. Exclusively breastfed babies have significantly lower rates of diarrhea, respiratory infections, and other infections compared to formula-fed or mixed-fed babies, particularly in the first 6 months of life. In the Philippine context, where infectious diseases remain a leading cause of childhood morbidity and mortality, early and exclusive breastfeeding is a low-cost, high-impact intervention. The midwife's role is to support, not interfere with, breastfeeding initiation and to educate mothers on the importance and benefits.