Normal Spontaneous Delivery — Independent Conduct & Hands-On Technique - Cheat Sheet
Your last-minute revision companion for conducting normal spontaneous delivery (NSD) under RA 7392. This cheat sheet covers the cardinal movements, hands-on techniques, AMTSL, and detection/referral of complications in the context of Philippine primary care (RHU/BHS/lying-in clinics) aligned with EINC standards.
Cardinal Movements of Labor (EDFIREE)
Important facts
- Mnemonic: EDFIREE = Engagement, Descent, Flexion, Internal rotation, Extension, Restitution, Expulsion.
- Flexion is the key to small presenting diameter (suboccipitobregmatic 9.5 cm); loss of flexion increases diameter to 11.5 cm (occipitofrontal).
- Internal rotation is the FIRST cardinal movement that brings the head into the vertical axis of the pelvis.
- Extension occurs AFTER internal rotation as the head passes under the pubic arch.
- Restitution (external rotation) happens AFTER the head is born and before shoulder delivery.
- The head is born by extension (back of head out first, then face), NOT by flexion.
- Descent occurs throughout first and second stage; NOT just in second stage.
- Engagement at the pelvic inlet occurs before labor in primigravidas; may occur in labor or even in second stage in multiparas.
Key definitions
Engagement
Example
Confirmed on abdominal examination (head no longer ballottable) and vaginal examination (head palpable at pelvic brim).
The biparietal diameter of the fetal head passes through the pelvic inlet; head is at 0 station or above.
Descent
Example
Station progresses from -5 to 0 to +5 cm as labor advances; assessed by vaginal examination.
Progressive downward movement of the fetal head through the pelvis, occurring throughout active labor and second stage.
Flexion
Example
Optimal for all pelvic types; loss of flexion results in a larger presenting diameter (e.g., occipitofrontal 11.5 cm) and prolongs labor.
The fetal chin tucks onto the chest, presenting the smallest diameter (suboccipitobregmatic ~9.5 cm) to the pelvis.
Internal Rotation
Example
Allows the narrower transverse diameter of the head to pass through the narrower transverse diameter of the pelvis at the inlet.
The occiput rotates anteriorly toward the symphysis pubis (usually 135° rotation) as the head adapts to pelvic diameters.
Extension
Example
The head 'crowns' (perineum stretches around the widest part of the head) and is delivered by extension, NOT flexion.
The flexed head extends under the pubic arch; this is how the head is actually born (occiput first, then bregma, forehead, face, chin).
Restitution (External Rotation)
Example
If head was rotated right during delivery, it restitutes by turning left; this confirms normal shoulder position.
After the head is born, it realigns with the fetal shoulders by rotating back to the transverse position (head turns ~45° back).
Expulsion
Example
Anterior shoulder delivered first (downward traction on head), then posterior shoulder (upward traction), then body.
Delivery of the anterior shoulder, posterior shoulder, and fetal body following shoulder restitution.
Diagrams to know
- Cross-section of pelvis showing head position at inlet, mid-pelvis, and outlet with rotation angle.
- Sagittal view of head extension as it crowns and is delivered.
- Superior view showing occipital position rotation from LOA (left occipital anterior) through transverse to ROA (right occipital anterior).
Preparation for Delivery & Maternal Positioning
Important facts
- Confirm FULL DILATATION by vaginal examination BEFORE allowing or encouraging pushing.
- Prepare the newborn corner BEFORE crowning: clean, dry, warm surface, two clean cloths, resuscitation equipment within arm's reach.
- Ensure oxytocin (10 IU IM) and delivery set (cord clamp, scissors, gloves, pads) are within reach BEFORE head crowns.
- Empty bladder: encourage voiding; only catheterize if necessary (distended bladder impedes descent).
- Allow mother to adopt a position of comfort: upright, semi-sitting, squatting, side-lying, or supported semi-recumbent.
- EINC discourages routine lithotomy position; upright/lateral positions use gravity, reduce aortocaval compression, and reduce perineal trauma.
- The perineum MUST be visible and accessible to the midwife regardless of position chosen.
- Spontaneous bearing-down is preferred over directed (breath-holding) pushing in EINC; reduces perineal trauma.
- Routine perineal shaving and enema are NOT recommended; not protective and unnecessary.
Key definitions
Full Dilatation (10 cm)
Example
Confirmed by vaginal examination; the os admits the whole of the examining finger(s).
Complete opening of the cervix; indicates readiness to move from first stage to second stage and to commence pushing.
Second Stage of Labor
Example
In primigravidas, normally lasts 30 min–2 hours; in multiparas, usually shorter (15–60 min).
From full dilatation to delivery of the baby; characterized by involuntary and voluntary pushing, perineal bulging, and gaping anus.
Crowning
Example
Signal that delivery is imminent; prepare for controlled head delivery and newborn resuscitation corner.
The widest part of the fetal head is visible at the introitus and does NOT recede between contractions.
Diagrams to know
- Positions for second stage labor: upright, semi-sitting, squatting, left lateral, supported semi-recumbent.
- Perineal anatomy at crowning (bulging, gaping anus, distended introitus).
Controlled Delivery of the Head (The Core Midwifery Skill)
Important facts
- NEVER let the head 'pop' out; apply controlled downward pressure on occiput to keep flexion and slow descent.
- Between contractions, ask mother to PANT/BREATHE rather than push—this allows perineal stretching.
- Gentle, spontaneous pushing with contractions is preferred to prolonged, forceful (Valsalva) pushing.
- Support the perineum with a cloth/pad throughout extension to reduce risk of third/fourth-degree tears.
- EPISIOTOMY is NOT routine; perform only for clear indication (imminent severe tear, fetal distress requiring rapid delivery).
- Routine episiotomy increases perineal trauma, dyspareunia, and anal sphincter injury—AVOID routine use.
- Nuchal cords are common and usually harmless; manage by slipping loose cords over the head.
- For a TIGHT nuchal cord: perform the 'somersault maneuver' (deliver body through the loop) to avoid cutting cord early and losing placental transfusion.
- Only clamp and cut a tight nuchal cord that CANNOT be reduced—modern EINC favors delayed cord clamping for placental transfusion.
- Wipe the newborn's face after head delivery; routine suctioning of mouth/nose is NOT done for vigorous babies with clear liquor (EINC-eliminated practice).
Key definitions
Controlled Head Delivery
Example
Prevents rapid decompression (risk of intracranial hemorrhage) and perineal trauma; is the single most important skill in NSD.
Slow, gradual expulsion of the fetal head with one hand controlling the occiput (flexion) and the other supporting the perineum, allowing tissue to stretch.
Ritgen Maneuver
Example
Applied as head crowns and extends; reduces third/fourth-degree perineal tears significantly.
Two-handed perineal support technique: one hand on occiput keeping head flexed and controlled; other hand (with pad) on perineum supporting tissue as head extends.
Perineal Support
Example
Using a clean pad or cloth, support the tissue just anterior to the anus as the head delivers by extension.
Gentle counter-pressure applied to the perineum (posterior to the introitus) during head extension to prevent sudden tearing.
Nuchal Cord
Example
If loose, slip it over the head; if tight, apply the 'somersault maneuver' (keep baby close to perineum, deliver body through loop) rather than clamping early.
The umbilical cord looped around the fetal neck after delivery of the head; present in ~20–30% of deliveries.
Diagrams to know
- Hand positions for Ritgen maneuver: occiput support + perineal support.
- Nuchal cord: slipping a loose cord over the head vs. somersault maneuver for a tight cord.
- Sequence of head extension during delivery: initial crowning → progressive extension → complete head delivery.
Delivery of Shoulders & Body
Important facts
- With the next contraction AFTER head delivery, apply gentle DOWNWARD traction to deliver the anterior shoulder.
- Then apply gentle UPWARD traction to deliver the posterior shoulder over the perineum.
- Continue to support the perineum as shoulders deliver to prevent further perineal trauma.
- Keep a firm but gentle grasp on the baby as shoulders and body are delivered—the baby is slippery.
- NEVER apply fundal pressure to deliver the baby or shoulders—risks uterine rupture, worsens shoulder dystocia, and increases risk of uterine inversion.
- Deliver the body slowly; announce and note the TIME OF BIRTH immediately.
- Place the newborn PRONE on mother's abdomen/chest immediately after birth—skin-to-skin contact.
- Begin IMMEDIATE and THOROUGH DRYING of the newborn (EINC Step 1) while maintaining skin-to-skin contact.
- Keep the newborn with the mother—do NOT separate for routine procedures; maintain non-separation EINC principle.
Key definitions
Anterior Shoulder
Example
As head restitutes, apply downward traction to bring the anterior (upper) shoulder under the symphysis pubis for delivery.
The shoulder closest to the symphysis pubis; delivered first after head restitution by gentle downward traction on the head.
Posterior Shoulder
Example
Once anterior shoulder is free, apply upward traction to deliver the posterior shoulder over the perineum.
The shoulder closest to the sacrum; delivered second by gentle upward traction on the head after anterior shoulder is born.
Diagrams to know
- Anterior and posterior shoulder positions in relation to the pelvis.
- Direction of traction for each shoulder: downward for anterior, upward for posterior.
- Sequence: head restitution → anterior shoulder delivery → posterior shoulder delivery → body delivery.
Active Management of Third Stage of Labor (AMTSL) — The Evidence-Based Standard
Formulas
Oxytocin 10 IU IM given within 1 minute of baby's birth
Meaning
IU = International Units; IM = Intramuscular; timing is CRITICAL to prevent PPH.
Watch out
RULE OUT A SECOND TWIN FIRST by palpating the abdomen—do NOT give oxytocin if a second baby is present; severe complications result.
When to use
Immediately after delivery of the baby, BEFORE delivery of the placenta; after ruling out a second twin.
Common values
Value
10 IU (10 units) intramuscularly
Symbol
Ox 10 IU IM
Quantity
Oxytocin dose
Value
Within 1 minute of baby's birth (before placental delivery)
Symbol
t = 0–60 sec after baby born
Quantity
Timing of oxytocin
Value
30–40 seconds of gentle traction
Symbol
CCT window
Quantity
CCT duration per contraction
Value
≥500 mL blood loss in first 24 hours (vaginal delivery)
Symbol
PPH ≥ 500 mL
Quantity
Postpartum hemorrhage threshold
Value
Every 15 minutes for first 2 hours postpartum
Symbol
15 min × 2 hrs
Quantity
Fundal tone checks
Important facts
- AMTSL is the GOLD STANDARD for preventing PPH and is a defining competency of the independent midwife under RA 7392.
- PALPATE THE ABDOMEN FIRST to exclude a second twin BEFORE giving any uterotonic.
- Oxytocin 10 IU IM is the uterotonic of CHOICE: effective, rapid onset, few side effects, SAFE in hypertension.
- Alternative uterotonics if oxytocin unavailable: misoprostol 600 mcg orally OR ergometrine 0.2 mg IM (ergot).
- ERGOMETRINE IS CONTRAINDICATED IN HYPERTENSION/PRE-ECLAMPSIA—do NOT use; use oxytocin or misoprostol instead.
- Apply CCT only after clear signs of placental separation appear; NEVER yank the cord.
- Counter-traction is ESSENTIAL during CCT: one hand on the uterus just above symphysis pubis prevents inversion.
- If placenta does not descend during 30–40 seconds of gentle traction, STOP, wait for next contraction, and repeat.
- As placenta appears, deliver it with both hands; gently twist membranes into a rope so they peel out intact (reduces retained fragments).
- MASSAGE THE UTERUS IMMEDIATELY after placental delivery until it is firm and well-contracted.
- Re-check fundal tone every 15 minutes for the first 2 hours postpartum—the highest-risk window for hemorrhage.
- Teach the mother to massage her own fundus and recognize a firm vs. boggy uterus.
- Current WHO guidance emphasizes the uterotonic as the ESSENTIAL component of AMTSL; uterine tone + early oxytocin = PPH prevention.
- NEVER apply fundal pressure passively—use oxytocin + maternal/self massage + counter-traction during CCT.
Key definitions
Active Management of Third Stage (AMTSL)
Example
Oxytocin 10 IU IM + Brandt-Andrews maneuver + fundal massage = the midwife's most important PPH prevention skill.
Three-part evidence-based protocol to prevent postpartum hemorrhage: (1) uterotonic within 1 min of birth, (2) controlled cord traction (CCT) with counter-traction, (3) uterine massage after placental delivery.
Controlled Cord Traction (CCT) / Brandt-Andrews Maneuver
Example
Wait for strong contraction + signs of separation (gush of blood, cord lengthening, uterus globular and rising), then apply counter-traction + gentle cord traction.
Steady, gentle downward traction on the cord during uterine contraction while applying counter-traction above the symphysis pubis to prevent uterine inversion.
Placental Separation Signs
Example
Do NOT attempt CCT until these signs appear; premature CCT risks uterine inversion and retained placenta.
Clinical indicators that the placenta has detached from the uterine wall: (1) gush of blood, (2) lengthening of the cord, (3) uterus becomes globular and rises in the abdomen.
Uterine Massage (Fundal Massage)
Example
Perform immediately after placental delivery; teach the mother to feel and massage her own fundus every 15 minutes for the first 2 hours.
Firm, circular massage of the uterine fundus through the abdominal wall to maintain uterine contraction and prevent atony.
Postpartum Hemorrhage (PPH)
Example
Detect & refer if bleeding is heavy/continuous, uterus is soft/boggy and will not stay contracted, vital signs are unstable.
Blood loss of ≥500 mL in the first 24 hours after vaginal delivery; major cause of maternal mortality worldwide.
Diagrams to know
- AMTSL sequence: uterotonic → wait for separation signs → CCT with counter-traction → placental delivery → uterine massage.
- Brandt-Andrews maneuver hand positions: counter-traction hand on abdomen + cord traction hand.
- Timeline of third stage: 0–3 minutes (oxytocin), 3–30 minutes (CCT), then uterine massage and monitoring.
Placental Delivery & Inspection (Detect Retained Tissue)
Common values
Value
500–600 g (normally)
Symbol
Wt
Quantity
Placental weight
Value
15–20 (normally)
Symbol
Cotyledons
Quantity
Number of cotyledons
Value
2 arteries + 1 vein
Symbol
2A:1V
Quantity
Normal umbilical cord vessels
Value
250–500 mL
Symbol
Normal loss
Quantity
Normal blood loss postpartum (vaginal)
Value
≥500 mL in first 24 hours
Symbol
PPH ≥ 500 mL
Quantity
PPH threshold (vaginal)
Important facts
- INSPECT THE PLACENTA AND MEMBRANES SYSTEMATICALLY immediately after delivery.
- Maternal (cotyledon) side: confirm ALL cotyledons are present; count them and note if any are missing.
- Fetal (shiny) side: trace the umbilical vessels; look for a vessel running to the membrane edge and STOPPING—indicates a succenturiate lobe left inside.
- Membranes: check that amnion and chorion are complete and intact.
- Cord: count the vessels—normal cord has TWO ARTERIES and ONE VEIN (2A:1V).
- Single umbilical artery (SUA = 1 artery + 1 vein) is abnormal and associated with fetal congenital anomalies—note and refer.
- Estimate and record BLOOD LOSS: PPH is ≥500 mL after vaginal delivery; normal blood loss is 250–500 mL.
- If any doubt about placental completeness, TREAT AS RETAINED TISSUE—this is a REFERRAL SITUATION (risk of severe bleeding and infection).
- Keep the placenta in a clean container for inspection by a physician if needed.
- Inform the mother about the condition of the placenta and newborn (some mothers wish to know for cultural/spiritual reasons).
Key definitions
Placenta
Example
Inspect both sides: maternal (cotyledon) side and fetal (shiny) side with umbilical vessels.
Discoid organ (fetal-maternal interface) weighing ~500–600 g; composed of ~15–20 cotyledons (lobes) on the maternal (beefy red) side.
Cotyledon
Example
A 'missing' cotyledon suggests a retained placental fragment—treat as retained tissue.
One lobe/subdivision of the placenta visible on the maternal surface; normally 15–20 present.
Succenturiate (Accessory) Lobe
Example
Look for a vessel running to the membrane edge and stopping—indicates the vessel led to an accessory lobe (likely still in uterus).
A small extra lobe of placenta connected to the main placenta by membrane; easy to leave behind if not recognized.
Retained Placenta / Retained Tissue
Example
If placenta does not deliver after 30 min or if fragments are visibly missing, REFER immediately.
Partial or complete failure of placental separation and expulsion after delivery; risks PPH and intrauterine infection.
Diagrams to know
- Placental anatomy: maternal (cotyledon) side vs. fetal (shiny, vessel-bearing) side.
- Normal umbilical cord cross-section: 2 arteries + 1 vein; single umbilical artery (abnormal).
- Succenturiate lobe: vessel running to membrane edge and terminating.
- Cotyledon inspection: complete set (15–20) vs. missing lobe (suggests retained fragment).
Immediate Postpartum Maternal Care (First 2 Hours = Highest Risk for PPH)
Common values
Value
Every 15 minutes for first 2 hours
Symbol
15 min checks
Quantity
Vital sign monitoring interval
Value
Every 15 minutes for first 2 hours
Symbol
15 min checks
Quantity
Fundal tone assessment interval
Value
Within 1 hour of birth
Symbol
Unang oras (EINC/Unang Yakap)
Quantity
Early breastfeeding timing
Important facts
- Keep the UTERUS CONTRACTED: massage, ensure bladder is empty, encourage early breastfeeding (releases natural oxytocin).
- Monitor VITAL SIGNS (BP, HR, temperature, RR) every 15 minutes for the first 2 hours—the highest-risk window for PPH.
- Monitor FUNDAL TONE every 15 minutes: should be firm, at or below umbilicus; a soft/boggy fundus = uterine atony = PPH risk.
- Assess LOCHIA: should be bright red, moderate flow; NOT soaking pads or large clots. Continuous heavy bleeding = detect & refer.
- Keep the mother WARM, CLEAN, COMFORTABLE, HYDRATED, and ensure she has VOIDED.
- Inspect the PERINEUM, VAGINA, AND CERVIX for lacerations and bleeding within the first hour.
- Repair 1st/2nd-degree tears within the midwife's competency using appropriate aseptic technique.
- REFER 3rd/4th-degree tears (involving anal sphincter or rectum) to a physician immediately.
- Support EARLY BREASTFEEDING within the first hour (non-separation, EINC principle)—breastfeeding stimulates uterine contractions and prevents bleeding.
- Keep mother and baby TOGETHER, SKIN-TO-SKIN—do NOT separate for routine procedures; maintain non-separation throughout.
Key definitions
Lochia
Example
Assess lochia at every vital sign check; excessive or continuous bleeding = detect & refer.
Vaginal discharge after delivery; normally bright red, moderate flow (not soaking pads), without large clots in the first 2 hours.
Uterine Atony
Example
Manage by massage, ensure empty bladder, encourage breastfeeding (releases oxytocin); if unresponsive to first-line measures, refer.
Loss of uterine muscle tone/contractility; results in a soft, boggy uterus unable to compress bleeding vessels, causing PPH.
Perineal Laceration
Example
Midwife repairs 1st/2nd-degree tears; refer 3rd/4th-degree tears to physician.
Tear of the perineum/vagina during delivery; classified as 1st (mucosa/submucosa), 2nd (extends to perineal muscle), 3rd (includes anal sphincter), 4th (includes rectal mucosa).
Diagrams to know
- Perineal laceration classification: 1st, 2nd, 3rd, 4th degree (anatomical extension).
- Postpartum monitoring checklist: vital signs, fundal tone, lochia, perineal status, urinary output.
- Timeline: immediate (0–5 min), early (5–30 min), active management phase (0–30 min placental delivery), monitoring phase (30 min–2 hours).
Danger Signs Requiring Detection & Referral (Midwife's Role: RECOGNIZE & REFER)
Common values
Value
≥500 mL blood loss
Symbol
≥500 mL
Quantity
PPH threshold (vaginal delivery)
Value
Beyond 30 minutes after AMTSL
Symbol
>30 min = refer
Quantity
Retained placenta time
Value
30 min–2 hours
Symbol
30 min–2 hrs
Quantity
Normal second stage duration (primigravida)
Value
15–60 minutes
Symbol
15–60 min
Quantity
Normal second stage duration (multipara)
Value
HR >100 bpm
Symbol
HR >100
Quantity
Tachycardia threshold (early shock)
Important facts
- HEAVY OR CONTINUOUS BLEEDING postpartum = PPH = REFER immediately.
- SOFT, BOGGY UTERUS that will NOT STAY CONTRACTED despite massage, empty bladder, and breastfeeding = uterine atony = REFER.
- RETAINED PLACENTA beyond 30 minutes = REFER; do NOT apply excessive force or attempt manual removal at RHU/BHS level.
- RETAINED PLACENTAL TISSUE (incomplete placenta, missing cotyledons, succenturiate lobe evident) = REFER to prevent PPH and infection.
- RISING PULSE, FALLING BLOOD PRESSURE, PALLOR, DIZZINESS (signs of shock) = early hemorrhage/shock = REFER immediately.
- TEAR EXTENDING INTO THE ANAL SPHINCTER OR RECTUM (3rd/4th-degree) = REFER to physician for proper repair.
- PROLONGED SECOND STAGE (>2 hours in primigravida, >1 hour in multipara) without descent despite adequate contractions = REFER.
- ANY EVIDENCE OF OBSTRUCTED LABOR (no descent despite strong contractions, caput/molding, meconium staining) = REFER immediately.
- FEVER/CHILLS/FOUL-SMELLING LOCHIA in the immediate postpartum period = possible intrauterine infection (sepsis risk) = REFER.
- SEVERE PERINEAL/VAGINAL BLEEDING from a tear = REFER; midwife can stop bleeding with haemostasis (pressure, sutures) but if uncontrolled, refer.
- The midwife's role is to RECOGNIZE danger signs early and REFER promptly—not to attempt emergency management beyond scope.
Key definitions
Postpartum Hemorrhage (PPH)
Example
Detect: heavy/continuous bleeding, soft/boggy uterus unresponsive to massage, rising pulse, falling BP, pallor. REFER immediately.
Blood loss ≥500 mL in first 24 hours after vaginal delivery; early PPH is within first 2 hours (highest-risk period).
Uterine Inversion
Example
Risk increased by fundal pressure, aggressive CCT without counter-traction, overly vigorous massage. REFER immediately.
Inversion of the uterine fundus into the uterine cavity; a true obstetric emergency associated with severe hemorrhage and shock.
Retained Placenta
Example
If placenta has not delivered after 30 min of AMTSL, STOP and refer. Do NOT apply excessive force or traction.
Failure of placental delivery after 30 minutes of AMTSL; risks severe PPH and intrauterine infection.
Shock (Hypovolemic)
Example
Detect early signs (mild shock): tachycardia + normal/borderline BP. Refer immediately for IV fluids and possible transfusion.
Insufficient tissue perfusion due to blood loss; signs include rising pulse (>100), falling BP, pallor, dizziness, restlessness, cold extremities.
Diagrams to know
- Shock progression: mild (tachycardia, normal BP) → moderate (tachycardia, borderline BP) → severe (tachycardia, hypotension, altered mental status).
- Early warning signs of PPH: uterine atony, rising pulse, soft uterus, heavy lochia, pallor.
- Referral triggers in third stage and early postpartum period.
Essential Newborn Care in Context of NSD (Unang Yakap / EINC Integration)
Common values
Value
1–3 minutes or until cord stops pulsating
Symbol
1–3 min
Quantity
Delayed cord clamping duration
Value
2–3 cm
Symbol
First clamp @ 2–3 cm
Quantity
First clamp position from umbilicus
Value
4–5 cm
Symbol
Second clamp @ 4–5 cm
Quantity
Second clamp position from first clamp
Value
Within 1 hour of birth (Golden Hour)
Symbol
<1 hour
Quantity
Early breastfeeding timing
Important facts
- IMMEDIATE AND THOROUGH DRYING is the first EINC step (heat loss is a major risk in newborns).
- Place the newborn PRONE (facedown) on the mother's chest/abdomen immediately after delivery—skin-to-skin contact.
- Dry the newborn while on mother's chest; cover both mother and baby with a clean, dry cloth to maintain warmth.
- ASSESS BREATHING immediately: vigorous cry, regular breathing, pink color = spontaneous initiation of breathing (normal).
- Do NOT routinely suction the mouth and nose of a vigorous baby with clear liquor—unnecessary and delays breastfeeding.
- Suction ONLY if meconium is present AND baby is not vigorous, or if respiratory distress is evident (not routine).
- DELAY CORD CLAMPING: wait 1–3 minutes or until the cord stops pulsating before clamping (maximizes placental transfusion).
- Apply the first clamp ~2–3 cm from the umbilicus; then the second clamp ~4–5 cm from the first; then cut between the clamps.
- After cutting the cord, wrap the placenta and cord in a clean cloth and place near the mother.
- Support EARLY BREASTFEEDING within the first hour (the Golden Hour)—skin-to-skin contact aids breastfeeding initiation.
- Do NOT separate mother and baby for routine procedures (weighing, bathing, eye care) in the immediate postpartum period.
- Vitamin K prophylaxis, eye care (0.5% tetracycline ointment for gonorrhea prophylaxis), and hepatitis B vaccination are given, but NOT before breastfeeding is established.
- Thermal care is paramount: prevent heat loss by keeping the baby dry, covered, and in skin-to-skin contact with the mother.
Key definitions
Immediate Newborn Care (EINC Steps 1–5)
Example
Perform while maintaining skin-to-skin contact; non-separation principle = mother and baby stay together.
Five critical actions in the first minute after birth: (1) dry thoroughly, (2) assess breathing, (3) keep warm, (4) early breastfeeding, (5) delay cord clamping.
Skin-to-Skin Contact
Example
Begin immediately after delivery; maintain throughout immediate postpartum period (Golden Hour).
Immediate placement of the naked newborn prone on the mother's bare chest; maintains warmth, promotes bonding, facilitates breastfeeding.
Delayed Cord Clamping
Example
Increases newborn hemoglobin, reduces anemia risk, reduces need for transfusion in the first few days of life.
Waiting 1–3 minutes (or until cord stops pulsating) before clamping the umbilical cord; allows placental transfusion (~40% of fetal blood volume).
Unang Yakap (First Embrace)
Example
Aligns with EINC and WHO guidelines; core principle of maternal–newborn care in Philippine context.
DOH program emphasizing immediate skin-to-skin contact, early initiation of breastfeeding, and non-separation of mother and baby.
Diagrams to know
- EINC sequence: immediate assessment → drying → thermal care → breastfeeding → monitoring of vital signs.
- Skin-to-skin positioning: baby prone on mother's bare chest, covered with a clean cloth.
- Golden Hour timeline: delivery → immediate drying → breastfeeding initiation → continuous skin-to-skin → bonding.
- Delayed cord clamping: physiological changes during the 1–3 minute wait (placental transfusion, cardiopulmonary transition).
Must remember
- CARDINAL MOVEMENTS (EDFIREE): Engagement → Descent → Flexion → Internal Rotation → Extension → Restitution → Expulsion; the head is born by EXTENSION (back of head out first), NOT by flexion.
- AMTSL IS THE STANDARD FOR PPH PREVENTION: (1) Oxytocin 10 IU IM within 1 minute of baby's birth, (2) Controlled cord traction with counter-traction after placental separation signs, (3) Uterine massage immediately after placental delivery. Rule out second twin BEFORE giving oxytocin.
- CONTROLLED HEAD DELIVERY IS THE CORE SKILL: Apply gentle downward pressure on the occiput to keep the head flexed and slow; support the perineum with the other hand; have mother PANT (not push) between contractions. This single skill prevents intracranial hemorrhage and severe perineal trauma.
- OXYTOCIN IS THE UTEROTONIC OF CHOICE (10 IU IM within 1 minute): Rapid, reliable, few side effects, SAFE in hypertension. Ergometrine is CONTRAINDICATED in hypertension/pre-eclampsia (vasoconstriction risk). Misoprostol 600 mcg orally is an alternative if oxytocin unavailable.
- NEVER APPLY FUNDAL PRESSURE: It does NOT help deliver the baby or placenta; risks uterine rupture, worsens shoulder dystocia, increases risk of uterine inversion. Use counter-traction instead during CCT.
- DELAYED CORD CLAMPING = 1–3 MINUTES OR UNTIL CORD STOPS PULSATING: Allows ~40% placental transfusion (fetal blood volume); reduces anemia risk. Do NOT clamp early unless a tight nuchal cord cannot be reduced (use somersault maneuver instead).
- ROUTINE EPISIOTOMY AND ROUTINE SUCTIONING ARE NOT DONE (EINC-ELIMINATED PRACTICES): Episiotomy only for clear indication (imminent severe tear, fetal distress requiring rapid delivery). Routine suctioning causes aspiration risk and delays breastfeeding; suction only if meconium present AND baby not vigorous, or if respiratory distress.
- IMMEDIATE NEWBORN CARE (EINC): (1) Thorough drying, (2) Assess breathing, (3) Keep warm (skin-to-skin), (4) Early breastfeeding within 1 hour, (5) Delayed cord clamping. Non-separation = mother and baby stay together; do NOT separate for routine procedures.
- DANGER SIGNS REQUIRING IMMEDIATE DETECTION & REFERRAL: Heavy/continuous bleeding ≥500 mL (PPH threshold); soft/boggy uterus unresponsive to massage; retained placenta >30 min; rising pulse + falling BP + pallor (shock); third/fourth-degree perineal tears; retained placental tissue; fever/chills with foul lochia (infection risk).
- INSPECT PLACENTA SYSTEMATICALLY: All cotyledons present (15–20), complete membranes, cord = 2 arteries + 1 vein (single artery = abnormal). If doubt about completeness, TREAT AS RETAINED TISSUE = REFER immediately (risk of severe PPH and intrauterine infection).
Last minute tips
- REMEMBER THE SEQUENCE IN AMTSL: Oxytocin FIRST (within 1 minute of baby's birth, AFTER ruling out second twin), THEN wait for placental separation signs, THEN controlled cord traction with counter-traction, THEN uterine massage after placenta is delivered. Do NOT give oxytocin after the placenta is already delivered—it must be within 1 minute of baby's birth to prevent PPH effectively.
- ON THE EXAM, IF ASKED ABOUT PERINEAL TRAUMA: Always know that 1st/2nd-degree tears are within the midwife's scope to repair, BUT 3rd/4th-degree tears (involving anal sphincter or rectal mucosa) MUST be referred to a physician. The midwife's role is to RECOGNIZE (assess the depth of the tear carefully) and REFER promptly, not to attempt repair beyond scope.
- CRITICAL DISTINCTION: The midwife is the PRIMARY ATTENDANT for NORMAL spontaneous delivery under RA 7392—she manages NSD independently. However, her role in complications is to DETECT and REFER, NOT to manage emergencies like uterine inversion, severe PPH, or retained placenta requiring manual removal. Know your scope and boundaries.
- IF A NUCHAL CORD IS PRESENT: Only clamp and cut EARLY if the cord is TIGHT and CANNOT be reduced. Modern practice favors the 'somersault maneuver' (keep baby close to perineum, deliver body through the loop) to preserve placental transfusion from delayed cord clamping. Loose cords slip over the head easily.
- QUICK EXAM TRICK: When asked about uterotonics, remember that oxytocin is SAFE in hypertension (use it), but ergometrine/methylergometrine is CONTRAINDICATED in hypertension (causes severe vasoconstriction, stroke risk). If a hypertensive woman delivers, use oxytocin or misoprostol, NOT ergot. This distinction appears frequently on exams.
Comparison tables
Maternal Positions in Second Stage Labor: Advantages & Considerations
| Position | Advantages | Considerations | EINC Status |
|---|---|---|---|
| Upright (standing/walking) | Uses gravity; faster descent; reduces aortocaval compression; less perineal trauma | May fatigue legs; less accessible perineum; less comfortable if epidural present | Encouraged; reduces trauma |
| Semi-sitting/Semi-recumbent | Comfortable for many; visible perineum; easy access for examination; gravity-assisted if propped up well | Moderate gravity advantage; may need support for lower limbs | Acceptable; common in hospital settings |
| Squatting | Maximum gravity benefit; enlarged pelvic outlet; may reduce second stage duration; reduced perineal trauma in some studies | Leg fatigue; needs strong support/partner; requires balance; not suitable for all laboring women | Encouraged if woman chooses; excellent for descent |
| Left lateral (side-lying) | Reduced aortocaval compression; perineum visible; good for epidural or low-resource settings; reduced trauma | Less gravity assistance; slower descent in some; less intuitive for pushing; less commonly chosen | Encouraged; reduces trauma; practical for RHU/BHS |
| Lithotomy (flat, supine, legs in stirrups) | Maximal perineal visibility and access for perineal support and suturing | Aortocaval compression increases; increased perineal trauma; no gravity; associated with higher episiotomy rates | NOT routine; reserved for specific indications (assisted delivery, extensive perineal repair) |
Danger Signs in Third Stage & Early Postpartum: Recognition & Referral
| Danger Sign | Possible Cause | Immediate Action (Midwife) | Referral Status |
|---|---|---|---|
| Heavy/continuous bleeding; soaking pads | PPH (uterine atony, retained tissue, laceration, placental defect) | Massage uterus, ensure empty bladder, start IV (if available), monitor vitals | REFER immediately to BEmONC facility |
| Soft, boggy uterus unresponsive to massage | Uterine atony (overdistended uterus, prolonged labor, oxytocin ineffectiveness) | Aggressive massage, empty bladder, breastfeeding, repeat oxytocin if indicated | REFER if unresponsive to first-line management |
| Placenta not delivered after 30 min AMTSL | Retained placenta (morbidly adherent, placental fragments) | STOP traction; do NOT attempt manual removal; keep mother NPO; prepare for referral | REFER immediately; manual removal is not midwife scope |
| Rising pulse (>100) + falling BP + pallor | Early hypovolemic shock (ongoing bleeding, blood loss) | IV access (if available), keep warm, elevate legs, monitor vitals q15 min, prepare for transport | REFER immediately to BEmONC; may need transfusion |
| Tear extending to anal sphincter/rectum | Third/fourth-degree perineal laceration (severe trauma during delivery) | Control bleeding with pressure/haemostasis; do NOT suture beyond midwife competency; prepare referral | REFER to physician; specialized repair required |
| Uncontrolled vaginal/perineal bleeding | Deep vaginal laceration, cervical tear, or perineal laceration beyond first/second-degree | Apply direct pressure with sterile gauze; haemostatic sutures if within competency; IV access | REFER if bleeding is not controlled within 15–20 minutes |
| Fever/chills/foul-smelling lochia early postpartum | Intrauterine infection/chorioamnionitis (ascending infection, retained tissue) | Monitor vitals, keep warm, encourage oral hydration, support breastfeeding | REFER for evaluation and possible antibiotic therapy |
Perineal Laceration Classification: Midwife Competency & Referral
| Degree | Anatomical Involvement | Complications if Not Repaired | Midwife Competency | Referral Status |
|---|---|---|---|---|
| First-degree | Mucosa and submucosa only (skin/epithelium); does NOT involve perineal muscles | Minimal; rarely causes long-term morbidity if not repaired (heals by secondary intention) | CAN repair (non-muscle tear); with appropriate aseptic technique, gentle opposition of edges | Repair within scope; counsel on perineal hygiene |
| Second-degree | Extends to perineal muscles (bulbocavernosus, transverse perineal); does NOT involve anal sphincter | Pain, dyspareunia, minor pelvic floor weakness if not repaired; increased risk if not closed properly | CAN repair (muscle is included, but not anal sphincter); requires careful layered closure and good technique | Repair within scope with proper training; counsel on healing and activity restrictions |
| Third-degree | Extends through perineal muscles AND involves the anal sphincter complex (external and/or internal sphincter) | Anal incontinence/fecal urgency if repaired poorly; severe dyspareunia; requires specialized repair | CANNOT repair at RHU/BHS (anal sphincter repair requires expertise); recognize and refer | REFER immediately to physician/hospital for specialized sphincter repair |
| Fourth-degree | Extends completely through anal sphincter AND involves the rectal mucosa | Complete anal incontinence, fecal urgency, severe dyspareunia; very high morbidity if repaired poorly | CANNOT repair at RHU/BHS (complex rectal and sphincter repair required); recognize and refer | REFER immediately to physician/hospital for specialized surgical repair |
Uterotonics in Third Stage: Choice & Contraindications in PH Context
| Uterotonic | Dose & Route | Onset & Duration | Advantages | Contraindications | When to Use |
|---|---|---|---|---|---|
| Oxytocin | 10 IU IM (preferred) or 5 IU IV (if IV access available) | IM: 2–3 min onset, 30–60 min duration; IV: immediate onset, brief duration | Rapid, reliable; few side effects; safe in hypertension/eclampsia; affordable; STABLE | None (safe in hypertension); safe in most clinical scenarios | FIRST-LINE choice; gold standard AMTSL uterotonic |
| Ergot alkaloid (Ergot/Methylergonovine) | 0.2 mg IM or IV (if IV available); can repeat q2–4h if needed (max 5 doses) | IM: 6–7 min; IV: 3–5 min; duration 3–4 hours | Potent, sustained contraction; longer duration than oxytocin; affordable; available in PH | HYPERTENSION, PRE-ECLAMPSIA/ECLAMPSIA, coronary artery disease (vasoconstriction risk) | Second-line if oxytocin unavailable; NOT in hypertensive crisis |
| Misoprostol (Cytotec) | 600 mcg orally (sublingual or buccal preferred for faster absorption) | 15–30 min onset; 30–60 min duration (variable) | Stable at room temperature (no refrigeration); affordable; oral route accessible at RHU | Diarrhea/GI upset; less predictable than oxytocin; slower onset | Alternative if oxytocin unavailable; especially useful in resource-limited settings |
| Carboprost (Hemabate) | 250 mcg IM (if PPH already present); can repeat q15 min (max 8 doses) | 1–3 min onset; 30–60 min duration | Potent for refractory PPH; reserved for severe atony | Asthma, hypertension (relative), fever; expensive; not first-line | Third-line for severe refractory PPH; usually given after oxytocin failure |
Diagrams
Normal Spontaneous Delivery: Sequence from Full Dilatation to Third Stage Management
Complete flowchart showing the sequence of a normal spontaneous delivery from full dilatation through third stage management, decision points for nuchal cord handling, AMTSL sequence, and danger sign detection/referral pathways. This flowchart integrates cardinal movements with the midwife's hands-on technique and active management of third stage.
AMTSL Components & Key Actions: Preventing Postpartum Hemorrhage
Mind map showing the three core components of AMTSL: (1) Uterotonic administration with timing and contraindications, (2) Controlled cord traction with counter-traction technique, (3) Uterine massage protocol. Each component includes key actions, decision points, and parameters. This visual emphasizes that all three components together (not just one) constitute full AMTSL and PPH prevention.
Danger Signs in Third Stage & Early Postpartum: Detect & Refer Pathways
Comprehensive flowchart for detecting danger signs in third stage and early postpartum, with clear decision pathways leading to either continued midwifery management or immediate referral. Covers PPH, uterine atony, retained placenta, retained tissue, shock signs, and perineal trauma classification.