Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Normal Spontaneous Delivery — Independent Conduct & Hands-On TechniqueCheat Sheet

Term

Engagement

Example

Confirmed on abdominal examination (head no longer ballottable) and vaginal examination (head palpable at pelvic brim).

Definition

The biparietal diameter of the fetal head passes through the pelvic inlet; head is at 0 station or above.

Term

Descent

Example

Station progresses from -5 to 0 to +5 cm as labor advances; assessed by vaginal examination.

Definition

Progressive downward movement of the fetal head through the pelvis, occurring throughout active labor and second stage.

Term

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.

Definition

The fetal chin tucks onto the chest, presenting the smallest diameter (suboccipitobregmatic ~9.5 cm) to the pelvis.

Term

Internal Rotation

Example

Allows the narrower transverse diameter of the head to pass through the narrower transverse diameter of the pelvis at the inlet.

Definition

The occiput rotates anteriorly toward the symphysis pubis (usually 135° rotation) as the head adapts to pelvic diameters.

Term

Extension

Example

The head 'crowns' (perineum stretches around the widest part of the head) and is delivered by extension, NOT flexion.

Definition

The flexed head extends under the pubic arch; this is how the head is actually born (occiput first, then bregma, forehead, face, chin).

Term

Restitution (External Rotation)

Example

If head was rotated right during delivery, it restitutes by turning left; this confirms normal shoulder position.

Definition

After the head is born, it realigns with the fetal shoulders by rotating back to the transverse position (head turns ~45° back).

Term

Expulsion

Example

Anterior shoulder delivered first (downward traction on head), then posterior shoulder (upward traction), then body.

Definition

Delivery of the anterior shoulder, posterior shoulder, and fetal body following shoulder restitution.

Term

Full Dilatation (10 cm)

Example

Confirmed by vaginal examination; the os admits the whole of the examining finger(s).

Definition

Complete opening of the cervix; indicates readiness to move from first stage to second stage and to commence pushing.

Term

Second Stage of Labor

Example

In primigravidas, normally lasts 30 min–2 hours; in multiparas, usually shorter (15–60 min).

Definition

From full dilatation to delivery of the baby; characterized by involuntary and voluntary pushing, perineal bulging, and gaping anus.

Term

Crowning

Example

Signal that delivery is imminent; prepare for controlled head delivery and newborn resuscitation corner.

Definition

The widest part of the fetal head is visible at the introitus and does NOT recede between contractions.

Term

Controlled Head Delivery

Example

Prevents rapid decompression (risk of intracranial hemorrhage) and perineal trauma; is the single most important skill in NSD.

Definition

Slow, gradual expulsion of the fetal head with one hand controlling the occiput (flexion) and the other supporting the perineum, allowing tissue to stretch.

Term

Ritgen Maneuver

Example

Applied as head crowns and extends; reduces third/fourth-degree perineal tears significantly.

Definition

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.

Term

Perineal Support

Example

Using a clean pad or cloth, support the tissue just anterior to the anus as the head delivers by extension.

Definition

Gentle counter-pressure applied to the perineum (posterior to the introitus) during head extension to prevent sudden tearing.

Term

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.

Definition

The umbilical cord looped around the fetal neck after delivery of the head; present in ~20–30% of deliveries.

Term

Anterior Shoulder

Example

As head restitutes, apply downward traction to bring the anterior (upper) shoulder under the symphysis pubis for delivery.

Definition

The shoulder closest to the symphysis pubis; delivered first after head restitution by gentle downward traction on the head.

Term

Posterior Shoulder

Example

Once anterior shoulder is free, apply upward traction to deliver the posterior shoulder over the perineum.

Definition

The shoulder closest to the sacrum; delivered second by gentle upward traction on the head after anterior shoulder is born.

Formula

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.

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

Term

Active Management of Third Stage (AMTSL)

Example

Oxytocin 10 IU IM + Brandt-Andrews maneuver + fundal massage = the midwife's most important PPH prevention skill.

Definition

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.

Term

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.

Definition

Steady, gentle downward traction on the cord during uterine contraction while applying counter-traction above the symphysis pubis to prevent uterine inversion.

Term

Placental Separation Signs

Example

Do NOT attempt CCT until these signs appear; premature CCT risks uterine inversion and retained placenta.

Definition

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.

Term

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.

Definition

Firm, circular massage of the uterine fundus through the abdominal wall to maintain uterine contraction and prevent atony.

Term

Postpartum Hemorrhage (PPH)

Example

Detect & refer if bleeding is heavy/continuous, uterus is soft/boggy and will not stay contracted, vital signs are unstable.

Definition

Blood loss of ≥500 mL in the first 24 hours after vaginal delivery; major cause of maternal mortality worldwide.

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)

Term

Placenta

Example

Inspect both sides: maternal (cotyledon) side and fetal (shiny) side with umbilical vessels.

Definition

Discoid organ (fetal-maternal interface) weighing ~500–600 g; composed of ~15–20 cotyledons (lobes) on the maternal (beefy red) side.

Term

Cotyledon

Example

A 'missing' cotyledon suggests a retained placental fragment—treat as retained tissue.

Definition

One lobe/subdivision of the placenta visible on the maternal surface; normally 15–20 present.

Term

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).

Definition

A small extra lobe of placenta connected to the main placenta by membrane; easy to leave behind if not recognized.

Term

Retained Placenta / Retained Tissue

Example

If placenta does not deliver after 30 min or if fragments are visibly missing, REFER immediately.

Definition

Partial or complete failure of placental separation and expulsion after delivery; risks PPH and intrauterine infection.

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

Term

Lochia

Example

Assess lochia at every vital sign check; excessive or continuous bleeding = detect & refer.

Definition

Vaginal discharge after delivery; normally bright red, moderate flow (not soaking pads), without large clots in the first 2 hours.

Term

Uterine Atony

Example

Manage by massage, ensure empty bladder, encourage breastfeeding (releases oxytocin); if unresponsive to first-line measures, refer.

Definition

Loss of uterine muscle tone/contractility; results in a soft, boggy uterus unable to compress bleeding vessels, causing PPH.

Term

Perineal Laceration

Example

Midwife repairs 1st/2nd-degree tears; refer 3rd/4th-degree tears to physician.

Definition

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).

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)

Term

Postpartum Hemorrhage (PPH)

Example

Detect: heavy/continuous bleeding, soft/boggy uterus unresponsive to massage, rising pulse, falling BP, pallor. REFER immediately.

Definition

Blood loss ≥500 mL in first 24 hours after vaginal delivery; early PPH is within first 2 hours (highest-risk period).

Term

Uterine Inversion

Example

Risk increased by fundal pressure, aggressive CCT without counter-traction, overly vigorous massage. REFER immediately.

Definition

Inversion of the uterine fundus into the uterine cavity; a true obstetric emergency associated with severe hemorrhage and shock.

Term

Retained Placenta

Example

If placenta has not delivered after 30 min of AMTSL, STOP and refer. Do NOT apply excessive force or traction.

Definition

Failure of placental delivery after 30 minutes of AMTSL; risks severe PPH and intrauterine infection.

Term

Shock (Hypovolemic)

Example

Detect early signs (mild shock): tachycardia + normal/borderline BP. Refer immediately for IV fluids and possible transfusion.

Definition

Insufficient tissue perfusion due to blood loss; signs include rising pulse (>100), falling BP, pallor, dizziness, restlessness, cold extremities.

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

Term

Immediate Newborn Care (EINC Steps 1–5)

Example

Perform while maintaining skin-to-skin contact; non-separation principle = mother and baby stay together.

Definition

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.

Term

Skin-to-Skin Contact

Example

Begin immediately after delivery; maintain throughout immediate postpartum period (Golden Hour).

Definition

Immediate placement of the naked newborn prone on the mother's bare chest; maintains warmth, promotes bonding, facilitates breastfeeding.

Term

Delayed Cord Clamping

Example

Increases newborn hemoglobin, reduces anemia risk, reduces need for transfusion in the first few days of life.

Definition

Waiting 1–3 minutes (or until cord stops pulsating) before clamping the umbilical cord; allows placental transfusion (~40% of fetal blood volume).

Term

Unang Yakap (First Embrace)

Example

Aligns with EINC and WHO guidelines; core principle of maternal–newborn care in Philippine context.

Definition

DOH program emphasizing immediate skin-to-skin contact, early initiation of breastfeeding, and non-separation of mother and baby.

Values

• Uses gravity; faster descent; reduces aortocaval compression; less perineal trauma
• May fatigue legs; less accessible perineum; less comfortable if epidural present
• Encouraged; reduces trauma

Property

Upright (standing/walking)

Values

• 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

Property

Semi-sitting/Semi-recumbent

Values

• 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

Property

Squatting

Values

• 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

Property

Left lateral (side-lying)

Values

• 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)

Property

Lithotomy (flat, supine, legs in stirrups)

Values

• PPH (uterine atony, retained tissue, laceration, placental defect)
• Massage uterus, ensure empty bladder, start IV (if available), monitor vitals
• REFER immediately to BEmONC facility

Property

Heavy/continuous bleeding; soaking pads

Values

• Uterine atony (overdistended uterus, prolonged labor, oxytocin ineffectiveness)
• Aggressive massage, empty bladder, breastfeeding, repeat oxytocin if indicated
• REFER if unresponsive to first-line management

Property

Soft, boggy uterus unresponsive to massage

Values

• 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

Property

Placenta not delivered after 30 min AMTSL

Values

• 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

Property

Rising pulse (>100) + falling BP + pallor

Values

• 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

Property

Tear extending to anal sphincter/rectum

Values

• 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

Property

Uncontrolled vaginal/perineal bleeding

Values

• Intrauterine infection/chorioamnionitis (ascending infection, retained tissue)
• Monitor vitals, keep warm, encourage oral hydration, support breastfeeding
• REFER for evaluation and possible antibiotic therapy

Property

Fever/chills/foul-smelling lochia early postpartum

Values

• 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

Property

First-degree

Values

• 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

Property

Second-degree

Values

• 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

Property

Third-degree

Values

• 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

Property

Fourth-degree

Values

• 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

Property

Oxytocin

Values

• 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

Property

Ergot alkaloid (Ergot/Methylergonovine)

Values

• 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

Property

Misoprostol (Cytotec)

Values

• 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

Property

Carboprost (Hemabate)