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

Concept

Mechanisms of Labor — Cardinal Movements

Sub Concepts

• Engagement — biparietal diameter passes pelvic inlet
• Descent — downward movement throughout labor
• Flexion — chin tucks to present smallest diameter (suboccipitobregmatic ~9.5 cm)
• Internal rotation — occiput rotates anteriorly toward symphysis pubis
• Extension — head extends under pubic arch (how the head is actually born)
• External rotation (restitution) — head realigns with shoulders after birth
• Expulsion — anterior shoulder, posterior shoulder, and body delivered

Relationship To Central

Foundation for understanding normal descent and recognizing when the delivery is progressing appropriately

Concept

Pre-Delivery Preparation and Readiness

Sub Concepts

• Confirm full dilation (10 cm) and station before allowing pushing
• Assess readiness: perineum distends, does not recede between contractions, anus gapes
• Prepare newborn corner with clean, dry, warm surface and two clean cloths
• Ensure oxytocin and delivery set within reach
• Empty bladder if distended
• Hand hygiene and sterile glove application

Relationship To Central

Essential steps that ensure safe, clean, and organized delivery environment aligned with EINC standards

Concept

Maternal Positioning and Second-Stage Management

Sub Concepts

• Allow mother to choose comfortable position: upright, semi-sitting, squatting, side-lying, semi-recumbent
• Avoid routine flat lithotomy position
• Encourage gentle, spontaneous pushing with contractions
• Avoid prolonged, forceful breath-holding (Valsalva)
• Between contractions: ask mother to pant/breathe rather than push
• Ensure perineum is visible and accessible to midwife

Relationship To Central

Optimizes labor progression, uses gravity, reduces complications, and respects maternal choice

Concept

Controlled Delivery of the Head and Perineal Support

Sub Concepts

• Apply gentle pressure on occiput to keep head flexed and slowly advancing
• Use Ritgen maneuver: support perineum with clean pad while head extends
• Guard tissue as head is delivered
• Support perineum throughout to reduce 3rd and 4th-degree tears
• Routine episiotomy is NOT performed
• Episiotomy only on clear indication: imminent severe tear, fetal distress, some assisted deliveries

Relationship To Central

The single most important skill in preventing perineal trauma and intracranial injury

Concept

Nuchal Cord Management and Face Clearing

Sub Concepts

• Feel gently around newborn's neck for nuchal cord
• If loose: slip over head
• If tight: attempt somersault maneuver (keep baby close to perineum, deliver through loop)
• Only clamp and cut tight cord if impossible to loosen
• Protects placental transfusion by avoiding early cord cutting
• Wipe face with clean cloth
• Routine suctioning of mouth/nose NOT done for baby with clear liquor who is crying/breathing

Relationship To Central

Safety check after head delivery to prevent complications and follow EINC guidelines on unnecessary interventions

Concept

Delivery of Shoulders and Body

Sub Concepts

• Apply gentle downward traction with next contraction to deliver anterior shoulder
• Apply gentle upward traction to deliver posterior shoulder over perineum
• Support perineum throughout
• Deliver body slowly with firm but gentle grasp
• Note and announce time of birth
• Place newborn prone on mother's abdomen/chest (skin-to-skin)
• Begin immediate and thorough drying (EINC step 1)
• Never apply fundal pressure to deliver baby

Relationship To Central

Completes the expulsion phase of labor with proper traction and handling

Concept

Active Management of Third Stage of Labor (AMTSL)

Sub Concepts

• Component 1: Uterotonic (Oxytocin)
• Component 2: Controlled Cord Traction (Brandt-Andrews Maneuver)
• Component 3: Uterine Massage
• Rule out second baby BEFORE giving uterotonic
• Oxytocin 10 IU IM within one minute of baby's birth
• Oxytocin is drug of choice — effective, few side effects, safe in hypertension

Relationship To Central

Evidence-based standard for preventing postpartum hemorrhage and a defining midwifery competency

Concept

Uterotonic Selection and Dosing

Sub Concepts

• First choice: Oxytocin 10 IU IM
• Alternative 1: Misoprostol 600 mcg orally (if oxytocin unavailable)
• Alternative 2: Ergometrine/methylergometrine 0.2 mg IM
• Ergometrine CONTRAINDICATED in hypertension and pre-eclampsia
• Oxytocin safe in hypertension
• Give within one minute of baby's birth for effectiveness

Relationship To Central

Critical pharmacological component of AMTSL with specific contraindications in high-risk conditions

Concept

Controlled Cord Traction and Brandt-Andrews Maneuver

Sub Concepts

• Wait for strong uterine contraction
• Wait for signs of placental separation: gush of blood, cord lengthening, uterus becomes globular and rises
• Apply counter-traction on uterus above symphysis pubis (prevent inversion)
• Apply steady, gentle downward traction on cord in direction of birth canal
• If placenta does not descend in 30-40 seconds, STOP
• Wait for next contraction and repeat
• Never yank the cord
• Deliver placenta with both hands
• Gently twist membranes into rope so they peel out intact

Relationship To Central

Technique for efficient, safe placental delivery that prevents uterine inversion

Concept

Uterine Massage and Postpartum Monitoring

Sub Concepts

• Massage uterine fundus immediately after placenta delivery until firm and well-contracted
• Check fundus every 15 minutes for first 2 hours postpartum
• Teach mother to feel and massage her own fundus
• Monitor vital signs every 15 minutes for first 2 hours
• Monitor lochia amount and character
• Highest-risk window for hemorrhage: immediate postpartum period
• Sustained uterine tone and early oxytocin prevent hemorrhage

Relationship To Central

Maintains uterine contraction to control bleeding and monitors for hemorrhage warning signs

Concept

Placental Inspection and Completeness Assessment

Sub Concepts

• Inspect maternal (cotyledon) side: confirm all cotyledons present, none missing
• Inspect fetal (shiny) side: trace vessels
• Suspect succenturiate (accessory) lobe if vessel runs to membrane edge and stops
• Check membranes: confirm amnion and chorion complete
• Count cord vessels: normal = 2 arteries and 1 vein
• Estimate and record blood loss
• If doubt about completeness: treat as retained tissue and REFER

Relationship To Central

Systematic evaluation ensures retained fragments are detected and appropriate referral made

Concept

Immediate Postpartum Maternal Care

Sub Concepts

• Inspect perineum, vagina, and cervix for lacerations and bleeding
• Keep uterus contracted: massage, empty bladder, encourage breastfeeding
• Monitor vital signs regularly
• Monitor fundal tone and lochia every 15 minutes for first 2 hours
• Keep mother and baby together, skin-to-skin
• Support early breastfeeding within first hour (non-separation, EINC)
• Ensure mother is warm, clean, comfortable, hydrated
• Ensure mother has voided

Relationship To Central

Essential interventions in first hours postpartum to promote recovery and detect complications

Concept

Perineal Tear Assessment and Repair

Sub Concepts

• First-degree tear: skin and superficial fascia only — repair by midwife
• Second-degree tear: includes perineal body muscle — repair by midwife
• Third-degree tear: extends into anal sphincter — REFER
• Fourth-degree tear: involves rectal mucosa — REFER
• Routine episiotomy NOT performed
• Episiotomy only on clear indication
• Systematic inspection of entire genital tract after delivery

Relationship To Central

Distinguishes within-scope midwifery repairs from complications requiring referral

Concept

Danger Signs Requiring Referral and Detection

Sub Concepts

• Heavy or continuous bleeding
• Soft, boggy uterus that will not stay contracted
• Retained placenta beyond ~30 minutes
• Incomplete placenta or membranes
• Rising pulse, falling blood pressure, pallor, dizziness (shock signs)
• Tear extending into anal sphincter or rectum
• Prolonged second stage without descent
• Any obstructed labor signs
• PPH defined as ≥500 mL blood loss after vaginal delivery

Relationship To Central

Red flags that signal complications necessitating immediate detection and referral to BEmONC facility

Concept

EINC and DOH Alignment — Midwife as Independent Provider

Sub Concepts

• RA 7392: Midwife may independently manage normal spontaneous vaginal delivery
• EINC principles: non-separation of mother and baby, early breastfeeding, delayed cord clamping where possible
• Eliminate unnecessary practices: routine episiotomy, routine suctioning, routine fundal pressure
• Emphasis on clean, safe delivery in primary-care setting (RHU, BHS, lying-in)
• Unang Yakap program integration: skin-to-skin contact immediately after birth
• Recognition and referral of complications to BEmONC facilities
• Detect and refer model: midwife identifies but does not manage complex cases

Relationship To Central

Frames the midwife's independent scope under RA 7392 and aligns with national guidelines

To

Controlled Delivery of the Head and Perineal Support

From

Mechanisms of Labor — Cardinal Movements

Strength

strong

Relationship

Understanding the cardinal movements, especially flexion and extension, enables the midwife to recognize when the head is in the correct position and delivers it safely with controlled traction

To

Controlled Delivery of the Head and Perineal Support

From

Pre-Delivery Preparation and Readiness

Strength

strong

Relationship

Proper preparation ensures sterile equipment, supplies, and positioning are ready before delivery begins, enabling smooth execution of the critical head delivery technique

To

Controlled Delivery of the Head and Perineal Support

From

Maternal Positioning and Second-Stage Management

Strength

strong

Relationship

Maternal positioning affects perineal visibility and accessibility; upright positions facilitate gravity-assisted descent and midwife's ability to support and control the perineum

To

Perineal Tear Assessment and Repair

From

Controlled Delivery of the Head and Perineal Support

Strength

strong

Relationship

Proper controlled technique during head delivery significantly reduces perineal trauma risk; tears that do occur are then assessed for midwife scope (1st/2nd degree repair) versus referral (3rd/4th degree)

To

Delivery of Shoulders and Body

From

Nucleal Cord Management and Face Clearing

Strength

strong

Relationship

After the head is delivered and nuchal cord managed, the midwife proceeds to deliver the shoulders and body with gentle traction

To

Active Management of Third Stage of Labor (AMTSL)

From

Delivery of Shoulders and Body

Strength

strong

Relationship

Once the baby is completely delivered and placed skin-to-skin, the third stage of labor begins; AMTSL is initiated immediately with oxytocin within one minute of birth

To

Uterotonic Selection and Dosing

From

Active Management of Third Stage of Labor (AMTSL)

Strength

strong

Relationship

AMTSL's first component is uterotonic administration; oxytocin is the drug of choice at 10 IU IM, with specific contraindications in hypertension requiring alternative agents

To

Controlled Cord Traction and Brandt-Andrews Maneuver

From

Uterotonic Selection and Dosing

Strength

moderate

Relationship

After oxytocin is given, the midwife waits for signs of placental separation before performing controlled cord traction, which is the second AMTSL component

To

Uterine Massage and Postpartum Monitoring

From

Controlled Cord Traction and Brandt-Andrews Maneuver

Strength

strong

Relationship

Following placental delivery via CCT, uterine massage is immediately begun to maintain contraction; monitoring continues every 15 minutes for 2 hours

To

Danger Signs Requiring Referral and Detection

From

Placental Inspection and Completeness Assessment

Strength

strong

Relationship

Systematic placental inspection identifies retained tissue or incomplete membranes, which trigger danger sign assessment and potential referral to BEmONC

To

Uterine Massage and Postpartum Monitoring

From

Immediate Postpartum Maternal Care

Strength

strong

Relationship

Postpartum maternal care includes regular assessment of fundal tone, lochia, and vital signs every 15 minutes in the highest-risk window, supported by continued uterine massage

To

Danger Signs Requiring Referral and Detection

From

Immediate Postpartum Maternal Care

Strength

strong

Relationship

During immediate postpartum care, the midwife continuously monitors for danger signs such as heavy bleeding, soft uterus, shock signs, and retained placenta

To

Immediate Postpartum Maternal Care

From

Perineal Tear Assessment and Repair

Strength

strong

Relationship

After delivery, the perineum is systematically inspected for lacerations; first and second-degree tears are repaired by the midwife while third and fourth-degree tears require referral

To

EINC and DOH Alignment — Midwife as Independent Provider

From

All Delivery Phases

Strength

strong

Relationship

All steps of normal spontaneous delivery management are conducted independently by the midwife under RA 7392, with strict adherence to EINC principles, elimination of unnecessary practices, and recognition of complications requiring referral

To

EINC and DOH Alignment — Midwife as Independent Provider

From

Danger Signs Requiring Referral and Detection

Strength

strong

Relationship

The midwife's role in the detect-and-refer model is exemplified by systematic danger sign monitoring and immediate referral to BEmONC facilities when complications arise

To

Maternal Positioning and Second-Stage Management

From

Mechanisms of Labor — Cardinal Movements

Strength

moderate

Relationship

Understanding the cardinal movements guides the midwife to position the mother in ways that facilitate normal descent and rotation of the fetal head

To

Maternal Positioning and Second-Stage Management

From

Pre-Delivery Preparation and Readiness

Strength

moderate

Relationship

Before delivery, the midwife explains positioning options and ensures the mother is comfortable and the perineum is visible and accessible

To

Immediate Postpartum Maternal Care

From

Placental Inspection and Completeness Assessment

Strength

moderate

Relationship

Systematic placental inspection provides information about completeness; findings guide postpartum management decisions and referral indications

To

Danger Signs Requiring Referral and Detection

From

Uterine Massage and Postpartum Monitoring

Strength

moderate

Relationship

Uterine massage maintains contraction to prevent hemorrhage; during monitoring, failure of the uterus to remain firm is a danger sign triggering further assessment and possible referral

To

Nucleal Cord Management and Face Clearing

From

Controlled Delivery of the Head and Perineal Support

Strength

strong

Relationship

Immediately after the head is delivered, the midwife assesses for nuchal cord and performs appropriate management before proceeding to shoulder delivery