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

The Seven Cardinal Movements of Labor

The fetal head must navigate the bony pelvis by changing its position and attitude at each level. These adaptations are called the Cardinal Movements of Labor — there are seven in sequence, and the order is frequently tested on the MLE. Think of it as a baby 'threading a needle' through the different diameters of the pelvis. 1. ENGAGEMENT: The widest part of the fetal head, the biparietal diameter (BPD, about 9.5 cm), passes through the pelvic inlet (brim). In primigravidas, this often happens 2–4 weeks before labor. In multigravidas, it may only happen during active labor. When engaged, the presenting part is at station 0. 2. DESCENT: The continuous downward movement of the fetal presenting part through the birth canal. It happens throughout labor — from engagement to delivery. Descent is what we monitor with station assessment (measured in cm above or below the ischial spines). 3. FLEXION: As the head meets resistance from the pelvic floor, the chin tucks down onto the chest. This flexion is crucial — it changes the presenting diameter from the larger occipitofrontal (~11 cm) to the smaller suboccipitobregmatic (~9.5 cm), making it easier for the head to pass through. 4. INTERNAL ROTATION: The occiput (back of the head) rotates from its original transverse or oblique position to face the symphysis pubis anteriorly (LOA → OA). This aligns the longest fetal head diameter with the widest pelvic diameter. Internal rotation is complete when the sagittal suture is in the anteroposterior diameter of the outlet. 5. EXTENSION: Once the fully rotated, flexed head reaches the vaginal outlet, it cannot continue downward — the pubic arch is in the way. Instead, the head EXTENDS (chin lifts off the chest) as it pivots under the symphysis pubis. The head is BORN by extension in this order: occiput → bregma → forehead → face → chin. 6. EXTERNAL ROTATION (RESTITUTION): After the head is born, it rotates back to align with the shoulders (which are still in the transverse diameter). The occiput turns to face the mother's inner thigh. This is the head 'undoing' the internal rotation it made inside. 7. EXPULSION: With the next contraction, the anterior shoulder delivers under the symphysis pubis (with gentle downward traction), followed by the posterior shoulder over the perineum (with gentle upward traction), and then the rest of the body delivers easily. Mnemonic: E-D-F-I-E-R-E = 'Every Delivery Follows Intelligent, Expert, Reliable Execution'

Preparing for Delivery — Setting Up and Readiness

Preparation before delivery is a critical skill tested on the MLE. A prepared midwife prevents emergencies. At the BHS or lying-in, you must confirm readiness before the baby arrives, not after. SIGNS THAT DELIVERY IS IMMINENT: - Second stage: cervix is fully dilated (10 cm), station is low (+3 to +4) - Perineum bulges and does not recede between contractions - Anus gapes open - The presenting part (usually the head) is visible at the vaginal opening during a contraction - The mother has an uncontrollable urge to push STEPS IN PREPARATION: 1. CONFIRM full dilatation and station before allowing active pushing — never encourage pushing in transition if not yet fully dilated. 2. HANDWASHING: Thorough surgical hand wash; don sterile gloves using aseptic technique. 3. NEWBORN CORNER (EINC): Prepare a clean, dry, warm, flat surface at the same level as the mother. Have TWO clean, dry, warm cloths ready — one for immediate drying, one for covering the baby. This is the most important EINC preparation step. 4. DELIVERY SET: Sterile clamp (2 Kelly clamps or cord clamps), sterile scissors for cord cutting, basin for placenta. 5. OXYTOCIN: Draw up Oxytocin 10 IU in a syringe and have it ready BEFORE the head crowns. Time is critical — it must be given within 1 minute of birth. 6. BLADDER: Encourage the mother to void. A full bladder impedes descent, increases pain, and can prevent the uterus from contracting well after delivery. Only catheterize if she cannot void and the bladder is significantly distended. 7. POSITIONING: Allow the mother to choose her position (see next concept). Confirm the perineum is visible and accessible. 8. EMOTIONAL SUPPORT: Inform the mother of what is happening. A calm, informed mother pushes more effectively and is less likely to tear. INFECTION PREVENTION: - Clean, not necessarily sterile, delivery environment (community context) - Strict hand hygiene and glove use - Clean cord cutting equipment - This is part of BEmONC infection prevention standards

Maternal Positioning and Controlled Delivery of the Head

HOW the head is delivered is as important as knowing when to deliver it. The two biggest causes of severe perineal tears are: (1) too-fast delivery of the head, and (2) poor positioning. EINC and WHO evidence have changed traditional practices. MATERNAL POSITIONING: EINC encourages FREEDOM OF POSITION — the mother chooses what is most comfortable and effective for her. Options include: - Upright (standing, squatting): uses gravity, reduces pushing time - Semi-sitting (semi-recumbent): common in Philippine BHS/lying-in, a good compromise - Left lateral (Sims): reduces aortocaval compression, good for the baby's heart rate, fewer severe tears - Hands-and-knees: useful for persistent occiput posterior - Routine flat lithotomy (lying flat on back with legs in stirrups) is NO LONGER recommended by EINC for normal birth — it compresses the aorta and inferior vena cava, reduces blood flow to the baby, and increases perineal tears. CONTROLLED DELIVERY OF THE HEAD (The most important hands-on skill): Step 1 — PUSHING TECHNIQUE: - Encourage SPONTANEOUS, physiologic pushing — the mother pushes when she feels the urge, bearing down with her own breath rhythm (open-glottis pushing). - AVOID prolonged Valsalva (breath-holding, counting to 10) directed pushing — EINC evidence shows this reduces oxygen to the baby and is associated with more tears. Step 2 — AS THE HEAD CROWNS: - Place one hand (over a clean cloth) on the OCCIPUT to apply gentle pressure, keeping the head FLEXED and slowing the advance. This prevents the head from 'popping out' suddenly. - BETWEEN contractions: ask the mother to PANT (breathe rapidly and shallowly) rather than push. Panting removes the bearing-down force and allows the perineum to SLOWLY STRETCH over the head. Step 3 — PERINEAL SUPPORT (Ritgen Maneuver / Hands-On Technique): - Place the other hand under a clean pad against the perineum, supporting the tissue as the head extends. - This 'hands-on' perineal support during crowning has strong evidence for REDUCING severe (3rd and 4th degree) perineal tears. - The Ritgen maneuver specifically uses the fingers under the pad to support the fetal chin through the perineum as the head extends — guarding the perineal body. EPISIOTOMY — NOT ROUTINE: - EINC and WHO are clear: routine episiotomy is ELIMINATED. It does not prevent severe tears, causes more blood loss, and is painful. - Episiotomy is ONLY performed when there is a CLEAR CLINICAL INDICATION: (a) Imminent severe tear that cannot be controlled by other means (b) Fetal distress requiring rapid delivery (c) Shoulder dystocia needing more room (d) Some instrumental (forceps/vacuum) deliveries - When done, a MEDIOLATERAL episiotomy is preferred (not midline) because midline episiotomies extend more easily into 3rd/4th degree tears.

Checking for Nuchal Cord and Delivery of Shoulders and Body

After the head is delivered and external rotation (restitution) has occurred, the midwife performs two important steps: checking for a nuchal cord and delivering the shoulders. CHECKING FOR NUCHAL CORD: A nuchal cord is the umbilical cord looped around the baby's neck — it is present in 20–30% of all deliveries and is usually not harmful. However, a tight nuchal cord can restrict blood flow or impede delivery. 1. After the head is born and has restituted, RUN your fingers gently around the baby's neck to feel for the cord. 2. If the cord is LOOSE: simply slip the loop over the head before the shoulders deliver. Easy — no problem. 3. If the cord is TIGHT (cannot be slipped over): Modern EINC practice recommends the SOMERSAULT MANEUVER — keep the cord intact, deliver the body by 'somersaulting' the baby through the loop (the baby does a forward roll under the mother's thigh). This preserves the umbilical circulation and allows placental transfusion to continue. 4. Clamp and cut a tight nuchal cord ONLY if it truly cannot be managed any other way — early cord clamping to cut a nuchal cord deprives the baby of placental transfusion (up to 30% of fetal blood volume). ROUTINE SUCTIONING — NOT DONE: - EINC removed routine suctioning of the mouth and nose after the head is born. - Suctioning is NOT done if the liquor is clear and the baby is vigorous (crying, breathing). - Suction ONLY if there is thick meconium and the baby is not crying/breathing — and this is a referral-level situation. DELIVERY OF THE SHOULDERS: 1. With the NEXT uterine contraction, apply GENTLE DOWNWARD TRACTION on the fetal head (toward the floor) to deliver the ANTERIOR shoulder from under the symphysis pubis. 2. Once the anterior shoulder is seen, apply GENTLE UPWARD TRACTION (toward the ceiling) to deliver the POSTERIOR shoulder over the perineum. Support the perineum during this step — the posterior shoulder delivery causes the most perineal stress. 3. The REST OF THE BODY (trunk, hips, legs) follows spontaneously — support it with both hands as it slides out. The baby is slippery! IMPORTANT: DO NOT apply FUNDAL PRESSURE to deliver the baby. - Fundal pressure (pushing on the fundus) during the second stage does NOT help and can: (a) Worsen shoulder dystocia (pushing the body when the shoulder is stuck) (b) Cause uterine rupture (c) Cause uterine inversion AFTER BIRTH: - Note and announce the EXACT TIME OF BIRTH. - Place the baby PRONE (face down, on the belly) on the mother's bare abdomen/chest — SKIN-TO-SKIN — this is EINC Step 1. - Begin IMMEDIATE AND THOROUGH DRYING using the first clean cloth.

Active Management of the Third Stage of Labor (AMTSL)

AMTSL is one of the MOST IMPORTANT topics on the MLE. Postpartum hemorrhage (PPH) is the NUMBER ONE cause of maternal death in the Philippines. AMTSL is the midwife's most powerful tool to prevent it. The third stage of labor is from the birth of the baby to the delivery of the placenta. Without intervention, the placenta separates and is expelled in 5–30 minutes. AMTSL shortens this and, most importantly, prevents the uterus from bleeding excessively. AMTSL has THREE COMPONENTS: ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ COMPONENT 1: UTEROTONIC (Oxytocin) ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ BEFORE giving any uterotonic, you MUST PALPATE THE ABDOMEN TO RULE OUT A SECOND BABY (undiagnosed twin). Giving oxytocin with a second baby inside can trap it — this is a life-threatening error. - Drug: OXYTOCIN 10 IU (10 units) IM - Route: Intramuscular injection (anterolateral thigh) - Timing: Within ONE MINUTE of the baby's birth - Why oxytocin? It is the DRUG OF CHOICE — effective, rapid onset, safe in hypertension (unlike ergometrine) Alternatives when oxytocin is unavailable: - MISOPROSTOL 600 mcg ORALLY — can be given by non-skilled attendants, does not need refrigeration; used in community/outreach settings - ERGOMETRINE/METHYLERGOMETRINE 0.2 mg IM — effective but CONTRAINDICATED in hypertension/pre-eclampsia (causes severe vasoconstriction and can trigger hypertensive crisis) ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ COMPONENT 2: CONTROLLED CORD TRACTION (CCT) — Brandt-Andrews Maneuver ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Wait for SIGNS OF PLACENTAL SEPARATION: 1. A sudden GUSH OF BLOOD from the vagina 2. The cord LENGTHENS (appears to come out more) 3. The uterus becomes GLOBULAR (ball-shaped) and RISES in the abdomen 4. The uterus becomes firm Technique: 1. Place one hand JUST ABOVE the symphysis pubis on the uterus — this is the COUNTER-TRACTION hand. Its job is to PUSH THE UTERUS UPWARD to prevent uterine inversion. 2. With the other hand, apply STEADY, GENTLE DOWNWARD TRACTION on the cord in the direction of the birth canal. 3. If the placenta does not descend in 30–40 seconds, STOP. Do NOT yank the cord. Wait for the next contraction. 4. As the placenta emerges at the vulva, receive it with both hands and gently TWIST the membranes into a rope to peel them out intact. KEY SAFETY: NEVER apply traction to the cord WITHOUT counter-traction on the uterus — doing so risks UTERINE INVERSION, a life-threatening emergency. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ COMPONENT 3: UTERINE MASSAGE ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ - Immediately after the placenta is delivered, massage the uterine fundus through the abdomen until it is FIRM AND CONTRACTED. - Re-check fundal tone EVERY 15 MINUTES for the FIRST 2 HOURS postpartum. - Teach the mother to CHECK AND MASSAGE HER OWN FUNDUS — this empowers her and maintains vigilance. CURRENT NOTE: WHO's updated guidance recognizes the UTEROTONIC (oxytocin) as the most essential component of AMTSL. CCT by a skilled provider and uterine massage complement it, but the oxytocin is what saves lives.

Placental Inspection

After delivery of the placenta, the midwife has a critical responsibility: to INSPECT THE PLACENTA COMPLETELY and confirm that nothing is retained inside the uterus. Retained placental fragments or membranes cause two major complications: POSTPARTUM HEMORRHAGE (immediate) and INFECTION/ENDOMETRITIS (delayed). This is a systematic, methodical examination. SYSTEMATIC PLACENTAL INSPECTION — 4 PARTS: ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ 1. MATERNAL SURFACE (Cotyledon side — DULL, MEATY, LOBULATED) ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ - The maternal surface has 15–20 COTYLEDONS (lobules) arranged in a disc. - Hold the placenta up and examine every cotyledon — they should FIT TOGETHER LIKE A PUZZLE, with no gaps or missing pieces. - If a cotyledon is missing or there is a rough, torn edge → SUSPECT RETAINED PLACENTAL FRAGMENT → REFER. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ 2. FETAL SURFACE (Shiny, smooth, covered by amnion — SHINY SIDE) ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ - The fetal surface is SHINY (covered by the chorion/amnion) and has visible blood vessels radiating from the cord insertion. - TRACE THE BLOOD VESSELS from the cord to the edge of the placenta. - If a vessel is seen running to the EDGE OF THE MEMBRANE and then stopping abruptly (like a cut-off vessel) → SUSPECT A SUCCENTURIATE (ACCESSORY) LOBE — a separate placental lobe left inside the uterus → REFER. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ 3. MEMBRANES (Chorion and Amnion) ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ - Hold the placenta up and allow the membranes to hang — they should form a complete SAC with a hole where the baby passed through. - Both layers (chorion = outer, amnion = inner) should be COMPLETE with no ragged, incomplete areas. - Incomplete membranes → risk of retained membranes → infection. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ 4. UMBILICAL CORD ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ - Cut a cross-section of the cord and count the vessels. - NORMAL: TWO ARTERIES + ONE VEIN = 3 vessels - ABNORMAL: A SINGLE UMBILICAL ARTERY (only 2 vessels visible) is associated with renal and cardiac anomalies in the newborn → document and refer for further evaluation. - The cord normally has WHARTON'S JELLY around the vessels. BLOOD LOSS ESTIMATION: - Estimate total blood loss during delivery and the third stage. - PPH DEFINITION: ≥500 mL blood loss after a VAGINAL delivery (≥1000 mL after cesarean). - Even suspected PPH should trigger close monitoring and potential referral. DOCUMENTATION: - Record: placenta complete/incomplete, membranes complete, cord vessels, estimated blood loss, time of placental delivery.

Immediate Postpartum Maternal Care and Danger Signs

The FIRST TWO HOURS after delivery is called the FOURTH STAGE OF LABOR. This is the MOST CRITICAL PERIOD for maternal mortality — most maternal deaths from PPH occur in this window. The midwife's role is continuous monitoring, early detection of complications, and timely referral. IMMEDIATE POSTPARTUM CARE STEPS: 1. PERINEAL INSPECTION AND REPAIR: - Inspect the perineum, vaginal walls, and cervix for lacerations under good lighting. - DEGREES OF PERINEAL TEARS: • 1st degree: Skin only — may heal without sutures or with simple repair • 2nd degree: Skin + perineal muscles (not the sphincter) — repair by the midwife • 3rd degree: Extends into the anal sphincter — REFER • 4th degree: Through the anal sphincter into the rectal mucosa — REFER - The midwife may independently repair 1st and 2nd degree tears. - 3rd and 4th degree tears require surgical repair at a hospital — REFER IMMEDIATELY. - Also repair episiotomy wound if episiotomy was performed. 2. UTERINE MONITORING: - Ensure the uterus remains FIRM AND CONTRACTED (palpate the fundus — it should feel like a firm ball at the umbilicus level). - A SOFT, BOGGY uterus = UTERINE ATONY = the most common cause of PPH. - If the uterus is boggy: MASSAGE FIRMLY, ensure bladder is empty, check for bleeding. - A FULL BLADDER can displace the uterus and prevent it from contracting properly. 3. VITAL SIGNS MONITORING — EVERY 15 MINUTES FOR THE FIRST 2 HOURS: - Blood pressure, pulse rate, respiratory rate - Increasing pulse (tachycardia) + decreasing BP = HEMORRHAGIC SHOCK → REFER IMMEDIATELY - Temperature checked at 1 and 2 hours 4. LOCHIA MONITORING: - Lochia is the postpartum vaginal discharge (blood, mucus, decidua). - Normal: Lochia RUBRA (red) for the first 3–4 days - Abnormal: Foul-smelling lochia (infection), excessive flow, or passing large clots = REFER 5. BREASTFEEDING AND NON-SEPARATION (EINC): - Keep the mother and baby together (NON-SEPARATION), skin-to-skin. - Initiate breastfeeding within the FIRST HOUR of birth (Unang Yakap / EINC core step). - Breastfeeding causes the release of NATURAL OXYTOCIN (from the posterior pituitary) which keeps the uterus contracted — it is the most natural PPH prevention. 6. COMFORT AND HYDRATION: - Ensure the mother is warm, dry, and comfortable. - Offer oral fluids and food. - Ensure she has voided — monitor the first void after delivery. DANGER SIGNS REQUIRING REFERRAL: - Heavy or continuous bright red bleeding (soaking >1 pad in 5 minutes) - Soft, boggy uterus that will NOT stay contracted despite massage - Rising pulse rate (>100 bpm), falling blood pressure, pallor, cold clammy skin, dizziness = SHOCK - Retained placenta (not delivered within 30 minutes) - Incomplete placenta or membranes on inspection - 3rd or 4th degree perineal tear - Prolonged second stage or obstructed labor (refer during labor)

A LOOSE nuchal cord (you can slip fingers under it) is simply slipped over the head. This is the most common scenario. A TIGHT cord (cannot be slipped) would require the somersault maneuver. Never clamp and cut a loose nuchal cord routinely — this would unnecessarily cut off placental transfusion.

Uterine inversion is an obstetric emergency caused by cord traction without adequate counter-traction. The counter-traction hand pushes the uterus UPWARD while the cord traction pulls DOWNWARD — keeping them working in opposite directions maintains uterine position. This is why the counter-traction step is NON-NEGOTIABLE in CCT.

This is the classic 'rule out second baby before oxytocin' safety check. Giving oxytocin to a mother with an unborn second twin would cause a powerful, sustained uterine contraction that could trap and suffocate the second baby. This abdominal palpation step is always the FIRST action before any uterotonic.

A torn, rough, or missing cotyledon is the classic sign of an incomplete placenta. Retained fragments cause PPH and infection. The midwife's role is to detect this through systematic inspection and refer. Manual removal of retained placenta (MROP) is done at a CEmONC facility, not at BHS/RHU level.

A uterus displaced to the right of midline in the early postpartum period almost always indicates a full bladder. A full bladder prevents the uterus from contracting normally. Address the bladder first, then reassess. If massage and bladder emptying do not restore a firm uterus, this is PPH from uterine atony → refer.

EINC/WHO evidence shows that prolonged Valsalva pushing reduces oxygen delivery to the baby and is associated with more severe perineal tears. Spontaneous bearing-down is effective, gentler on the perineum, and better for the baby.