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

Exam Tips

• PRC boards frequently ask: 'Which cardinal movement is responsible for the actual birth of the fetal head?' Answer: EXTENSION.
• Which movement presents the smallest fetal head diameter? FLEXION (suboccipitobregmatic ~9.5 cm).
• The correct ORDER is heavily tested — memorize the mnemonic: Every Doting Filipino In-law Expects Roasted Eel.
• Internal rotation occurs in the MID-pelvis (at the level of the ischial spines).
• The head is born by EXTENSION — not flexion. Do not reverse these.

Key Points

• The cardinal movements describe how the fetal head adapts to the shape and changing diameters of the maternal pelvis during descent through the birth canal.
• The order is: Engagement → Descent → Flexion → Internal Rotation → Extension → Restitution (External Rotation) → Expulsion.
• Mnemonic: 'Every Doting Filipino In-law Expects Roasted Eel' — Engagement, Descent, Flexion, Internal rotation, Extension, Restitution, Expulsion.
• Engagement: The widest part of the presenting part (biparietal diameter, ~9.5 cm) passes through the pelvic inlet (linea terminalis).
• Descent: Downward movement of the fetus throughout the entire labor — it does NOT stop between contractions.
• Flexion: The chin tucks onto the chest; the presenting diameter becomes the suboccipitobregmatic (~9.5 cm), the SMALLEST diameter of the fetal head.
• Internal Rotation: The occiput rotates toward the symphysis pubis (from transverse to anteroposterior), aligning the fetal head with the pelvic outlet.
• Extension: The head EXTENDS under the pubic arch; this is the actual mechanism by which the head is BORN — occiput first, then bregma, forehead, face, then chin.
• Restitution / External Rotation: After birth of the head, it rotates back to align with the fetal shoulders.
• Expulsion: Anterior shoulder born first (under symphysis), then posterior shoulder (over perineum), then the rest of the body.
• Good flexion is critical — it presents the SMALLEST diameter and prevents perineal tears.

Definitions

Section Title

The Seven Cardinal Movements of Labor

Common Mistakes

• Confusing 'extension' (mechanism by which the HEAD IS BORN) with 'flexion' (mechanism that REDUCES the presenting diameter). Students often mix these up.
• Saying the occiput rotates POSTERIORLY during internal rotation — it rotates ANTERIORLY toward the symphysis pubis.
• Forgetting that descent occurs THROUGHOUT labor, not just in the second stage.
• Mixing up restitution and internal rotation — restitution happens AFTER the head is born; internal rotation happens BEFORE.

Exam Tips

• EINC newborn corner = warm surface + TWO clean dry cloths. If the exam asks 'how many cloths,' the answer is TWO.
• Oxytocin must be drawn up and ready BEFORE delivery — given within 1 minute of birth.
• Routine dorsal lithotomy = ELIMINATED by EINC. Upright/lateral positions are PREFERRED.
• A full bladder must be emptied before active pushing — remember this as a preparation step.
• The EINC/Unang Yakap 4 core practices: (1) Immediate drying, (2) Skin-to-skin contact, (3) Properly timed cord clamping, (4) Non-separation and breastfeeding support.

Key Points

• Delivery is imminent when: presenting part no longer recedes between contractions, perineum bulges visibly, anus gapes, and mother has an uncontrollable urge to push (second stage, fully dilated at 10 cm).
• CONFIRM full dilatation (10 cm) before allowing active pushing — premature pushing wastes energy and causes cervical edema.
• Strict aseptic technique: wash hands thoroughly, don sterile gloves, use sterile delivery set.
• EINC newborn corner preparation: clean, dry, warm surface (not cold table); prepare TWO clean, dry cloths — one for initial drying, one for covering. This is a core Unang Yakap readiness step.
• Have Oxytocin 10 IU drawn up and ready BEFORE the head crowns — timing is critical for AMTSL.
• Encourage the mother to empty her bladder before the second stage — a full bladder impedes descent and increases risk of PPH.
• Maternal positioning: allow the woman to choose — upright, side-lying, squatting, semi-sitting. EINC discourages routine flat dorsal lithotomy.
• Upright and lateral positions use gravity, reduce aortocaval compression, and are associated with fewer severe (3rd/4th-degree) perineal tears.
• Never leave the mother unattended during the second stage.

Definitions

Section Title

Preparing for Delivery — EINC Readiness

Common Mistakes

• Allowing the mother to push before confirming full dilatation — always confirm 10 cm first.
• Forgetting to draw up oxytocin BEFORE delivery — the drug must be given within ONE MINUTE of birth.
• Preparing only ONE cloth for the newborn — EINC requires TWO (one to dry, one to cover).
• Placing the mother in the flat lithotomy position routinely — this is an EINC-eliminated practice.
• Leaving the delivery room or area to get supplies after crowning — everything must be ready BEFORE.

Exam Tips

• The answer 'episiotomy is performed routinely' is ALWAYS WRONG in a PRC board context. It is performed only on SPECIFIC indications.
• Routine suctioning of the mouth and nose = ELIMINATED by EINC. Only suction if the baby is NOT breathing and fluids are NOT clear.
• When asked about nuchal cord management: loose = slip over head; tight = somersault maneuver; only cut if truly cannot be reduced.
• The 'hands-on' technique (Ritgen/perineal support) is the PREFERRED approach for reducing perineal tears.
• Panting between contractions at crowning = slows head delivery = fewer tears. This is a high-yield clinical application.

Key Points

• The MOST IMPORTANT skill during NSD is controlling the SPEED of the fetal head as it is born — preventing it from 'popping' out suddenly.
• Encourage spontaneous, gentle bearing-down WITH contractions. Avoid prolonged Valsalva (breath-holding, purple pushing) — EINC promotes spontaneous bearing-down.
• As the head crowns: apply gentle pressure over a cloth on the OCCIPUT to keep the head FLEXED and slow its advance.
• Between contractions: ask the mother to PANT (short, shallow breaths) instead of pushing — this slows birth of the head and gives the perineum time to stretch.
• Perineal support (Ritgen-like maneuver): support the perineum with the OTHER hand using a clean pad as the head extends. This 'hands-on' technique reduces 3rd- and 4th-degree tears.
• EPISIOTOMY IS NOT ROUTINE — perform ONLY on specific indications: imminent severe tear, fetal distress requiring rapid delivery, or certain assisted deliveries. Routine episiotomy is an EINC-eliminated practice.
• After the head is born and performs restitution, CHECK FOR NUCHAL CORD by gently feeling around the baby's neck.
• Nuchal cord: LOOSE — slip over the head gently. TIGHT — use the SOMERSAULT MANEUVER (deliver the body through the loop, keeping the baby close to the perineum). Only clamp and cut a tight cord that truly cannot be reduced.
• Routine suctioning of the mouth and nose is NOT done for babies born in clear liquor who are breathing/crying — this is an EINC-eliminated procedure.
• After the head is born: wipe the face, check for cord, then wait for the next contraction for shoulder delivery.

Definitions

Section Title

Controlled Delivery of the Head — Hands-On Technique

Common Mistakes

• Letting the head 'pop out' quickly — always control the speed with counter-pressure on the occiput.
• Telling the mother to push hard and hold her breath (Valsalva) — EINC recommends spontaneous bearing-down.
• Forgetting to check for a nuchal cord after head delivery — this is a routine step every time.
• Clamping and cutting a loose nuchal cord — a loose cord should simply be slipped over the head.
• Performing routine episiotomy — this is a very common wrong answer on the boards. Episiotomy is NOT routine.
• Performing routine suctioning of airway — this is ELIMINATED by EINC for a baby in clear liquor who is crying.

Exam Tips

• PRC exam question: 'When should the umbilical cord be clamped?' Answer: After cord pulsations have stopped (delayed/properly timed clamping), NOT immediately.
• EINC eliminated practice: immediate bathing, immediate cord clamping, routine suctioning, separation of mother and baby in first 90 minutes.
• Two cloths: FIRST cloth = for drying (becomes wet, then REMOVED). SECOND cloth = for covering (stays dry and warm).
• Delivery sequence: anterior shoulder (downward traction) FIRST, then posterior shoulder (upward traction) SECOND.
• Time of birth must be announced and recorded — this is always correct on the exam.

Key Points

• With the NEXT contraction after the head is born, apply GENTLE DOWNWARD traction on the head to deliver the ANTERIOR shoulder from under the symphysis pubis.
• Then apply GENTLE UPWARD traction to deliver the POSTERIOR shoulder over the perineum. Support the perineum throughout.
• Deliver the body slowly with a firm grasp — babies are slippery and can be dropped.
• DO NOT apply fundal pressure to deliver the baby — this is dangerous and can worsen shoulder dystocia, cause uterine rupture, or cause inversion.
• Note and announce the EXACT TIME OF BIRTH — this is a legal and clinical requirement.
• EINC STEP 1 — Immediate and Thorough Drying: Place the baby PRONE on the mother's abdomen/chest and DRY IMMEDIATELY and THOROUGHLY for 30 seconds using the first dry cloth. This stimulates breathing, prevents hypothermia, and IS the initial newborn assessment.
• After drying, REMOVE the WET cloth and replace with the DRY second cloth. A wet cloth causes hypothermia.
• EINC Step 2 — Skin-to-skin contact: Keep the baby on the mother's chest, skin-to-skin, for at least 90 minutes.
• EINC Step 3 — Properly timed cord clamping: Clamp and cut the cord ONLY AFTER it has stopped pulsating (approximately 1–3 minutes after birth) or when pulsations stop.
• EINC Step 4 — Breastfeeding: Support early breastfeeding within the first hour (the 'Golden Hour').
• Non-separation of mother and baby: the newborn must NOT be separated from the mother to be weighed, measured, or bathed during the first 90 minutes.

Definitions

Section Title

Delivery of the Shoulders and Body — EINC Immediate Newborn Care

Common Mistakes

• Applying fundal pressure to speed up delivery — this is PROHIBITED and dangerous.
• Cutting the cord immediately after birth — this is an EINC-eliminated practice. Wait for pulsations to stop.
• Separating the baby from the mother immediately to weigh or measure — the baby must stay skin-to-skin for at least 90 minutes.
• Forgetting to remove the wet drying cloth and replace it with a dry one — the wet cloth causes rapid heat loss.
• Forgetting to announce and record the EXACT time of birth.

Formulas

Exam Tips

• AMTSL sequence on the boards: RULE OUT TWIN → Oxytocin 10 IU IM within 1 min → CCT with counter-traction → Uterine massage after placental delivery.
• Drug of choice for AMTSL = OXYTOCIN 10 IU IM. Misoprostol 600 mcg oral = alternative if no oxytocin.
• Ergometrine is CONTRAINDICATED in hypertension — this is a classic PRC board question.
• Counter-traction (above the symphysis) prevents UTERINE INVERSION during CCT — extremely high-yield.
• PPH = ≥500 mL blood loss after vaginal delivery. Monitor fundal tone and lochia every 15 minutes for 2 hours.
• Never apply fundal pressure to deliver the placenta — use CCT with counter-traction.

Key Points

• AMTSL is the EVIDENCE-BASED STANDARD for preventing Postpartum Hemorrhage (PPH) — the leading cause of maternal death in the Philippines and globally.
• AMTSL has THREE components: (1) Uterotonic drug, (2) Controlled Cord Traction (CCT) with counter-traction, (3) Uterine massage after placental delivery.
• COMPONENT 1 — UTEROTONIC: Give OXYTOCIN 10 IU IM within ONE MINUTE of the baby's birth. This is the drug of CHOICE.
• CRITICAL STEP: BEFORE giving any uterotonic — PALPATE THE ABDOMEN to RULE OUT A SECOND BABY (undiagnosed twin). Giving a uterotonic with a second baby in the uterus can trap it.
• If oxytocin is unavailable: Misoprostol 600 mcg ORALLY is the alternative.
• Ergometrine / Methylergometrine 0.2 mg IM: effective but CONTRAINDICATED in hypertension and pre-eclampsia (causes vasospasm and can dangerously raise BP).
• COMPONENT 2 — CONTROLLED CORD TRACTION (CCT / Brandt-Andrews Maneuver): Wait for signs of placental separation (gush of blood, cord lengthens, uterus rises and becomes globular), then apply steady gentle downward cord traction with ONE hand while the OTHER hand applies COUNTER-TRACTION just ABOVE the symphysis pubis to prevent uterine INVERSION.
• If the placenta does not descend in 30–40 seconds — STOP, wait for the next contraction, then repeat. NEVER yank the cord.
• As the placenta appears at the vagina, deliver it gently with both hands and twist the membranes into a rope to peel them out intact.
• COMPONENT 3 — UTERINE MASSAGE: Massage the fundus through the abdomen IMMEDIATELY after placental delivery until it is firm and well-contracted.
• Continue checking fundal firmness EVERY 15 MINUTES for the FIRST 2 HOURS after delivery.
• Teach the mother to feel and massage her own fundus — empowers her to self-monitor.
• Current WHO guidance: the uterotonic (oxytocin) is the ESSENTIAL component; CCT is performed by skilled attendants when possible.

Definitions

Section Title

Active Management of the Third Stage of Labor (AMTSL)

Common Mistakes

• Giving oxytocin WITHOUT first palpating to rule out a second baby — this is a life-threatening error.
• Giving ergometrine to a hypertensive mother — ergometrine is CONTRAINDICATED in hypertension.
• Pulling the cord without applying counter-traction — can cause uterine inversion.
• Applying FUNDAL PRESSURE (Credé maneuver) to deliver the placenta — this is dangerous and not recommended; use CCT with counter-traction instead.
• Not massaging the uterus after placental delivery — the uterus must be firmly contracted to prevent PPH.
• Forgetting to re-check the fundus every 15 minutes for the first 2 hours.
• Yanking the cord — always use steady, GENTLE, sustained traction.

Exam Tips

• Normal cord vessels = 2 ARTERIES + 1 VEIN. Boards love this. Single umbilical artery = renal anomaly screening.
• Suspect succenturiate lobe when: a vessel on the fetal side runs to the membrane edge and STOPS — no tissue at the end.
• Suspect retained fragment when: a cotyledon on the maternal side is MISSING or the surface is not complete.
• ANY doubt about placenta completeness = retained tissue = REFER.
• Blood loss ≥500 mL after vaginal delivery = PPH = act and refer.

Key Points

• ALWAYS inspect the placenta and membranes IMMEDIATELY after delivery — retained placental fragments cause hemorrhage and infection (puerperal sepsis).
• A SYSTEMATIC inspection has four parts: (1) Maternal surface (cotyledons), (2) Fetal surface and vessels, (3) Membranes, (4) Umbilical cord.
• MATERNAL SURFACE (cotyledon side): Examine all cotyledons. They should be intact and fit together like puzzle pieces with no missing areas. A missing cotyledon = suspect RETAINED PLACENTAL FRAGMENT → refer.
• FETAL SURFACE (shiny, amnion side): Trace the blood vessels from the insertion point. A blood vessel running to the MEMBRANE EDGE and STOPPING abruptly (no placental tissue there) = SUCCENTURIATE LOBE (accessory lobe) left inside the uterus → refer.
• MEMBRANES: Check that both the amnion (inner layer) and chorion (outer layer) are complete and intact.
• UMBILICAL CORD: Count the vessels — a NORMAL cord has TWO ARTERIES and ONE VEIN (2 arteries + 1 vein = 3 vessels total). A single umbilical artery (SUA) may be associated with fetal renal anomalies.
• ESTIMATE AND RECORD BLOOD LOSS — Normal: <500 mL. PPH: ≥500 mL.
• If any doubt about completeness of the placenta or membranes → treat as retained tissue → REFER to higher facility.
• A normal placenta weighs approximately 500 g and measures 15–20 cm in diameter.

Definitions

Section Title

Placental Inspection — Ensuring Completeness

Common Mistakes

• Failing to inspect the placenta systematically — incomplete inspection misses retained fragments.
• Confusing the fetal surface with the maternal surface: MATERNAL = rough, dull, dark red (cotyledons); FETAL = shiny, smooth, glistening (covered by amnion).
• Saying the normal cord has '2 veins and 1 artery' — it is TWO ARTERIES and ONE VEIN.
• Discarding the placenta before the full inspection is complete.
• Not recording blood loss — estimated blood loss must be documented.

Exam Tips

• Monitor VS and fundal tone every 15 minutes for 2 hours = the '4th stage of labor' monitoring protocol. Very commonly tested.
• Soft, boggy uterus = uterine ATONY = #1 cause of PPH. Massage, give uterotonic, refer.
• 3rd and 4th degree tears = REFER (involves anal sphincter or rectal mucosa). 1st and 2nd = midwife may repair.
• Encourage breastfeeding immediately — natural oxytocin = uterine contraction = PPH prevention.
• The 4 T's of PPH: Tone, Tissue, Trauma, Thrombin. TONE (atony) is the most common cause.

Key Points

• The FIRST 2 HOURS after delivery is the HIGHEST-RISK window for PPH — the midwife must NOT leave the mother during this time.
• Monitor VITAL SIGNS (BP, PR, RR, Temperature) every 15 minutes for the first 2 hours.
• Assess FUNDAL TONE every 15 minutes for the first 2 hours — the fundus should be FIRM (contracted), midline, at or below the level of the umbilicus.
• A SOFT, BOGGY UTERUS = uterine atony = leading cause of PPH → massage immediately, give additional uterotonic, REFER if unresolved.
• Monitor LOCHIA (vaginal discharge) — should be lochia rubra (red, mixed blood and decidua). Heavy, continuous bleeding = PPH → refer.
• INSPECT PERINEUM for lacerations: 1st-degree (skin only) and 2nd-degree (skin + muscle, not sphincter) tears are within the midwife's scope to repair. 3rd-degree (anal sphincter involved) and 4th-degree (rectal mucosa involved) tears MUST BE REFERRED.
• Encourage EARLY BREASTFEEDING — suckling stimulates endogenous oxytocin release, which helps the uterus contract and reduces PPH risk.
• Keep mother and baby TOGETHER (non-separation EINC principle) — skin-to-skin for at least 90 minutes.
• Ensure the mother has VOIDED — a full bladder displaces the uterus and prevents proper contraction.
• Keep the mother WARM, CLEAN, COMFORTABLE, and adequately HYDRATED.
• Teach the mother to feel and massage her own fundus for self-monitoring.
• Documentation: complete all records — date/time of birth, APGAR score, maternal VS, blood loss, medications given, procedures done.

Definitions

Section Title

Immediate Maternal Care — The Fourth Stage (First 2 Hours Postpartum)

Common Mistakes

• Leaving the mother alone in the first 2 hours — the midwife must stay and monitor.
• Not checking whether the mother has voided — a full bladder prevents uterine contraction.
• Attempting to repair 3rd- or 4th-degree tears independently — these MUST be referred.
• Not teaching the mother fundal self-massage — this is an important empowerment and safety step.
• Separating the baby from the mother to weigh, measure, or bathe in the first 90 minutes — EINC violation.

Exam Tips

• Retained placenta = not delivered in 30 minutes = REFER. Do not attempt manual removal at the BHS.
• Signs of shock: PR >100, SBP <90, pallor, cold clammy skin = REFER with IV access and rapid transport.
• 3rd/4th degree tear, incomplete placenta, retained placenta, uncontrolled PPH, obstructed labor = ALL REFER.
• The midwife's role with complications = DETECT early + STABILIZE + REFER promptly. This framing is always correct.
• Prolonged second stage: >2 hours (nullipara) or >1 hour (multipara) without descent = obstructed labor = REFER.

Key Points

• The midwife's role is to DETECT complications early and REFER promptly — do not attempt to manage obstetric emergencies beyond your scope at the BHS or lying-in.
• REFER IMMEDIATELY if you observe: heavy or continuous vaginal bleeding not controlled by massage and oxytocin.
• REFER if: the uterus is soft and boggy and DOES NOT FIRM UP with massage (uterine atony unresponsive to initial measures).
• REFER if: the placenta is not delivered within 30 minutes (retained placenta) — do not attempt manual removal at the BHS.
• REFER if: the placenta appears incomplete (missing cotyledon, suspected succenturiate lobe, incomplete membranes).
• REFER if: rising pulse rate, falling blood pressure, pallor, cold clammy skin, dizziness — these are signs of HYPOVOLEMIC SHOCK.
• REFER if: a 3rd- or 4th-degree perineal tear is identified.
• REFER if: the second stage of labor is prolonged with no descent (obstructed labor) — prolonged second stage: >2 hours in nulliparas, >1 hour in multiparas, with or without regional anesthesia.
• REFER if: any sign of obstructed labor (pathological retraction ring, severe caput, moulding).
• Before referral: stabilize the patient (IV access, maintain airway if needed), give first aid as appropriate, document, communicate with receiving facility, and accompany if possible.
• REMEMBER: A midwife who refers promptly saves a life. Delayed referral is a leading contributor to maternal death.

Definitions

Section Title

Danger Signs Requiring Referral — When to Escalate

Common Mistakes

• Waiting too long before referring — early referral saves lives. Do not wait for the patient to deteriorate.
• Attempting manual removal of a retained placenta at the BHS without proper training and facilities.
• Not establishing IV access before referring a patient in shock — give IV fluids while transferring.
• Failing to document and communicate with the receiving facility before transport.
• Continuing to attempt delivery in obstructed labor instead of referring.