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

As the fetus descends through the birth canal, it must navigate a constantly changing pelvic architecture. The head rotates, flexes, and extends in a precise sequence to adapt to the widest and narrowest diameters of the maternal pelvis. Understanding these cardinal movements tells you what should be happening at each stage of labor and alerts you to descent problems early. **The Seven Cardinal Movements (in order):** **Engagement** — The biparietal diameter (the widest part of the fetal head, measured between the two parietal bones) passes through the pelvic inlet. Engagement is confirmed when the lowest point of the skull reaches the level of the ischial spines (station 0 or below the level of the spines). In a primigravida, engagement often occurs in the last 2 weeks before labor; in multiparas, it may occur during labor itself. **Descent** — Continuous downward movement of the fetus through the pelvis, occurring throughout labor and accelerating in the second stage. Progress is measured by station (the position relative to the ischial spines: -5 to 0 = above spines, +1 to +5 = below spines, +5 = at the introitus). **Flexion** — The fetal chin tucks firmly onto the chest. This presents the smallest diameter of the head — the **suboccipitobregmatic diameter** (approximately 9.5 cm) — compared to a deflexed head which presents a larger diameter (occipitofrontal, ~11.5 cm). Good flexion is maintained by the resistance of the pelvic floor and uterine contractions; poor flexion is a sign of possible cephalopelvic disproportion (CPD) or asynclitism (tilting of the head). **Internal Rotation** — The occiput (back of the head) rotates anteriorly toward the symphysis pubis, and the face rotates posteriorly toward the sacrum. This rotation occurs as the head descends; it aligns the widest diameter of the head (the biparietal) with the widest diameter of the maternal pelvis at the level of the ischial spines. In the majority of cases, a vertex (well-flexed) presentation rotates from right occiput transverse (ROT) or left occiput transverse (LOT) to occiput anterior (OA) before crowning. Internal rotation is a critical movement; failure to rotate suggests obstruction or a non-vertex presentation and requires evaluation for referral. **Extension** — Under the pubic arch, the head extends (tips backward). The occiput escapes under the symphysis pubis first, then the bregma (top of the head), forehead, nose, and finally the chin emerge. **This is the mechanism by which the head is actually born.** The perineal body stretches around the extending head; a slowly extended head causes less trauma than rapid extension. **External Rotation (Restitution)** — After the head is born, it rotates back (restitutes) to realign with the shoulders as they rotate and descend internally. This returns the head to face the thigh (usually the right thigh in a left occiput anterior delivery). **Expulsion** — With the next contraction, the anterior shoulder (the one under the symphysis pubis) is delivered first, followed by the posterior shoulder, and then the body follows easily. **Memory Aid:** **E-D-F-I-E-R-E** (Engagement, Descent, Flexion, Internal rotation, Extension, Restitution, Expulsion). Practice visualizing these movements; doing so helps you recognize when labor is progressing normally and when something is amiss.

Second stage labor begins at full dilatation (10 cm) and ends with delivery of the baby. The length of the second stage depends on parity, anesthesia, and maternal effort. Once full dilatation is confirmed and descent is evident, delivery is imminent when the presenting part no longer recedes between contractions. **Signs of Imminent Delivery:** - **The perineum bulges visibly** with contractions and no longer returns to resting position between contractions. - **The anus gapes and shows visible puckering** as the head presses on the pelvic floor. - **The presenting part is visible at the introitus without separating the labia** — the head does not slip back inside after a contraction. - **The mother feels a strong urge to push** and the involuntary bearing-down reflex is strong. - **Caput succedaneum (swelling of the scalp) and molding of the skull bones** are evident (assessed by feeling the fontanels and sutures during a vaginal exam). **Preparation Steps — Hands-on Readiness:** 1. **Confirm full dilatation and appropriate station** — perform a vaginal examination to rule out a cervical lip, check for a palpable cord, and assess fetal position. Do not allow pushing until full dilatation is confirmed; pushing against a partially dilated cervix causes cervical edema and increases risk of cervical tears. 2. **Wash hands thoroughly with soap and running water,** don sterile gloves or high-level disinfected gloves if sterile are unavailable (context-appropriate for RHU/lying-in), and observe strict aseptic technique throughout delivery. Hand hygiene is a non-negotiable EINC standard. 3. **Prepare the newborn corner** — this is a critical EINC readiness step, often checked during simulation exams. Ensure: - A clean, dry, warm surface (e.g., a crib with a clean sheet or the mother's abdomen/chest for skin-to-skin). - **Two clean, dry cloths** within reach — one for drying the baby immediately and one for keeping the baby warm. - A plastic resuscitation bag (or bulb syringe if bag unavailable) and mask in case stimulation/suction is needed. - Oxytocin 10 IU drawn up and within arm's reach, along with a 1 mL syringe and needle (or pre-filled syringe if available). - Delivery set (sterile scissors, clamps or ties, cord cutting tray) easily accessible. 4. **Empty the bladder** — a full bladder blocks descent and increases risk of urinary injury and postpartum retention. Encourage the mother to void. If she cannot void and the bladder is palpably distended, a straight catheterization may be necessary; this is within the midwife's scope under EINC guidelines, but only when clinically indicated (not routine). 5. **Position the mother comfortably** and ensure good visualization of the perineum. The midwife must be able to see and support the perineal tissues throughout delivery. 6. **Place absorbent pads or a clean drape under the mother's buttocks** to keep the environment clean and prevent contamination. Have extra cloths at hand for drying and wiping. **Second Stage Duration (Normal Limits):** - **Primigravida without regional anesthesia:** up to 2 hours. - **Primigravida with epidural anesthesia:** up to 3 hours (with expectant management and descent) or 2 hours if active pushing. - **Multiparous women:** up to 1 hour without anesthesia, up to 2 hours with. **Referral Indicators:** - No descent after 1 hour of strong pushing in a primigravida (2 hours if using regional anesthesia) without descent despite adequate uterine contractions. - Pathological partograph findings (crossing alert or action line in second stage). - Signs of obstructed labor: excessive caput, severe molding, bandl's ring (upper segment contraction).

The position a mother assumes during labor and delivery affects gravity, pelvic diameter, uterine contractions, comfort, and perineal stretch. RA 7392 and EINC emphasize **freedom of movement and maternal choice,** moving away from the routine lithotomy position which has been questioned in modern practice. **Why Positioning Matters:** - **Upright and lateral positions use gravity,** assisting descent of the fetus and often shortening the second stage. - **Supine (flat on the back) and lithotomy positions compress the aorta and vena cava,** reducing placental perfusion and potentially causing maternal hypotension, fetal bradycardia, and reduced effectiveness of contractions. - **Supported semi-recumbent and lateral positions reduce perineal trauma** compared to lithotomy, especially when combined with controlled head delivery and perineal support. - **Upright positions (standing, squatting, kneeling) widen the pelvic outlet** and may facilitate internal rotation and descent. - **Maternal comfort and psychological well-being** improve when the mother chooses her position and moves freely during labor. **Recommended Positions (EINC-aligned):** 1. **Upright (standing or kneeling)** — Uses gravity fully, promotes descent, and allows movement. The mother can lean on a support person, cling to a labor bar, or squat. Effective for descent and internal rotation. Drawback: perineum less visible to the attendant; the mother may fatigue if standing long hours. 2. **Squatting** — Opens the pelvic outlet to its maximum and uses gravity. Excellent for the second stage. Risk: difficult to monitor if the midwife cannot position well; the mother may slip on a wet floor. 3. **Semi-sitting (supported upright with pillows behind the back and shoulders)** — Allows the mother to see her baby being born, provides some gravity assistance, and keeps the perineum accessible. Very practical in most settings (RHU, lying-in). This is often the default position in Philippine practice. 4. **Side-lying (left or right lateral position)** — Reduces perineal pressure and tears, improves blood flow to the placenta, and is restful for a tired mother. The perineum is fully accessible. Excellent for the second stage and delivery. The mother can be on the left side (to optimize placental perfusion) or right side, whichever is comfortable. 5. **Left occiput lateral (LOL) or right occiput lateral (ROL) — hands and knees** — Reduces pressure on perineum and may help with shoulder dystocia or fetal malposition. Useful if the baby is in a posterior position or if the mother wants to change position mid-delivery. **Positions to AVOID:** - **Supine (flat on back, no support).** This position compresses major vessels, reduces placental perfusion, and is associated with more severe perineal trauma. It is also uncomfortable and does not use gravity. - **Lithotomy (legs in stirrups).** Routine lithotomy is discouraged by EINC/WHO. It restricts movement, increases aortocaval compression, and is associated with increased perineal trauma. Reserve it only if there are specific clinical reasons (e.g., need for instrumental delivery, specific tear repair). **Practical Midwifery Approach:** - **Ask the mother what position feels comfortable.** Trust her instinct; movement and position changes are therapeutic. - **Offer alternatives.** Some mothers do not know what options exist; a sentence like "Would you like to try sitting up, lying on your side, or squatting?" empowers choice. - **Adjust for visibility.** Whatever position the mother chooses, ensure the perineum is visible and accessible so you can support it during delivery. If the perineum is not visible (e.g., in an all-fours position), reposition or use tactile assessment. - **For delivery specifically,** many mothers naturally shift to a semi-sitting or side-lying position when the head crowns; this is normal. Follow her lead. - **Document the position** in which delivery occurred. **Example in Philippine Context:** A mother in labor at a rural RHU sits on the edge of a delivery bed, leaning against her partner. She rocks slightly with each contraction. When full dilatation is reached and she begins pushing, she remains in a supported sitting position, which allows gravity to assist and keeps her perineum accessible to you. She feels empowered by choosing her position, the baby descends well, and the second stage lasts 45 minutes — a normal duration.

The single most important skill in minimizing perineal trauma (tears) and protecting the newborn from intracranial injury is **controlling the speed at which the fetal head emerges from the perineum.** A head delivered too rapidly ("popping out") causes acute overstretching of the perineal tissues, leading to third- and fourth-degree tears, and puts pressure on the newborn's skull and intracranial structures. Conversely, a head delivered too slowly (held back excessively) is uncomfortable and may reduce placental blood flow if cord compression occurs. The goal is **slow, controlled delivery with perineal support.** **The Four Key Principles of Head Delivery:** **1. Encourage Gentle, Spontaneous Pushing (Not Directed, Forceful Valsalva)** INEC and modern midwifery practice distinguish between: - **Spontaneous pushing:** The mother bears down involuntarily when she feels the urge to push, using her own effort and breathing pattern. She may push for 5–10 seconds, release, breathe, and push again with the next urge. This is **maternal-controlled** and is the preferred style. - **Directed pushing (or coached Valsalva pushing):** An attendant counts to 10 while the mother performs a prolonged breath-hold and forced push. This style was historically common but increases maternal hypotension, fetal hypoxia, and perineal trauma, and is no longer encouraged routinely. **EINC Recommendation:** Support spontaneous, non-directed pushing. This allows the mother to regulate her own effort, is less exhausting, and is associated with fewer perineal tears and better fetal oxygenation. **2. Apply Gentle Occiput Pressure — Keep the Head Flexed and Advancing Slowly** As the head crowns (the widest part of the skull bulges at the introitus), place one hand (with a clean, dry cloth to prevent slipping) on the **occiput (back of the head).** Apply gentle, steady pressure in the direction of the birth canal (angling slightly downward and backward toward the coccyx). This pressure: - **Maintains flexion** of the head, keeping the smallest diameter (suboccipitobregmatic) presenting. - **Controls the speed of advance,** preventing the head from "popping out" suddenly. - **Prevents extension from happening too rapidly** before the perineum has time to stretch. The pressure should be **gentle and continuous, not forceful or repetitive.** You are not pushing the head out; you are **slowing its emergence and guiding it.** Between contractions, ease off the pressure so the head rests, allowing the perineum to stretch. **3. Coach the Mother to Pant or Breathe, Not Push, Between Contractions** This is a critical technique often tested on the PRC MLE. Between contractions (in the last moments of crowning): - **Tell the mother, "Pant, pant, pant" or "Breathe, breathe, breathe"** — small, quick breaths through the mouth. - Do NOT tell her to push or bear down. - This voluntary controlled breathing relaxes the perineal muscles and slows the exit of the head, giving the tissues maximum time to stretch. - Panting also prevents the mother from reflexively holding her breath and pushing, which would cause rapid head delivery. **Technique in Action:** As the head crowns and the perineum is maximally stretched, a contraction builds. The mother begins to push. You support her effort for the first 5–8 seconds, then say, "Stop pushing, pant, pant, pant. Breathe with me." She shifts to quick breathing, the perineal tissues are no longer being forcefully pushed, and the head advances slowly due to the residual contraction and your occiput pressure. As the contraction weakens, the head rests. The next contraction comes, you encourage a gentle push, and the cycle repeats until the head is fully delivered. **4. Perineal Support (Ritgen Maneuver) — Guard the Tissue and Control Extension** The **Ritgen maneuver** or modified Ritgen maneuver is the hands-on technique that, combined with occiput pressure, provides full perineal support. This is a procedural skill essential to your role as an independent delivery attendant. **Standard Ritgen Maneuver (two-handed perineal support):** - With **one hand on the occiput** (as described above), use your **other hand (with a clean, dry pad or cloth) to support the perineum** from below and behind. - Place your fingers (index and middle) **inside the vagina, just below the symphysis pubis,** and your thumb **behind the perineum (between the vagina and anus).** - As the head extends, your thumb and fingers guide the extending head through the introitus, **stretching and supporting the perineal body,** vaginal tissue, and the area between the vagina and anus. - Your downward pressure on the perineum **"splints" the tissue,** preventing sudden tearing, and guides the head smoothly through. - As the occiput emerges under the symphysis pubis, you angle your hand upward slightly to support the bregma, forehead, and face as they emerge. **Modified Ritgen (one-handed perineal support):** Some midwives use a modified approach: - One hand on the occiput as before. - The other hand (with a cloth) placed **externally on the perineum,** pressing gently downward and forward as the head extends. - This external support is gentler and is often preferred in modern EINC practice, especially when the perineum is stretching well. **Whether you use standard or modified Ritgen, the goal is the same: support and guide the perineum as the head exits, preventing sudden trauma.** **Episiotomy — When Is It Necessary?** **Routine episiotomy is NOT performed.** EINC and WHO guidelines recommend selective episiotomy only when there is a clear clinical indication: 1. **Imminent severe tear** — if the perineum is blanching (whitening) or if you see a crack beginning to spread, a small episiotomy may prevent a larger spontaneous tear. This is a clinical judgment call based on experience. 2. **Fetal distress requiring rapid delivery** — in rare cases of severe fetal bradycardia or meconium staining, a midline episiotomy can shorten the second stage by ~30 seconds. 3. **Instrumental delivery (forceps or vacuum),** if needed, though even this is controversial and often avoided in normal births. 4. **To prevent significant third-degree tear** — if you assess that the tissues are going to tear severely, a controlled cut may be preferable, though evidence for this is mixed. **Risks of Routine Episiotomy:** - Increases pain and dyspareunia (painful intercourse) postpartum. - Does not prevent severe tears; it simply converts a spontaneous tear into a surgical one. - Increases blood loss and risk of infection. - Requires suturing, which is an added procedure and cost. **Modern Practice in the Philippines:** Most RHUs, lying-in centers, and midwife-led birth centers follow the EINC guideline of **selective episiotomy only.** Protect the perineum with controlled delivery; allow it to stretch. If a tear occurs, repair it appropriately. Many women deliver without episiotomy or tears with good technique. **Crowning — The Moment of Peak Perineal Stretch:** Crowning is when the widest part of the fetal head (the biparietal diameter) is at the introitus. At this moment: - The perineum is maximally stretched and most at risk for tearing. - The fetal head is most compressed; any continued rapid advance increases pressure on the skull and brain. - This is **the critical moment for slow delivery and maximum perineal support.** **Summary: Three-Point Technique at Crowning:** 1. **Occiput hand:** Gentle, continuous pressure on the back of the head, angling downward and backward. Guides descent and maintains flexion. 2. **Perineal hand:** Ritgen maneuver (standard or modified) supporting the perineal tissues as the head extends. 3. **Maternal effort:** Encourage gentle pushing with contractions, panting/breathing between contractions, and spontaneous (not coached) bearing-down. **Result:** A slowly delivered head with maximal perineal protection, minimal trauma, and a newborn born without excessive intracranial pressure.

A nuchal cord (umbilical cord looped around the fetal neck) is a common finding at delivery, occurring in approximately 20–30% of births. The presence of a nuchal cord does NOT automatically harm the baby or require urgent intervention. However, the midwife must assess whether the cord is loose or tight and manage it according to current EINC evidence. **Assessment of Nuchal Cord:** Once the fetal head is delivered and has restituted (rotated back), **feel gently around the baby's neck with your fingers** to determine if a cord is present. - **No cord:** None is felt; proceed to delivery of shoulders. - **Loose nuchal cord:** The cord is palpable but can be easily slipped over the head or stretched enough to allow the body to pass through without traction. - **Tight nuchal cord:** The cord is wrapped snugly and cannot be stretched over the head without applying significant traction. - **Nuchal cord with a knot:** Rarely, the cord may be knotted as well; this is noted but managed the same way. **Management According to Modern Evidence (EINC-Aligned):** **For a Loose Nuchal Cord:** - **Simply slip the cord over the head** and proceed to delivery of the shoulders. - No clamping or cutting needed. - The baby is delivered normally, and placental transfusion is preserved. **For a Tight Nuchal Cord (Standard Approach):** The **standard modern approach is the "somersault maneuver":** 1. Do NOT clamp and cut the cord before the baby's body is delivered (unless it is absolutely impossible to loosen or reduce the cord and delivery is obstructed). 2. Instead, keep the baby **close to the perineum** and gently guide the baby's body in a forward rolling or somersault motion, **delivering the anterior shoulder first and then rolling the body under the tight cord loop.** 3. Once the shoulders and chest are free, the body follows easily, and the cord naturally releases from the neck. 4. This preserves the placental transfusion (important for term and preterm newborns) and avoids the need for cord clamping while the head is still in the pelvis. 5. After the baby is completely delivered and the cord has stopped pulsating (typically 1–3 minutes), clamp and cut the cord as usual. **When to Clamp and Cut a Tight Cord Before Body Delivery (Exception):** Rarely, if: - The cord is so tightly looped that it cannot be loosened or reduced, AND - The tight cord is preventing descent or delivery of the body (obstructed delivery), AND - The baby appears to be in distress (cyanosis, severe bradycardia), Then **clamp and cut the cord immediately** to free the baby and allow delivery. However, this is an exception; most tight cords can be reduced using the somersault maneuver. **Historical Context (Why This Matters for the Exam):** Older textbooks and some older practitioners taught **routine clamping of a tight nuchal cord before the body is delivered.** This practice was based on the false concern that a tight cord would asphyxiate the baby. However, modern evidence (and long clinical experience) shows that: - The brief time required for shoulder/body delivery (usually <1 minute even with a tight cord) is not harmful. - The somersault maneuver is safe and avoids early cord clamping. - Early cord clamping deprives the newborn of valuable placental transfusion (40–100 mL of blood, ~20 mL/kg body weight), which improves iron stores and hematocrit, especially important for at-risk infants. The PRC MLE and EINC guidelines expect midwives to use the somersault maneuver for tight cords and reserve early cord clamping for true obstruction. **Routine Suctioning — NOT Recommended** Related to cord management is the topic of **routine suctioning of the mouth and nose** after the head is delivered. **EINC Standard:** Routine suctioning is **NOT done** for a baby with clear amniotic fluid who is crying and breathing spontaneously. **Why?** - The baby's respiratory tract is self-clearing; amniotic fluid moves out with the baby's first cries and breathing. - Routine suctioning delays maternal-baby contact, interrupts temperature regulation, and can cause vagal stimulation (bradycardia). - Suctioning is **only indicated** if there is visible meconium-stained amniotic fluid (MSAF) and the baby is not vigorous (depressed, not breathing, limp) — in which case the mouth and oropharynx are suctioned before the baby's first breath to prevent aspiration of meconium into the lungs. **In the Philippine context (RHU, lying-in):** - If the liquor is clear and the baby cries and breathes, **do not suction.** - If there is thick meconium and the baby is not vigorous, have a person trained in newborn resuscitation ready, suction the mouth and oropharynx gently, and be prepared to provide bag-and-mask support if needed. Refer to a facility with NICU capability if the baby does not respond to initial stimulation and suctioning. - If there is thin meconium (liquor stained but not thick) and the baby is vigorous, suctioning is not necessary. **Wipe the Face (Not Suction):** - After the head is delivered, you may **wipe the baby's face with a clean cloth** to clear visible fluid, which is a courtesy and makes the baby more comfortable. This is gentle and does not require suctioning equipment.

Once the head is delivered, restituted, and the cord situation is assessed, the next cardinal movement is the delivery of the shoulders. This must be done gently and with proper technique to avoid shoulder dystocia (rare but serious), brachial plexus injuries, and unnecessary trauma. **Normal Mechanism of Shoulder Delivery:** Under normal circumstances (most births), **the shoulders do NOT deliver with a single contraction.** Instead: 1. The **anterior shoulder (the one under the symphysis pubis)** is delivered first, with gentle **downward traction** (pulling the head downward and slightly backward, in the direction of the birth canal/toward the floor if the mother is upright, toward the back if she is supine). 2. Once the anterior shoulder is free under the symphysis pubis, **gentle upward traction** (pulling the head upward and forward) brings the **posterior shoulder** over the perineal body and out. 3. The body then follows easily. **Key Principle: Traction in the Axis of the Pelvis** - Apply traction along the natural path of the birth canal, NOT straight outward. - Downward traction for the anterior shoulder, upward traction for the posterior shoulder. - Use **steady, gentle traction,** not jerky or forceful movements. - If resistance is felt, **STOP and wait for the next contraction.** Do not force the shoulders. **Perineal Support Throughout:** - While delivering the shoulders, **continue to support the perineum** with your other hand (the hand not applying traction), using the cloth/pad to guard the tissue as the widest part of the shoulders (the shoulder-to-shoulder diameter) passes through the introitus. - The perineal body experiences its maximum stretch as the shoulders pass; injury is most likely here if traction is too forceful or too fast. - Some midwives support the perineum bilaterally (on both sides of the perineum) as the shoulders deliver; others use one hand and allow the tissues to stretch naturally. Both approaches are acceptable; choose what feels secure to you. **Timing:** - The shoulders may deliver with the next contraction after the head, or the mother may have a brief pause (10–30 seconds) before the next contraction begins. - **Do NOT apply fundal pressure** (pushing on the top of the uterus) to speed up shoulder delivery. Fundal pressure: - Is not effective and may actually worsen dystocia if it occurs. - Risks uterine rupture. - May cause uterine inversion. - Is NOT part of EINC guidelines. - If the shoulders do not deliver with gentle traction during a contraction, wait for the next contraction and try again. **What NOT to Do:** - **Avoid excessive traction on the head.** Pulling too hard on the head does not help and risks brachial plexus injury (stretching the nerves of the arm), Erb's palsy, and intracranial injury. - **Avoid twisting or rotating the body excessively.** The body should deliver in a smooth, forward motion. - **Do NOT use the perineal support hand to push the baby out.** Use it to protect tissue, not to propel the baby. **If the Shoulders Do NOT Deliver Easily (Suspected Shoulder Dystocia):** Shoulder dystocia is the entrapment of the anterior shoulder behind the symphysis pubis after delivery of the head. It is uncommon (~0.1% of vaginal deliveries) but is a true obstetric emergency requiring rapid action and knowledge of maneuvers. However, **shoulder dystocia is a DETECTION & REFERRAL situation for the midwife.** If you encounter a tight shoulder that does not deliver with gentle traction: 1. **Call for help immediately.** Alert any available staff, call 911 or the referral facility. 2. **Do NOT panic or apply excessive force,** which may worsen the problem. 3. **Lay the mother flat (supine) if she is not already** to increase pelvic diameter. 4. **Perform a maneuver such as: - **Suprapubic pressure:** Have a helper push downward and slightly backward just above the symphysis pubis to dislodge the anterior shoulder. - **Rubin maneuver:** Push the anterior shoulder posteriorly from behind to reduce the shoulder-to-shoulder diameter. 5. **Deliver the posterior shoulder first** if the anterior is truly stuck (this reduces the shoulder diameter and may free the anterior shoulder). However, **in the Philippine primary-care context (RHU, lying-in),** if shoulder dystocia occurs and simple maneuvers do not relieve it within seconds, **refer urgently to a hospital/BEmONC facility.** Do not delay transfer attempting complicated maneuvers if you are uncomfortable or if initial efforts fail; the hospital may have more personnel and equipment. **In Practice (Expected on the PRC MLE):** - Most deliveries proceed without shoulder dystocia. - Use gentle traction, wait for contractions, and do not force. - If shoulders are truly stuck (rare), call for help, perform basic maneuvers (suprapubic pressure, Rubin maneuver), and be prepared to refer. - Do NOT use fundal pressure or apply excessive force. **Delivery of the Body:** Once both shoulders are free, the body **slides out easily** with minimal effort. Support the baby with both hands (or one hand under the axillae and one supporting the buttocks) to prevent dropping. The baby is wet and slippery; a firm but gentle grasp is needed. **Announcing the Time of Birth:** - **Note and announce the exact time the baby is completely delivered** (when the entire body has emerged). - Record this in the partograph/delivery notes immediately. - The time of birth is used to calculate the duration of each stage of labor and is important for newborn care (timing of vitamin K, eye drops, breastfeeding, etc.).

The newborn's first minutes of life are critical. The immediate care provided in the delivery room sets the stage for the newborn's transition from fetal to extrauterine life and establishes the foundation for breastfeeding and maternal-baby bonding. **Step 1: Placement, Drying & Warming (EINC Core Competency)** **Immediate Placement:** - As soon as the baby is completely delivered, place the baby **prone (face down, but head to the side to keep the airway open) or supine (face up) on the mother's abdomen or chest,** **skin-to-skin.** - Do NOT separate the mother and baby for non-urgent care. Skin-to-skin contact is protective and promotes bonding. - Prevent the "Unang Yakap" (first embrace); this is a Filipino DOH program promoting immediate skin-to-skin contact. **Immediate Drying:** - **Immediately and thoroughly dry the baby** using a pre-prepared clean, dry cloth. Dry the head, face, body, and creases (under arms, groin, between toes). - A wet baby loses heat rapidly through evaporation; drying is the single most important intervention to prevent hypothermia in the newborn. - As you dry, this tactile stimulation often encourages the baby to cry and breathe if not already doing so. - Replace the wet cloth with a warm, dry cloth; keep the baby covered to conserve heat. **Warming:** - Ensure the delivery environment is warm (at least 25°C / 77°F if possible, though RHUs may not always achieve this). - Skin-to-skin contact with the mother provides radiant body heat and is very effective for warmth. - In some settings, a dry cloth or blanket covers the baby and mother together. - A hat or hood on the newborn further reduces head heat loss. - Avoid bathing the newborn immediately; delay the bath until the baby is warm and feeding is established (within 6–12 hours or later). **Step 2: Assessment of Newborn Vigour — Apgar Score** The **Apgar score** is assessed at 1 minute and 5 minutes after delivery. It is a rapid tool to assess the newborn's cardiopulmonary and neurological transition. **Apgar Score Components (each 0–2 points, total 0–10):** | Component | 0 Points | 1 Point | 2 Points | |-----------|----------|---------|----------| | **Appearance (Skin Color)** | Pale or blue (cyanotic) | Body pink, extremities blue | Completely pink | | **Pulse (Heart Rate)** | Absent | <100 bpm | >100 bpm | | **Grimace (Reflex Irritability / Response to Stimulation)** | No response to stimulation | Grimace or weak cry with stimulation | Cry or cough with stimulation | | **Activity (Muscle Tone)** | Limp (flaccid) | Some flexion of extremities | Active movement, good flexion | | **Respiration (Breathing Effort)** | Absent (apneic) | Slow, weak, irregular | Crying, vigorous | **Scoring Interpretation:** - **8–10:** Vigorous newborn; no resuscitation needed; routine care. - **4–7:** Moderately depressed; may need stimulation and monitoring; give brief resuscitation if not improving. - **0–3:** Severely depressed; needs immediate resuscitation; refer to a facility with neonatal intensive care capability (BEmONC/hospital with NICU). **Practical Assessment (in the RHU/lying-in context):** - At 1 minute, most vigorous babies are pink, breathing/crying, moving actively, and have a heart rate >100. Apgar is 8–10. - A baby who is dusky, weak cry, minimal movement, or heart rate 80–100 is moderately depressed (Apgar 4–7) and needs brief stimulation and monitoring. - A baby who is limp, cyanotic, not breathing, and has no pulse is severely depressed (Apgar 0–3) and needs immediate resuscitation and urgent referral to a hospital. **In the Primary-Care Setting:** If a baby has an Apgar of 0–3 at 1 minute: 1. **Begin basic resuscitation:** Stimulate by rubbing the back and flicking soles of feet; position the head in a neutral, slightly extended position to open the airway. 2. **Clear the airway** if needed (suction only if meconium is present and baby is not vigorous; otherwise, airway is self-clearing). 3. **Initiate bag-and-mask ventilation** if the baby does not begin breathing after stimulation within 15–30 seconds (requires training). 4. **Call for urgent referral to a hospital** with neonatal resuscitation and NICU capability. 5. **Do NOT delay transfer waiting for improvement** if you do not have the expertise or equipment for advanced resuscitation. **Routine Suctioning — REMINDER:** As noted earlier, routine suctioning is NOT done. Stimulation (rubbing, flicking heels) is often sufficient to trigger breathing if the baby is not already vigorous. Suctioning is reserved for visible meconium/obstruction in a non-vigorous baby. **Step 3: Umbilical Cord Clamping & Cutting (Delayed Cord Clamping)** **Delayed Cord Clamping (DCC) — EINC Standard:** DCC is the **evidence-based practice of waiting before clamping the umbilical cord,** allowing blood to transfer from the placenta to the baby. This is now the standard of care globally and is recommended by EINC, WHO, and the Philippine DOH. **Timing:** - **Wait at least 30–60 seconds** after delivery before clamping, preferably **longer (1–3 minutes) if the baby is vigorous and breathing.** - For **preterm babies (<37 weeks),** DCC is especially important; wait **at least 30–60 seconds,** ideally 1–3 minutes (improves hematocrit, reduces intraventricular hemorrhage, reduces necrotizing enterocolitis). - For **term babies,** the evidence is strong that DCC improves iron stores and hematocrit, reducing anemia in infancy; minimal risk of polycythemia (high blood counts) in healthy term infants. - **If the baby requires resuscitation and the cord needs to be moved to access the baby,** or if there is active bleeding from the cord, it is acceptable to clamp and cut earlier; resuscitation takes priority. **How to Perform DCC:** 1. After the baby is born and dried, place the baby **skin-to-skin on the mother** or **at the level of the mother's abdomen/thigh** (at or below the level of the placenta to ensure gravity assists blood transfer). 2. **Do NOT squeeze or "milk" the umbilical cord.** Allow blood to flow passively into the baby. Cord milking is controversial and not part of EINC guidelines. 3. **Feel the cord periodically** to assess when pulsation ceases (typically 1–3 minutes after delivery). You can feel the pulse in the cord by gently placing two fingers on it. 4. Once pulsation stops (or after 1–3 minutes in a vigorous baby), **place two clamps or ties on the cord** — the first clamp 4–6 cm from the baby's umbilicus (toward the baby), the second clamp 10–15 cm away (toward the placenta). 5. **Cut the cord between the two clamps** using sterile scissors. The clamp toward the baby protects against infection; the clamp toward the placenta is held by the midwife to prevent blood loss and aid in placental delivery. **In the Philippine Context:** - Many RHUs and lying-in centers are adopting DCC; ask about local protocols. - If the facility policy is to clamp immediately, discuss the evidence with your supervisor; many facilities are transitioning to DCC and may welcome your knowledge. - If delays in third-stage management are anticipated (e.g., lack of oxytocin), DCC is even more important. **Step 4: Initial Newborn Screening (Abbreviated in the Delivery Room)** **In the delivery room or immediate postpartum area, observe for:** 1. **Obvious anomalies:** Cleft palate, absence of limbs, abdominal wall defects, etc. These are referred; you note them and inform the parents compassionately. 2. **Breathing effort:** Is the baby breathing without retractions? Retractions (drawing in of the chest, abdomen, or neck with breathing) suggest respiratory distress and warrant referral for assessment. 3. **Skin color:** Pink, or is there persistent cyanosis despite breathing? Some cyanosis of the hands and feet (acrocyanosis) is normal in the first hours; central cyanosis (lips, tongue) is not normal and requires evaluation. 4. **Muscle tone and activity:** Is the baby moving and flexed, or limp? 5. **Feeding readiness:** Is the baby alert and rooting (looking for the breast) within the first hour? **Full newborn screening (weight, length, head circumference, reflexes, detailed examination)** is done in the first few hours postpartum in the postpartum/newborn care area, not in the delivery room during active delivery.

The third stage of labor is from delivery of the baby to delivery of the placenta. This stage lasts 5–30 minutes on average (normal range up to 30 minutes or occasionally longer). The third stage is when the risk of postpartum hemorrhage (PPH) is highest because the placental site is a large wound. **Active management of the third stage of labor (AMTSL) is the evidence-based intervention that prevents severe PPH and is a defining competency of the midwife under RA 7392.** AMTSL has **three key components,** all of which should be performed in sequence: **COMPONENT 1: Uterotonic Administration — Oxytocin 10 IU IM** **Critical FIRST step: Rule out a second baby (twin pregnancy) BEFORE administering any uterotonic.** - **Palpate the abdomen** to assess for a second baby; feel for another head or buttocks. Examine for size asymmetry (one side firm and large, the other soft). - If there is any suspicion of a second baby, **do NOT give oxytocin.** A uterotonic in the presence of a second baby may cause the uterus to contract, trapping the second baby inside and making delivery much more difficult. - In most pregnancies, a second baby has been diagnosed on antenatal imaging. But in some settings (limited ultrasound access, some home births), an undiagnosed twin may occur. This check is essential. **Once a single baby is confirmed (or second baby ruled out):** - **Give Oxytocin 10 IU (10 units) by intramuscular (IM) injection within one minute of the baby's birth** (some guidelines say within 5 minutes). - The standard dose for IM injection is **10 IU oxytocin**; draw this up into a 1 mL syringe with a 25-gauge needle and administer into the deltoid (arm) muscle or gluteal (buttock) muscle. - **Onset of action:** Oxytocin begins to work within 2–3 minutes IM, causing the uterus to contract firmly and compress the bleeding vessels at the placental site. - **If oxytocin is unavailable,** alternatives (from WHO and EINC guidelines) are: - **Misoprostol 600 mcg orally** (swallowed); onset is slower (10–15 minutes) but it works. - **Ergot alkaloids (ergotamine or methylergonovine) 0.2 mg IM** — BUT, **ergot is CONTRAINDICATED in hypertension, pre-eclampsia, or eclampsia** because it causes vasoconstriction and can severely elevate blood pressure or trigger a hypertensive crisis. If the mother is hypertensive, use oxytocin or misoprostol only. **Rationale for Oxytocin:** - It is effective, fast-acting, and safe even in hypertension. - It has minimal side effects (mild nausea, transient hypotension). - It is the uterotonic of choice globally. **Why AMTSL Prevents PPH:** After the baby is born, the uterus must contract and remain contracted to compress the blood vessels at the placental site. Without oxytocin, the uterus is "soft" (atonic), blood vessels remain open, and the mother can lose 500–1000 mL or more of blood before the uterus contracts on its own. Oxytocin ensures prompt, firm uterine contraction, minimizing blood loss. **COMPONENT 2: Controlled Cord Traction (CCT) — The Brandt-Andrews Maneuver** Controlled cord traction is the **gentle, controlled delivery of the placenta** using counter-traction on the uterus to prevent uterine inversion. **Steps:** 1. **Wait for signs of placental separation** — these are clinical signs that the placenta has detached from the uterine wall: - **A gush of blood** (usually a larger amount of blood suddenly fills the vagina). - **Lengthening of the umbilical cord** (the cord extends further out of the vagina; this occurs because the placenta, which was higher in the uterus, has descended). - **The uterus becomes globular** (rather than broad and flat, the uterus becomes more ball-shaped) **and rises** (ascends into the abdomen as the placenta descends into the lower uterine segment). These signs take 5–15 minutes to appear; **do not rush.** If there is any doubt about separation, wait another minute or two. 2. **Once separation signs are evident,** perform the **Brandt-Andrews maneuver:** - **Place one hand just above the symphysis pubis,** pressing upward and backward against the lower uterine segment. This is **counter-traction** — it stabilizes the uterus and prevents inversion if you apply downward traction on the cord. - **With the other hand, grasp the umbilical cord gently and apply steady, gentle downward traction** (in the direction of the birth canal, toward the floor if the mother is upright, toward the back if supine) **for 30–40 seconds.** - **If the placenta descends into the lower vagina, you can see the edge of the placenta;** continue gentle traction until it is fully delivered. - **If no descent occurs during 30–40 seconds, STOP traction, release, and wait for the next uterine contraction.** Then repeat. 3. **As the placenta is delivered,** support it gently with both hands and guide it out. **Inspect the fetal (shiny) side and maternal (beefy red) side** as it emerges. 4. **Gently twist the membranes** (the thin placental membranes attached to the placenta) **into a rope** so they peel out intact and do not tear off inside the uterus (retained membranes cause infection and bleeding). **Important Principles:** - **Never yank or apply forceful traction on the cord.** This risks cord breakage, retained placenta, and uterine inversion. - **Counter-traction on the uterus is essential.** Without it, pulling the cord can invert the uterus (the uterus turns inside-out), which is an obstetric emergency. Always have one hand on the uterus providing counter-traction. - **If strong resistance is felt, STOP immediately.** Do not force a placenta that is not separating. This is a referral situation. - **In most normal births, CCT is effective and the placenta delivers within 5–10 minutes of the baby's birth.** **COMPONENT 3: Uterine Massage** **After the placenta is delivered,** immediately massage the uterine fundus through the abdominal wall to encourage contraction and compression of bleeding vessels. **Technique:** 1. **Place your hand on the lower abdomen, palpating the top of the uterus (the fundus).** The uterus should feel like a firm, grapefruit-sized mass just below the umbilicus. 2. **Gently but firmly massage the fundus** in a circular or "kneading" motion for 30–60 seconds, encouraging the myometrium (muscle) to contract. 3. **If the fundus is soft (atonic) and will not contract,** massage more vigorously and assess for retained placenta or placental fragments (uncommon if the placenta was complete). 4. **Continue monitoring** every 15 minutes for the first 2 hours postpartum. **Teach the mother to feel and massage her own fundus;** this is empowering and shares responsibility for preventing hemorrhage. 5. **A well-contracted uterus should be firm, hard, and about the size of a grapefruit.** A soft, boggy, enlarged uterus suggests atony (uterine inversion is rare but is a surgical emergency requiring immediate referral). **Timeline of AMTSL:** - **Within 1 minute of baby's birth:** Give oxytocin 10 IU IM. - **Within 5 minutes:** Signs of placental separation appear. - **By 10 minutes:** Placenta is delivered with CCT and counter-traction. - **Immediately after placental delivery:** Uterine massage begins. - **Every 15 minutes for 2 hours:** Monitor fundal tone, vital signs, and lochia (vaginal bleeding). **Current WHO Guidance on AMTSL:** Recent WHO guidance (2022) emphasizes that **the uterotonic (oxytocin) is the essential, life-saving component** of AMTSL. CCT is important but is most safely performed by a trained, skilled attendant. In very low-resource settings where training is limited, **early oxytocin + uterine massage may be prioritized** over CCT if there is concern about performing it correctly. However, in the Philippine context, where midwives receive training in delivery, **all three components (oxytocin + CCT + massage) are expected and are part of your competency.** **Danger Signs in the Third Stage — Referral Indicators:** - **Placenta not delivered after 30 minutes** — this is retained placenta; refer for manual removal under anesthesia in a hospital setting. - **Heavy or continuous bleeding,** or a **soft uterus that will not stay contracted** despite massage and oxytocin — this is PPH; refer immediately. - **Incomplete placenta or membranes** — if any fragments are missing or if membranes are torn and incomplete, this is a REFERRAL for evaluation and possible evacuation. - **Umbilical cord breaking during traction** — this suggests retained placenta; refer. - **Uterine inversion** — the uterus turns inside-out (rare); this is a surgical emergency requiring immediate referral and careful, urgent care.

After delivery, the placenta and membranes must be carefully inspected to ensure completeness. A **retained placental fragment is a cause of postpartum hemorrhage and infection;** detecting incompleteness is part of the midwife's role and guides decisions about referral. **Systematic Inspection:** **1. Maternal (Cotyledon) Side — The Rough, Beefy Red Side** - **Count and inspect all cotyledons** (the 15–25 dark red, bumpy lobes that were in contact with the uterine wall). They should be roughly equal in size. - **Look for missing lobes** — if one or more are obviously absent, this suggests a **retained fragment** inside the uterus. - **Identify any raw or torn areas** where a lobe appears to have torn away or where placental tissue is missing; these also suggest incomplete delivery. - **Compare both sides** if the placenta is partially inverted; check that all cotyledons present on one side have corresponding bumpy areas on the other. **2. Fetal (Shiny) Side — The Smooth, Fetal Side with Vessels** - **Inspect the amnion and chorion** (the two membranes that covered the placenta). They should be thin, translucent, and intact. - **Trace the umbilical vessels** — there should be two arteries and one vein (2+1). A single artery is abnormal and associated with congenital anomalies; note it. - **Check for a **succenturiate (accessory) lobe** — follow the vessels from the insertion site toward the edges of the placenta. If a vessel runs toward the edge of the membranes (rather than stopping within the placental disk), it may indicate a small lobe of placenta separated from the main placenta. **If you see a vessel running off the membrane edge without placental tissue backing it, this suggests a succenturiate lobe left inside,** which is a retained fragment and a referral situation. - **Inspect the membranes for completeness** — are the amnion and chorion intact, or are there tears/gaps? If membranes are incomplete or if you find free-floating fetal skin or chorion, this may indicate a retained fragment. **3. Umbilical Cord — Vessels & Insertions** - **Count the vessels:** normally two arteries and one vein (2:1 ratio, or simply "two arteries, one vein"). - **Describe any abnormalities:** single umbilical artery, nuchal cord (if you have not already noted it), long or short cord, knots, etc. These are documented but do not change immediate management (they inform future prenatal care for the next pregnancy). - **Note the insertion:** where the cord inserts into the placenta. A normal insertion is into the placental disk (centric insertion). An insertion into the membranes away from the placental disk is a **velamentous insertion** (vessels cross the membranes), which is associated with risks but is noted; it does not change immediate postpartum care. **4. Membranes — Amnion & Chorion Integrity** - **Confirm that amnion and chorion are complete** and in one piece (having peeled as they should during delivery). - **If membranes are ragged, torn, or if pieces are missing,** suspect a retained membrane fragment. These cause infection (chorioamnionitis/endometritis) and hemorrhage (fragments prevent full uterine contraction). **Abnormalities Detected — Actions:** | Abnormality | Clinical Significance | Action | |-------------|----------------------|--------| | **Missing cotyledon(s) or torn placental tissue** | Retained fragment inside uterus | REFER for evaluation (may need evacuation) | | **Succenturiate lobe (vessel running off membrane edge without placental tissue)** | Small lobe left inside uterus | REFER for evaluation | | **Incomplete or ragged membranes** | Fragment retained; risk of infection and bleeding | REFER for evaluation | | **Single umbilical artery** | Associated with congenital anomalies | Document; observe baby for other anomalies; routine referral for pediatric evaluation | | **Velamentous cord insertion** | Increased risks in future pregnancies | Document; discuss with mother for future planning | | **Long cord (>100 cm)** | Associated with nuchal cords, knots | Document; relevant to delivery mechanics | | **Placental infarction, calcification** | Reduced fetal nutrition; assess baby for growth | Document; observe baby's feeding and weight | **Practical Assessment in the RHU/Lying-In Setting:** - Most placentas are normal and complete; suspicion of retained tissue is uncommon if the placenta was delivered as a whole and the membranes peeled out. - **Key signs of incompleteness:** - **Missing lobe(s)** — look at the maternal side; are all 15–25 lobes present? - **Vessel running off membrane edge** — when you trace the vessels on the fetal side, do they stay on the placental disk or run off onto the membranes? - **Incomplete membranes** — torn, ragged, or if you can see through a hole and identify missing tissue. - If you detect any of these, **keep the placenta for the referral hospital to examine,** inform the mother that a fragment may be retained and she may need evaluation, and arrange referral. - **Do NOT perform manual evacuation of the uterus in the primary-care setting** if you suspect retained tissue; this risks perforation and infection. Refer to a hospital where evacuation can be done under anesthesia with ultrasound guidance if indicated. **Blood Loss Estimation & PPH Definition:** After inspecting the placenta, **estimate blood loss:** - **Normal blood loss:** <500 mL (most mothers lose 200–400 mL). - **PPH (Postpartum Hemorrhage):** ≥500 mL after vaginal delivery (≥1000 mL after cesarean section). - **Severe PPH:** ≥1000 mL or ongoing heavy bleeding despite AMTSL. **Visual Estimation:** - A 1×1 cm blood spot on a cloth = ~1 mL of blood. - A cloth soaked through = ~10 mL. - A pail (bucket) filled to various levels = estimate by volume. - **Weigh soaked pads/cloths if scales are available:** each gram of absorbed blood ≈ 1 mL (accounting for the weight of the cloth itself). In the Philippine context (RHU with minimal equipment), careful observation and clinical judgment are used. A mother who is pale, dizzy, with a rapid pulse, and continuing to bleed heavily clearly has significant PPH even without precise measurement — these are clinical red flags for referral. **Documentation:** - **Record findings:** "Placenta: complete, all lobes present, membranes intact, no succenturiate lobe noted. Cord: three vessels, central insertion. Blood loss: ~350 mL." - If abnormal, document what you saw: "Placenta delivered in two pieces; maternal side shows a missing lobe on the lower segment. Suspect retained fragment. Referred for evaluation." - Include any observations about the baby's condition and feeding readiness on the delivery notes.

The immediate postpartum period (the first 2 hours after placental delivery) is the **"golden window"** — the time of highest risk for serious complications such as postpartum hemorrhage, infection, and maternal shock. Vigilant monitoring, skilled assessment, and timely referral are essential. **Goals of Immediate Postpartum Care:** 1. **Prevent and detect postpartum hemorrhage.** 2. **Maintain maternal comfort, hydration, and warmth.** 3. **Support maternal-infant bonding and early breastfeeding.** 4. **Identify and refer complications early.** 5. **Provide reassurance and emotional support.** **Vital Assessments — Every 15 Minutes for the First 2 Hours:** **1. Fundal Tone & Lochia** - **Palpate the fundus** (the top of the uterus) every 15 minutes. It should be firm, hard, and approximately **at the level of the umbilicus immediately after placental delivery,** then **involutes (shrinks) about one fingerbreadth per day** (by day 1, it is at the umbilicus; by day 2, one finger below; etc.). - **A soft, boggy, enlarged fundus** suggests uterine atony (loss of tone) and risk of hemorrhage. **Massage it immediately** until it firms. If it will not firm despite massage, this is a red flag — refer. - **Lochia (vaginal bleeding):** - **Normal lochia:** dark red, mixed with small clots (smaller than a grape), moderate amount (soaking ~1 pad per hour on average). - **Heavy lochia:** soaking a pad in 15 minutes or less, large clots (larger than a plum), bright red blood (suggests active bleeding from a vessel). If this occurs, massage the fundus, ensure oxytocin has been given, and be prepared to refer. - **Lochia should gradually decrease over the next hours.** **2. Vital Signs — Blood Pressure, Pulse, Temperature, Respirations** - **Baseline vitals are recorded immediately after delivery.** Subsequent vitals are checked at 15 minutes, 30 minutes, 1 hour, and 2 hours. - **Normal postpartum BP:** should be similar to antenatal baseline (within 10–15 mmHg). A significant drop (>20 mmHg) or a systolic BP <90 mmHg suggests hypovolemia (low blood volume from hemorrhage) or shock. - **Normal postpartum pulse:** ~60–100 bpm. A rising pulse (>100 bpm and increasing) with falling BP suggests hemorrhagic shock — immediate referral. - **Temperature:** should be <37.5°C (98.6°F). A fever postpartum suggests infection (endometritis from retained tissue or infection); monitor and refer if fever persists or if other signs of infection appear (foul-smelling lochia, abdominal pain, malaise). - **Respirations:** should be normal (~16–20 breaths/min). Tachypnea (fast breathing) with low BP and a rising pulse may indicate shock. **3. Perineal Assessment & Repair** - **Inspect the perineum, vagina, and cervix for lacerations** in the first few minutes postpartum, while they are fresh and bleeding is still evident (making visualization easier). - **Types of tears (by severity):** - **First-degree:** involves only the skin/epithelium of the perineum; no muscle involvement. - **Second-degree:** involves the perineal body muscles; extends to the vaginal tissue. - **Third-degree:** involves the external anal sphincter (EAS); extends to the anal canal. **This is a REFERRAL.** - **Fourth-degree:** involves the internal anal sphincter (IAS) and rectal mucosa. **This is a REFERRAL.** - **Repair first- and second-degree tears** within the midwife's competency, if you have training (most Filipino midwives are trained in simple tear repair under RA 7392). - Use absorbable sutures (chromic catgut or synthetic absorbable sutures). - Repair in a clean, well-lit area with adequate assistance (someone to hold the light and hand you instruments). - Use anesthesia (local anesthetic infiltrated into the tear site); this reduces pain and allows better visualization. - Technique: approximate the edges of the tear using interrupted or running sutures, starting deep and working outward. - **Refer third- and fourth-degree tears** — these require repair by a physician under controlled conditions (adequate anesthesia, good lighting, possibly in an operating room). Improper repair risks fecal incontinence and other long-term complications. - **If there is cervical bleeding** (bright red blood flowing from the cervical os even with a well-contracted uterus and normal lochia), this suggests a **cervical laceration.** Small cervical tears (often from rapid descent or instrumentation) may stop bleeding on their own or may require suturing. If bleeding is brisk, refer. **4. Bladder & Urination** - **Assess bladder fullness** by palpating the lower abdomen; a full bladder is palpable above the symphysis pubis. - **Encourage voiding** — a full bladder impedes uterine involution and increases risk of retention and infection. - **Monitor urine output:** the mother should void within the first 4 hours postpartum and pass clear or pale urine in adequate volumes (at least 200–300 mL). - **If the mother cannot void** and the bladder is distended, and if voiding has not occurred by 4–6 hours postpartum, **straight catheterization may be necessary** (only if truly indicated; do not catheterize routinely). Use a sterile, single-use catheter and maintain strict asepsis. **5. Maternal Comfort & Hydration** - **Encourage oral fluids** — the mother should be offered water, juice, broth, or light snacks if hungry. There is no need to restrict food intake postpartum unless anesthesia complicates swallowing. - **Ensure warmth:** provide clean, dry cloths or blankets; the postpartum environment should be warm. A cold mother shivers, which increases energy expenditure and may worsen any ongoing bleeding. - **Pain relief:** if the mother is in perineal pain from a tear or repair, offer paracetamol (acetaminophen) or ibuprofen as available and appropriate. Avoid codeine-based analgesics if breastfeeding (opioids pass into breast milk). - **Rest:** promote quiet, dark environment so the mother can rest if desired. Sleep is healing. **6. Maternal-Infant Bonding & Early Breastfeeding** - **Keep the mother and baby together (rooming-in).** Separation for non-urgent procedures is discouraged by EINC and Unang Yakap. - **Initiate breastfeeding within the first hour if the baby is awake and alert.** Early breastfeeding stimulates oxytocin release (which contracts the uterus and helps prevent hemorrhage), establishes milk production, and promotes bonding. - **Observe the first breastfeed** — is the baby latching well? Is the mother comfortable? If there are difficulties (poor latch, pain), provide support and education. Lactation counseling in the first few hours sets the tone for successful breastfeeding. - **Teach the mother** that breastfeeding may cause mild cramping (afterpains) as oxytocin contracts the uterus; this is normal and helpful. **Danger Signs Requiring Urgent Referral — Detect & Refer:** 1. **Postpartum Hemorrhage (PPH):** ≥500 mL blood loss or ongoing brisk bleeding despite AMTSL and uterine massage. - **Signs:** pale skin, cold clammy extremities, rapid weak pulse, low BP, dizziness, confusion. - **Action:** Call for urgent referral; keep IV access if available; do NOT delay waiting for improvement. In the RHU, if the mother is in shock (altered mental status, profound hypotension, severe tachycardia), do not wait for complete workup — transfer immediately. 2. **Uterine Atony Not Responding to Massage:** Soft, boggy fundus that will not contract despite massage and oxytocin. - **Action:** Recheck for retained placenta or tissue; if placenta is complete, refer for evaluation (may need uterotonic infusion, evacuation, or rarely, peripartum hysterectomy if hemorrhage is life-threatening). 3. **Uterine Inversion (Rare but Serious):** The uterus protrudes out of the vagina (looks like a "grapefruit" at the introitus) or the fundus is inverted (you cannot feel it above the symphysis pubis). - **Cause:** usually excessive cord traction without counter-traction during CCT, or aggressive fundal massage/pressure. - **Action:** This is a surgical emergency. Call for immediate referral to a hospital. Do NOT push the uterus back yourself; this risks further trauma and hemorrhage. In the ambulance, keep IV access, position the mother left lateral (to prevent aortocaval compression), and prepare for OR delivery. 4. **Fever or Signs of Infection:** - **Temperature ≥38.5°C (101.3°F)** in the first 24 hours postpartum, or **fever + foul-smelling lochia, lower abdominal pain, pelvic tenderness.** - **Suspect:** endometritis (infection of the uterine lining), often from retained placental tissue or prolonged labor with rupture of membranes. - **Action:** Refer for antibiotic therapy; ensure retained tissue is not present (ultrasound if available); may need evacuation if tissue is retained. 5. **Severe Headache or Visual Changes:** - **Postpartum eclampsia** (seizure) can occur in the first 24–48 hours even if the mother was normotensive during pregnancy. - **Warning signs:** severe headache (worse than normal), visual disturbances (seeing spots, blurred vision), epigastric pain, confusion, agitation. - **Action:** Refer immediately to a hospital for evaluation and management (IV magnesium sulfate may be given to prevent seizures). 6. **Leg Swelling, Pain, or Warmth:** - **Suspect deep vein thrombosis (DVT),** rare in vaginal births but possible postpartum. - **Signs:** unilateral leg swelling, calf pain, warmth, redness. - **Action:** Refer for ultrasound and possible anticoagulation. 7. **Severe Abdominal Pain or Guarding:** - **Suspect rupture, infection, or other intra-abdominal pathology.** - **Action:** Refer for evaluation. **Documentation of Postpartum Care:** Record in the mother's notes: - **Time of delivery and time of placental delivery.** - **Blood loss (estimated).** - **Vital signs** at key intervals (immediately after delivery, 15 min, 30 min, 1 hr, 2 hr). - **Fundal tone and location** at each assessment. - **Lochia description** (color, amount, clots). - **Perineal status:** tears, if repaired; suture material used; how repair was tolerated. - **Urination:** time of first void, amount, color. - **Breastfeeding:** baby latched, fed how long, mother's comfort, any issues. - **Maternal and infant bonding observations.** - **Any complications** detected and action taken. - **Disposition:** discharged to home, transferred to postpartum ward, referred to hospital, etc.