Mandated Newborn Procedures by the Midwife - Cheat Sheet
Your last-minute exam companion for RA 7392 newborn care. Master EINC/Unang Yakap timing, mandatory statutes (RA 9288, RA 9709), and every procedure a midwife must perform at RHU/BHS. Focus on sequence, dose, and timing — the exam tests these ruthlessly.
EINC / Unang Yakap — The Four Sacred Steps (First Minutes)
Common values
Value
30 seconds
Symbol
t₁
Quantity
Drying time (STEP 1)
Value
1–3 minutes after birth (after pulsations stop)
Symbol
t₂
Quantity
Delayed cord clamping window
Value
Ideally within 90 minutes
Symbol
t₃
Quantity
Early breastfeeding window
Value
6 hours; ideally 24 hours
Symbol
t₄
Quantity
Delayed bathing (minimum)
Important facts
- STEP 1 — IMMEDIATE & THOROUGH DRYING (first 30 seconds): Dry the entire body and head with a clean, warm, dry cloth. Do NOT wipe off vernix. Purpose: prevent hypothermia and stimulate breathing.
- STEP 2 — EARLY SKIN-TO-SKIN CONTACT (immediately after drying): Place naked, dried baby prone on mother's bare abdomen/chest. Cover both with a warm, dry cloth. Put a bonnet on baby. Purpose: maintain warmth, promote bonding, facilitate crawling to breast.
- STEP 3 — PROPERLY TIMED CORD CLAMPING (1–3 minutes after birth): Clamp and cut cord ONLY AFTER cord pulsations stop completely. Delayed cord clamping improves newborn iron stores and reduces anemia risk.
- STEP 4 — NON-SEPARATION FOR EARLY BREASTFEEDING (ideally within 90 minutes): Keep mother and baby together continuously. Support baby's crawl to breast and first latch. Facilitate rooming-in.
- DO NOT routine suction, routine early bathing (delay ≥6 h, ideally 24 h), routine suctioning of meconium if baby is vigorous, or separate mother and baby.
- Suctioning ONLY if baby is not breathing or has obvious airway obstruction; never routine.
- Meconium-stained amniotic fluid (MSAF): If baby is VIGOROUS (breathing/crying, good tone, HR ≥100), treat as normal and do NOT suction. If baby is NOT breathing or gasping, call for help, clamp cord, begin bag-mask ventilation within 60 seconds (golden minute).
Key definitions
EINC (Essential Intrapartum and Newborn Care)
Example
At RHU or BHS, midwife follows EINC sequence with every vaginal delivery.
DOH protocol organizing immediate newborn care into four timed, evidence-based steps to optimize maternal-newborn bonding, thermoregulation, and breastfeeding initiation.
Unang Yakap (First Embrace)
Example
Slogan used in DOH campaigns: 'Unang Yakap, Unang Pagmamahal.'
Popular Filipino name for EINC; emphasizes 'first loving touch' as core principle of immediate newborn care.
Diagrams to know
- Sequence of four EINC steps with timing labels
- Skin-to-skin positioning diagram (baby prone on mother's abdomen)
- Delayed cord clamping timeline (1–3 min post-birth)
APGAR Score & Immediate Assessment
Common values
Value
1 minute after complete birth
Symbol
t₁
Quantity
APGAR timing (first assessment)
Value
5 minutes after birth
Symbol
t₂
Quantity
APGAR timing (second assessment)
Value
120–160 bpm
Symbol
HR
Quantity
Normal newborn HR
Value
40–60 breaths/min
Symbol
RR
Quantity
Normal newborn RR
Important facts
- APGAR is NOT a resuscitation trigger; breathing, tone, and HR guide resuscitation, which begins immediately if needed—do not wait for 1-minute score.
- Score 7–10 = GOOD/NORMAL; score 4–6 = MODERATELY DEPRESSED (needs stimulation, possible support); score 0–3 = SEVERELY DEPRESSED (active resuscitation + referral).
- Score at 1 minute AND 5 minutes (then every 5 min up to 20 min if depressed).
- If 1-minute score is 0–3, continue resuscitation and recheck at 5, 10, 15, 20 minutes.
- Appearance (color): 0 = blue/pale all over, 1 = body pink/extremities blue, 2 = completely pink.
- Pulse (HR): 0 = absent, 1 = <100/min, 2 = ≥100/min.
- Grimace (reflex irritability): 0 = no response, 1 = grimace, 2 = cry/cough/sneeze.
- Activity (muscle tone): 0 = limp, 1 = some flexion, 2 = active motion.
- Respiration: 0 = absent, 1 = slow/irregular/weak cry, 2 = good strong cry.
Key definitions
APGAR Score
Example
A baby with pink body, HR 110, grimace to stimuli, flexed limbs, and strong cry scores 9–10.
Rapid 5-component assessment (Appearance, Pulse, Grimace, Activity, Respiration) done at 1 and 5 minutes to evaluate newborn transition; scored 0–2 per component, total 0–10.
Diagrams to know
- APGAR scoring table with 5 components and 0–2 point ranges
- APGAR interpretation flowchart (score → action pathway)
Thermoregulation & Vital Signs
Common values
Value
36.5–37.5 °C
Symbol
T
Quantity
Normal axillary temperature
Value
<36.5 °C
Symbol
T_hypo
Quantity
Hypothermia threshold
Value
25–28 °C
Symbol
T_room
Quantity
Ideal room temperature
Value
40–60 breaths/min
Symbol
RR
Quantity
Normal newborn RR
Value
120–160 bpm
Symbol
HR
Quantity
Normal newborn HR
Value
2,500–4,000 g
Symbol
Wt
Quantity
Normal term birth weight
Value
<2,500 g
Symbol
LBW
Quantity
Low birth weight threshold
Important facts
- Normal axillary temperature: 36.5–37.5 °C.
- Below 36.5 °C = hypothermia; above 37.5 °C = hyperthermia (less common).
- Newborns lose heat via evaporation (fastest, during drying), conduction, convection, radiation.
- Room temperature should be 25–28 °C (warm and draft-free).
- Skin-to-skin contact is the PRIMARY heat source; use bonnet to prevent head heat loss.
- Delayed bathing (≥6 h, ideally 24 h) preserves vernix and prevents heat loss.
- Normal newborn RR: 40–60 breaths/min (may be irregular in first hours).
- Normal newborn HR: 120–160 bpm (lower during sleep, higher during crying/activity).
- Hypothermia is an emergency in small/preterm babies; refer if does not correct with warmth.
Key definitions
Hypothermia (Newborn)
Example
A term baby at 35.8 °C is hypothermic; place skin-to-skin immediately and recheck in 30 min.
Axillary temperature <36.5 °C; a dangerous state in newborns that impairs breathing, feeding, and glucose metabolism; corrected by skin-to-skin contact (Kangaroo Mother Care) and re-checking.
Warm Chain
Example
At RHU, midwife pre-warms the weighing scale, room, and drying cloths to maintain warm chain.
Sequence of practices to maintain newborn thermoregulation: immediate drying, skin-to-skin, bonnet, delayed bathing, warm room (25–28 °C), warm hands and surfaces.
Diagrams to know
- Warm chain sequence diagram (5–6 practices in order)
- Heat loss mechanisms in newborn (evaporation, conduction, convection, radiation)
Cord Care & Management
Common values
Value
1–3 minutes (after pulsations stop)
Symbol
DCC_time
Quantity
DCC window (after birth)
Value
5–15 days
Symbol
t_sep
Quantity
Cord separation timeline
Important facts
- Delayed cord clamping (DCC) timing: 1–3 minutes AFTER birth, AFTER cord pulsations stop (not before).
- DCC benefits: increases placental blood volume → higher hemoglobin and iron stores in baby → reduces anemia risk.
- Cord is cut with sterile blade/scissors between two clamps or ties.
- After clamping, fold the diaper BELOW the cord to expose it to air.
- Dry cord care: keep clean and dry. Do NOT apply alcohol, chlorhexidine (unless high-risk), antiseptic, or any dressing in routine settings.
- Cord stump separates naturally in 5–15 days.
- Teach mother the DANGER SIGNS of omphalitis: redness, swelling, foul-smelling discharge, bleeding from the cord.
- If omphalitis suspected, refer immediately; do NOT treat at home.
- Document cord care counseling in delivery notes.
Key definitions
Delayed Cord Clamping (DCC)
Example
At BHS, midwife waits 2 minutes while counting cord pulsations before clamping.
Clamping and cutting the umbilical cord 1–3 minutes after birth (AFTER pulsations stop), allowing placental transfusion and improving newborn iron stores.
Dry Cord Care
Example
Mother folds diaper below cord and changes it when wet; no home remedies or 'pusod' potions.
Modern DOH standard: keep the cord stump clean and dry, expose to air, do NOT apply alcohol, antiseptic, or dressing unless local high-risk protocol specifies chlorhexidine.
Omphalitis
Example
Mother returns on day 6 with cord oozing greenish discharge and red streaking—refer immediately.
Infection of the umbilical cord stump; signs include redness, swelling, foul-smelling discharge around the cord; a reason for immediate referral.
Diagrams to know
- Timeline of delayed cord clamping (pulsation → wait 1–3 min → clamp)
- Cord care steps (clamping position, cutting, stump care, diaper folding)
Vitamin K Prophylaxis (VKDB Prevention)
Formulas
Vitamin K1 (phytomenadione) IM: Term/normal-weight baby: 1 mg IM single dose; Preterm or LBW (<1.5 kg): 0.5 mg IM single dose
Meaning
1 mg for term infants; 0.5 mg for preterm/LBW to prevent Vitamin K Deficiency Bleeding
Watch out
Do NOT give IV (causes hemolysis and death); always give IM in vastus lateralis (anterolateral thigh). Do NOT delay if baby is feeding.
When to use
Within the first hour(s) after birth, AFTER drying and skin-to-skin, and BEFORE any procedure that could cause bleeding (e.g., before newborn screening heel-prick if sequencing allows).
Common values
Value
1 mg IM
Symbol
D_term
Quantity
Vitamin K1 dose (term)
Value
0.5 mg IM
Symbol
D_preterm
Quantity
Vitamin K1 dose (preterm/LBW)
Value
<1.5 kg
Symbol
Wt_threshold
Quantity
LBW threshold for 0.5 mg dose
Value
Within first hour(s)
Symbol
t_VK
Quantity
Timing after birth
Important facts
- Every newborn receives Vitamin K1 (phytomenadione) IM as routine prophylaxis.
- Dose: 1 mg IM for term or normal-weight baby.
- Dose: 0.5 mg IM for preterm or LBW baby (<1.5 kg).
- Route: ALWAYS intramuscular (IM), NEVER intravenous (IV). IV causes hemolysis and is fatal.
- Site: Anterolateral thigh (vastus lateralis muscle)—safest, least pain, no nerve/vessel damage.
- Timing: Within first hour(s) after birth, AFTER drying and skin-to-skin.
- Give Vitamin K BEFORE newborn screening heel-prick if possible (reduces bruising/bleeding risk).
- Can be given during first breastfeed without delaying feeding.
- Document: time, dose, route, site, batch number of vaccine.
Key definitions
VKDB (Vitamin K Deficiency Bleeding)
Example
Unimmunized newborn presents with melena (black stool) on day 3 → VKDB → refer for urgent FFP/bleeding management.
Hemorrhagic disease of newborn caused by transient physiologic Vitamin K deficiency; manifests as bleeding (GI, intracranial, other sites) in first days/weeks; prevented by routine Vitamin K at birth.
Diagrams to know
- Vitamin K prophylaxis checklist (dose, route, site, timing)
- Vastus lateralis injection site diagram
Eye Prophylaxis (Ophthalmia Neonatorum Prevention)
Formulas
Erythromycin 0.5% ophthalmic ointment: Thin ribbon into each lower conjunctival sac (inner to outer canthus), both eyes, single application.
Meaning
Standard erythromycin concentration (0.5%) and application technique to prevent gonococcal/chlamydial ophthalmia
Watch out
Do NOT irrigate after application—ointment stays in conjunctival sac. Do NOT confuse with topical antibiotics (wrong concentration). Do NOT skip based on 'low-risk' maternal history—is mandatory for all.
When to use
After first breastfeed/bonding, ideally within first hour after birth, for EVERY newborn regardless of maternal history.
Common values
Value
0.5% ophthalmic ointment
Symbol
C_erythro
Quantity
Erythromycin concentration
Value
1% ointment
Symbol
C_tetra
Quantity
Alternative (tetracycline)
Value
Ideally within 1 hour, after first breastfeed
Symbol
t_eye
Quantity
Timing after birth
Important facts
- Mandated eye prophylaxis for EVERY newborn (regardless of maternal history).
- Agent: Erythromycin 0.5% ophthalmic ointment (or tetracycline 1% ointment as alternative).
- Method: Instill thin ribbon of ointment into EACH lower conjunctival sac, from inner canthus to outer canthus.
- Timing: After first breastfeed/bonding, ideally within first hour of birth.
- Do NOT irrigate after instillation; ointment must stay in contact with conjunctiva.
- Check both eyes are treated; do NOT skip one eye.
- No adverse effects from erythromycin ointment in newborn eyes.
- Document: agent used, both eyes treated, time, any reaction.
Key definitions
Ophthalmia Neonatorum
Example
Baby born vaginally to mother with untreated gonorrhea: without prophylaxis develops purulent conjunctivitis by day 2–3 → scarring and blindness.
Newborn eye infection (conjunctivitis) caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired during vaginal delivery; prevented by eye prophylaxis at birth; untreated causes blindness.
Diagrams to know
- Eye anatomy diagram showing lower conjunctival sac and application technique (inner to outer canthus)
- Step-by-step eye prophylaxis procedure
Newborn Screening (RA 9288)
Common values
Value
24–72 hours after birth
Symbol
t_NBS
Quantity
Ideal NBS collection window
Value
NOT before 24 hours
Symbol
t_NBS_min
Quantity
Minimum NBS timing
Value
By 2 weeks of age
Symbol
t_repeat
Quantity
Repeat NBS if discharged early
Important facts
- RA 9288 (Newborn Screening Act of 2004) makes NBS mandatory for every newborn.
- Method: Heel-prick (capillary blood) onto special filter-paper card.
- Ideal timing: 24 to 72 hours after birth. Do NOT collect before 24 h (false results, esp. 17-OHP/CAH).
- If baby discharged before 24 h, collect at 24 h anyway; if discharged before 24 h is possible, REPEAT screen by 2 weeks of age.
- Attendant (midwife) is LEGALLY RESPONSIBLE for collecting sample and informing parents of availability/benefits.
- Parents may refuse ONLY after being fully informed; refusal must be documented.
- Expanded panel screens: Congenital Hypothyroidism (CH), Congenital Adrenal Hyperplasia (CAH), Galactosemia (GAL), Phenylketonuria (PKU), Glucose-6-Phosphate Dehydrogenase deficiency (G6PD), Maple Syrup Urine Disease (MSUD), plus hemoglobinopathies, biotinidase deficiency, cystic fibrosis (in expanded panels).
- Congenital Hypothyroidism (CH): Prevents severe intellectual disability with early thyroxine. Most common screened disorder.
- Positive/High-risk results: Family referred urgently for confirmatory testing (serum TSH, free T4, 17-OHP, etc.). Do NOT delay.
- Second-tier screening: Some high-risk results get second-tier test (reflex testing) before notifying family to reduce false positives.
- Midwife documents: timing of collection, card number, baby's name, date of birth, mother's name, serial number, and sends to regional NBS center.
Key definitions
Newborn Screening (NBS / RA 9288)
Example
Midwife collects heel-stick sample at 48 h, counsels mother on importance, and sends to regional NBS center.
Mandatory population-based screening program using heel-prick capillary blood on filter-paper card (ideally 24–72 h after birth) to detect treatable congenital disorders (CH, CAH, GAL, PKU, G6PD, MSUD) and prevent disability/death.
Congenital Hypothyroidism (CH)
Example
Baby screened positive for elevated TSH at 72 h → immediate thyroxine started → normal neurodevelopment.
Most common screened disorder; absence/deficiency of thyroid hormone at birth; undetected causes severe intellectual disability, but early thyroxine replacement prevents all effects.
Diagrams to know
- NBS timeline (24–72 h after birth, ideal 48 h)
- Heel-prick sampling technique (site, needle angle)
- Expanded panel disorders and their preventable sequelae
Newborn Hearing Screening (RA 9709)
Common values
Value
Before discharge or within 1 month
Symbol
t_NHHS
Quantity
Ideal screening timing
Value
By 3 months of age
Symbol
t_NHHS_max
Quantity
Latest screening timing
Value
By 6 months of age
Symbol
t_intervention
Quantity
Intervention initiation window
Important facts
- RA 9709 (Universal Newborn Hearing Screening and Intervention Act of 2009) mandates screening for every newborn.
- Methods: Otoacoustic Emissions (OAE) and/or Automated Auditory Brainstem Response (AABR)—both painless, quick (<5 min).
- Timing: Before discharge from hospital/BHS, or within first month of life (latest by 3 months).
- No special preparation needed; baby can be sleeping or awake.
- Purpose: Early detection of congenital hearing loss to enable intervention by 6 months and prevent speech/language delay.
- Results: 'Pass' = normal hearing; 'Refer' = needs repeat/confirmatory testing (NOT confirmed hearing loss, just needs follow-up).
- Positive/Refer result: Schedule follow-up audiologic evaluation (otoacoustic emissions, auditory brainstem response, behavioral testing).
- At RHU/BHS without screening equipment: Midwife counsels on importance, provides written referral to screening facility, documents referral and date.
- Risk factors for hearing loss: Family hx of hearing loss, prematurity, low birth weight, maternal infections (TORCH), aminoglycoside exposure, birth asphyxia.
- Document: screening date, method used (OAE/AABR), result (pass/refer), follow-up plan, referral given if needed.
Key definitions
Newborn Hearing Screening (RA 9709)
Example
At RHU BHS with no OAE equipment, midwife counsels mother on universal newborn hearing screening, provides referral to screening center, and documents referral.
Mandatory universal hearing screening (OAE/AABR) for every newborn done before discharge or within 1 month (latest 3 months) to detect congenital hearing loss early, enabling intervention by 6 months and preserving speech/language development.
Diagrams to know
- Newborn hearing screening pathway (screening → pass/refer → follow-up)
- OAE and AABR testing techniques (simple diagram)
Birth Immunizations (BCG & Hepatitis B)
Common values
Value
0.05 mL intradermal
Symbol
D_BCG
Quantity
BCG dose
Value
0.5 mL IM
Symbol
D_HBV
Quantity
Hepatitis B dose (birth)
Value
Within 24 hours
Symbol
t_birth_vacc
Quantity
Timing after birth
Value
Within 6–12 hours
Symbol
t_urgent_HBV
Quantity
Urgent HBV timing (if HBsAg+)
Important facts
- BCG vaccine: Dose 0.05 mL (intradermal, not IM), given into upper arm within 24 hours of birth.
- BCG creates a small papule at site; ulceration and healing is normal (BCG-itis is expected).
- Hepatitis B (HBV) vaccine: 0.5 mL IM (intramuscular), given within 24 hours of birth.
- If mother is HBsAg-positive: Give HBV + HBIG (Hepatitis B Immune Globulin) within 6–12 hours (urgent).
- Both vaccines are part of Philippine EPI (Expanded Program on Immunization) and are mandatory.
- BCG and HBV do NOT have to be simultaneous; can be given separately.
- Sites: BCG in upper arm (intradermal); HBV preferably in anterolateral thigh (IM) to avoid confusion with vitamin K injection site.
- Document: vaccine name, dose, route, site, time, batch number, mother's HBsAg status (for HBV).
- Inform mother: BCG will ulcerate and drain—this is normal; no dressing needed; baby should not have repeated TB tests (BCG causes false positive TB skin test).
Key definitions
BCG (Bacille Calmette-Guérin)
Example
At BHS, midwife gives BCG 0.05 mL IM (intradermal) into upper arm within 24 h of birth.
Live attenuated tuberculosis vaccine given IM within 24 hours of birth to provide early protection against TB; part of Philippine EPI (Expanded Program on Immunization).
Hepatitis B Birth Dose
Example
Midwife gives HBV vaccine 0.5 mL IM to baby born to HBsAg-positive mother within 6 hours (urgent in this case).
Recombinant hepatitis B vaccine (0.5 mL) given IM within 24 hours of birth to prevent perinatal HBV transmission; part of Philippine EPI.
Diagrams to know
- Birth immunization schedule (BCG and HBV within 24 h)
- Injection sites (BCG arm, HBV thigh) to avoid overlap
Recognition & Referral of Complications (Detect & Refer)
Common values
Value
First 60 seconds after delivery
Symbol
t_golden
Quantity
Golden Minute
Value
<36.5°C not correcting
Symbol
T_refer
Quantity
Hypothermia threshold for referral
Value
>38°C axillary
Symbol
T_fever_refer
Quantity
Fever threshold for referral
Value
RR >60 breaths/min
Symbol
RR_refer
Quantity
Tachypnea threshold for referral
Important facts
- REFER IF BABY NOT BREATHING AT 1 MIN: Do NOT wait for APGAR score. Begin resuscitation (positioning, airway, ventilation) immediately within golden minute.
- REFER IF APGAR 0–3 AT 5 MIN: Continue resuscitation, maintain warmth, prepare for transfer to hospital.
- REFER IF SEVERE BIRTH ASPHYXIA SIGNS: Central cyanosis not resolving, gasping, extreme lethargy, absent reflexes—begin resuscitation, notify family, transfer emergently.
- REFER IF HYPOTHERMIA (<36.5°C) not correcting: Keep skin-to-skin, recheck in 30 min; if persistent despite warmth, refer.
- REFER IF OMPHALITIS SUSPECTED: Cord redness, swelling, foul discharge—do NOT treat at RHU; refer to hospital for IV antibiotics.
- REFER IF OMPHALOCELE/GASTROSCHISIS: Abdominal wall defect with intestines visible or in sac. Do NOT manipulate. Cover with clean dry cloth, keep warm, refer immediately.
- REFER IF SEVERE JAUNDICE IN FIRST 24 H: Bilirubin phototherapy needed; refer to hospital.
- REFER IF SIGNS OF INFECTION: Fever (>38°C axillary), hypothermia (<36.5°C), lethargy, poor feeding, respiratory distress, pustules, umbilical cellulitis.
- REFER IF RESPIRATORY DISTRESS: RR >60, grunting, nasal flaring, retractions, cyanosis—refer to hospital for oxygen/CPAP.
- REFER IF SEVERE BLEEDING: Cord bleeding >5 min after clamping, cephalohematoma with signs of hypovolemia, petechiae/purpura (sepsis risk).
- REFER IF GROSS ANOMALIES: Cleft palate, major cardiac defect, Down syndrome phenotype, ambiguous genitalia (needs evaluation).
- REFER IF POOR FEEDING/LETHARGY: Weak suck, refusal of breast despite positioning, extreme sleepiness—may indicate infection, jaundice, metabolic problem.
- REFER IF SEIZURES/ABNORMAL MOVEMENTS: Jitteriness that does NOT stop with gentle handling, true seizures—refer for evaluation.
- At RHU/BHS: Midwife recognizes danger signs early, informs family clearly, documents reason for referral, arranges transport, and if possible, accompanies or sends written referral with baby.
Key definitions
Golden Minute
Example
Baby born limp, not breathing. Midwife positions, clears airway, begins bag-mask ventilation immediately—within golden minute—while calling for ambulance.
First 60 seconds after delivery in which resuscitation interventions (positioning, airway clearing, bag-mask ventilation) must begin if baby is not breathing; critical window for survival.
Diagrams to know
- Newborn danger signs checklist (respiratory, thermal, infectious, hemorrhagic, neurologic)
- Referral flowchart (sign detected → action → transfer)
Procedural Sequence & Timing Summary
Important facts
- MINUTE 0–1: Delivery. Dry baby (30 s). Assess breathing/crying. If NOT breathing → golden minute resuscitation + referral.
- MINUTE 1: APGAR score at 1 minute.
- MINUTE 1–3: Skin-to-skin contact. Support early breastfeeding initiation. Delayed cord clamping (wait until pulsations stop).
- MINUTE 5: APGAR score at 5 minutes.
- WITHIN 1 HOUR: Vitamin K1 IM (1 mg term, 0.5 mg preterm), eye prophylaxis (erythromycin), BCG IM (0.05 mL intradermal), HBV IM (0.5 mL).
- WITHIN 24 HOURS: Complete weight, length, head circumference. Full head-to-toe exam. Cord care (dry, expose, diaper below). Counseling on danger signs, omphalitis, feeding, thermal care.
- AT 24–72 HOURS: Newborn screening (heel-prick filter-paper card) collected, ideally at 48 hours.
- BEFORE DISCHARGE / WITHIN 1 MONTH: Newborn hearing screening (OAE/AABR) or referral for screening if no equipment.
- DELAYED (6–24 HOURS): First bath (after stable, normothermic, feeding established).
- ONGOING: Rooming-in, exclusive breastfeeding, thermal monitoring, cord care, observation for danger signs.
Diagrams to know
- Timeline of mandated procedures (first hour, first 24 h, 24–72 h, before discharge)
Must remember
- EINC/Unang Yakap Four Steps IN ORDER: (1) Immediate drying (30 s) → (2) Skin-to-skin (immediately after) → (3) Delayed cord clamping (1–3 min, after pulsations stop) → (4) Non-separation for early breastfeeding (ideally within 90 min). This sequence is the cornerstone of newborn care and is tested ruthlessly.
- NEVER do routine suctioning, routine early bathing, routine cord separation, or separate mother and baby in EINC. Meconium-stained vigorous baby = treat as normal (no suction). Non-breathing baby in first minute = resuscitate (bag-mask) within golden minute; do NOT wait for APGAR.
- APGAR Score: 7–10 = normal (routine care), 4–6 = moderately depressed (stimulate/support), 0–3 = severely depressed (resuscitate). APGAR is NOT a trigger for resuscitation—use breathing/HR/tone. Resuscitate first, score second.
- Vitamin K1 IM: 1 mg for term, 0.5 mg for preterm/LBW (<1.5 kg); ALWAYS IM (never IV = fatal), anterolateral thigh, within first hour(s), BEFORE heel-prick if possible. This prevents Vitamin K Deficiency Bleeding (VKDB).
- Eye prophylaxis: Erythromycin 0.5% ointment (or tetracycline 1%), thin ribbon into EACH lower conjunctival sac (inner to outer canthus), after first breastfeed/bonding, ideally within 1 hour, for EVERY baby. Do NOT irrigate after. Prevents ophthalmia neonatorum (blindness from gonorrhea/chlamydia).
- Newborn Screening (RA 9288): Heel-prick filter-paper card, IDEAL 24–72 hours after birth (NOT before 24 h). Midwife is LEGALLY RESPONSIBLE for collection and informing parents. Congenital Hypothyroidism (CH) is the classic high-yield example—undetected causes intellectual disability, but early thyroxine prevents it entirely.
- Newborn Hearing Screening (RA 9709): OAE or AABR before discharge or within 1 month (by 3 months latest). 'Refer' result means needs follow-up, NOT confirmed deafness. At RHU/BHS without equipment: refer to screening facility and document referral.
- Birth immunizations: BCG 0.05 mL intradermal (upper arm) + HBV 0.5 mL IM (anterolateral thigh) within 24 hours of birth. If mother HBsAg+: give HBV + HBIG within 6–12 hours (urgent). Both are mandated, non-negotiable.
- Detect & Refer (Golden Minute Rule): If baby NOT breathing at delivery → position, clear airway, bag-mask ventilation WITHIN 60 SECONDS while arranging referral. Resuscitation begins immediately; referral simultaneous. Thermal care, danger signs (fever >38°C, hypothermia <36.5°C not correcting, respiratory distress RR >60, poor feeding, seizures, hemorrhage, anomalies) = all refer immediately.
- Cord care (Dry Cord Care): After delayed clamping (1–3 min, after pulsations stop), cut with sterile scissors between clamps. Fold diaper BELOW cord. Keep cord clean and dry; apply NOTHING (no alcohol, no antiseptic, no home remedies) unless local high-risk protocol specifies chlorhexidine. Teach mother danger signs of omphalitis (redness, swelling, foul discharge) = immediate referral. Cord separates 5–15 days.
Last minute tips
- TIMING IS EVERYTHING: The exam tests exact timing ruthlessly. Delayed cord clamping is 1–3 MINUTES (not 30 sec, not 5 min). Newborn screening ideal is 24–72 HOURS (not before 24 h). Eye prophylaxis within first HOUR ideally. Birth vaccines within 24 HOURS. Memorize every timing threshold.
- EINC = NO ROUTINES: The exam loves 'which procedure should NOT be done?' Remember the EINC 'do NOT' list: Do NOT routine suction, do NOT routine bath (delay ≥6 h, ideally 24 h), do NOT separate baby from mother, do NOT wipe off vernix, do NOT foot-print before skin-to-skin. If a question says 'routine' prophylactic action → often the answer is 'not indicated in EINC.'
- DOSE MATTERS: Vitamin K is dose-dependent (1 mg vs. 0.5 mg by weight), route is non-negotiable (IM only, never IV), and site is specific (vastus lateralis). Eye prophylaxis is dose-dependent (0.5% erythromycin, not other concentrations). BCG is 0.05 mL intradermal (NOT IM). HBV is 0.5 mL IM. Exam will ask 'what is the correct dose/route?' — be precise.
- STATUTES BY ACRONYM: Know RA 7392 (Midwife scope), RA 9288 (Newborn Screening), RA 9709 (Newborn Hearing). Exam will ask 'Under what law?' or 'Which statute mandates X procedure?' Have these three at the forefront. EINC = Essential Intrapartum and Newborn Care protocol by DOH.
- HIGH-RISK SCENARIOS (Detect & Refer): Exam will give a clinical vignette and ask 'what should the midwife do?' If baby not breathing → resuscitate within golden minute (60 sec). If APGAR 0–3 → resuscitate + refer. If hypothermia not correcting → refer. If omphalitis signs → refer. If respiratory distress → refer. Your job is early RECOGNITION and REFERRAL, not management. Midwife 'detects and refers,' not 'manages complications.'
Comparison tables
APGAR Scoring Breakdown
| Component | 0 Points | 1 Point | 2 Points |
|---|---|---|---|
| Appearance (Color) | Blue/pale all over | Body pink, extremities blue | Completely pink |
| Pulse (Heart Rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (Reflex Irritability) | No response | Grimace | Cry / cough / sneeze |
| Activity (Muscle Tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Slow/irregular/weak cry | Good strong cry |
APGAR Interpretation & Action
| Score Range | Interpretation | Midwife Action |
|---|---|---|
| 7–10 | Good/Normal | Routine EINC: skin-to-skin, breastfeeding, monitor, no intervention needed. |
| 4–6 | Moderately Depressed | Stimulation (dry, tap feet); assess breathing/HR. If not improving, begin gentle support (positive pressure). Recheck at 5 min. |
| 0–3 | Severely Depressed | IMMEDIATE resuscitation: position, airway, bag-mask ventilation. Clamp cord. Refer urgently. Recheck APGAR every 5 min up to 20 min. |
Vitamin K1 Dosing by Birth Weight/Maturity
| Category | Birth Weight | Dose | Route | Site |
|---|---|---|---|---|
| Term / Normal-Weight | ≥2,500 g | 1 mg | IM | Anterolateral thigh (vastus lateralis) |
| Preterm / LBW | <2,500 g (ideally <1.5 kg) | 0.5 mg | IM | Anterolateral thigh (vastus lateralis) |
Normal Newborn Vital Signs & Physical Findings
| Parameter | Normal Range | Abnormal / Referral Threshold |
|---|---|---|
| Heart Rate | 120–160 bpm | <100 bpm or >160 bpm; persistent bradycardia |
| Respiratory Rate | 40–60 breaths/min (irregular OK in first hours) | >60 breaths/min (tachypnea); <30 min; grunting/nasal flaring |
| Axillary Temperature | 36.5–37.5 °C | <36.5 °C (hypothermia) or >37.5 °C (hyperthermia) |
| Birth Weight (Term) | 2,500–4,000 g | <2,500 g (LBW) or >4,000 g (macrosomia) |
| Blood Glucose (random) | Generally >40 mg/dL is acceptable in well babies | <40 mg/dL in symptomatic baby; hypoglycemia |
Newborn Screening (RA 9288) Disorders
| Disorder (Abbreviation) | Presentation if Untreated | With Early Detection/Treatment |
|---|---|---|
| Congenital Hypothyroidism (CH) | Severe intellectual disability, growth retardation, developmental delay | Normal development with early thyroxine replacement |
| Congenital Adrenal Hyperplasia (CAH) | Salt-wasting crisis, ambiguous genitalia (females), death in infancy | Normal development with early steroid/salt replacement |
| Phenylketonuria (PKU) | Severe intellectual disability, light hair, 'mousy' odor | Normal development with early phenylalanine-restricted diet |
| Galactosemia (GAL) | Intellectual disability, cataracts, hepatomegaly, neonatal jaundice | Normal development with early galactose-free (lactose-free) diet |
| Glucose-6-Phosphate Dehydrogenase deficiency (G6PD) | Hemolytic anemia, severe jaundice, kernicterus | Normal development with avoidance of triggers (fava beans, infections, certain drugs) |
| Maple Syrup Urine Disease (MSUD) | Developmental delay, seizures, death | Normal development with early dietary management (branched-chain amino acid restriction) |
Diagrams
EINC/Unang Yakap Protocol — Immediate Newborn Care Sequence
Step-by-step flowchart of the four EINC steps in correct sequence, with decision points for breathing and cord pulsations. Shows the immediate resuscitation pathway (non-breathing baby) branching from routine care, and the full timeline from birth through newborn screening.
Mandated Newborn Procedures — Timeline from Birth to Discharge
Timeline showing exact timing of all mandated procedures from delivery through discharge, organized chronologically. Emphasizes critical early timing (APGAR, cord clamping, skin-to-skin) and grouped procedures (birth vaccines at 24 h, screening at 24–72 h).
Mandated Newborn Procedures — Complete Concept Map
Comprehensive mind map showing the entire chapter organized into five major branches: EINC protocol, assessment tools, immediate procedures, screening programs per statute, and danger signs requiring detection and referral. Shows hierarchical relationship and grouping of all major topics.
Newborn State Transitions — From Birth to Stable
State diagram showing the progression of a normal newborn from delivery through stable state and discharge, with a branch pathway for the non-breathing baby requiring golden minute resuscitation and urgent referral. Illustrates decision points and state transitions.
Newborn Screening & Hearing Screening Pathways (RA 9288 & RA 9709)
Decision flowchart showing the complete Newborn Screening (RA 9288) and Newborn Hearing Screening (RA 9709) pathways, including timing considerations, results interpretation, and referral pathways for both normal and abnormal/high-risk results.